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On Rounds Excitement Brewing for Local Gastro Physician Though “medicine” and “microbrewery” may be near one another in a dictionary, for most people the two words are not a combination of pursuits that immediately come to mind. But Rajat Parikh, MD is having significant success with both ... page 3
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Reversing Diabetes
Could a Four Dollar Generic be the Answer? By Laura Freeman
Rogue T- cells that attack the body’s own pancreatic beta cells have long been known as the primary villains in the autoimmune process that becomes Type 1 diabetes. Several years ago, a second culprit was discovered lurking behind the scenes. Its role in contributing to beta cell death and diminished function was unmasked in research led by Anath Shalev, MD, director of UAB’s Comprehensive Diabetes Center. “We started by looking to see which gene in human islet cells seems to be most affected by the high glucose levels that are a hallmark of diabetes,” Shalev said. “That’s what brought our attention to a strong over-expression of thioredoxin-interacting protein, or TXNIP. As we continued to investigate, we found that high levels of TXNIP destroyed beta cells through a mitochondrial death pathway, and it seems to be involved in inflammation related to some of the more serious complications of diabetes, including cardiomyopathy, retinopathy and kidney damage.” The center’s continuing research recently identified a second critical role TXNIP plays in diabetes when it found (CONTINUED ON PAGE 6)
Practicing Medicine in Britain (No, they don’t prescribe tea) America’s healthcare system landed at the bottom of a list of 11 industrialized countries last year. The report, the fifth one produced by the Washington-based Commonwealth Fund in the last ten years, evaluated the systems based on quality, efficiency, access to care, equity, and healthy lives ... page 10
Anath Shalev, MD (right) and a researcher in Shalev’s lab.
The Increasing Stress of Practice Administration By Jane Ehrhardt
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Jimmy Norman sits in the dunking tank.
“You have to wear so many hats,” says Jimmy Norman, practice administrator at University Orthopeadic Clinic (UOC) in Tuscaloosa. He has run five practices in his 22-year career. “No job is too small that you may find yourself a part of as a practice administrator.” Norman has cleaned toilets and kept out-of-line patients at bay while security was called. “I never thought I’d be a bodyguard,” he says. “I never thought I’d be cleaning the gutters,” says Jim Carson, practice administrator at Southside Pain Specialists in Birmingham. A leaky roof called for temporary patching while roofers were enroute. “I never thought I’d be setting an IT network either.” Practice managers run the business side of medical practices. From equipment pur(CONTINUED ON PAGE 12)
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HEALTHCARE SPOTLIGHT
Excitement Brewing for Local Gastro Physician By daLe short
Though “medicine” and “microbrewery” may be near one another in a dictionary, for most people the two words are not a combination of pursuits that immediately come to mind. But Rajat Parikh, MD is having significant success with both. The son of a cardiologist from India, Parikh was born in Brooklyn, New York, raised in Manhattan, and traveled much of the world before joining his current practice with Birmingham Gastroenterology Associates in 2011. His specialties are endoscopic ultrasound and gastrointestinal oncology. Parikh graduated from New York University, received his MD (with honors) from St. George’s University School of Medicine on the Caribbean island of Grenada, and served as chief medical resident at the University of Medicine and Dentistry of New Jersey. He wasn’t quite sure what to expect when he moved to the south, he says, but has found it a pleasure: “There are fewer distractions and a somewhat slower pace. People are friendly, and they’re neighborly,” he says, “so it’s helped make my transition easy.” Parikh’s interest in medicine first surfaced in high school. “I was a physics and chemistry guy, leaning mostly toward a science track,” he says. “As a medical student I enjoyed the technical and procedural side--surgery and clinical work.” In graduate school he first focused on neurology, but was gradually drawn to gastroenterology instead. The biggest advance in the specialty during recent years, he says, is the endoscopic ultrasound--a procedure that gives physicians better images of internal organs, including the gastrointestinal tract that previously would have required surgery. “It’s been very useful in diagnosing both GI and non-GI cancers,” he says, “and therapeutic options have been evolving-such as tissue biopsies made with a small needle, to help identify future malignant lesions. It’s a much less invasive way than before. “By using the scope, patients often don’t feel or remember the surgery, and
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Rajat Parikh, MD
they have no scars. But the images give us an idea whether they would benefit from surgery, or hopefully avoid it. The therapeutic options have altered very rapidly.” But the newest pursuit on Parikh’s horizon is connected to one of his pastimes rather than to his clinical work. “I’m not exactly what you’d call a ‘foodie,’ he says, “but I’m a big fan of high-quality bev-
erages and food. In college I drank the typical types of beer and found that they weren’t very tasteful. So it’s exciting to see the growth of craft breweries around the country. I have a lot of family in California, and there are many micro-brewers there who are passionate about their work.” After the move to Alabama, he and his wife—who is an obstetrician and gynecologist--took some brewing classes at Hop City Craft Beer and Wine in Pepper Place and experimented with making beer at home. The experience spurred him to learn more about the process. “Beer is much easier than making wine,” Parikh says. “The only ingredients are water, hops, and yeast. You can adjust them to your liking, and have a product in six to eight weeks. Plus, the beer doesn’t have to be pricey at all.” Along the way he was introduced to another craft brewer, Joe Pillateri, who happened to be involved in a Homewood business startup called Red Hills Brewing Company, and Parikh became a partner. The brewing process takes place in special vats, away from light and air. “Bacteria is the enemy of beer,” Parikh says, “as is too much oxygen and too much light.” The Homewood Planning Com-
mission recently approved Red Hills’ rezoning application. The brewery will be located on Central Avenue next to Steel City Pops, and will concentrate on socalled “session beers,” with an alcohol content of five percent or less. As for Parikh’s own beer preferences, he says he enjoys a wide variety but his taste tends toward pale ale. One of his favorites is a variety known as India Pale Ale, for its “smoky flavor, and a little bit of spiciness.” One process that organizations such as the Alabama Brewers Guild are watching with interest is in the state legislature: House Bill 69, which would update Alabama’s restrictions on craft brewers by allowing them to serve food on site and to sell their beer in bottles for off-site consumption. Nowadays, according to Parikh, local stores are making more brands of craftbrewed beer available, which he says is part of a national trend. “Right now, craft beers make up about 15 percent of the market, compared to only five percent back in 2009. So they’re growing significantly and it’s good to see more.” Parikh says the target date for Red Hills being operational is around Labor Day.
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Birmingham Medical News
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APRIL 2015 • 3
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Allergic Esophagus Leads to Discovery of New Disease By Ann B. DeBellis
Eosinophil esophagitis (EoE) is becoming a more widely recognized disease among allergists and gastroenterologists. However, treatment and management of this disease remain controversial among members of the medical community. What doctors do know is that allergies are playing a role in EoE, and pinpointing the exact cause can be difficult. As far back as the 1960s, eosinophils were seen in the esophagus, but there was no connection Dr. Soong demonstrates a treatment option for EoE. to a disease. “By 1995, lergy & Asthma Center. “The prevalence there was a connection in infants that EoE of EoE is increasing now, because we are might be a food-related process. Fast fordoing the right tests to catch them. It is still ward to the 2000s, and the recommendaa mysterious disease, and we still have a lot tions for people with bad reflux changed. of questions. At the same time, I find the They had to have a biopsy for cancers world of EoE fascinating.” and other screenings. Eosinophils in the While controversial, there appears to esophagus were found in these patients,” be two distinct phenotypes among people says Weily Soong, MD, of Alabama Al-
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– eyes, nose, skin, and lungs. Why not the esophagus? It comes in contact with the air, too. It is also interesting that we are becoming more allergic as a nation, and all of a sudden this allergy pops up. It’s one of those diseases that you wouldn’t find if you weren’t looking for it. Now that we are looking for it, we’re finding it.” Most EoE patients who have reflux symptoms see a gastroenterologist. “When these patients present with bad reflux, you are supposed to put them on a two-month trial of a proton pump inhibitor, do an endoscopy and biopsy. If the pathology report shows greater than 15 eosinophils per high power field, it’s likely to be EoE,” Soong says. “At that point, the allergist gets involved in the treatment. In children and adults, we do skin and patch testing for food allergies and environmental testing. Some patients elect to do an elimination diet.” Once the EoE diagnosis is confirmed, there are several treatment options that have led to some controversy among physicians. “We can put the patient on elemental formula which works great if the patient is an infant, but not if she is school age or an adult,” Soong says. “We will try
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with EoE symptoms. “Infants and toddlers have feeding difficulties, fail to thrive, with vomiting and bad reflux. School age children tend to have reflux and more vomiting and pain,” Soong says. “Late teenagers and adults usually present with food getting stuck and dysphagia, food impaction, upper abdominal pain and heartburn.” In children, especially infants, food allergies seem to be more predominant in association with EoE. “Milk, eggs, soy, peanuts, and wheat tend to play a big role,” Soong says, “while the majority of teenagers and adults appear to be environmentally allergic. However, we also may find a food allergy in 40 to 50 percent of adults. “Patients with EoE might also have asthma and eczema. I think it is interesting that you have people with allergic lungs, which is asthma, and people with allergic skin, which is eczema. Now we’re finding an esophagus that is allergic. Allergies are in places that come in contact with the air
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Solving the Mystery of Fibromyalgia New Clues Link Leptin and Microglia as Suspects By Laura Freeman
It has been one of the most elusive whodunits in medicine for over 40 years, with more suspects than Murder on the Orient Express, and enough red herrings to confound even the astute powers of deduction of Sherlock Holmes. Solving a mystery with logic requires objective evidence, which in the case of fibromyalgia has been in short supply since the condition of unexplained muscle pain, fatigue and cognitive symptoms was first described centuries ago. In modern times, the lack of measurable evidence that could be detected in medical tests led fibromyalgia to be labeled as a psychological condition. The patients, a great majority of whom were women, were often thought to be attention-seeking hypochondriacs. Office visits could easily become exercises in mutual frustration, which frequently led to followup referrals with a psychologist or rheumatologist, beginning what in many cases became a diagnostic odyssey that could take years. As growing numbers of victims complained of similar patterns of symptoms, eventually the inescapable conclusion was that something real was afoot. Identifying exactly what is going on in the body during a flare, with limited sources of objective data, is the mystery research sleuths have focused on most recently. Now, new clues that may not be the smoking gun—but bear witness to definite, measureable changes in body chemistry— seem to support a new theory of the “howdunit” of fibromyalgia and the means by which it creates havoc in the body. The evidence that has become a topic of major interest at national conferences on pain came from two studies of leptin that were done by experimental psychophysiologist Jarrod Younger, PhD and his team at Stanford. They recently moved to UAB to set up Alabama’s first Neuroinflammation, Pain and Fatigue Laboratory. “Elevated leptin levels seem to be implicated in chronic pain and fatigue, especially in women, who tend to have higher leptin levels than men. This could be one reason fibromyalgia is more common in women,” Younger said. “When the microglia in the brain’s immune system are exposed to too much leptin for too long, it doesn’t cause fibromyalgia directly, but it makes the microglia start behaving like an angry drunk, spoiling for a fight. Just about anything that comes along - stress, an illness, an injury - will trigger the microglia to start pumping cytokines and other proinflammatory substances into the central nervous system, resulting in pain and many of the symptoms we associate with the flu.” Since much of the immune system defenses protecting the rest of the body are unable to breach the blood-brain barrier, the microglia are essentially the brain’s
Jarrod Younger PHD
own immune system. Neuroinflammation from over activation of the microglia is also becoming a primary focus in recent research into myalgic encephalomyelitis, MS, Parkinson’s and Alzheimer’s.
Younger and his team are now recruiting volunteers for the first of dozens of planned studies funded by the NIH, the DOD, foundations and other contributors. The first study scheduled to launch within weeks will chart the levels of substances found in daily blood draws for a month and compare them to patient logs of changes in the intensity of symptoms to look for patterns and correlations. “Right now, we really don’t have a technology to detect neuroinflammation. That’s why one of the goals of our research is to develop better tools for detecting and monitoring,” Younger said. “We’re looking at spectroscopy, using an fMRI as an MRS. We hope to detect tiny
changes in brain temperature, which we think are likely to be present in neuroinflammation.” Another upcoming study will look at the effects of injecting small amounts of endotoxins from the surface of bacteria to determine whether the response in those who have neuroinflammatory disorders is stronger or different than the response in those who do not. Beyond diagnosis and monitoring, the ultimate goal of Younger’s research is finding better modes of treatment. In the first two clinical trials in humans, very low doses of naltrexone, a drug used for decades to treat addiction, showed positive (CONTINUED ON PAGE 14)
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Reversing Diabetes, continued from page 1 that high levels of the protein directly block insulin production through a new pathway. It induces a microRNA, miR-204, to down-regulate the MAFA transcription factor involved in promoting transcription of the insulin gene. This offers a second new target for therapies to counteract the progression of The first target was reducing the overproduction of TXNIP itself. Shalev had noticed in an earlier study that a calcium channel blocker seemed to be effective in
inhibiting TXNIP overproduction. “We were able to show that Verapamil had this effect. It has been around for over 30 years and has been used extensively in hypertension and migraine headaches with minimal side effects,” Shalev said. “In both mouse studies and human islet cells, Verapamil reduced TXNIP levels.” In fact, the response was so dramatic that when mouse models with established diabetes and blood sugars above 300 milligrams per deciliter were treated with Vera-
pamil, the disease was eradicated. The next thought is how well will human diabetics respond? Answering that question is the goal of a new clinical study funded by the JDRF that has just begun recruiting 52 subjects, and recruitment is expected to continue through the end of the year. To qualify, subjects must be between the ages of 19 and 45, and have been diagnosed with Type 1 diabetes within the past three months. Fernando Ovalle, MD, director of
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UAB’s Comprehensive Diabetes Clinic, and co-principal investigator, will oversee all clinical aspects of the trial. Patients will be using insulin pumps and 24-hour glucose monitoring. Shalev is optimistic, but cautions that with such different life spans, what can be achieved in a one-year study in humans compared to a one-year study in mice is hard to predict. “We think we will see some improvement, and even a small amount of improvement in beta cell survival and function can make a significant difference,” Shalev said. “Recent research has shown that even after decades, a large number of diabetics have more surviving beta cells than we once thought possible. If we can create an environment more conducive to protecting beta cells and improving their function by inhibiting excessive TXNIP expression, we could advance the treatment of diabetes from an entirely new direction. It may also be possible to reduce the complications from damage excessive TXNIP does in other tissues.” The ability to inhibit over expression of the gene producing the TXNIP protein would also likely have benefits for patients who have Type 2 diabetes, since high glucose levels seem to be triggering similar effects and problems from the protein. Shalev also pointed out that two additional advantages to this approach is that reducing TXNIP doesn’t require any suppression of the immune system and Verapamil is a known drug already approved by the FDA. Its action is well understood and it is generally well tolerated. At dosages used to treat migraines, it has already been used in patients without hypertension with no significant impact on blood pressure. “Generally, thought in the field has moved from transplants to the less invasive approach of protecting and improving the patient’s own beta cell mass and function. In our mouse studies, we’ve seen some indirect indications that it may be possible to encourage beta cell replication or even perhaps regeneration,” Shalev said. “Something seems to be going on. We haven’t been able to determine whether it’s just improvement in beta cell function, or actual regeneration, but whatever it is, the possibilities are exciting.”
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New Peanut Allergy Study Offers Hope, Raises New Questions By Ann B. DeBellis
The prevalence of peanut allergy in children has more than quadrupled over the past 15 years and can be a cause of life-threatening reactions in some cases. It has become the leading cause of anaphylaxis and death related to food allergy in the United States. Because of the high number of children impacted, researchers are working to find better ways to care for these young patients. “Peanut allergy significantly affects quality of life for these children and their families because of dietary and social restrictions, but the main stress factor stems from a fear of accidental peanut ingestion,” says Carol Smith, MD, of Birmingham Allergy & Asthma Specialists. “Currently, we treat our patients with peanut allergy through strict avoidance of peanuts, education, and rescue medications, but these methods can be challenging for families because peanut is hidden in so many food products.” Smith says the best scenario would be to find a way to avoid developing peanut allergy in the first place. “The American Academy of Pediatrics initially recom-
Allergist Carol Smith, MD examines one of her young patients.
mended that high-risk infants avoid having peanut in their diets until age three,” she says. “But as the prevalence of peanut allergy continues to rise, there appears to be insufficient evidence to support early
avoidance. In fact, subsequent studies have suggested that earlier introduction was associated with a decrease in the development of food allergy.” A new study published in the New England Journal of Medicine online is generating some excitement among allergists. In the Learning Early About Peanut (LEAP) study, findings suggest that the risk of developing peanut allergy can be dramatically reduced with early introduction (before 11 months) of peanut-based products. “The LEAP study makes it clear that we can do something now to reverse the increasing prevalence of peanut allergy,” authors of the study say. “Because the results of this trial are so compelling and the problem of the increasing prevalence of peanut allergy is so alarming, new guidelines should be forthcoming soon.” The study included 640 infants between four and 11 months of age who were considered at high risk for developing peanut allergy because of severe eczema, egg allergy or both. Participants in the study were assigned randomly to peanut consumption or peanut avoidance after undergoing a baseline skin prick pea-
nut test. Those assigned to consumption were also given a baseline food challenge. The children who tested negative on the initial skin-prick test underwent primary prevention and were given two grams of peanut protein in a single dose. Those who tested positive on the initial skin-prick test underwent secondary prevention and were given incremental doses up to a total of 3.9 grams. Anyone who had a reaction to the food challenge was moved into the avoidance group. Those who passed the food challenge were moved into the consumption group and fed at least six grams of peanut protein per week, distributed in three or more meals, until they reached age 60 months. According to study investigators, “This intervention was safe, tolerated, and highly efficacious. In the intentionto-treat analysis, peanut consumption was associated with an 86-percent reduction in peanut allergy at 60 months of age among participants who had had negative results on a peanut-based skin-prick test at study entry and with a 70-percent reduction among those who had had positive skin(CONTINUED ON PAGE 20
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APRIL 2015 • 7
Gearing up for ICD-10 By JULIE PARKER Successful completion of a full week of end-to-end testing of the new ICD-10 coding shows the healthcare industry is ready for the next step toward total conversion from ICD-9 coding, Marilyn Tavenner,
former administrator of the Centers for Medicare and Medicaid Services (CMS) said before her departure from the federal agency earlier this year. To promote the healthcare industry’s smooth transition from ICD-9 to ICD-
10, CMS is conducting a comprehensive program of testing. In the first full week of testing -- from Jan. 26 to Feb. 3 – CMS received nearly 15,000 test claims from 660 providers. “Testing allows us to identify areas of improvement, and we’ll work with outside entities and stakeholders to improve those very small deficiencies identified,” she said at the time. “And we’ll continue to do testing, especially in those areas we identify as needing improvement.” Tavenner added, “Because ICD codes are required on medi-
cal bills, we want healthcare providers to be confident they can submit Medicare claims and get paid as the nation switches to ICD10.” CMS also identified a point that’s prompted some confusion among the healthcare community. Acting Administrator Andy Slavic has reiterated ICD-9 coding is to be used for services provided before the Oct. 1 deadline; ICD-10 coding will be used for services provided on or after Oct. 1. Prior to Oct. 1, ICD-10 can be used only for test purposes. However, once we hit
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Oct. 1, 2015 only ICD-10 can be used for services rendered on or after that date. But claims submitted after Oct. 1, 2015, for services provided before that date, must still use ICD-9 codes. Margie Maley, BSN, MS, coding educator and consultant with KarenZupko & Associates Inc., a national consulting firm based in Chicago, said she’s strongly advising clients that bill directly to Medicare to apply for end-toend testing. “If you don’t get accepted for end-to-end testing, at the very least Margie Maley, BSN, MS conduct acknowledgement testing,” she said, noting that applications for the next available end-to-end testing (mid-July) became available on all carrier websites (MACs) on March 13. “Medicare is only accepting up to 850 providers per testing week, so act fast,” urged Maley. “Even our orthopedic clients who must deal with the greatest increase in ICD-10 codes and reorganization have jumped onto the testing bandwagon successfully.” Maley pointed out that claims testing highlights more than ICD-10 issues. “Medicare says that 6 percent of testing errors were due to ICD-10,” she emphasized. “Yet more than twice that – 13 percent – were due to provider-preventable errors, such as incorrect NPI or submitter ID, or invalid place of service or HCPCS codes.” Carrier software bugs are also being caught in the testing phase. “A lot of this is just the nature of software development … not necessarily a coding issue,” Maley said. “Everyone is creating new features to deal with ICD-10 and they need to be tested so bugs are caught and fixed before the deadline. So make sure your practice is part of the testing process. You never know what you might learn about your own processes.” CMS is clearly ready for ICD-10, emphasized federal officials. “And thanks to our many partners — spanning providers, health plans, coders, clearinghouses, professional associations and vendor groups — the healthcare community at large will be ready for ICD-10 on Oct. 1,” Tavenner promised before stepping down. “I appreciate the tremendous efforts and achievements of health professionals as we work together to realize the benefits of ICD-10 and other advances toward the ultimate goal of improving the quality and affordability of healthcare for all Americans.” For healthcare providers unable to complete the necessary systems changes to submit claims with ICD-10 codes by Oct. 1, CMS has provided free billing software via MAC websites. This billing software has been updated to support ICD-10 codes to offer submitters an ICD-10 compliant claims submission form; coding assistance isn’t provided. Alternatively, all MACs websites provide internet portals; a subset of those portals offer claims submission.
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Birmingham Medical News
APRIL 2015 • 9
Practicing Medicine in Britain (No, they don’t prescribe tea) By Jane Ehrhardt
America’s healthcare system landed at the bottom of a list of 11 industrialized countries last year. The report, the fifth one produced by the Washington-based Commonwealth Fund in the last ten years, evaluated the systems based on quality, efficiency, access to care, equity, and healthy lives. In each report, the U.S. has fallen last, even as more countries were added. In this latest ranking, Britain’s National Health Service (NHS) topped the list. One of America’s Sippu Momin, MD at Stonehenge. downfalls was expense. The U.S. spent $8,508 per person on which she served as a general practitioner healthcare in 2011 compared to $3,406 (GP), the equivalent of a U.S. primary by England. care physician. She came to Birmingham “We do a lot of prevention in Engin 2013, and recently joined UAB as a reland; not as much acute care as here in searcher. America. That’s because of the governIn England, GPs receive a specific ment rationing the money,” says Sippu amount of money per year for each perMomin, MD, who practiced medicine son in their care. “It’s very limited money, in England for eight years, 18 months of so we’re more focused on prevention
so it does not get into a stage where it requires a lot of money,” Momin says. “Here there is a lot of scope for money to be used.” The allowance doled out by the NHS has to cover overhead as well, such as receptionists or secretaries. But it increases per person for those with certain conditions, such as diabetes. Salaries for physicians, Momin says, run the same throughout the country. In America, specialists earn higher reimbursements than primary care physicians because procedures garner higher fees. But in Britain, GPs make more, and U.S. healthcare is following their example. “General practitioners take on a lot of responsibility in England and are quite wealthy,” she says. A healthier patient population reaps financial rewards for the GP. “For instance, they can get more money if they have less smokers or less patients with asthma,” Momin says. Ac-
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10 • APRIL 2015
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Birmingham Medical News
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cess to more incentives combined with the GP’s heavier patient load means GPs can earn more than specialists. “We rarely send patients to specialists,” Momin says. She treated entire generations of each family from pregnancy to death, with specialists like obstetricians, rarely utilized. “I got to know their family finances, their social background, and to understand them as a whole rather than just a child who comes to me, like a pediatrician.” Expectant mothers see their general practitioner, not their gynecologist. “When they got pregnant, I would do the paperwork and then hand them off to a midwife team,” Momin says, adding that the physicians then received regular midwifery reports. They only saw an OB/ GYN if complications arose. “After delivery, the general practitioner does the post-natal check and the baby check. If they have a urinary infection or a child gets chickenpox, they come to us. We only use pediatricians if there’s a complication,” Momin says. The focus on prevention in England gets a substantial boost from a nationwide network of wellness and cessation clinics as part of the government’s healthcare system. According to the NHR, studies show smok-
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Birmingham Medical News
APRIL 2015 • 11
The Increasing Stress of Practice Administration, continued from page 1 chase, IT, pension plans, billing, inventory and staffing to building upkeep, marketing and planning for the growth of the practice, they are the go-to person. Any situation that arises that impacts the flow of work at a practice, then it’s the administrator who gets the call and takes the action. Now, with the healthcare landscape constantly shifting, administrators are burning out. Carson has known four people who moved on to other careers, mostly in healthcare. Norman knows of a dozen or so who have opted out. “The interesting part,” he says, “is several of those ended up coming back to practice management because there were problems and issues in those other lines of work too. The grass wasn’t always greener.” Last year, Karen Roden called it quits after 19 years as a practice administrator. “When meaningful use came around two years ago, I already had a full-time job,”
she says. But the small general surgery practice meant limited resources on which to off-load the numerous demands of proving meaningful use to earn EMR incentives. “I felt like I was caught in a vise with reimbursements declining and not able to control expenses. In my opinion, I could never win.” The constantly in- Karen Roden creasing demands on practice managers call for an entrepreneurial spirit, says Norman. “You have to be an agent of change; you have to embrace that,” he says. Job satisfaction has to derive from things like tweaking billing to gain revenue or reducing transcription costs through EMR usage to offset decreasing reimbursements. “That’s the kind of thing that keeps me invigorated
and passionate about my career,” Norman says. “You need to feel as if this practice is yours and nothing is too beneath you to be handled.” Roden says her burn out came from feeling ownership all the time. “I couldn’t turn it off. Unless you can turn off that feeling of responsibility, then the job is probably not a good fit.” She is relishing her new career as a credentialist at a healthcare system that employs 200 physicians. But she says if there was a practice administrator job within the healthcare system, she would be interested. “The difference is there is support in place for things like [human resources] and IT.” The administrators say human resources top their list of stress points. “Our hardest role is hiring good talent and keeping it,” says Carson, who oversees 23 employees and four physicians. Norman says most healthcare applicants don’t realize
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how fast paced the environment is at a practice. “It’s customer service but at break-neck speed. It’s like drinking out of a fire hose.” Tied with HR as the greatest stress point sits government regulations. Jim Carson “Every time we turn around, there are new hurdles that lead to high jumps and then pole vaults,” Norman says. “These days, you can get penalized for doing the same job you’ve been doing for the same physicians your whole career.” Ten years ago, practices did procedures, billed, and got paid. “Now there’s so much more to it. You have to cross your T’s and dot your I’s before you even see the patient,” Carson says. To relieve stress within the practice, building relationships goes a long way. Last spring, Norman volunteered for the dunking booth at the employee appreciation event. “The doctors brought their chairs over to the booth to watch and laugh. It was fun, until I realized everyone had lined up to take a shot,” he says. Carson takes his staff bowling and plays golf with his physicians. “It takes your relationship to a different stage because you know each other on a personal level. It lets you find common ground,” Carson says. Those connections make oneon-one talks easier when things are not so rosy, such as when a physician’s production has declined. Finding support from other practice administrators is the most powerful destresser. “Get advice, because you’re not in the boat alone,” Norman says. “Reaching out to a group is one of the best things you can do.” The Birmingham MGMA and the Alabama MGMA meet regularly. “Surround yourself with colleagues in the same game,” Norman says, but don’t just sit and listen to the program. “The best conversation isn’t happening in the conference room, it’s outside the door.” Carson says his renewal comes from getting letters saying what a difference the practice made to someone and then passing that along to the physicians and staff. “And it’s a lot of fun to see the practice grow and generate more revenue. Then I get to tell everyone that those numbers mean we’re doing this the right way, we’re growing, and you’re all going to benefit from that.”
Read Birmingham Medical News Online: (205) 930-0920 | 800-452-1464 27 skilled physicians | practicing in 14 locations 3485 Independence Drive | Homewood, AL 35209
12 • APRIL 2015
Birmingham Medical News
BIRMINGHAM MEDICAL NEWS.COM
Survey Says … A Digital Disconnect Exists Between Patients, Practices By CINDY SANDERS
Patients increasingly want to access online services to enhance convenience and communication with providers, according to a recent national survey conducted by TechnologyAdvice Research. Yet, the majority of respondents in the “2015 Trends in Patient Engagement” survey said a number of digital solutions that would be helpful are not offered by their primary care practices. “Only 19 percent said their physician offered online appointment scheduling,” noted Cameron Graham, survey author and managing editor for TechnologyAdvice, a company that conducts research and analysis of IT products in a number of industries including healthcare. “Only 17 percent said their physiCameron cian offered online bill Graham pay.” In addition to scheduling and payment functions, Graham said viewing test results or diagnoses online also ranked high among survey participants. However, only 27.8 percent said their physician provided that option. Graham pointed out all
three of the most desired digital services are fundamental patient portal features. With that in mind, he continued, “There’s a big discrepancy between what patients report having access to and the EHR adoption rate among physicians.” Graham said electronic health record adoption rates are in the “high 70s, low 80s” by office-based physicians in the United States. “A lot of those systems should have online appointment and bill pay capabilities,” he said, adding some of the older systems might not have those options but virtually all newer products offer robust patient portal resources. “I think one of the big takeaways is that the patients don’t seem to be aware of the tools their physicians probably have,” he said. The other option, Graham continued, is that offices have these capabilities but are not using them. Either answer could spell trouble for practices. “When we asked how important these services were when people were choosing a physician, 60.8 percent said it was ‘important’ or ‘somewhat important,’’ Graham said. “If physicians are offering these in-demand digital services, a more proactive approach to promoting them is needed and could create an advantage in attracting and retaining patients.”
Weily Soong, MD Meghan Lemke, MD Maxcie Sikora, MD John Anderson, MD Sunena Argo, MD James R. Bonner, MD (Emeritus) Patricia Luthin, CRNP Blake Youngblood, CRNP Liz DeBerry, CRNP
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Graham added he also believes physicians need to more fully embrace digital services. “Patients value them a lot. Physicians think of them as an extra or addon.” With meaningful use requirements staged to increase health information exchange and promote patient engagement, Graham noted the effective use of patient portals could help practices hit the necessary benchmarks to access incentives. However, he noted, there probably won’t be a ‘one size fits all’ solution when it comes to patient engagement. “We did find age played a role in which services patients wanted their physicians to offer,” he said. Not surprisingly, the demand was much higher by younger adults than in the senior population. “Among the 25- to 34-year-old demographic, almost 40 percent said they would like to have a smart phone app for scheduling appointments; but among the 65 and older demographic, only 3.8 percent said that would be something they’d want.” Similarly, 35.3 percent of patients ages 25-34 would like for their physician practice to offer secure messaging outside of office hours compared to just 11.5 percent of those ages 65 and older. Of the six digital services listed on the survey (online appointment scheduling, smartphone app
for scheduling, online test results/diagnoses, online bill pay, secure messaging, and health resources/educational material), 23.5 percent of those ages 25-34 reported they didn’t want their physician to offer any of the services, while 44.2 percent of participants 65 and older had that same response. Graham continued, “I think it’s important for physicians to be aware of what these different demographic groups want.” He added such information could help providers tailor their message accordingly when discussing the different ways patients could access the practice and engage with providers. Another disconnect highlighted by the survey was provider follow-up. While 68.6 percent of respondents said it was either ‘very important’ or ‘somewhat important’ that a physician follow up with them, only 30 percent reported receiving any follow-up from the practice that wasn’t tied to bill pay. “They’re very good about following up related to money,” Graham pointed out, but patients want more than that. In addition to building rapport with a patient, Graham said digital communication offers an easy way to make sure instructions were understood and are being (CONTINUED ON PAGE 22)
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Spring Allergies Are Fast Approaching With the changing of the seasons comes an increase of pollen and mold in the environment, which means a lot of people are going to be sneezing. Spring pollen season here should begin in February, although weather can sometimes alter the start and end dates. If your patients are already dreading the return of sneezing, sniffles, headaches, stuffiness and itchy, watery or dry eyes, they can take steps to help keep allergy symptoms from activating their immune system. Encourage your patients to see a Board-Certified Allergist before spring allergies start. We should start seeing pollen in trees in early February. Once patients have been allergy-tested and
their allergy triggers have been identified, they should start medications and follow their allergist’s recommendations beginning early in the season, before pollen peaks in March and April. Even if previous attempts at treatment weren’t successful, there are newer treatments and combinations of therapy that may offer renewed hope for feeling better. For the daily certified pollen report, visit our website at www.aalabamaallergy.com. Bookmark it on your computer for easy daily access. If you prefer to use a weather app that also provides pollen and mold count reports, try the Weather Channel app.
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APRIL 2015 • 13
Allergic Esophagus Leads to Discovery of New Disease, continued from page 4 to find the problem food and eliminate it. Some people do a six-food elimination diet avoiding the major allergic foods – milk, eggs, wheat, soy, peanuts, and tree nuts – which can be tedious. We’ve found that the easiest medical treatment is to put the patient on a proton pump inhibitor and a swallowed steroid like budesonide or fluticasone. It’s like treating asthma of the esophagus.” There is also controversy surrounding maintenance of the disease. “No one knows how long to treat these patients, and what the proper dosage and adminis-
tration of these medicines is,” Soong says. “Then there is the question of endoscopy. Do you scope once they are asymptomatic? Do you scope years afterward? Nobody really knows. And no one knows what your end point is with these patients. We are dealing with a disease that has only attracted interest in the past 10 years. There is still a lot that is unknown about the natural history of EoE.” Unfortunately, the asthma drugs required to treat EoE are not officially approved for use in EoE by the Federal Drug Administration (FDA). As a result, some
insurance companies do not cover the high dosage levels needed to treat EoE. “There are insurance issues because there is a lack of recognition of EoE since it is a new disease,” Soong says. “I think a lot of people, both insurance companies and physicians, have been behind the eight ball on this disease. Because these drugs are not FDA approved for EoE, some insurance carriers wonder why they have to pay for the drugs when the patient doesn’t have asthma, which is what the drugs are indicated for.” Allergy testing and endoscopies on
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Birmingham Medical News
results in reducing pain. Younger plans to continue his work with this drug and will be looking at other substances that may prove even more effective in calming hypersensitive microglia. “Prescription anti-inflammatories that are now available aren’t very effective at getting through the blood-brain barrier. While we are waiting for new drugs to be developed and tested, we need to find better ways to help people who are suffering now,” Younger said. Some new possibilities may be confirmed through research into Gulf War Syndrome that Younger’s lab will soon be doing for the Department of Defense. “There has been a lot of research into botanicals that show anti-inflammatory activity, and are able to get past the bloodbrain barrier,” Younger said. “We’ll be looking at curcumin from turmeric, resveratrol, boswellia, and several other botanical that have good data supporting their anti-inflammatory effects. We want to see whether we will be able to reduce neuroinflammation and ease symptoms with what we have available now.” Pursing clues through research, Younger and his team may soon find answers that will finally solve the mystery of fibromyalgia in many cases and develop better ways to diagnose, monitor and treat neuroinflammatory disorders.
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these patients also can cause problems with insurance. “In Alabama, the majority of patients are limited to 65 allergy tests every three years. With this disease, there are so many potential foods and allergens that can be the cause of the problem,” Soong says. “Patients often have to pay out of pocket for endoscopies and allergy testing since most insurance companies put them under the major medical deductible. Some patients do not get the proper work up for EoE because of this barrier. It is a big issue and needs to be on people’s radar.” Soong hopes that more doctors will begin to recognize the symptoms of EoE. Researchers are studying new treatments for the disease, including a drug to inhibit interleukin (IL) 5, which stimulates eosinophil production. “There are two other products, Anti IL 13 and Anti IL 4,” he says. “It will be exciting to see where these studies lead us in the near future.”
Read Birmingham Medical News Online: BIRMINGHAM MEDICALNEWS.COM
New Smartphone Software Provides Opportunity for Medical Research By Maggie Lester
Smartphone applications (“app”) are saturating the health care world in numerous and various ways. There is an app to track your sleep, one to track your heart rate, one to track steps and even one to measure your blood pressure. The prevalence of this technology is allowing consumers to utilize an inexpensive and convenient method for getting healthy and staying healthy. Now, iPhone users have the opportunity to become a part of groundbreaking research and sign up for medical research studies through an app on their iPhone. Last week, Apple announced that its new software, ResearchKit, will provide researches with a platform to develop apps that will be used for clinical studies. This technology is the first of its kind and researches are extremely excited about the opportunities this software provides. The key component for any medical research is data, and this new software promises plenty of it. Currently there are over a million users of IOS software across the globe. Right now, the software is only available in the United States on the iPhone 5, iPhone 5s, iPhone 6, iPhone 6 Plus and the latest generation of iPod touches, so some critics worry that the sample size will necessarily be limited to those who can afford these devices. However, even though the studies are limited to iPhone users, that number is still larger than any number medical researchers have been able to reach before. Accordingly, the implications from these studies could be significant for health care providers and patients alike. Apple worked with research institutions like UCLA’s Jonsson Comprehensive Cancer Center, Stanford Medicine, University of Rochester, Icahn School of Medicine at Mount Sinai and Massachusetts General Hospital. These institutions then developed five different apps that will collect data in the following areas: (1) asthma; (2) breast cancer; (3) cardiovascular health; (4) Parkinson’s disease; and (5) diabetes. In developing this software, Apple has implemented a requirement that each institution developing an app must comply with the laws of the territory in which the app will be used and must also obtain approval from an institutional review board (otherwise known as an IRB). Users may sign up for the apps via electronic signature on their phones. Research institutions utilizing the ResearchKit software are able to develop an interactive consent form for users. Additionally, users are able to control what information is sent to the app in order to alleviate privacy concerns. The ResearchKit software works by allowing the institutions to develop apps that can track disease signs and symptoms right from their iPhones. Take, for example, the
University of Rochesters’s app for patients with Parkinson’s Disease, called Parkinson mPower (Mobile Parkinson Observatory for Worldwide, Evidenced-based Research). Parkinson mPower allows patients to take a proactive approach to managing their disease by allowing them to actively participate in the study and receive frequent feedback on their condition. Typically Parkinson’s patients visit their doctors every six months, and their trajectory is based on those two visits. With the Parkinson mPower app, patients are able to track their disease day-by-day and week-byweek which gives researchers a more accurate way to measure users’ symptoms on a consistent basis. By receiving the data from a larger number of people and on a more consistent basis, researchers will be provided with a better understanding of the disease which will hopefully result in better patient care. The app will perform a variety of functions to test and monitor users’ symptoms and motor skills. For instance, there is a function that allows the user to say “Ahhhhh” and the app will measure the user’s tone, pitch and the presence of any tremors. Researches maintain that tremors found in a user’s voice are an accurate way to gauge the severity of Parkinson’s symptoms. There is also a function that will measure the user’s gait when walking. Additionally, there are “games” that track motor skills and dexterity exercises that users may perform. In addition to providing a better understanding of the disease, the app also allows users to monitor their symptoms and to keep track of how any medication or exercise effects those symptoms. Another research institution, Stanford University, has launched an app for cardiovascular health. Through the app, MyHeart Counts, Stanford is hoping to conduct the largest study of cardiovascular health to date while also learning what modification behaviors actually impact a person’s cardiovascular health and well-being. The app will utilize the iPhone’s built in motion sensors to track and collect data on the user’s physical activity. Additionally, users will be allowed to enter information regarding their heart health and any risk factors they may have for heart disease. The Parkinson mPower app and the MyHeart Counts app are just two examples of the forerunners of this technology. While users might be unaccustomed to this technology right now, there is no doubt that it is an exciting time for medical researchers and the subjects they study. Proponents of this new technology believe that it will redefine how we think about health care and that the results from these studies will ultimately have a significant, positive impact on people’s lives.
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Birmingham Medical News
APRIL 2015 • 15
The Literary Examiner BY TERRI SCHLICHENMEYER
Resilience: Two Sisters and a Story of Mental Illness by Jessie Close with Pete Earley; c.2015, Grand Central Publishing; $27.00 / $30.00 Canada; 306 pages Your friends think you’re made of rubber. You always bounce back, as they point out. You’re always happy when the good times roll but when they don’t, you reach for your bootstraps. Nothing lays you low for long because you just bounce back. And it seemed that way for Jessie Close. But in her new memoir Resilience: Two Sisters and a Story of Mental Illness (with Pete Earley), she wasn’t bouncing back. She was bouncing around. The Creature lived right behind her left ear. It had been screaming “over and over and over again,” taunting Jessie Close to kill herself. She didn’t want to do it, but that wasn’t the first time suicide had entered her mind. Born the last of four children, Close had always been the family troublemaker. The trouble, however, wasn’t all hers: when she was five years old, Close’s parents joined the Moral Re-Armament, which was “a cult, plain and simple.” The
family moved to New York, to an MRA estate where they were purposely separated. Eventually, Close’s father was sent to Africa and the family joined him there. By that time, Close was “isolated and
lonely,” prone to picking at a spot on her hand until it bled. She felt abandoned, and started acting out until she was sent back to the United States, to various family members and schools in an attempt to control her behavior. She began drinking and sleeping around, much to her parents’ horror. At seventeen, she married her first of five husbands, a man whose abuse drove her further into the mania she’d been experiencing for years. But the relationship Close had with him wasn’t the only thing that turned bad: through the ‘60s and ‘70s, she held a series of jobs in various parts of the country, married and left men impulsively, had an abortion and gave birth to three children. She received tentative diagnoses and medications but their effects didn’t last. By the time Close neared her 50s, the Creature was winning. Of course, there’s much more to this story and therein lies the issue I had with this book: there’s almost too much to take in when you’re reading “Resilience.”
Author Jessie Close (with Pete Earley) packs a tornado in this memoir, in the form of multiple moves, jobs, and loves. She’s here on one page and there a page later, only to move the story to a new locale again in a few paragraphs. Yes, you could argue that the narrative explains the illness, but it was a bit too much. The appeal of this book, I think, lies between those lines. Close brings readers to the edge with her, clearly giving us a sense of the helplessness and fear that accompanied her mental illness. That, not the frenzied travelogue, is what’s worth reading. Add in a few second-viewpoint chapters from big sister Glenn and you’ve got a memoir that, as a whole, is pretty powerful. See if you can overlook the relentlessness of it, and “Resilience” could be a book you’ll bounce for. Terri Schlichenmeyer. Terri is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.
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16 • APRIL 2015
Birmingham Medical News
Compiling ‘The Notebook’
A free comprehensive standards ‘cleaning product’ directory is near completion for the healthcare industry By JULIE PARKER
It’s not sexy, but it’s certainly important. The Notebook, that is, a new standards “cleaning product” directory so completely new across the entire acute care spectrum that no one has touched it. “If it was easy to do, it’d have been done,” said Stephen Sawyer, director of healthcare strategic sourcing for CBRE | Global Corporate Services in Charlotte, NC. Sawyer, who previously worked in a group purchasing organization, has voluntarily underStephen taken the tedious task of Sawyer assembling a compendium of cleaning product information for healthcare administrators, with information ranging from the listing of chemicals used in cleaning products to the infectious diseases germs killed by antibacterial lotions. “The healthcare industry could learn a lot from the hospitality sector,” said Sawyer, noting that hotel chains like Marriott set the standard for homogenous janitorial supplies. “As hospitals merge and acquire physician practices, it would benefit them to follow this standardization trend. Like a hotel, hospitals can and should condense their manufacturer supply base to one brand. Standards by definition reducing waste and hard cost.” Sawyer, who suffered from asthma and allergies as a child, was recently in a cough-riddled waiting room of an urgent care clinic when he asked the administrator which germs their antibacterial lotion killed. “Administrators and clinicians are so busy, it’s one of the last things they might think about,” said Sawyer. “Knowing the particulars of varying manufactured products is a task that gets buried with higher priority patient care and administrative processing tasks. If they do have or know information, it’s typically piecemeal because that information isn’t commonly shared with its venue of use. I consider this product directory a support mechanism – an important component of the educational toolbox – to hand out to patients and anyone in a medical office that needs or wants to know how these products will affect them.” To complete this arduous task, Sawyer partnered with various manufacturers in five janitorial industries. “I haven’t had one manufacturer tell me they already have this information handy,” he noted. To facilitate manufacturer responses, Sawyer provided questionnaires that made it easy for them to fit their solutions into the mold or wireframe. “For example, can liners more commonly known as trash bags, and other
products are categorized in multiple ways, such as soaps and lotions, housekeeping and floor care chemicals and related products, and paper towels, tissues and dispensers,” he said. “The Notebook will eliminate inconsistencies of products, service cleaning and pricing.” At press time, Sawyer was near completion of the soup-to-nuts “cleaning program” compendium that CRBE will gladly share with healthcare clientele at no charge. As products are added, deleted or changed to the skeleton directory, he’ll provide instantaneous updates. “We’re not expecting accolades for compiling this information,” said Sawyer. “Packaging this important type of information was simply the right thing to do. When the next epidemic comes, with healthcare providers having instant access to this specific data, we’ll be better prepared to deal with it and therefore mitigate the damage.” Sawyer, who specializes in healthcare brand identity, said the information will also boost the patient experience, which represents one of the top three priorities of healthcare leaders over the next three years, according to new research by The Beryl Institute, a global company focusing
on patient experience improvement. “Creating consistency while capitalizing on economies of scale should be a core proponent of a system’s strategy,” he said. “Identifying solutions that assist in delivering a uniform brand while challenging suppliers to create new visual and budgetary business models will produce a competitive advantage and best-in-class outcomes.”
Creating standards that can be replicated from location to location will deliver the outcomes that enhance the patient experience, Sawyer pointed out. “Leveraging the expertise and knowledge available,” he said, “will eliminate waste and reduce cost while promoting the brand and allowing healthcare leaders to keep their eye on delivering superior patient care.”
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APRIL 2015 • 17
What Does UnitedHealth’s Latest Move on Hysterectomies Mean? By JULIE PARKER
UnitedHealth Group, the nation’s biggest player in the health insurance market, recently announced a policy change to narrow the rules on hysterectomy coverage. Even though the insurer’s plan to impose tighter restrictions on the use of the morcellator has garnered the most attention – many hospitals ceased using the laparoscopic surgical device after the FDA reported in April 2014 the fastspinning blade can actually spread uterine sarcoma in some women undergoing hysterectomies – the squeeze is also being felt on the performance of hysterectomies in general. UnitedHealth (NYSE: UNH), the insurer of 40 million patients based in Minneapolis, Minn., now requires specific authorization before most types of hysterectomies are performed. Only vaginal hysterectomies – the least invasive and inexpensive option – done on an outpatient basis are exempt. The policy doesn’t affect hysterectomies performed in cancer treatment. Approximately half a million hysterectomies are performed annually in the United States. Before UnitedHealth announced its policy decision, Anthem was the only
major commercial insurer requiring preauthorization for hysterectomies. Cigna and Aetna haven’t indicated they will follow suit. An Aetna spokesperson said the decision is “best left up to the physician and patient based on clinical circumstances,” a position also adopted by the American College of Obstetricians and Gynecologists (ACOG). Days after UnitedHealth’s announcement, ACOG members buzzed about the issue at an ACOG national leadership conference. “It’s been good fodder for discussion, though we’re taking it very seriously,” said Ravi Johar, MD, an OB/GYN from St. Louis, Mo., past president of the St. Louis Metropolitan Medical Society. “For UnitedHealth to reverse course, no one knows exactly what it means.” Johar, council chair of the Missouri State Medical Association, said OB/GYNs are certainly accustomed to the pre-certification process. “We’ll do what we’ve always done,” he said. “We’ll discuss with patients all of the options and go from there. The decision is between the patient and physician. My job is to provide the best medical care possible. How that affects them financially is a big impact, but it’s not my area of expertise.” UnitedHealth is a good weathervane Colin Luke is the former chair of the Alabama Bar’s Health Law Section and is a partner with Waller where he specializes in healthcare law.
18 • APRIL 2015
Birmingham Medical News
in the post Affordable Care Act era, with its combination of market power, community support, and access to exceptional data, said Jay Wolfson, DrPH, JD, Distinguished Professor of Public Health, Medicine and Pharmacy at the University of South Florida (USF) Morsani College of Medicine. “In this case in particular, it’s important to recognize that UnitedHealth, over the past couple of years, has been the most aggressive of the health insurers in tightening up their markets,” he said. “They began eliminating a lot of physicians and hospitals from their panels in many communities.” For example, said Wolfson, cancer and children’s hospitals were removed from UnitedHealth’s list of risk providers, based on the argument of cost being significantly higher at those healthcare facilities than others. “Procedures in hospitals like MD Anderson, Sloan Kettering and Moffitt may cost 50 percent more than non-specialty, community facilities,” he said. “That’s to be expected because they’re teaching hospitals.” Wolfson also pointed out that UnitedHealth acquired Optum, a healthcare technology firm established in 2010, which he considers one of the “best staffed analytic division of third parties.” “Optum focuses on quality, outcome
and cost-effective analyses of United’s (and other available) databases” said Wolfson. “Their research translates into what, to whom and how much United will pay.” That influence has infiltrated the healthcare industry in many ways. In January 2013, while outsourcing work with Optum before bringing the firm in-house, UnitedHealth Group’s Center for Health Reform and Modernization proposed the use of predictive modeling software, particularly in Medicare and Medicaid programs, as tools for care management and information security as a possible solution to both healthcare fraud and preventable hospitalizations. “As part of the ACA, they’ll continue to drill down and drive down costs and utilization and attempt to be as directive as they can to their patients, physicians, hospitals … to optimize cost, utilization and safety while also reducing liability,” said Wolfson. Some hospital systems are adopting a tough stance against UnitedHealth’s culling process and policy changes they view as unfavorable. “Three years ago, BayCare (Health System, Tampa Bay’s dominant non-profit hospital chain), went up against UnitedHealth over reimbursement issues,” noted Wolfson. “Unlike most standoffs, there was (CONTINUED ON PAGE 20)
The Final Step: Meaningful Use Stage 3 By Beth Pitman and Zachary Trotter
Is it already time for Stage 3 Meaningful Use? While most health care providers and EHR companies work through implementations and workflows for the 2014 Edition of certified electronic health records (CEHRT) and have completed at most Stage 1 attestation, the Centers for Medicare & Medicaid Services (CMS) has been preparing the Stage 3 Rule. Stage 3 Proposed Rule will be published on March 30th. CMS proposes a final set of criteria for eligible professionals (EPs), eligible hospitals and critical access hospitals (CAH) to qualify for receipt of Medicare and Medicaid incentive payments and to avoid downward adjustments to future Medicare payments. The Meaningful Use program created in 2009 offers incentive payments to EPs, eligible hospitals, CAHs and Medicare Advantage organizations by Medicare and Medicaid for demonstrating meaningful use of CEHRT and a subsequent downward adjustment of Medicare payments for failure to do so. The triple phased program is intended to improve healthcare quality and encourage innovation through technology while minimizing the burden on healthcare providers. The ultimate goal is that “meaningful use of CEHRT should result in health care that is patient centered, evidence-based, prevention-oriented, and equitable.” Proposed Rule, p. 27. Each phase involves more progressively advanced use of EHR functionality and IT-based processes in clinical or hospital settings. Stage 1 (July 2010) set initial criteria for meaningful use and established timelines for incentive payments and Medicare payment reductions. Medicare incentive payments began in 2011 and end in 2016. Medicaid incentive payments are capped at 5 years and end in 2021. After 2016, to qualify for Medicaid incentives, a provider must successfully and successively attest to meaningful use. Medicare payment reductions begin in 2015. Stage 2 (September 2012) introduces interoperability, focuses on patient coordination of care through exchange of patient health information, and establishes a set clinical quality measures (CQMs) for all providers to report to CMS beginning in 2014. Under both earlier Stages, “meaningful use” could be met through paper and electronic documentation and participants who failed any two objectives could still meet meaningful use. Not so under the proposed Stage 3 Rule. Stage 3 is intended to be the final rule under the Program, but CMS has left a window to address changes in technology and clinical care standards. The Rule proposes uniformity in reporting by consolidating meaningful use objectives under Stage 3 and merging Medicare reporting
requirements for EPs and hospitals. In addition, Stage 3 addresses inconsistent reporting periods by, beginning in 2017, eliminating the 90-day EHR reporting period and transitioning participants to a calendar year reporting period. Thereafter, there will be a single calendar year reporting period for all participants. In 2014, the EHR industry and providers faced a challenge after delayed publication of the final rule for Stage 2 and then unavoidable delayed availability of certified 2014 Edition CEHRTs prior to the end of the 2014 reporting period. Stage 3 drafters have attempted to anticipate and prepare for implementation issues relating to the 2015 Edition CEHRT. In 2017, the proposed Rule allows providers flexibility to repeat attestation for meaningful use at the prior year’s Stage and using the 2014 Edition; however, in 2018 and afterward, only Stage 3 attestation and 2015 or subsequent Edition CEHRT may be used in demonstrating meaningful use. CMS identified eight objectives directed toward aligning advanced use of EHR technology with program foundational goals and overall national health care improvement goals. Proposed Stage 3 focuses primarily on moving providers toward a more electronic environment, encouraging patient engagement and care coordination through the CEHRT and certified third party technology, providing a more patient-centered health record, and utilizing more interoperability with third parties and public sources. Proposed Objectives are: (1) protect patient health information, (2) electronic prescribing, (3) clinical decision support, (4) computerized provider order entry, (5) patient electronic access to health information, (6) coordination of care through patient engagement, (7) health information exchange (HIE), and (8) public health and clinical data registry reporting. While some objectives appear to mirror those found in Stage 2 and exceptions for hardship remain unchanged, there are important differences: (1) each measurement may be met only with electronic processes, (2) attestation measurements under each have been increased, and (3) participants must meet all eight objectives. Although patient access and engagement are dependent on patient participation and certified third-party applications (outside of the CEHRT), providers will still be required to meet these objectives. Comments on the Proposed Rule are accepted for sixty days from the date of publication. Beth Pitman and Zachary Trotter practice in the health law department in the Birmingham office of Waller.
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ers are four times more likely to quit successfully with their help. Their Stop Smoking Service includes advisers, support groups, stop-smoking medicines, and nicotine replacement therapies, like patches; all free. The same concept also holds with nationwide clinics for sexually transmitted diseases, diabetes, contraception, and alcohol cessation. No referral is needed to access the clinics. Patients can work with their general practitioner as well. “We don’t just say, ‘Go to the clinic. Bye bye’,” Momin says. “We call back to know where they are. And if they need motivation, we give it. If I need to see you every week to keep motivating you, I do.” Schools in Britain even report obese children to their GP. “The school nurse writes to the practice and then we write to the parents to come see us,” Momin says. “Then we talk to them so the child does not get diabetes.” She regularly gave talks at elementary schools about how to
choose healthy drinks and food. “We’re like hawks on asthma,” Momin adds. GPs take a lot of time explaining to patients how their asthma gets triggered and when and how to take the medications. “We tell them when to call for help before they get into a seizure, and we have to see them at least twice a year,” she says. GPs also make sure vulnerable populations, like asthma and diabetic patients, get flu vaccines. “We work prevention at the ground level in England,” Momin says. “It is not like it is very hard work, but it is taking responsibility and talking about it all.” The Commonwealth Fund report did find American healthcare topping other countries in some areas, such as breast cancer survival, whereas Britain bottomed out on serious cancer treatments. “America has established a research-based, hightech medicine,” Momin says. “And that creates good opportunities.”
New Peanut Allergy, continued from page 7 prick test results at study entry.” Smith is encouraged by the results of the study but is cautious about the call for an immediate change in guidelines. “The good news is the results show that children who are given peanut early have a significantly reduced risk for developing the allergy,” she says,” but what do we do with this information? Should the guidelines be changed? Should we recommend introducing peanuts to all infants before 11 months of age? It’s not clear yet.” The study investigators acknowledge that there still are unanswered questions, such as how much peanut protein should children consume and how frequently, and how long children will remain protected from developing the allergy, especially if they stop consuming peanuts. These and many other issues must be evaluated further. In the meantime, Smith suggests that high-risk infants between four and eight
months of age undergo skin-prick testing for peanut. If the test results are negative, consider early introduction of peanut products in a diet that includes two grams of peanut protein three times a week for at least three years. Smith points out that any allergy practice guidelines will be developed by the American Academy of Allergy, Asthma & Immunology, but a certified allergist could go ahead and try the treatment described in the LEAP study. “Over the past 20 years, parents didn’t feed peanuts to their allergic children. Avoidance was thought to be the safest course,” she says. “LEAP has given us good information that we can continue to evaluate. I hope the remaining questions can be answered soon so we can begin to reduce the prevalence of peanut allergy in these patients and offer treatment that will improve their lives.”
UnitedHealth, continued from page 18
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Birmingham Medical News
no last minute negotiation and 450,000 members in Tampa Bay had to change hospitals and physicians because BayCare stood its ground against this healthcare delivery powerhouse.” Wolfson also sees a trend of separate policy issues, in part led by UnitedHealth, that are shaking up the medical device manufacturing industry and the pharmaceutical sector. “Until recently, pharmaceutical companies have had a tremendous influence in medical schools and communities concerning what medications physicians prescribe,” he said. “Now some medical schools across the country like ours have gone ‘drug-free’ and no longer allow pharmaceutical reps to teach in our classrooms or offer ‘educational’ program lunches.” The same cycle holds true for manufacturers of medical devices, Wolfson said. “The device manufacturing industry
has also heavily affected medical practice,” he said. “Their significant influence is waning.” In response to UnitedHealth’s policy change on hysterectomies, medical schools will place a stronger emphasis on technical skills to perform vaginal hysterectomies. “We’ve developed a generation of surgeons who don’t know how to do vaginal surgery, quite frankly,” said Neil Finkler, MD, an OB/GYN in Orlando and CMO at Florida Hospital Orlando. “So many physicians stopped using vaginal hysterectomies and it’s not being taught very much,” Wolfson added. “Our younger medical students don’t have the skills. It’s easier to use a device, which generates more revenue and becomes a standard. Most clinicians interviewed say it’s safer, less complications, but it’s not done because it’s just not being done. That’ll change.”
Marijuana, Medicine & Addiction A conversation with ASAM President Dr. Stuart Gitlow By CINDY SANDERS
With three states plus the District of Columbia sanctioning recreational use of marijuana and virtually all other states either allowing for or considering decriminalization and/or medical use of the drug, the great marijuana debate has become a legislative hot topic over the last three years. For Stuart Gitlow, MD, MPH, DFAPA, however, talk of medical benefits associated with inhaling the plant is just smoke and mirrors. Gitlow, who concludes his term as president of the American Society of Addiction Medicine this month, said there are two major issues with the drug … addiction and toxicity. The double board-certified psychiatrist, who has a private practice in Rhode Island, is concerned by Dr. Stuart Gitlow the possibility of adding marijuana to the mix of alcohol and tobacco as yet another substance with the potential to do more harm than good.
The Drug
Marijuana refers to the dried leaves, flowers, stems and seeds from the hemp plant Cannabis sativa, which contains the mind-altering chemical delta-9-tetrahydrocannabinol (THC), along with other compounds. The National Institute on Drug Abuse (NIDA) has found marijuana to be the most common illicit drug in America and one for which usage is on the rise. The national organization stated marijuana’s popularity, particularly since 2007, has coincided with a diminishing public perception of the drug’s risks. However, at the same time risk perception has been declining, the drug’s potency has actually been on the rise. In looking at the amount of THC in marijuana samples confiscated by the police, the THC concentration averaged close to 15 percent in 2012 as compared to around 4 percent in the 1980s, according to the NIDA fact sheet on marijuana. Gitlow agreed, saying, “The marijuana that is available today is much different, much more potent, than the marijuana that was available in the ‘60s. More research needs to be done to see if there are even more long-term issues with this more potent form.”
Addiction
Gitlow noted marijuana works like any other addictive drug. “There’s not
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debate at all within the medical community that it’s addictive … that’s a given,” he said. “It’s like any other psychoactive drug … it’s not addictive to the majority of those using it once or twice.” However, he continued, “There’s no way of knowing if a person is going to have a problem with the drug until they try it … and then they are playing Russian roulette.” Gitlow explained, “Addictive disease is not about the drug, it’s about a brain abnormality. It exists before somebody picks up the drug.” The three factors required for addiction, he said, are a genetic abnormality, environmental trigger and the drug. “Addictive disease is in only, give or take, 15 percent of the population.” He added popular consensus is that about 9 percent of adults and 17 percent of adolescents who use marijuana become addicted. In addition, NIDA’s marijuana fact sheet noted addiction rates jump in daily users, with as many as 25-50 percent becoming addicted.
Toxicity
“There’s a second issue with marijuana, and it’s independent of addiction. Marijuana has toxic ramifications,” Gitlow said. “Marijuana makes you stupid,” he stated bluntly. “It lowers IQ. It causes slowing of the processing speed. It causes abnormalities of attention and focus. It basically dumbs you down, and it does that more or less universally.” When marijuana is smoked, the THC passes quickly from the lungs into the bloodstream and to the brain. THC targets cannabinoid receptors, which have a higher density in areas of the brain that influence pleasure, memory, concentration, coordination, thinking and time perception. Additionally, THC’s chemical makeup is similar to a naturally occurring brain chemical called anandamide. That similar structure lets THC be ‘recognized’ by the brain, allowing the outside compound to alter normal brain communication. Of major concern is the affect mari-
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Marijuana, Medicine & Addiction, continued from page 21 juana has on brain development when used heavily among adolescents. A recent study showed marijuana users who began in adolescence had fewer connections in the areas of the brain that control memory and learning. A large, long-term New Zealand study found those who began heavily smoking marijuana in their teens lost an average of eight IQ points between ages 13 and 38. However, that impact on IQ wasn’t replicated in the study among those who didn’t begin smoking until adulthood. NIDA also cited issues with cardiopulmonary and mental health. Gitlow said, “There’s a five-fold increase in psychotic disorders among those who use marijuana as compared to those who don’t.”
Alcohol vs. Tobacco, Marijuana
Last month, results of a new study stating marijuana is 114 times less lethal than alcohol made the media rounds and became fodder for late night comics. Gitlow said comparing the two is like comparing apples and oranges. “They affect different parts of the brain,” he said. Gitlow also noted it is possible to ingest enough alcohol in one sitting to kill you, which isn’t really true of marijuana or tobacco. “So I could make the argument that cigarettes are safer than alcohol,” he said. However, there aren’t many physicians recommending a patient give
up the occasional glass of wine and take up smoking tobacco instead. “We’re not prohibitionists,” Gitlow continued. “No one at the American Society of Addiction Medicine says alcohol should be banned, but all these drugs collectively are an enormous burden on the American public from an economic and health-related standpoint.” Considering the dangers of tobacco and alcohol, Gitlow said he couldn’t fathom why, as a country, we would want to add marijuana to the mix. “Why would we want to make our burden worse?” he questioned.
Possible Benefits
Gitlow reiterated his frustration at claims of marijuana being a medical marvel. “There is no medical purpose. No one has ever proven through a double-blinded trial a medical benefit of marijuana.” He continued, “That’s not to say there aren’t components within the plant that might not have medical application.” However, Gitlow said breaking down the more than 100 components in marijuana would require scientific investigation just like any other drug in this country seeking approval from the Food and Drug Administration. He added marijuana lobbyists bringing anecdotal evidence to legislators interested in the bottom line doesn’t constitute a thorough research endeavor. NIDA’s viewpoint is similar, noting
Survey Says,
that so far clinical evidence does not show the therapeutic benefits of marijuana outweigh the health risk. In it’s assessment of the drug, the national organization stated, “To be considered a legitimate medicine by the FDA, a substance must have welldefined and measurable ingredients that are consistent from one unit (such as a pill or injection) to the next. As the marijuana plant contains hundreds of chemical compounds that may have different effects and that vary from plant to plant, and because the plant is typically ingested via smoking, its use as a medicine is difficult to evaluate. “However, THC-based drugs to treat pain and nausea are already FDA approved and prescribed, and scientists continue to investigate the medicinal properties of other chemicals found in the cannabis plant – such as cannabidiol, a non-psychoactive cannabinoid compound that is being studied for its effects at treating pain, pediatric epilepsy, and other disorders.” With the increased attention being given to marijuana around the country, it’s a safe assumption that opponents and proponents will continue the debate.
continued from page 13
followed, check on medication adherence, share prevention tips, and remind patients about the need to schedule routine screenings and services. The “Trends in Patient Engagement” survey included responses from more than 400 adults across the United States regarding their digital experience at primary care practices. The survey was conducted Jan. 5-7, 2015. A download of the survey whitepaper is available at technologyadvice.com/research. TechnologyAdvice, which is headquartered in Brentwood, Tenn., offers free, neutral research and analysis of IT products to connect businesses with technology options that best address each company’s specific needs. The company works with businesses and practices looking for the right software for just a few people up to large enterprises in need of solutions for thousands and has assisted Apple, Oracle and HP in selecting new technology. Last year, TechnologyAdvice was named to the top half of the Inc. 5000 list of America’s fastest-growing private companies.
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Birmingham Medical News
Confronting the Night Thief By H. Andrew (Drew) Wilson, Jr. MD, FCCP
The first week of March was designated as National Sleep Awareness Week, designed to help increase understanding of the importance of sleep in overall health. We will celebrate the occasion by highlighting one of the most common medical complaints experienced in society: Insomnia. Insomnia is a sleep symptom that virtually everyone has at one time or another. It may take the form of difficulty falling asleep, staying asleep, or waking up earlier than desired, with some associated deficit in daytime functioning. Sometimes the sleep difficulty may last for days or even weeks, but often it will resolve without the need for a great deal of intervention by a physician. There are a multitude of known causes of insomnia. We’ve all had those nights when stress, excitement or a change in schedule rob us of a good night’s sleep. Poor sleep habits such as daytime napping, heavy caffeine use, smoking, drinking alcohol at bedtime and use of electronic devices in the bed can dramatically affect sleep quality. Circadian rhythm shifts (i.e., jet lag or shift work) can realign the brain’s clock, moving the “sleep on” switch to a later hour. If such shifts occur on a recurrent basis, the brain is left in a constant state of playing catchup. Medications are notorious causes of insomnia. Typical culprits include antidepressants, steroids, and beta blockers. Mood disorders such as depression and anxiety are common causes of insomnia. Medical conditions such as COPD, heart failure, and arthritis are frequently associated with sleep disruption. Obstructive Sleep Apnea can lead to insomnia by repeatedly fragmenting the sleep cycle. Restless Legs Syndrome and nighttime repetitive leg jerks, known as Periodic Limb Movement Disorder, can also result in trouble falling and staying asleep. And then, there are those people who suffer from chronic insomnia that describe virtually lifelong difficulty sleeping. Bottom line - sleep is a complex physiologic state, and the interplay of multiple influences can disrupt the harmonious functioning of the brain’s sleep centers. So what’s a physician to do when confronted with the poor sleeper? First of all, realize insomnia is usually temporary. If insomnia lasts less than three months, it can be considered short term, and there is often an identifiable stressor. These patients may benefit from a review of good sleep habits, perhaps a hypnotic such as zolpidem or eszopiclone, and a bit of reassurance. There are a number of basic sleep hygiene recommendations that can be recommended to all patients, whether they have insomnia or not. A list can be accessed at the National Sleep Foundation website: http://sleepfoundation.org/
sleep-tools-tips/healthy-sleep-tips . Patients with chronic insomnia are more of a challenge. Chronic insomnia is typically the result of years of learned behaviors that may have medical, psychological and even genetic influences. There are many insomniacs that live in a state of hyperarousal such that they often do not feel especially sleepy during the day regardless of how little sleep they get at night. They’ve often tried all the OTC aids, melatonin, herbal remedies, and prescription hypnotics with usually limited benefit. Some of the most helpful techniques in treating chronic insomnia include stimulus control, sleep restriction and Cognitive Behavioral Therapy. Stimulus control is geared to break the association that a patient has with being in bed and the inability to sleep. It works like this: if a patient is lying in bed more than 20 minutes and is unable to sleep, he should get out of bed, go to another room, and do something rather non-stimulating, (i.e., reading) until he feels so sleepy he is ready to fall asleep. Only then should he go back to bed. If he again has trouble sleeping later that night, the process should be repeated. It may seem a bit contrived, but it does work, though it takes some discipline (and several books). Sleep restriction is designed to increase sleep efficiency, which is the time a person is asleep relative to the time he is in bed. The physician should determine a patient’s usual bedtime and rise time to estimate his total hours in the bed. Next, ask the patient the total amount of sleep he thinks he actually gets, (or consider using a sleep diary for a more accurate estimate). Then, while maintaining the same rise time, adjust the patient’s bedtime to a later hour such that the time in bed approximates the estimated sleep time, (just be sure to allow at least five hours of time
in bed). This process will typically lead to a mild state of sleep deprivation. The patient should avoid the temptation to nap during the day to preserve an adequate sleep pressure at the scheduled bedtime. Once it becomes easier to fall asleep at night, the bedtime can be set 15 minutes earlier every few days until a more desirable bedtime is achieved. Again, this technique takes a fair amount of motivation and discipline on the part of the patient. The other arm of management of chronic insomnia is what’s known as Cognitive Behavioral Therapy, or CBT. CBT addresses a patient’s ideas about sleep. Chronic insomniacs often harbor faulty beliefs about the reasons for their sleep problems and hold unrealistic expectations about what they should consider a good night’s sleep. Altering these beliefs may require several sessions using such techniques as biofeedback and relaxation training. CBT is often best handled by a psychologist with expertise in dealing with sleep issues. To summarize, when your next pa-
tient comes in complaining of the inability to sleep, resist the urge to simply write a prescription for a hypnotic. Give such patients a list of good sleep habits. Assess their caffeine, tobacco, and alcohol intake. Review their medications. Ask about their sleep environment. Determine if they could be depressed, anxious or have new life stressors. Finally, ask if they snore or have daytime sleepiness, which may suggest OSA or another sleep disorder. If your patient fails to respond to treatment, or if Sleep Apnea or another sleep disorder is suspected, consider referral to a sleep specialist. Insomnia is common and often very treatable. If you can help your patient enjoy restful nights on a consistent basis, you will have earned yourself a good night’s sleep to boot. H. Andrew (Drew) Wilson, Jr. MD, FCCP, Diplomate, American Board of Sleep Medicine, practices medicine at Pulmonary & Sleep Associates of Alabama.
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APRIL 2015 • 23
Is Your Data Protected When Disaster Strikes? By Jay Helms, TekLinks Health Service Group Sales Director
There is a certain local weatherman here in Birmingham who knows his stuff when it comes to tornadoes (snow & ice… not so much). Recently, he shared data defining the “new” tornado alley as a path pushing right through Alabama, which has brought disaster recovery to the fore-
front of business continuity for health care practices in Birmingham. Sure, you may know how to protect your patients’ safety in the event of a tornado, flood or fire, but do you know how to protect their patient data? Preparing your practice for a disaster is crucial to keeping your practice and patient information safe. Hosting your EMR and ePHI in a highly secure and redundant
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have or are attesting for Meaningful Use you’ve probably heard of, or experienced firsthand, the increasing amount of MU Audits being performed. Many practices think they are covered because they have a backup plan for their data. While a backup plan compliments a disaster recovery plan and is a great first step, a backup plan is not the same as a DR plan. You must first consider how you’re going to treat patients if a natural disaster makes your EMR unavailable. If your IT infrastructure is destroyed, most IT vendors in the Birmingham area do not inventory server infrastructure: it’s nearly impossible to do with the ever-changing technology and new requirements associated with PM/ EMR version updates. This means it will be a minimum of two to three weeks before your EMR is functioning again. Let’s go back to the tornado scenario mentioned earlier. If a tornado thrusts your unencrypted server miles away from your office, and if the ePHI data on that server’s disks is retrieved by anyone other than your practice or an entity covered under your BAA, you’re forced to implement data breach procedures and make an expensive claim on your cyber security insurance policy. This is something that can easily be avoided with a true Disaster Recovery Plan. We all want to avoid a disaster, but if we can’t, the next best thing is to be prepared. Migrating to a cloud environment optimizes your business continuity and disaster readiness, while helping to ensure compliance in 12 areas of the HIPAA Security Standards for Administrative, Physical, & Technical Safeguards for ePHI. Jay Helms is the Sales Director of the TekLinks Health Service Group.
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24 • APRIL 2015
Birmingham Medical News
Grand Rounds
Relax. Recover. Regain.
Biddle Named Senior VP Ascension Health Neeysa Biddle, FACHE, has been named Senior Vice President, Ascension Health and Birmingham Market Executive. In this role she has leadership responsibility for St. Vincent’s Health System (STVHS). Since September 2014 Biddle has served Neeysa Biddle as interim President and CEO of STVHS, where she had served as Executive Vice President and Chief Operating Officer from 2005-2011. Before rejoining STVHS she served as national Director for the Ascension Leadership Academy, a subsidiary of Ascension. “We are delighted that Neeysa has returned to St. Vincent’s Health System,” said Bob Barnett, STVHS Board Chair. “She is an accomplished leader with a strong commitment to our mission.” A fellow of the American College of Healthcare Executives, Biddle has more than 25 years of healthcare administrative and executive experience. She holds a Bachelor of Science degree and a Master of Health Administration from UAB. Prior to joining STVHS in 2005, she was Chief Operating Officer of Brookwood Medical Center. She has served on the Alabama Hospital Association’s Board of Directors and as an adjunct faculty member at UAB’s School of Health Professions, where she was selected as the 2001 Alumnus of the Year. She has been named one of the Top 40 Graduates of the UAB Health Administration program and North Alabama Girl Scouts’ 2012 Woman of the Year.
Demers Named HealthSouth Lakeshore CEO Vickie Demers has joined HealthSouth Lakeshore Rehabilitation Hospital as Chief Executive Officer. She has more than 20 years of healthcare experience and 14 years of hospital leadership. Demers graduated from Bob Jones University Vickie Demers with a degree in biology and chemistry. She received her master’s degree from Georgia State University in business administration and health administration.
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CORRECTION In the Birmingham Medical News February Grand Rounds, F. Cleveland Kinney, PhD, MD was identified as the new PresidentElect of the Jefferson County Medical Society. Actually, Kinney is President in this current year.
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APRIL 2015 • 25
Grand Rounds Trinity Names Chief Operating Officer
Drew Mason has been promoted to Chief Operating Officer at Trinity Medical Center. He joined the Trinity team in 2014 as Assistant CEO. Mason has managed and implemented numerous healthcare projects during his career. Prior to Drew Mason his appointment at Trinity, Mason served as Assistant CEO of Gadsden Regional Medical Center in Gadsden, AL. His past experience has also
included projects in the corporate offices of Community Health Systems (CHS) and with hospitals in other divisions of the company. While at Trinity, Mason has been responsible for various operations including market development initiatives, Trinity’s physician clinic network and the new Grandview Medical Center construction and relocation project. Mason received his bachelor’s degree in business administration from Villanova University and his master’s degree in business administration with specialization in healthcare from Owen Graduate School
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of Management at Vanderbilt University. He is also a graduate of the CHS leadership development program.
CON Board Approves 30 Beds for CRMC
The State of Alabama Certificate of Need (CON) Review Board has unanimously approved a 30-bed Certificate of Need for Cullman Regional Medical Center (CRMC). In 2009, CRMC acquired 30 beds following the Healthcare Authority of Cullman County’s purchase of Woodland Medical Center. CRMC was granted a three year waiver by the Alabama Department of Public Health (ADPH) with respect to these beds which were added to CRMC’s licensed capacity through January of 2015 without a construction project. CRMC needed to obtain a new CON to put these beds back into service after the expiration of the waiver.
MGMA/Alabama Holds Statewide Conference
MGMA/Alabama held its statewide winter conference at the Wynfrey Hotel in early March. Dan Thurmon, the author of Off Balance on Purpose, opened the conference at the Wednesday morning general session with a talk on balancing work with the demands of daily life. That afternoon, Aaron Beam, the former CFO of HealthSouth, discussed corporate fraud. Cynthia Ransburg Brown, an attorney with Sirote & Permutt, addressed the Thursday morning general session where she discussed the latest compliance and regulatory issues facing medical practices. The conference included ten breakout sessions. Terrie Munroe of Focused LLC discussed creating conversations the encourage helpful dialogue in the workplace. Jeb Sheppard with MGMA Government Affairs in Washington, DC updated the group on recent actions by Congress and federal agencies affecting healthcare providers. Russ Dorsey of Kassouf & Company spoke on HIPAA security audits. Jim Stroud of Warren Averett hosted a session on hiring new physicians. Jerry Callahan and Joni Wyatt of Kassouf & Company talked about the reimbursement cycle and operational costs.
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