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On Rounds Urologist Finds Second Calling Through Foster Parenting In his medical practice with Urology Centers of Alabama, urologist Dr. Mark DeGuenther uses high-tech tools that weren’t available just a generation ago. But in his off-time, he’s gotten an unusual amount of experience with an ageold skill: parenting ... page 3

Trinity on the Move

Trinity Plans Orchestrated Patient Relocation to Grandview Medical Center in October By Ann B. DeBellis

On the second Saturday in October, U.S. 280 in Birmingham will be buzzing with activity, but it will have nothing to do with football traffic. Trinity Medical Center will be relocating approximately 150 patients, its staff and hospital operations to the new Grandview Medical Center on 280 with the help of local ambulance companies, state and local law enforcement. They hope to complete the move in 10 hours or less. Trinity Chief Operating Officer Drew Mason says the move will start at approximately 6:00 a.m. and will be done in phases based on patient type and acuity. “We will start with our neonates, followed by mother/baby, critical care, psychiatric and finally general acute medical/surgical patients,” he says. “We will be continuously assessing activity at both locations and will have multiple routes with 30 to 40 ambulances. We will not take emergency (CONTINUED ON PAGE 10)

Taking on the Number One Killer of Teens

Trinity staff and local emergency personnel discuss move to Grandview.

New Cardiac Monitoring Device Can Reduce Health Care Costs By Ann B. DeBellis

Congestive heart failure is a common and expensive medical problem that accounts for one million hospitalizations and almost three million office and emergency room visits each year. A new remote monitoring device is showing promise for reducing symptoms and costs while extending the lives of the seven million patients in the United States who suffer from congestive heart failure. Recent clinical trials have shown that information provided by the CardioMEMS device can reduce hospital readmissions by about 37 percent. Cardiologists at Cardiovascular Associates (CVA) in Birmingham implanted one of the first devices in Alabama following the May 2014 approval of the device by the FDA. They have been using the monitoring system for heart failure patients since early 2015. “Congestive heart failure is a difficult problem that affects a patient’s lifestyle and also the country’s economy as a utilization of health care,” says Barry Rayburn, MD of CVA. “Regardless of what kind of disease caused the heart failure, when one of these patients is (CONTINUED ON PAGE 8)

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HEALTHCARE SPOTLIGHT

Urologist Finds Second Calling Through Foster Parenting By DAle shorT

In his medical practice with Urology Centers of Alabama, urologist Dr. Mark DeGuenther uses high-tech tools that weren’t available just a generation ago. But in his off-time, he’s gotten an unusual amount of experience with an age-old skill: parenting. Advances such as laparoscopic surgery make it possible to perform procedures that are minimally invasive. “Previously, such surgeries required large incisions,” DeGuenther says, “but today’s techniques mean less post-operative bleeding, less pain, and a quicker recovery overall.” How he and his wife Laura--who have raised five children of their own-first became involved in foster parenting is a more complicated story, and begins when they participated in a mission trip several years ago. “We work with the youth at our church and we just love kids,” DeGuenther says. “We had discussed being foster parents for a year and a half. My wife was willing but I was making excuses. When we were on an urban mission trip to Memphis, we met a 12-year-old boy who lived with his grandmother because his mother was addicted to drugs. It broke my heart to leave him. “Then the pastor’s sermon that day was about being obedient to the will of God. He said, ‘There are some of you currently struggling with that issue, and I just urge you to hear God’s call to obedience.’” The next day, DeGuenther heard a story on the radio about fostering and the host said there was “likely someone out there considering doing this, but holding back for whatever reason.” She then urged “obedience to God’s call.” He remembers, “It hit me right between the eyes.” The DeGuenthers came home and found information about the Alabama Baptist Children’s Home: “They were just starting a 10-week class from the Department of Human Resources for becoming certified as foster parents, and we signed up.” None of those events were “coinci-

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Mark DeGuenther, MD

dences,” DeGuenther believes now. In the years since, he and Laura have fostered more than 15 children, from ages three to 12. But the process has been far from a smooth path. “Caring for foster children is one hundred percent different,” he says. “In the beginning we thought, ‘Well, we’ll just raise them like we raised our own.’ But in the classes we learned that the same strategies and techniques either don’t work, or are counterproductive, because of the

foster kids’ backgrounds.” Some of those differences can make communication a whole new ball game. “With our kids, I could give them what I referred to as ‘the daddy look,’ or ‘the daddy tone of voice’”, DeGuenther says, “and immediately they knew, ‘Hey, Dad’s serious here. Don’t mess around.’ And they would correct their own behavior. “Whereas if you use that approach for a kid with an abusive or neglectful background, they just recoil and block you out. They don’t hear you. They put up a wall that creates this sensory input barrier, and once that happens you’ve lost them. You’re not going to have the opportunity for any meaningful communication. “So that’s been a huge challenge for me, after raising five kids of our own, having to re-learn parenting skills. It’s tough.” Discipline has to take other forms as well, DeGuenther says: “Becoming angry is not a good way to communicate with anyone, so this is a positive in all of my relationships. With foster kids, though, no spanking or corporal punishment is ever allowed, so you feel like an important tool has been taken out of your tool belt. “But when you consider that so many of these kids have been physically abused by their parents or uncles or aunts or whatever, the anger sends a message

that ‘You’re just like all the other adults I’ve known, and you’re going to hurt me.’ That’s counter, of course, to what you want to be sharing with them, which is God’s love.” The trusted parental tool of “Time out!” has to be modified as well. “We have plenty of discipline with our foster kids,” he says, “but when they’ve been basically abandoned so much of their lives, making them go to their room is just not an effective thing. Instead, we have ‘Time in,’ which means their punishment is having to sit there in the room with you while you’re doing what you need to be doing.” All in all, no small challenge. But DeGuenther credits the Alabama Baptist Children’s Home for “doing an incredible job of giving resources and support to the families and kids.” Perhaps the hardest part of the experience is giving kids up, he says. “You love them, and for all intents and purposes they become one of your own. But our attitude is that God has put these children into our lives--and us into their lives--for a period of time to teach each other things about His love.” DeGuenther invites anyone considering foster parenting to contact him or the Alabama Baptist Children’s Home for more information.

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Pediatric Anesthesia Small Patients, Big Differences By Laura Freeman

Thinking back to childhood, most of us have memories of the little hurts kids are prone to, and running to mom for a Band-aid and a kiss to make the hurt go away. But some hurts are beyond the soothing power of kisses. Serious injuries and health problems may require surgery and the full range of pain management a pediatric anesthesiologist can offer. “The primary difference in anesthesia for adults and for children is that our patients come in all sizes, from tiny newborns to teens who may be larger than their parents,” Jennifer Dollar, MD , chief of Pediatrics Anesthesia Associates at Children’s Hospital of Alabama, said. “That means every anesthesia plan is unique. Dosages have to be individually calculated and every piece of equipment Jennifer we use is selected for that Dollar, MD

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Birmingham Medical News

particular patient’s size and weight.” Size isn’t the only thing different in children. They aren’t just little adults. Children are more prone to conditions like asthma and more frequent colds that have to be taken into account when an anesthesiologist is planning the preparations they need to make before surgery. “On the positive side, children are less likely to have issues like smoking, drinking and other lifestyle-related health problems that can complicate adult anesthesia,” Dollar said. The challenge now in pediatric anesthesia is finding the right balance between two emerging topics of research. Recent studies suggest that childhood pain that isn’t adequately addressed can predispose a patient to a chronic pain syndrome in later life. On the other hand, research in young primates has raised the possibility that general anesthesia in patients under age four may affect neurological development, which could reduce the density of gray matter and may be associated with learning disorders, attention deficit and slower speech development. “In every surgery and every anesthesia, we have to weigh the risks and benefits. We can’t allow children to suffer needlessly, and there are some surgeries that must be done very young, even for newborns, to protect their health and survival,” Dollar said. “However, if a surgery can wait till a child’s neurological development is farther along, that may be a consideration in timing the procedure.” Whatever the age of the child undergoing surgery, Dollar focuses on keeping dosages as small as possible and the duration they are used as short as possible. “We begin with a plan that uses a combination of strategies to keep the child comfortable. Going into surgery without their parents can be scary for a child. We talk with both the patient and the family so they know what to expect, and we discuss ways to make it easier for them,” Dollar said. “In most surgeries, we use both inhaled anesthesia and IV anesthesia, along with a combination of other medications, all dosed by weight. If we are doing a procedure in an area that a block might be helpful in pain relief, such as a knee

surgery, where a femoral nerve block can help control pain for 12 hours, we do the block then. This allows us to reduce the amount of medication needed after surgery to keep the patient comfortable. “All through the procedure, we closely monitor blood pressure, heart rate, breathing and other indicators to make sure the patient isn’t in pain and that vital signs are optimum. Our recovery room nurses look for many of the same indicators to see that pain is being managed appropriately and that the patient is doing well.” Outside the operating room, pain in children can be an issue pediatricians and family practice physicians have to deal with in their office--and in late night phone calls from frantic parents. “If an infant too young to speak is crying inconsolably in its mother’s arms, if it’s drawing its legs up and crying, if it won’t eat, or if its heart rate and blood pressure are elevated, those are common indications of pain. Diagnosing the cause of the pain is the next step. If it’s something a pain reliever can help, I usually recommend an over the counter medication whenever possible, unless something stronger is necessary and if so, it should be closely monitored. “Even with something like acetaminophen, there is a very narrow range of dosage that is safe. So teaching parents is essential. They need to be careful to make sure they are giving their child the right dose at the right time, and understand how important it is not to give the next dose too soon. Parents also need to look at any other medications the child is taking. Acetaminophen is often in cough syrups and even in prescription medications. Parents need to read every label to make sure their children aren’t getting a combined dose that could be dangerous.” As children grow into teens, the questions an anesthesiologist asks in the presurgery conversation also change. “We have to ask about smoking, drinking and possibly drugs that might interact with medications. If we suspect we may not be getting a straight answer when parents are around, we might have to ask the parents to step out or we may ask again later to see if we can get a more candid answer,” Dollar said. During discharge planning, pain management is part of the teaching and after care instructions patients and their families receive. Few of us get through life without pain. But with good pain management available at every age, there’s no need to hurt when you don’t have to.

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Taking on the Number One Killer of Teens By Laura Freeman

The girl’s face was strangely beautiful, covered with a shimmering powder that glistened like diamond dust beneath the lights of I-59. The pulverized glass might have been makeup for a prom, but this girl would never go shopping for a prom dress. She would never dance again. Her friend in the driver’s seat beside her had died, too, not quite instantly enough after impact with the guard rail that had driven through the center of the car. Leaning between the two, a Birmingham firefighter worked to free their friend in the back seat. She was unhurt, but trapped and terrified. To calm her, he talked with her as he worked. Her story was all too familiar; three teenage girls having a fun night out, and three teenage boys in another car who were either chasing or racing them. The firefighter recognized the shock in her voice as she struggled with the idea of mortality, and the fact that physics doesn’t care how old you are, or that you have dreams or should have years of life ahead.* “Young people don’t realize that traffic accidents are the leading cause of death among teens in the United States. Alabama is number two in the nation in teen traffic fatalities,” Kathy Monroe, MD, Medical Director of Children’s Hospital of Alabama’s Emergency Department, said.

While a child dying of an incurable disease is sad, a child dying in a traffic accident often meets the criteria of a Greek tragedy. Too many of these deaths are preventable if someone takes action soon enough to address the issues that cause them. Just as the campaign for using car seats is saving the lives of small children, and the campaign for using bike helmets is making progress in reducing head injuries, a concerted effort led by the Alabama Safe Teen Driving Coalition is working to stop preventable deaths and injuries by changing

the behaviors that are most often linked to traffic accidents involving teens. Healthcare providers are in a position of unique credibility in getting that message across. “We have study data that shows teens whose doctors have talked with them about safe driving are less likely to engage in risky behaviors linked to accidents,” Monroe said. Among these behaviors are distracted driving from handheld devices or having too many friends in the car, not wearing a seatbelt, speeding, reckless driving, and

driving under the influence of alcohol or drugs. Another problem is lack of skill in driving at night, in rain, in interstate traffic and other conditions before they have had enough supervised practice. “On our website, ChildrensofAlabama.org, we have a Teen Driver’s Toolkit that physicians can print out to give young patients and their families the resources they need to help them become better drivers. Click ‘For Health Professionals,’ then ‘Health Professionals Information.’ You’ll see the toolkit in the list on the left. It also provides links to more online resources and explains Alabama’s graduated driver’s license law.” The graduated driver’s license law in Alabama applies to 16-year-olds, and to 17-year-olds with less than six months of driving experience. Limits include no more than one non-family passenger, no nonessential handheld devices and no driving between midnight and six a.m. except under specific exceptions such as medical emergencies or driving to or from work. “The toolkit also includes a log for the recommended 50 hours of supervised driving practice under a variety of road conditions to help young drivers build their skills,” Monroe said. Why are healthcare providers particularly well equipped to speak persua(CONTINUED ON PAGE 16)

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At the Intersection of Education and Healthcare By CINDY SANDERS

According to statistics from the Centers for Disease Control and Prevention, one in 68 children falls somewhere on the autism spectrum. The fastest-growing developmental disorder in the United States, autism spectrum disorder (ASD) is almost five times more common in boys (1 in 42) than girls (1 in 189). Additionally, the CDC estimates it costs at least $17,000 more per year to care for a child with autism, including extra expenditures for healthcare, education and ASD-related therapy. While there is still no cure for ASD, research has shown early intervention can have a significant impact on a child’s development and ability to more fully interact with peers at school. It’s at this intersection of education and healthcare where Educational Services of America (ESA) offers resources to help these children thrive. Headquartered in Nashville, Tenn., the company currently provides services in 27 states. “We serve about 17,000 kids a day, and they have a very wide variety of disabilities,” explained ESA President and CEO Mark Claypool, who founded

the company in 1999. “We work primarily with public school systems,” he said, noting the company partners with about 250 different systems. He added ESA also works directly with some state Mark governments and insurClaypool ance carriers. “Providing quality services to children and young adults who need them is more important to us than who pays the bill,” Claypool stated. While ESA, which has about 3,000 employees nationwide, has been in business for more than 15 years, Claypool said many of the programs being used have been around much longer with measurable results. The company has grown significantly through acquisitions and mergers, including the purchase three years ago of South Carolina-based Early Autism Project, Inc. (EAP). “We had been working with older kids through school systems for a long time, but we wanted to identify a strong provider in the early intervention space,” Claypool explained. “Autism is a very dynamic disability, and the sooner you can

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intervene, the greater the impact on the child’s life.” With EAP, he noted, “We acquired this really strong regional brand and put tremendous resources behind them.” Today, EAP reaches four times the number of children and continues to expand with additional clinics coming online at a rapid pace. Currently, there are clinics and/or in-home services being provided in 11 states including Arkansas, Florida, Georgia, Kentucky, South Carolina and Tennessee in the Southeast. “We’re growing very rapidly,” Claypool said. “In fact, we’re in the process of opening 15 new autism clinics in the next year.” Applied Behavior At the heart of the program is the use of Applied Behavioral Analysis (ABA). “We know the evidence supports ABA as the most effective treatment, by far,” said Claypool. “It enhances positive behaviors and diminishes negative behaviors.” According to the Center for Autism and Related Disorders, the effectiveness of this evidence-based therapy has been well documented over the past 40 years. ABA utilizes the principles of learning theory to craft interventions designed to measurably improve ‘socially significant behaviors,’ which include reading, academics, social skills, communication, and adaptive living skills including self-care, toileting, understanding time and money, and honing work skills. “The same model of behavioral therapy is applied to all of our children across the board but will vary in its intensity,” Claypool explained of addressing individual needs depending on where a child falls on the spectrum. Finding a way to help these children is critical considering the number of children diagnosed with ASD. “If we don’t do this, the cost will be staggering. These young people will not be able to transition to adulthood and lead normal adult lives,” Claypool pointed out. With ABA therapy, however, he said the team has seen some remarkable outcomes. “There is no one type of child with autism. There are IQs all over the board, but many do have high IQs and need to have their potential unlocked,” he continued. That was certainly true for one South Carolina mom. Told it would be best to find her son a residential program because he would never function on his own, she took matters into her own hands and became the co-founder of the Early Autism

Project. Today, that son is working on his master’s degree at the University of South Carolina and speaks eight languages. While certainly not every child with autism will perform at that level, Claypool said all children deserve the chance to reach their own potential.

The Intersection of Healthcare & Education

Realizing that ability, however, can be more difficult in some states than in others. Claypool explained Part C of the Individuals with Disabilities Education Act requires public school systems to identify preschool children with special needs. However, he added, “It’s very, very loose how to do that. Frankly, it’s not followed through on very often. That issue really drove parents who had children with autism to find another way to have their children identified, diagnosed and treated.” Of importance, he continued, is the understanding that special education, as it is constructed, is built on civil rights law. “That’s important because it was built on a minimum set of services defined as ‘free and appropriate.’ “But that’s not enough for parents,” Claypool said. “They want progress, and they want to know their child is going to get the very best treatments.” Therefore, he continued, “More and more, they are looking to healthcare rather than education systems to bridge the gap.” According to the Autism Health Insurance Project, 39 states plus the District of Columbia have now enacted autism insurance mandates, meaning all fully funded, state-regulated insurance plans must provide the benefits specified by law. While the specifics vary from state-tostate, each of the mandates requires insurers to provide ABA to young children with autism. Self-funded (employer-sponsored) plans, however, are not legally required to offer autism benefits even in states that have mandates. As of May 2015, Alabama, Idaho, North Dakota, Oklahoma, Tennessee and Wyoming had no autism insurance mandate. Ohio, Hawaii, Mississippi and North Carolina were in process of enacting a mandate, and Utah had passed legislation, but it won’t go into effect until 2016. Additionally, the federal government has recently told all states their Medicaid programs must offer ABA therapy for children under 21, but only a handful of states have put this directive into action at this point.

For More Info & Referrals For more information on autism and other programming by Educational Services of America, go online to esa-education.com. For more information or to refer a child with autism to EAP, go to earlyautismproject.com.

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The Crisis of Alabama Medicaid Cuts By Glenn sisk

On behalf of the 84,000 people who work in Alabama hospitals and the seven million patients they serve each year, we implore our state leaders to do what is right and what is needed to maintain access to hospital services for all of us. Currently, 79 percent of Alabama’s hospitals are operating at a loss, with the average margin being a negative 2.7 percent. In most hospitals, Medicaid covers approximately 12 percent of patients; however, in some areas, that percentage is much higher. Approximately 60 percent of Children’s of Alabama patients are supported by Medicaid and at USA Children’s and Women’s Hospital the number is 70 percent. So, when state officials begin talking about cuts that could cripple Medicaid, mental health or other vital health care programs, everyone should realize that those cuts won’t just be felt by recipients of those services; they will be felt by all of us. Any businessman or woman understands that when you’re operating in the red, you don’t have money to replace worn out equipment or to make needed renovations. In fact, to survive you have to dip into dwindling reserves or start eliminating staff and/or services. That’s exactly what Alabama’s hospitals have been doing the last several years. Many of them have eliminated services, cut staff positions, and over the past five years, eight hospitals have closed, five of which were located in rural areas. Others have already cut expenses to the bone and are struggling to survive. None of us like the thought of additional taxes, and we understand the hesitation on the part of lawmakers, but

there’s simply no other way out of the state budget dilemma. The increases being discussed would hardly be felt by the majority of Alabamians, yet without them we’re all going to feel the pain, not just in health care, but also in public safety, in corrections and any number of areas supported by our state’s General Fund. Reductions in Medicaid and/or mental health funding could risk the collapse of the programs. For those who might read this with a jaded eye, we urge you to talk with your local hospital leaders. Ask them how such a collapse in either program would impact their ability to provide care to everyone. Then, ask yourself how much you are willing to lose. Do you really want to risk losing access to critical hospital services? Do you want to take a chance that your hospital might not survive? Do you want to jeopardize your access to other health care providers, such as your local physicians and pharmacies? We need to be realistic about our state budget and support our lawmakers in making the tough call to raise enough revenue to adequately fund our necessary state services. Glenn Sisk is the Chief Executive Officer of Coosa Valley Medical Center and chairman of the Alabama Hospital Association Board of Trustees. Hospitals represented on the Board include: Coosa Valley Medical Center, Huntsville Hospital, Providence Hospital, UAB Health System, Baptist Health System, Children’s of Alabama, St. Vincent’s Health System, Baptist Medical Center South, RMC Jacksonville, Medical Center Barbour, USA Children’s and Women’s Hospital, Northport Medical Center, Russellville Hospital, Trinity Medical Center, Russell Medical Center, Monroe County Hospital, and Flowers Hospital.

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New Cardiac Monitoring Device Can Reduce Health Care Costs, continued from page 1 admitted to the hospital, the risk of readmission within the next three to six months is high. Those readmissions often become repetitive, with a patient being in and out of the hospital several times over a few months.” The primary goal of treating heart failure is to extend a patient’s life and to reduce symptoms. Barry “We know that by keep- Rayburn, MD ing patients out of the hospital, we can prolong their lives, not just manage their symptoms,” Rayburn says. “Measuring how often a patient comes to the hospital is a useful fact and has led to a variety of monitoring strategies, which have shown that there almost always is a lead time of up to a couple of months where a patient’s condition begins to deteriorate while they are at home. If we can catch that downturn earlier, we may can stop it and prevent the patient’s admission to the hospital.” Reducing the hospitalizations as well as medical costs was a driving force behind the development of the CardioMEMS, which allows medical personnel to monitor pulmonary artery pressures from the patient’s home or other remote locations. Pulmonary artery systolic pressure is a strong predictor of death in heart failure patients, and remote monitoring of that information is helping medical personnel stay abreast of their patients’ conditions. “The device is small, about the size of a grain of rice, and is mounted inside a small block of inert plastic. A couple of small ropes of wire hold it in place. It has no battery and it has no internal power supply, so it can be used indefinitely and doesn’t have to be replaced,” Rayburn says. “In the catheterization laboratory,

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a cardiologist places the device into one of the pulmonary arteries that sits behind the heart. For the remote monitoring, the patient is given a pillow with an antenna inside it and a small box that is the control system. Once a day, the patient lies down on the pillow and the antenna sends a signal to the device. The reading takes about 18 seconds. The device then transmits information about the pulmonary artery pressure and heart rate back to a secure web site where the medical team can access it. We watch the pressure trend and if we see it going in the wrong direction, we will contact the patient, maybe bring him into the office or adjust his medication. It allows us to do something to treat the problem before it gets to the point that the patient has to be hospitalized.” Several CVA patients who use the CardioMEMS system are more comfortable with the remote monitoring. “Some of the patients feel better because we have a better handle on their situations,” Rayburn says, “and being able to access their information on a regular basis allows us to be more proactive with adjusting medications between visits.” Rayburn is optimistic about this new treatment device and hopes the medical community and insurance companies can work together to make sure this opportunity is extended to all who need it. “We are still early enough in this process that reimbursement models for the work involved with ongoing remote monitoring haven’t been established. I think this is a ripe opportunity for payers who are interested in improving quality care at a reduced cost could partner with providers. By creating a model where the extra work, the extra burden of providing this monitoring, and proactively reacting to the changes is actually reimbursed in a meaningful way, it is likely that they would be reducing costs for hospitalization, patient outcomes, and more,” he says. “This is a classic example of a procedure that can contribute to value-based and quality-based medicine.”

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Pain Clinic Raids: Blocking and Tackling Drills for Physician Practices By Tom Wood

Every day, medical providers are asked to serve a population that largely expects their healthcare to be free, and that everything they want is covered by insurance or government. Providers want to serve these needs, but they face scrutiny on multiple levels in seeking to satisfy the patients. Perhaps the most aggressive are today’s governmental actions against physicians, sourced by their patients, staff, pharmacies, vendors, and even their own partners. Pain clinics have been the most recent targets, and it’s important for the medical community to learn from these raids. Better understanding and applying the basics are the best ways to avoid mistakes that could bring unfounded scrutiny. Once upon a time, providers were attacked for not prescribing enough pain medicines. Now the pendulum has swung the other way, and the mass of healthcare oversight appears focused, in large part, on the epidemic abuse and diversion of prescription amphetamines and opioid pain medications. Motivated by the bipartisan focuses on patient care, cost control, or “stamping out waste fraud and abuse”, physicians are on the front lines and in the cross-hairs of regulators, prosecutors, and contractors. Additional substance and context to recent news on raids of pain clinics across Alabama and the country presents opportunities to review some basic blocking and tackling. The recent raid in Mobile followed indictments of two pain management specialists who owned a pain clinic and an attached pharmacy. The charges are (1) distributing or dispensing controlled substances by providing them “outside the usual course of professional practice and not for a legitimate medical purpose,” and (2) healthcare fraud in billing a private insurer. Both present standard of care issues. The alleged billing fraud is that the providers charged private insurers for medically unnecessary testing to analyze patient urine samples, and also billed for other services provided by their physician extenders under the physicians’ NPI numbers (for greater reimbursement), rather than under the physician extenders’ NPI numbers. These charges are not unique to providers in Alabama, nor are they unique to pain management. In Mobile, for example, an OBGYN and his nurse practitioner were recently sentenced for basically the same billing issue. The only apparent difference in the allegation was that the insurer denied claims when submitted under the nurse practitioner’s NPI, so they were REPRINTS: If you would like to order a reprint of a Medical News article in a PDF format or request an additional copy of an issue, please email: subscribe@medicalnewsinc. com for information.

re-submitted them under the physician’s NPI. Still, if proven, both scenarios are criminal fraud. In our law practice, we certainly see honest mistakes in billing and coding, and the lively debates on medical necessity. Government and ultimately the jurors, however, may never appreciate the subtle differences between simple negligence or professional disagreement, and criminal fraud. Fair or not, this is the present reality. For pain management specialists, basic blocking and tackling may be no different than any other medical specialty. Physician ownership in a pharmacy certainly raises specific Anti-Kickback, Stark, and other ethical regulatory issues that bring added oversight. Still, government and industry agree that opioids and amphetamines are medically necessary and that their prescription is the standard of care in many contexts. Any prescriber may find it beneficial to review some basics by asking himself a few questions: • Am I the right person to treat this person’s pain? • Do I have experience and training to recognize a drug-seeker? • Is this really an emergency situation where prescribing this medicine is appropriate? • Do I control my prescription pad and DEA number, and my staff’s access to both? • May I ethically prescribe this to my family or friend?

• Am I current on the standard of care and billing requirements within this specialty? • Am I confident my records are compliant with the various billing requirements? • In giving an order, am I focused on the patient or something else? • Before referring to another specialist, do I know that physician and her credentials? • Do I even know how my office is billing for my work here, and do I know the answers to any of these questions? Physicians know to stay current on the standard of care for what they do. They’re the quarterbacks of the practice ultimately responsible for correctly billing and prescribing. In the current environment that is no easy task. Administrators can play a key role, especially for their physicians who “just want to take care of the patients.” The recent Mobile raid and its aftermath also exposed some misunderstandings of state and federal oversight. The two may coordinate, but not always. Physicians received the message from the Alabama Board of Medical Examiners to be not afraid: “Just take care of the patients. We’re not looking over your shoulder, and neither are the feds. They’re just after big fish, like drug cartels” (paraphrasing). The Board’s message about a specific time of emergency for many patients left without

care for legitimate needs, is no excuse to ignore the basics that apply to not only pain specialist but all prescribers or billing providers because drug distribution is not the only issue in these federal criminal prosecutions. Oversight comes from the state and the federal government. In Alabama, physicians are licensed and regulated by the Alabama State Board of Medical Examiners. To dispense pain medications or serve most patients these days, however, physicians must accept DEA oversight, Medicare reimbursement rates, and billing and documentation rules created and dictated by government and its contractors. In the wake of these raids, the media’s focus on asset seizures, which is standard practice for prosecutors, distracts from the substantive questions on the standard of care, billing and reimbursement, insurance provider agreements, pre-certifications, audits, contractual relationships, staffing, benefits, and overhead. This is an opportunity to review standard business practices, blocking and tackling. By evaluating their business as a whole, and asking a few basic questions, many physicians can vastly improve how the business of caring for patients is done. Tom Wood is a partner in the healthcare practice of Burr Forman.

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Trinity on the Move, continued from page 1 services away from local municipalities. They will be covered as normal.” Mason says the emergency management personnel who are assisting with the move will be able to use the event for future emergencies. “We will set up a command center at our current site and also at the future site. They will be participating in this relocation as a training event on how to respond to any sort of traumatic Drew Mason incident that could occur in our community in the future,” Mason says. “They will use our resources and procedures along with the structure and organization of the move as a learning experience and documentation of resource preparedness.” Trinity Chief Executive Officer Keith Granger says they have not set a finish time for the move, because it will depend on circumstances of the day. “We want to keep patient safety paramount during that period of time, so if we finish at 5:00 p.m. that’s okay. If we finish at 3:00 p.m., that’s also okay,” he says. “We’re going to Keith Granger be methodical about this Have Ayou Technology Partner With Your Best Interest At At Integrated SolutionsAnd we are so sure will be impressed process. We will be going based on patient by our capabilities to meet your IT needs we will bet money need and circumstance. Patient safety will be the priority, not the clock.” on it. Go to the link below today to schedule a For 19 Years, We Have Been That Partner. While Trinity’s executive leadership free network assessment.* will sponsor the move, all members of the hospital staff will play a role in the relocaWe have taken a leading role in HIPAA/HITECH www.It4theplanet.com/freeassessment/medical tion plan. “There is no question the plan awareness and IT security preparedness. has to be broad and encompassing, but for We invite you to learn more about our company. the departments it has to be drilled down We monitor our clients’ IT systems around the clock  We offer faster,and smarter, and safer information only senior engineers perform scheduled to the staff level,” Granger says. “Going technology solutions maintenance and upgrades. We don’t outinto the new hospital, staff members must source anything. know their way around the building and  We support over 100 medical practices know how to take care of patients with provide data protection solutions, utiliz 20 years servingWe the medical community the new technology and equipment that ing a wide range of products and techwill be in place at Grandview. We want  HIPAA medicalnologies, security assessments instead of what is simply our their input into those plans and we want branded offering.  Knowledgeable in over 20 EMR software products to make sure they have participated in the preparation. The more collaborative the  Excellent customer satisfaction We build disaster plansfeedback and fail-over plan, the greater the likelihood of success.” systems for data, connectivity and For Granger, one of the most comeven cooling. Information We test real world Our goal is to be the leading Technology pelling things about the relocation will be scenarios, so we know they will provider in the Birmingham market. Our successful track having two institutions operating simulwork when it counts. record demonstrates our ability to meet or exceed expectations for our medical We are partners with Medical clients.

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taneously. “Once we start the move, we must have our laboratory, radiology department, labor and delivery, operating rooms, security, and all other departments up and running at the new hospital,” he says. “Having those services duplicated at both facilities is almost unsustainable over a protracted period of time, so we need to get the move done as quickly as possible so we can reunite all of those resources.” During the move, ambulance personnel will transport patient by patient, and they will make sure each patient is secured at the Grandview facility before returning to Trinity for another. “We will have a master list of patients at our current site, and that list will be duplicated at the new site. We will predetermine what room each patient goes to when they arrive at the new site,” Granger says. “For each patient, there will be a designated door, a designated ambulance, and a designated nurse. Before departing Trinity, each patient will be signed off by a physician. When they arrive at Grandview, they will go to a designated area where they will be unloaded and taken to their new room after being checked by a physician upon arrival.” Plans are also under way to head off any potential traffic issues during the move. There will be a designated route for the ambulances with alternate routes available if needed. “Almost without exHeart ception, there will be an escort that will create a pathway, somewhat like police do on a football game day. Some traffic lights will be controlled to facilitate traffic movement,” Mason says. “We’ve had lots of discussions around traffic logistics, and we don’t anticipate our creating any sort of traffic hindrance with three to four transports every 15 minutes. The Alabama Department of Transportation will use traffic communication boards on Interstate 459 to inform drivers on move day, and we plan to educate the community prior to move day about what we are trying to accomplish on October 10th.” Granger appreciates the participation and support they have received from the physicians, many of whom will be relocating to the new physician office building at Grandview Medical Center. “They will be an important part of our move, and we look forward to giving them a new home where they can practice for the rest of their careers,” he says. “They will have a shiny new building to complement the skills they offer to our community.” Throughout the planning process, Granger says the hospital staff has made sure to dot all i’s and cross all t’s. “We have a great team of people working on the project, and we hope to avoid disruptions on the day of the move, but if something happens we will use our back-up mechanisms to take care of issues,” he says. “I expect to have a successful move, and I think the excitement about being a part of this and working in the new building is going to give us a good relocation weekend. We will look back fondly in years to come on how meaningful it was to be a part of something that rarely happens in one’s health care career.”

4/25/2013 9:38:20 PM

REIMBURSEMENT

Reimbursement Errors from a CPA’s View By Jane Ehrhardt

Jerry Callahan, a CPA with Kassouf & Company, finds that every practice he consults has a problem wasting time verifying insurance coverage before a patient crosses the threshold. At many practices, the staff looks up a patient’s coverage on the payer’s website. “Some staffers still spend time calling to verify insur- Jerry Callahan ance,” Callahan says. “But all they need to do is use the autoverification feature on their practice management software. The problem lies in poor training on the software.” Practices today miss quite a few easy opportunities to increase their reimbursements or save on billing expenses. Family Practice Management magazine estimates that losing only five percent of revenue results in a 13 percent loss of income for the physicians. “The savings are in the details,” Callahan says. For instance, secondary insurance is no longer just for those on Medicare, says Justin Berry, a CPA with Pearce Bevill. “I’m experiencing this often with the solo Blues and government coverage.” Front office staff now needs to ask every-

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one, even parents, if the patient has secondary insurance. Even when the practice gets the information, the billing staff are missing out on this potentially easy source of revenue. Justin Berry “The back office is not billing the secondaries in a timely manner, if at all,” Berry says. After a family member’s stay at an area hospital, Berry received multiple bills for something covered by his secondary policy. When he called the hospital, they recited all the information for the secondary coverage but had, for unknown reasons, not bothered to bill them. “They told us ‘OK, we’ll file it.’ So the back office may have been hoping the primaries — that allow electronic filing—would cover it, because secondaries are mostly paper clients,” Berry says. Besides the expense of recouping the payments from patients rather than insurance, Berry says this oversight can result in unhappy patients, which could mean lower reimbursements. “The move toward value-based reimbursement models means this situation could result in the provider getting poor patient-satisfaction scores,” he says. That will trigger lower reimbursement fees. The back office also needs to ensure physicians stay credentialed with all insurers. “I can’t tell you how many times we have found offices where everyone is responsible for this, so no one’s being re-

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sponsible for it,” Callahan says. In the last six months, Callahan has seen Medicare suspend the billing privileges of eight providers until they revalidated. “That meant they couldn’t see a Medicare patient for two to three weeks,” he says. “The best practice would be to schedule on your calendar when revalidation is due for each provider, because the reminder letters can get lost.” Once the patient enters the building, Callahan advises that practices utilizing nurse practitioners and physician assistants adapt their office visit protocol to suit the patient’s insurance coverage. “Some payer contracts do not pay for extenders at all,” he says. “So if only the extender sees the patient without any physician input, the practice will receive no reimbursement for that visit.” During the visit, providers can also lose large amounts of reimbursements from slightly incorrect documentation. Berry had a client practice in pain management who was audited by Medicare. Though they had regularly billed for two coding components — one related to procedure and one related to evaluation and management — the notes were for both aspects of the procedure were written as one large paragraph. “So the payer saw it as one procedure, and we had to write checks back to CMS for almost $20,000,” he says. More reimbursement monies get lost when practices fail to load each payer’s fee schedule into their billing software. This annually updated data states how much to

expect for each CPT code. With this information in place, the practice can produce a variance report to reveal where expected claim payments fall short. “About 60 percent of practices don’t do this,” Callahan says. Without that report, the difference in payment gets written off as a loss and noted as a contractual adjustment. But discovering why a reimbursement is underpaid on a procedure or service can lead to notable revenue. “Because most things you’re doing, you’re doing a lot of, so it’s all volume driven,” Callahan says. “A small difference multiplied by a large number of occurrences over time means you’re going to end up with a significant amount.” The same reasoning applies to billing chart audits. Berry says they took over the administration of a practice where “everybody thought the previous administrator, who had been there for a long time, had done a great job. Like collecting receivables within 25 days.” But when they brought in a billing specialist to audit the charts, they found that the use of some modifiers had been overlooked. “We refiled and collected $80,000 for the previous six months,” Berry says. Since they could only refile so far back, the prior 10 years of that earned revenue was simply lost. “Even though you want to trust that people are doing their job properly, it’s just good practice to have an outside set of eyes look at your reimbursements.”

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REIMBURSEMENT

Code Modifiers Generate Reimbursements By Jane Ehrhardt

“A lot of people think there’s nothing to coding and billing. They say, ‘How complicated can it be?,” says Eddye Sheffield, a certified professional coder with Medcorp. “But it is complex. Diabetes alone has something like 12 pages of diagnosis codes.” Skillful use of modifiers can generate tens of thousands of dollars in reimbursements a year. Eddye On a claim, attaching Sheffield the two-digit modifier to a CPT code tells the payer that the service or procedure was altered by some circumstance. “When you bill, you don’t generally send other notes or documentation with a claim, so modifiers explain and eliminate questions,” Sheffield says. One of the most common errors made with modifiers is assigning one to the wrong code group. CPT codes fall into two groups: procedure and evaluation and management (E/M). Some modifiers have a similar meaning but can only be used in one group. For instance, modifier 25 only works with an E/M code. “It means that particular service was done for a separate reason from the office visit, so you deserve additional reimbursement,” Sheffield says. The modifier with a similar meaning in the procedure group is 59. “If you mess those up, you don’t get paid for a service,” Sheffield says. For instance, if a facility billed for both indirect and direct rehab in the same visit without a modifier, they miss out on a reimbursement for one of those services every time the error occurs. Maximizing the earning potential of modifiers requires knowing more than the definitions of each modifier. Each commercial payer also follows different rules for their use. “You can charge for a venipuncture to send out blood for analysis with a 90 modifier,” Sheffield says. “But only some payers cover using the 90 modifier – others do not want a modifier.” The reimbursement averages $3. “Which doesn’t sound like much, but if you do 30 a week it adds up,” she says. In 5 years, it would total over $23,000. Modifiers can also validate reimbursements during the global period of a procedure or service when anything more done with that patient pertaining to that original condition is not billable. For E/M codes, use, 24; for procedures, 79. Global periods can also extend prior to the condition designated by the code, such as with surgery. Usually anything done the day prior to the procedure is included in the global period, including of-

fice visits. “But if you decide to do surgery on the same day that someone comes to see you, then append the 57 modifier to get reimbursement for that office visit outside the global package,” Sheffield says. The modifier tells the payer the patient came in for an office visit and a sudden decision for surgery was made during that visit. Modifiers can also justify what appears to be two disparate codes. For instance, a physician can get reimbursements for both a well visit and a sick visit in the same visit. A patient may come in for an annual exam (a well visit) but then complain of an earache (a sick visit). “You can bill for both on the same visit if your documentation backs it up,” Sheffield says. “That’s another use for your 25 modifier.” Physicians may also be required to perform certain tasks that may seem superfluous or questionable to a payer. A 32 modifier signals that the service was mandated. “Like if you’ve got someone requiring a second opinion before a surgical procedure, you can use modifier 32 to indicate that you’re essentially being made to do this,” Sheffield says. “This one doesn’t really get you a higher reimbursement, but it might get you the normal reimbursement rather than nothing.” One of the more complex examples of the use of modifiers comes into play with chronic conditions. If a patient has sinusitis and also has chronic problems, like high blood pressure and diabetes, additional reimbursements can be earned with the right modifier. For instance, if the physician gives an antibiotic injection for sinusitis, the injection reimbursement would normally be bundled into the sinusitis-focused office visit. “But you can bill for both the office visit and for administering the shot — in addition to the antibiotic itself, that’s a different code — with a 25 modifier,” Sheffield says. When you append a 25 modifier to the office visit, “you show that the office visit had to do with something beyond the sinusitis, because other conditions had to be taken into consideration,” Sheffield says. “Those conditions make for a more complicated visit, so you can code with modifiers to earn the maximum reimbursement from that.” The change to ICD-10 coding will not be affecting E/M codes, procedure codes, or modifiers for outpatient billing at this point. “You’ll be using the same modifiers that you’ve been using the last 10 years or so,” Sheffield says. But she recommends that practices learn all they can about modifiers. “They make you more money and help you avoid having to refile claims,” she says. “How is that not a worthwhile investment?”

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REIMBURSEMENT

IMOs and ICD-10 By Jane Ehrhardt

More tools are rolling out to help with the onerous transition to ICD-10 codes due to start on October 1. “You have options,” says Tammie R. Olson, CPC, CPCO, a certified professional coder with Management Resource Group (MRG). In Alabama, if a practice hits an issue, Olson recommends contacting the provider desk Tammy R. at Cahaba Government Olson, CPC, Benefit Administrators CPCO (Cahaba GBA). They administer all Medicare Part A and Part B claims in Alabama, Georgia, and Tennessee. “It’s a resource where you actually talk to a person,” she says. “They even assign someone to you, no matter what stage you’re in.” Medicare also recently announced a process for providers to continue receiving their reimbursements should they hit ongoing coding problems. “If you’re having a lot of denials with Medicare because of ICD-10, Medicare will work with you,” Olson says. “You are not going to get cut off from income.” But she cautions that though errors will be tolerated, Medicare will require the

codes to at least be in the right group. “If you don’t put that it’s a left leg on there, you’ll only get a caution,” she says. “But good coding is always about what is documented, so code to the highest level of specificity your documentation allows.” To make matters more confusing during this switch, not all situations fall clearly on the October 1 transition date. For hospitals, the date of discharge determines when to start using ICD-10. Someone admitted in September but discharged in October, will need their entire stay coded in ICD-10. With workers’ compensation claims, the use of ICD-10 becomes even more nebulous. “Double check with the payer, because workers’ comp does not fall under HIPAA, so they’re not obligated to use ICD-10,” Olson says. “Some are and some aren’t.” Most healthcare institutions by now have developed some sort of transition tool, either manual or digital, to bypass the onerous task of finding a code in the 21-chapter ICD-10 book. But even superbills — a list of a provider’s most commonly used codes — will likely swell from one page with ICD-9 to four or five pages with ICD-10. “And more like 10 to 12 pages for specialists,” says Carrie Gulledge, RHIA, with MediSYS. Even an electronic superbill, which would allow keyword searches to help

speed up the hunt for a code, is “the bottom of the barrel in the EHR [electronic health record] world,” Gulledge says. A far more efficient tool for those with EHRs is Intelligent Medical Objects Carrie (IMO), a software that Gulledge, RHIA embeds right into EHRs. “It’s in essence a wizard that helps a provider select the most applicable code for ICD-10,” she says. The third-party tool also shows details about the code, such as inclusions and exclusions, along with additional codes that commonly bill alongside that ICD-10 code. “It gives the provider a deeper level of incite without having a full blown 10 coder at their disposal,” Gulledge says. IMO users can search by diagnosis or acronym, such as DM for diabetes mellitus. Even partial keywords, such as “abd pain” for abdominal pain, are enough to start the wizard toward finding the ICD10 code. “It asks you questions until you’re driven to the correct code,” Gulledge says. “And that’s a huge, huge time saver. If you were trying to do that with a code book or even an electronic superbill, it would take you so much longer.” Not all EHRs have this third-party functionality added to their system. Or pro-

viders have found their EHR vendors want to charge upgrade fees or monthly subscription rates for the IMO option or something similar. “But those people don’t have to be left high and dry,” Gulledge says. Some electronic apps exist that run without EHRs. Basically these options, like White Plus, are a customized electronic superbill offered online. They save practices from creating their own superbills and could save them unsustainable fees offered by their EHR vendor. “Providers have been focused on what they have to do for meaningful use with its incentives and penalties programs and have probably assumed their EHR vendor would take care of ICD-10 for them,” Gulledge says. “But that’s not always the case.” Without some sort of tool to help with selecting codes in the new ICD-10, “you not only introduce another level of frustration to the practice, you effectively slow down the revenue coming back into your office,” Gulledge says. “Keep calm,” Olson says. “We all know there’s going to be issues.” She says if providers get bogged down or overwhelmed, even with electronic tools, they can find a solution. “You may want to outsource it, even for a while. Or get a professional to come in and help you,” she says. “It’s just a code.”

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14 • SEPTEMBER 2015

Birmingham Medical News

8/17/15 3:44 PM

MGMA Releases Latest Provider Compensation Data By CinDy sAnDers

In late July, the Medical Group Management Association (MGMA) released findings from the 2015 Provider Compensation Survey Report, an annual analysis of compensation and productivity data illustrating market characteristics across specialties and organizational settings. “MGMA has been collecting data on medical group management since 1926,” noted Todd B. Evenson, chief operating officer of the national organization for healthcare administration and medical practice management. “For the last 25 years, we’ve also been specializing in the space of physician compensation and non-physician compensation.” Based on 2014 data, this year’s survey found physicians reported salary increases over the Todd Evenson past year with primary care physician increases outpacing those of specialists (3.56 percent increase vs. 2.39 percent, respectively). Specialists, however, still report a higher median compensation at $411,852 compared to a median compensation of

$241,273 for primary care physicians. The 2015 benchmarking report included information on nearly 70,000 providers across the United States. In addition to geographic diversity, Evenson said the data was representative of both large and small practices, various ownership structures including hospital-based providers, and more than 170 specialties. Evenson said the collected data is important for a number of reasons, not the least of which is that physicians are being recruited on a national level. To remain competitive, he noted, it’s important to look at the compensation methodologies being used by colleagues in various parts of the country. While primary care physicians enjoyed a 3.5 percent increase in median compensation between 2013 and 2014, the figures are even more interesting when

taking a slightly longer view. Evenson noted physicians in this space have seen a 9.2 percent increase in compensation since 2012. “Will primary care physicians be compensated at the same levels as specialists? Not likely,” Evenson said. However, he continued, “They will continue to play an integral role as care models evolve. Primary care physicians are truly the lynchpin of the new practice model as we move from fee-for-service to fee-for-value.” Evenson added, “There’s a particular demand for primary care physicians … both because they are the backbone of the referral system and key to a value-based system.” The latest MGMA survey also showed a continuing shift towards newer models of care. “Historically, it was normal to see 100 percent of compensation plans be productivity based,” explained

Evenson. “In 2012, 50 percent of respondents said they were on a 100 percent productivity based compensation plan. In 2013, it was 39 percent; and actually this year, it was 25 percent of respondents.” As he noted, that’s a 25 percent decline in that metric over the past three years. Evenson said the current data highlights the gradual shift toward rewarding practitioners for improved operational efficiencies, enhanced quality and access to care. While the direct link to quality is still relatively small, it is growing. Just a few years ago, only 3.4 percent of physician compensation was tied to quality metrics. “Now we’re seeing as high as 10 or 11 percent,” he said. “That value over volume concept that physicians seem to be embracing is really beginning to pay off for them.” He added, “The behaviors they are trying to promote are tied to that triple aim (of healthcare) … reducing the per capita cost of healthcare, improving the health of populations, and improving the patient experience of care.” Evenson said those in the behavioral health sector are also seeing improved compensation as their work complements that of primary care providers in manag(CONTINUED ON PAGE 16)

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Taking on the Number One Killer, continued from page 5 sively with young drivers? In addition to being able to speak from direct experience—almost everyone who has done an emergency department rotation has seen what two tons of moving metal can do to a body—health professionals can help teens understand the whys behind the rules. Repeated “no’s” or “because I said so” are easy to ignore when no one is watching. However, teen who understand the reasons behind the rules, are more likely to remember and practice safe driving habits. “Although fast reflexes make teens good gamers, the part of their brain that governs impulses and prioritizing doesn’t develop until they are around 24 years old. That’s why there are rules to rely on until the rest of their brain catches up with their reflexes,” Monroe said.

Teens who are good with computers may look at a car as just another machine and underestimate the skill needed to drive well. It takes time for muscles and nerves to learn to act in situations where there is little time to think. Inexperienced drivers are less likely to leave adequate space between cars, or to recognize hazards, and they tend to underestimate the distance required to stop at higher speeds. Like learning to tie shoes, becoming a good football player, dancer or musician, driving skills improve with practice. The graduated drivers license and supervised practice sessions are opportunities to build those skills. Another topic to talk about with teens is why seatbelts make sense. Compared with other age groups, teens have the lowest rate of seat belt use. Only 55 percent

reported always using seat belts when riding with someone else. The reasons they gave for not using seatbelts included a fear of being trapped, and the belief that they could hold on in a crash. Simple math shows otherwise. If a car travelling at 30 miles an hour hits a stationary object, a 100-pound girl without a seat belt would be thrown forward with 3,000 pounds of force. Her 150-pound boyfriend would hurtle forward with 4,500 pounds of force. Even the greatest weight lifter ever known couldn’t grab and hold on to that kind of weight. When the body makes contact with an object, the sudden deceleration is even worse. If the person’s face hits the dash, the windshield or the steering wheel, all that energy goes into less than an inch of depth. After such a strong impact, the odds

MGMA Releases Latest, continued from page 15 ing a population’s health. The industry is really recognizing a need to look to behavioral health services to better deliver quality care. The likelihood that someone dealing with a chronic health condition is also dealing with a behavioral health issue is high,” Evenson pointed out. Recognition of that link has been evident in the MGMA compensation survey over the last few years. “Since 2009, there has been a 21.9 percent increase in compensation for psychiatrists. Now, their median compensation is $244,796,” Evenson said, noting that now puts psychiatrists roughly equivalent to their primary care counterparts. Economic forces of supply and demand are another issue factoring into phy-

sician compensation. A predicted shortage of physician providers in both primary and specialty care could fuel higher compensation rates down the road. Referencing a March 2015 report from the Association of American Medical Colleges (AAMC), Evenson noted the analysis projected a shortfall of between 46,000 and 90,000 physicians by 2025. In addition to compensation figures, Evenson said MGMA’s annual report also collects information regarding total charges, collections, encounters, RVUs (relative value unit), productivity, benefits, demographics, organizational types, and regional differences all the way down to a state level. He said drilling down in the data allows those in healthcare to dissect the in-

formation in myriad ways, and added it’s critical to learn from one another to adopt best practices that address the triple aim. “You can take these benchmarks and truly understand what opportunities you have for efficiencies and for providing better care by understanding your colleagues’ activities in the industry,” Evenson concluded. For more information on the 2015 Provider Compensation Survey Report, go online to mgma.com. Detailed data is available for purchase in two formats – electronically through MGMA DataDive™ or by ordering printed reports. Compensation and the many other market forces impacting healthcare management will be explored in depth at MGMA’s annual conference scheduled for Oct. 11-14 in Nashville, Tenn.

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of being conscious and able to open a car door would be near zero. Unfortunately, even if the girl and her boyfriend use their seatbelts every time, an unbelted passenger behind them could be thrown forward into their head and kill them. Everyone in the car needs to use seatbelts—even the family dog, so Fido doesn’t become a lethal unguided missile. Riding with a friend who has been drinking is another point that needs to be discussed. In a national survey, 22 percent of teens reported that in the past month they had ridden with a driver who had been drinking. Wanting to be cool and appear grown up are big pressures—but in a recent year, almost one in four teen drivers involved in a deadly accident had been drinking. Putting a friend’s life at risk by driving under the influence of alcohol or drugs isn’t cool. It’s a sign of immaturity. Good drivers take the responsibility for the safety of their passengers seriously. Staying alive and safe is more important than indulging a friend’s bad habits. Teens should always have a plan B for how to get home. Per mile driven, teen drivers age 16 to 19 are nearly three times more likely to be in a fatal crash than drivers over 20. With safer teen driving habits, many of the deaths and injuries that occur in traffic accidents could be preventable. We would be overjoyed with a cure rate that high for so many deadly diseases. It doesn’t take millions of research dollars, or new drugs or medical equipment to save those lives. It takes a few minutes to share some words of wisdom that could work wonders. *The opening paragraphs are based on actual events as told to the writer by firefighters on the scene.

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Telemedicine: A Virtual Compliance Jigsaw Puzzle A Closer Look at the New Wave in Healthcare Delivery By LYNNE JETER

Telemedicine has quickly become the hottest topic in healthcare delivery, as the industry strives to adapt to its murky waters of compliance. New services, such as Zwivel, a cosmetic surgery consultation service, are coming online with unprecedented frequency, piquing the interest of physicians and administrators about the unknown possibilities of telemedicine. “Perhaps we shouldn’t be surprised by this trend,” said Michael Sacopulos, JD, CEO of Medical Risk Institute and general counsel for Medical Justice Services, a 4,000-member group with physicians in all 50 states. “High speed interMichael net connections are now Sacopulos the norm. Services like Facetime and Skype are more popular than ever. Under continued pressure to cut costs and cope with declining reimbursements, administrators believe telemedicine offers a tool for increasing efficiency. Patients also like the convenience and increased options that flow from telemedicine. So what’s not

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to like? Shouldn’t we embrace the ‘new normal’ and sign on to a great, brave new world? Maybe, first let’s proceed with caution.” Among the state and federal compliance requirements when taking a practice online are licensure, professional liability considerations, standard of care, patient privacy, informed consent, and referrals for emergency surgery.

Licensure

Medical providers “must be licensed by, or under the jurisdiction of, the Medical Board of the State where the patient is located,” according to the Federation of State Medical Boards’ Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine. “Unfortunately,” noted Sacopulos, “this requirement imposes traditional state boundaries on the cyber world. Efforts need to be made to identify the residences of prospective telemedicine patients so the medical provider does not accidentally practice in a state without a license.”

Professional Liability

Most professional liability insurance policies provide state-specific coverage, meaning that if a provider accidentally practices telemedicine on an out-of-state patient, there may be no coverage, said Sacopulos. “Providers wanting to expand into the area of telemedicine should check with their insurance carrier,” he suggested. “Another consideration relates to cyber issues. Traditional medical malpractice policies provide little to no coverage for electronic breaches. The nature of a telemedicine generates exposures to a variety of cyber

risks. Any practice moving forward with offering telemedicine should have a comprehensive cyber insurance policy.”

Standard of Care

It’s imperative to note that telemedicine is the practice of medicine, and not “medicine lite,” Sacopulos pointed out. “All the duties and obligations that come with in person consultations are owed to the remote telemedicine patient,” he explained. The American Medical Association (AMA) recently stated there’s a general consensus among AMA members that care provided via telemedicine needs to meet the same standard as care provided in person.” Also, the Federation of State Medical Boards made clear the position by stating: “In fact, these guidelines support a consistent standard of care and scope of practice notwithstanding the delivery tool or business method in enabling physician-to-patient communications.” “Before starting to use telemedicine as a tool to consult with remote patients, a practice should plan how it will meet the standard of care it provides for its in-office patients,” said Sacopulos. “For example, how will it document a dermatological condition? If the condition is normally photographed when a patient is in the office, then the practice should be ready to capture the same quality of image via telemedicine. Each step of the consultation should be planned in advance to ensure it is equal in quality to an in-office evaluation.”

Patient Privacy

Sacopulos said it’s also important to note that any form of electronic commu-

nication with a patient should immediately bring to mind HIPAA and HITECH Act obligations. “Whether the electronic connection with the patient is via email, text messaging, or video conference, the platform should be secure,” he said. “Private and confidential patient information is being transmitted and the patient has a legal right to protect the information in transit.” The Federation of State and Board Telemedicine (FSMB) Guidelines specifically state: “Physicians should meet or exceed applicable federal and state requirements of medical/health information privacy, including compliance with HIPAA and state privacy, confidentiality, security, and medical retention rules,” said Sacopulos, adding that FSMB Guidelines suggest maintaining written policies to address: • Privacy; • Healthcare personnel who will be processing messages and patient communications; • Hours of operations; • Types of transactions that will be permitted electronically; • Required patient information to be included in the communication, such as patient’s name, identification number and type of transaction; • Archival and retrieval; and • Quality oversight mechanisms. “Finally, telemedicine practitioners are cautioned to periodically evaluate their policies and procedures to insure they remain current and readily accessible,” he said. “FSMB informs us that electronic communications received from patients must be maintained within secured technology password-protected encrypted electronic (CONTINUED ON PAGE 18)

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Telemedicine: A Virtual Compliance, continued from page 17 prescriptions, or other reliable authentication and techniques.” Sacopulos said it’s reasonable to assume that additional patient privacy requirements will be coming in the near future. “This well may be in reaction to large scale breaches, such as Anthem Insurance experienced earlier this year,” he said. “Studies show that medical identity theft grew at an alarming rate in 2014. Government officials, including the FBI and California Attorney General, have specifically cautioned medical providers that their patients’ electronic data is at risk for hacking and theft. All of this should serve as a warning to telemedicine providers to comply with existing state and federal regulations. Telemedicine providers should also anticipate increasing privacy standards.”

Informed Consent

Before practicing telemedicine, a medical provider should obtain appropriate patient informed consent. The informed consent document should: Clearly state the patient’s identity; Clearly state the physician’s identity and qualifications; Specify the scope of activities the practice will be using telemedicine technologies to fulfill, such as patient education, prescription refills, and scheduling appointments; The patient must acknowledge that it is within the medical provider’s sole discre-

18 • SEPTEMBER 2015

tion to determine if the available telemedicine technologies are adequate to diagnose and/or treat the patient; The patient should acknowledge the possibility of, and hold harmless the medical provider for, any technology failures and/or interruptions; The practice should, as part of the informed consent process, provide information on the telemedicine technologies privacy and security standards, such as the inscription of data and firewalls; and The informed consent document should specify express patient consent to forward patient information to a third party if necessary.

Referrals for Emergency Service

“The FSMB suggests that telemedicine practitioners have a written protocol in the event that a remote patient needs emergency services,” said Sacopulos. “This emergency protocol should cover possible scenarios when patients require acute care. How and where referrals are to be made should be covered in this protocol.”

State-Specific Requirements

The scope of permissible telemedicine varies significantly by state. Some states specifically require a physician/patient relationship to be established first in person with an exam and diagnosis and treatment plan, including prescriptions. Only then may telemedicine be conducted.

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“Telemedicine is receiving much attention at the moment,” said Sacopulos. “The American Medical Association is in the process of adopting a Code of Ethics for physicians who provide clinical services through telemedicine. Texas has recently

issued new telemedicine guidelines to its practitioners. All of this should serve as a warning to those interested in telemedicine to consult with their State Board of Medicine before engaging in telemedicine activities.”

Physicians’ Telemedicine Checklist Physicians interested in electronically interacting with their patients should first work their way through this checklist: • Examine the electronic communication between the practice and its patients. From patients portals to staff testing, a complete picture is needed of the practice’s electronic communications before engaging in telemedicine; • Make sure forms of electronic patient communications are HIPAAcompliant and secure; • The internet may know no bounds, but a medical license does. Be careful not to provide medical services to individuals who live in states in which there’s no license; • Check with the State Board of Medicine to determine state-specific telemedicine limitations; • Develop a specific informed consent document that complies with state requirements and also the Federation of State Medical Board’s suggestions; • Develop a list of disclosures to provide to prospective patients before engaging in telemedicine services; and • ºMake sure there’s adequate insurance coverage. Check with a professional liability carrier and secure a cyber-insurance policy. “With advanced planning and a little effort, you’ll be able to weave your way through the compliance requirements to practice telemedicine, leaving you and your patients to enjoy the benefits of a telemedicine practice,” said Michael J. Sacopulos, JD, CEO of Medical Risk Institute and general counsel for Medical Justice Services. SOURCE: Michael J. Sacopulos, JD.

The AMA Steps Up with STEPS Forward By LYNNE JETER

Editor’s Note: This article is part of a Medical News exclusive series, “Who’s Tending Our Doctors?” to focus on ways the industry can help alleviate physician stress and allow physicians to return to the joy of practicing medicine. Several years ago, Christine A. Sinsky, MD, FACP, made two significant time-saving changes to her practice life that allowed her to leave work sooner and have more time for family and personal interests. The first: taking a streamlined approach to prescription management. Second: taking proactive planned care measures with patients via previsit laboratory tests. “Just making a single change – prescription management – decreased phone calls to the practice by 50 percent. It saved 30 minutes of doctor time and 60 minutes of nursing time per doctor per day,” said Sinsky, an internist and partner in Medical Associates Clinic, a multispecialty group practice with sites in Iowa, Wisconsin and Illinois. Sinsky is also the point person at the American Medical Association (AMA) for an ambitious new initiative offering physicians strategies to revitalize their medical practices and improve patient care. The practice changes she references are found in the initial 16 modules available online – free for AMA and non-AMA members – via www.STEPSforward.org. “If you can follow one or two recommendations and go home earlier by reengineering the way you do your work, that’s a win-win all around,” said Sinsky. The AMA took action to improve the lives of practicing physicians after a recent RAND survey showed the satisfaction physicians derive from their work is quickly eroding as time continues to be taken away from direct patient care because of grueling, bureaucratic obstacles. “Research shows that rates of overall burnout among U.S. physicians approach 40 percent,” said AMA CEO James L. Madara, MD. “That’s why the AMA is taking a hands-on approach to meeting their day-to-day concerns through the new online series, AMA Steps Forward.” Broadly, the 16 modules address four key areas: practice efficiency and patient care, patient health, physician health, and technology and innovation. Specifically, the modules cover these topics: • Conducting effective team meetings • Creating strong team culture • Electronic health record (EHR) implementation • EHR software selection and purchase • Expanding rooming and discharge protocols • Improving blood pressure control • Improving physician resiliency • Medication adherence • Panel management • Preventing physician burnout • Preventing type 2 diabetes in at-risk patients

• Pre-visit laboratory testing • Pre-visit planning • Starting lean healthcare • Synchronized prescription renewal • Team documentation Each module requires only snippets of time to study either online or printed in PDF format for a more traditional approach to learning. Live events provide yet another learning option. To earn AMA PRA Category 1 Credit™, participants must view the module content in its entirety, successfully complete the quiz answering four of five questions correctly, and complete the evaluation. Modules include steps for implementation, case studies and downloadable videos, tools and resources. “Within 30 minutes, physicians will know how to take the next step in their practices to work smarter, not harder,” said Sinsky. For example, the module on effective team meetings begins with a 10-step process: • Identify the team. • Meet routinely and “on the clock.” • Agree on ground rules. • Set a consistent meeting agenda. • Rotate meeting roles. • Solve problems as a group. • Record action steps, owners and due dates. • Practice good meeting skills. • Have fun! • Celebrate success. Under ground rules, helpful hints include starting and ending each meeting on time, being fully present in the moment, staying on topic, focusing on the issue and not the individual, stepping up or back as needed, and giving thanks to the staff for their time. To stay on topic and maintain efficiency during the dedicated meeting time, it’s suggested that: “if the discussion wanders, the chair or other member can say, ‘Let’s take that offline,’ or ‘that sounds like an issue to put in the “parking lot” to talk about at another meeting.’ If the discussion strays, there may not be time at the end of the meeting for all the items on the agenda.” In October, 10 modules will be added to the website. By the end of 2016, the AMA plans to have up to 50 modules available online. Concurrently with the rollout, the AMA and the Medical Group Management Association (MGMA) issued a practice innovation challenge, seeking more high-value, easy-to-adopt, and transformative medical practice solutions. Proposals were submitted through Sept. 1; the best solutions were eligible for one of several $10,000 prizes, in addition to having the ideas developed into future STEPS Forward modules. Winners will be announced at MGMA’s annual conference Oct. 11-14 in Nashville, Tenn. “We issued the innovation challenge to tap into the creative energy that we know is present among physicians,” said Sinsky. “The goal is to help physicians take better care of themselves and their practices so they can, in turn, take better care of their patients.”

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Lessons Learned from Tuomey By Jennifer Nicaud

The Fourth Circuit Court of Appeals recently affirmed a $237 million judgment against Tuomey Healthcare System, Inc. (Tuomey) in United State ex rel Drakeford v. Tuomey Healthcare System, Inc. which sent chills down the backs of many health care counsel with regard to issues arising under the Physicians Self-Referral Law (Stark) and the False Claims Act (FCA). Tuomey, a nonprofit hospital in rural South Carolina, began losing revenue due to physician’s transfer of their outpatient surgeries, from the hospital, to private offices or ambulatory surgery centers. To stop this bleeding, Tuomey negotiated part-time employment contracts with nineteen physicians. Under the part-time employment contract, each

physician agreed to perform outpatient services exclusively at the hospital assigning their right to bill third-party payers for their professional service to the hospital. Each physician was paid a guaranteed base salary adjusted annually based on the amount the physician collected from the services rendered during the previous year. However, the bulk of the physician’s compensation was a productivity bonus in the amount of 80 percent of his collections for that year. Physicians were also eligible for an incentive bonus of up to 7 percent of their earned productivity bonus. Drakeford, an orthopedic surgeon, claimed that the arrangements were inconsistent with fair market value (FMV). Drakeford argued that the physicians were being paid more than total collections for their services which violated Stark.

To address Drakeford’s allegations, Tuomey hired Kevin McAnaney, former Chief of the Industry Guidance Branch of the U.S. Department of Health and Human Services Office of Counsel to the Inspector General, who was the author of a “’substantial portion’ of the regulations implementing Stark.” The case turns on McAnaney’s advice and Tuomey’s desire to forget it. McAnaney opined that the employment contract raised red flags under Stark and in opposition to the role he had been hired for, McAnaney affirmed Drakeford’s position by concluding that Tuomey would have ”serious difficulty convincing the government that the contracts did not compensate the physicians in excess of FMV.” Drakeford declined to enter into the contract and later, sued the hospital in a qui tam action creat-

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ing this suit. Stark prohibits a physician from making a referral to a hospital which he has a financial relationship for furnishing health services. The Court specifically found that the more procedures the physicians performed at Tuomey, the more facility fees Tuomey collected and the more compensation the physicians received in the form of increased base salaries and productivity bonuses. The CFO of Tuomey specifically avowed “that every time one of the nineteen physicians did a legitimate procedure on a Medicare patient at the hospital pursuant to the agreement the doctor got more money and the hospital got more money.” The Court rejected Tuomey’s argument finding that Tuomey could provide a productivity bonus for work personally performed by the physician, but could not vary the physician’s base salary based on the volume or value of referrals which was understood to be the policy by many due to commentary promulgated by Center for Medicare & Medicaid Service. Second, the opinion laid precedent for the measure and constitutionality of damages in an FCA case premised on Stark by finding that the measure of damages is the total amount that Medicare paid for the designated health services performed pursuant to a prohibited referral. Finally, the opinion sets limits on a client‘s ability to rely on advice of counsel as a defense to FCA claims. The findings with regard to Tuomey’s actions are the crux of the case. The Court determined that Tuomey hired an undisputed expert of intricacies of Stark, who advised “Tuomey in graphic detail of the thin legal ice on which it was treading.” The opinion discussed the plethora of evidence presented at the second trial demonstrating the culpability of Tuomey with regard to McAnaney’s unheeded advice including a board member’s concerns over McAnaney’s opinions, Drakeford’s letter to the Board summarizing McAnaney’s opinion and, Tuomey’s refusal to allow McAnaney’s preparation of a written opinion regarding the contracts and his subsequent termination. As a result, the judgment against Tuomey was not found to be in violation of the Excessive Fines Clause of the Eighth Amendment in light of the degree of Tuomey’s reprehensible conduct. Tuomey was found to have knowingly violated FCA, even though other counsel advised Tuomey that its contract satisfied Stark. What is implicit in the determination of the Tuomey case is that if an acknowledged expert is hired, his advice must be heeded. The jury and the Court determined Tuomey’s attempt to ignore and distance itself of the advice of its undisputed expert created its culpability. Jennifer Nicaud is a member of the Litigation and Health Law Practice Groups at the Gulfport, Mississippi office of Balch & Bingham LLP. Ms. Nicaud has over 25 years of litigation experience and is licensed in Louisiana, Florida and Mississippi.

The Opiate Escalation Trap By Ty ThomAs, mD

When a patient is prescribed high doses of opiate medication for chronic nonmalignant pain, most providers cringe and view that patient in a negative light. In our current medical climate, with opiates considered an epidemic, the practice of prescribing opiates for nonmalignant pain is dicey. The state board has done a good job educating providers about the basics of opiate prescribing and its associated rules and regulations. First on that list is “make sure you have a good reason to prescribe these first.” Second on that list is “not everyone with a good reason should get opiate medications.” The third thing is “if you do it, make sure you monitor them.” I paraphrase a bit, but, if you have been to any of these education sessions, this is how the message is delivered. I agree wholly with that message. However, that “good reason” often goes assumed and rarely fully interrogated to warrant a solid, soon to be extinct, five digit ICD-9 diagnosis code. The purpose of this article is to take those three rules and add a caveat for those patients on high doses. When I see these patients, I ask, “Why did they require such an escalation for this?” High dose opiates are rarely indicated for nonmalignant pain at any stage. Tolerance is often the reason most providers and patients give when asked why. This makes sense to a degree. Mr. Smith has been suffering this pain for 15 years now. A little increase here and there adds up over time. However, there are medication management techniques to avoid this. One of the escalation traps I see providers get stuck in is when the patient correctly or incorrectly perceives euphoria for pain relief. “Doc, this pain med isn’t

working as well as it used to.” Trying to explain the distinction between euphoria and pain reduction to someone can be like trying to recite beautiful poetry with a mouthful of marbles. It just doesn’t come out right. Besides, the euphoric feeling of an opiate sure goes a long way when trying to overcome the suffering of a perceived terrible pain. Tolerance to euphoria does develop quite quickly in some. This is the trap. As a provider, this distinction of euphoria versus absence of pain is always in the decision making process when it comes to escalation or perhaps opiate cycling. So this is my thought process: First, it is my policy to never escalate someone over 120 mg morphine equivalents daily for nonmalignant pain. Anything more increases the risk for serious adverse events

by at least six-fold depending on the study. So how do I overcome this? I start by making sure I have a solid diagnosis warranting an opiate as one of many tools to use to manage pain. I then make sure the patient is a solid candidate to responsibly take these medications. I monitor for patient compliance as much as I can (insurance changes have made this more difficult lately). Then I explore why someone might be incompatible for a specific opiate or delivery method. I also look for other reasons why someone might fail standard opiate therapy (requiring escalation beyond 100mg morphine equivalents daily). These include: • Opioid malabsorption • Genetic defects • Neuroinflammation • Hormonal Deficiencies

In summary, most patients do not need or require high doses of an opiate for chronic nonmalignant pain management. If they do, patient aberrance is not usually the reason. Instead, there has likely been a failure to differentiate euphoria from pain relief leading to euphoria tolerance and or a failure to recognize why a patient has failed standard opiate dosing therapy as listed above. While complicated, time consuming, and frustrating at times, responsible, comprehensive pain management is possible even in this health care environment. Ty Thomas, MD is a pain management specialist with Alabama Pain Physicians.

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Workflow is Key to ICD-10 Readiness By Tammie Lunceford, CPC BSHA

It is now less than 30 days until the implementation of ICD 10 on October 1, 2015. Most medical entities have completed training but not assessed provider documentation for improvement goals. Many providers and billing offices are completely relying on their electronic medical record to code diagnoses for them. While conducting training sessions, I have encouraged practices to assure they are able to view ICD 10 coding in their current EMR workflow. They should walk through the ICD 10 options on at least one or two patients a day and let the billing office review the electronic superbill. If there is not consistent use of the EMR, the physicians may not be fluent in using the diagnosis coding option in the EMR. Many physicians utilize voice recognition or continue to dictate to avoid clicking through the EMR. These physicians likely rely on a paper superbill or handwritten descriptions to list diagnoses. Allowing a “have it your way” work-

flow for physicians can create multiple problems for ICD 10 implementation. The billing office will deal with different workflows related to charge capture for each physician, if it is a group practice. One practice removed all the ICD 9 codes to force the physician to write in diagnoses, but the physicians were not specific enough in the description to code a valid diagnosis, which then caused the staff to refer to the documentation. The physicians are not going to write multiple diagnoses needed for risk adjustment. Practices without an EMR are dealing with more workflow issues. There are resources to code through an electronic

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app or crosswalk but those who elected to not implement an EMR are not likely to look for technology to assist them. What Should You Do? • Reach out to a consultant for assistance • Look for options to create an electronic superbill • Assess the number of provider workflows • Review provider documentation and benchmark for improvement goals • Review clinical best practices with your EMR vendor • Prepare or obtain a top 50 diagnosis crosswalk as a quick reference for workstations While CMS has offered some leniency, other carriers have not. It will cost commercial carriers if the risk adjustment is not accurate. The risk adjustment relies on ICD 10 for accuracy, which is why ICD 10 was not delayed. There are resources to assist in your success. Don’t wait, and get prepared now.

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Radiofrequency Ablation for Barrett’s Esophagus By Mark R. Janich, MD

With an estimated 20 percent of American adults affected by Gastroesophageal Reflux Disease (GERD), physicians diagnose patients with this disease daily. While the symptoms of GERD are troublesome, an estimated 10 to 15 percent of these patients will develop a serious complication, Barrett’s Esophagus. Barrett’s esophagus is a condition in which the lining of the esophagus changes and it becomes similar to the tissue that lines the intestines. While frequency and severity of GERD does not affect the likelihood of Barrett’s, it is more likely to occur in patients who developed GERD at a young age or have had a longer duration of symptoms. Dysplasia, a precancerous change in tissue, can occur in any Barrett’s tissue. Endoscopy is utilized to diagnose Barrett’s. Biopsy confirmation is required for a definitive diagnosis, but the tissue is visible during endoscopy. Radiofrequency ablation can safely remove the abnormal cells before they become cancereous. During the procedure, a gastroenterologist inserts an endoscope down the esophagus of a sedated patient. The endoscope has an electrode pad attached to the tip that delivers short pulses of energy to destroy the Barrett’s tissue that lines the inner surface of the esophagus. Birmingham Gastroenterology Associates utilizes the HALO system for this procedure. The key to this technology is the fact that the Barrett’s epithelium is approximately ½ millimeter thick, and the HALO system can deliver bipolar energy that ablates to a depth of greater than ½ millimeter, but less than one millimeter. HALO ablation removes the Barrett’s cells, but limits damage to the surrounding healthy tissue. The superficial ablation results in an extremely low complication rate. The patient has an outpatient procedure and is home the same day. It is recommended that patients with longstanding GERD should undergo screening for Barrett’s. If a patient has Barrett’s without dysplasia, they should have a surveillance endoscopy every three years to monitor for dysplasia and early cancer. Patients with Barrett’s esophagus and dysplasia will require more frequent monitoring. Data shows that each year two patients in 1000 with simple Barrett’s will progress to esophageal cancer. This number increases significantly with progressive forms of dysplasia, so the use of radiofrequency ablation for any form of dysplasia is appropriate. Mark R. Janich, MD practices with Birmingham Gastroenterology Associates.

Research Notes Potential Drug Lessens Neurodegeneration in Parkinson’s

The first test in a mammalian model of a potential new class of drugs to treat Parkinson’s disease shows abatement of neurodegeneration in the brains of test rats and no significant toxicities, UAB and Pfizer Inc. researchers report online in The Journal of Biological Chemistry. At present, there are no therapies to slow the progression of Parkinson’s disease, a common neurodegenerative disorder that affects up to 10 million people worldwide. The rat model overexpresses the protein α-synuclein in one side of the brain. This leads to degeneration of the dopamine-generating neurons of the substantia nigra region of the brain. “Because our observations were limited to a four-week period, we are not sure whether neurodegeneration associated with α-synuclein is truly prevented or just delayed,” senior author Andrew West, PhD wrote. Andrew West, “Either way, any interrupPhD tion of neurodegeneration associated with Parkinson’s disease might represent a significant therapeutic advance.” The rat model used mimics two cardinal features of Parkinson’s disease: degeneration of dopamine neurons in the brain, and the accumulation of alphasynuclein in surviving neurons. Patients with Parkinson’s have significant degeneration of dopaminergic neurons in the substantia nigra, up to 70 percent losses at even mid-stages of their disease, and abnormal accumulation of α-synuclein in many of the surviving neurons that occurs years earlier. Details of how Parkinson’s begins and progresses are still unclear. The potential new class of drugs is kinase inhibitors that are active against the enzyme “leucine-rich repeat kinase 2” (LRRK2, pronounced “lark two”). Two clues point to LRRK2 as a possible target for therapy in Parkinson’s. First, about two percent of Parkinson’s disease patients have a specific mutation in LRRK2 called G2019S that increases the kinase activity of LRRK2; this suggests that increased activity plays a role in progression of the disease. Second, the West lab last year reported that gene “knockout” rats with no LRRK2 are completely protected from neurodegeneration in the α-synucleinoverexpression model, suggesting pharmacological inhibition may be a viable approach. The model uses rats that express a cloned human G2019S-LRRK2 gene. Then these rats are injected in the brain (specifically the substantia nigra) with a virus that expresses human α-synuclein. Test rats were fed the test inhibitor for four weeks, beginning at the time of infection. The small-molecule inhibitor easily passes through the blood-brain barrier to reach the brain from the bloodstream. Besides protecting against neurodegeneration, the inhibitor also lessened an inflammatory response by microglial cells seen

in the brain in association with G2019SLRRK2 expression. West and colleagues also tested the inhibitor in outbred, wild-type rats, animals that are distinct from the strain that has the human G2019S-LRRK2. With the placebo, these rats showed about a 20 percent loss of neurons after four weeks of α-synuclein overexpression; but treatment with the inhibitor completely abated that loss. This result suggests that the inhibitor also has efficacy in the absence of the human G2019S-LRRK2. “That is important because only two percent of Parkinson’s disease patients have the G2019S mutation,” West said. “These wild-type rats really excited us because it suggests the therapeutic action of the drug may extend to the majority of Parkinson’s disease patients.”

The First Toxin Ever Found for M. Tuberculosis

Despite 132 years of study, no toxin had ever been found for the deadly pathogen Mycobacterium tuberculosis, which infects nine million people a year and kills more than one million. Now Michael Niederweis, PhD, professor of microbiology at the UAB, and colleagues have described the first known toxin of this pathogenic bacterium. This toxin — Tuberculosis Necrotizing Toxin, or TNT — is the founding member of a novel class of previously Michael unrecognized toxins presNiederweis, PhD ent in 246 bacterial and fungal species, as determined by protein sequence similarity. Before the Niederweis discovery, those toxins were identified only as the “Domain of Unknown Function 4237.” Bacteria with those newly recognized toxins include Yersinia pestis, the pathogen that caused the bubonic plague known as the Black Death in Medieval Europe, and Listeria monocytogenes, one of the most deadly food-borne infections and the cause of Blue Bell Creameries recalls this year. The lack of an identified toxin in M. tuberculosis had contrasted with nearly all other pathogenic bacteria whose toxins contribute to illness or death. M. tuberculosis is notable for its survival inside macrophages, the immune cells that ingest and destroy infectious bacteria. The newly identified TNT plays a key role to induce necrotic death of the infected macrophage. Thus, TNT enables the M. tuberculosis bacteria to escape from the macrophage and disseminate to other host cells in a person infected with tuberculosis, thus contributing to the survival of M. tuberculosis and spreading the disease. “The battle between M. tuberculosis and the human immune system to control the fate of infected macrophages is critical in determining the outcome of the infection,” Niederweis wrote in the TNT paper. “The control of host cell death is of utmost importance for the survival, escape and dissemination of M. tuberculosis.”

Drug Improves Cognition in Alzheimer’s Disease-Model Mice

Long-term administration of a drug that mimics the hunger-signaling hormone ghrelin protected Alzheimer’s disease-model mice from memory deterioration, despite a highglycemic-index (GI) diet, according to research published in the journal Inga Kadish, Scientific Reports by UAB PhD investigator Inga Kadish, PhD and colleagues. In 2013, Kadish found that longterm (four months) administration of the ghrelin agonist — an experimental drug that binds to the ghrelin receptor and produces a greater response than ghrelin — protected Alzheimer’s disease-model mice from memory deterioration. The current paper expands that research by including a possible risk factor for Alzheimer’s disease, the high-GI diet. With chronic diseases like diabetes and Alzheimer’s, you need to do a longterm study,” said Kadish, an assistant professor in the Department of Cell, Developmental and Integrative Biology, UAB School of Medicine. “So we did the long-term experiment with the worst-case scenario, a high-GI diet. Alzheimer’s disease has 10 or 20 risk factors, and some of the strongest risk factors are diabetes or metabolic syndrome.”

In contrast to short-term administration of the ghrelin agonist drug — which impairs insulin sensitivity and glucose tolerance, which are signs of metabolic syndrome and diabetes — the researchers found that the long-term ghrelin agonist treatment did not impair insulin signaling and glucose tolerance in Alzheimer’s disease mice fed a high GI diet. The Alzheimer’s disease-model mice have three mutations in the amyloid beta (A4) precursor protein that have come from human families in Sweden, the Netherlands and Iowa that have familial Alzheimer’s. These mice show a deterioration in spatial learning as they age. The test mice fed with the ghrelin agonist and the high-GI diet showed long-term cognitive enhancement as compared to the mice fed with a normal diet or high-GI diet only. The test mice were also more active with reduced body weight and fat mass. And the test mice showed a beneficial impact of the long-term ghrelin agonist treatment on insulin signaling pathways in hippocampal brain tissue. Alzheimer’s patients show significant shrinkage of the hippocampus, a part of the brain cortex that has a key role in forming new memories. The present results suggest that ghrelin might improve cognition in Alzheimer’s disease via a central nervous system mechanism involving insulin signaling.

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Grand Rounds AQAF Leaders Named to Malcolm Baldrige Award Board

Alabama Quality Assurance Foundation (AQAF) CEO Wes Smith, MD and Vice President of Quality Liz Prosch, have been named to the Board of Examiners for the 2015 Malcolm Baldrige National Quality Award. The Baldrige Award is the nation’s highest honor for organizational

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innovation and excellence. Appointed by the National Institute of Standards and Technology Director, examiners are responsible for reviewing and evaluating applications submitted for the Baldrige Award, as well as other assessment-related tasks. The examiner board is composed of more than 350 leading experts selected from industry, professional, trade, education, health care and nonprofitvorganizations from across the United States. Named after Malcolm Baldrige, the 26th Secretary of Commerce, the Baldrige Award was established by Congress in 1987. Awards may be given annually to organizations in each of six categories: manufacturing, service, small business, education, health care and nonprofit.

Snowmageddon Survivor to Speak at Medical West Meeting

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Medical West’s Diabetic Education Meeting in September will feature special guest speaker, Kelly Garner. During the “snowmageddon” storm of 2013, Garner was helping a stranded motorist when he suddenly disappeared. As the temperature dropped to 9° F that night, the worst was feared for Garner. When a search party found him at the bottom of a 40 foot ravine the next morning, they were astonished to find that he was still alive. With a head injury and multiple broken vertebrae in his back, not to mention being out all night in the frigid temperature, it was doubtful he would survive, and if he managed to live, he was not expected to ever walk again or have meaningful brain function. In the end, not only did Garner survive, but he completed the Mercedes HalfMarathon this past February. Garner, a diabetic himself, will share his story of endurance and the importance exercise played in his recovery. The meeting will be held on Thurs-

day, September 24th at 6 p.m. at Medical West Hospital - Civic Room located on Level C of the Professional Building. Please call or email to register for this meeting at 205.481.7496 or smaxwell@ uabmw.org.

Gregory Mayberry, MD Joins Norwood

Gregory F. Mayberry, MD is joining the Department of Family Medicine at Norwood Clinic Brookwood. Mayberry is board certified in Family Medicine. He received his medical degree from Saba University School of Medicine in Gregory F. the Netherlands and comMayberry pleted his residency at St. Vincent’s East as Chief Resident.

Gardendale Physician Associates Joins St. Vincent’s

Gardendale Physician Associates has joined St. Vincent’s Health System. The new practice name is St. Vincent’s Primary Care – Gardendale. “Gardendale Physician Associates decided to move our medical practice to Gardendale over ten years ago. With the support of patients in this area we have been very successful,” said Nolan L. Hudson, MD, FACP, Medical Director for Gardendale Physician Associates. “Major changes in healthcare are coming. In order to preserve what Nolan L. we have accomplished and Hudson continue to provide services for this area in the future, we felt it was important for us to align with a major health system in the Birmingham area. We look forward to a long and rewarding relationship with St. Vincent’s for us and our patients.”

Sirote’s Pate Honored as Lawyer of the Year in Birmingham Healthcare Law

Sirote & Permutt healthcare attorneys Lenora Pate and Cynthia Ransburg-Brown were included in The Best Lawyers in America© for 2016. The annual directory recognizes those who most excel in the legal profession based upon evaluations by Lenora Pate colleagues and other legal professionals. In addition to her recognition among the best lawyers in the healthcare category, Lenora Pate was also specifically chosen as Cynthia 2016 Health Care Law RansburgBrown “Lawyer of the Year” for Birmingham. According to Best Lawyers, “Only a single lawyer in each practice area in each community is being honored as a ‘Lawyer of the Year.’”

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Grand Rounds UAB Adds Leading Surgeon as head of Department of Surgery

Herbert Chen, MD, an internationally recognized surgeon and medical educator, has been named chair of the Department of Surgery at the UAB School of Medicine and surgeon-in-chief of UAB Hospital. Chen, Chen comes to UAB Herbert MD from the University of Wisconsin School of Medicine and Public Health, where he is the Layton F. Rikkers, MD, Chair in Surgical Leadership, chair of the Division of General Surgery, vice chair of Research for the Department of Surgery and professor in the departments of Surgery, Biomedical Engineering and Pediatrics. Chen will succeed longtime chair Kirby I. Bland, MD, who will continue his surgical practice as he steps down from the top post after 16 years of leadership. Chen is a specialist in endocrine surgery, specifically in thyroid disease, hyperparathyroidism, adrenal neoplasms and neuroendocrine tumors. He has mentored more than 100 faculty, postdoctoral fellows, residents, medical students and undergraduates in his lab. He has published more than 430 research and review articles and has edited 12 textbooks. A native of Wisconsin, Chen received his undergraduate degree from Stanford

University and began his medical education at the Duke University School of Medicine, graduating in 1992.

Monheit One of Few Worldwide to Treat with KYBELLA™

Total Skin and Beauty Dermatology Center is the first in Alabama to introduce the FDA-approved injectable drug, KYBELLA™ which is used to improve the appearance of submental fullness, often referred to as double chin. Gary Monheit, MD, Total Skin & Beauty’s founding dermatologist, is one of the few doctors worldwide trained to administer KYBELLA™. “I have worked on the clinical studies of this product for the last 10 years, and it has been a satisfying journey. Now we have a nonsurgical method to remove submental fat and correct neck and chin contour,” Monheit said. Each in-office treatment session is typically 15 to 20 minutes. When injected into subcutaneous fat, KYBELLA™ causes the destruction of fat cells. Once destroyed, those cells cannot store fat. After the aesthetic response is achieved with KYBELLA™, re-treatment is not expected. Many patients experience visible results in two to four treatment sessions spaced at least one month apart. Up to six treatments may be administered.

The most common side effects are swelling, bruising, pain, numbness, redness and formation of areas of hardness in the treatment area. In clinical trials, the incidence and severity of most side effects decreased with subsequent treatments. KYBELLA™ can cause serious side effects, including trouble swallowing and nerve injury in the jaw that can cause an uneven smile or facial muscle weakness.

Tara Fales, MD Joins Cullman Regional

Cullman Regional Medical Center welcomes Tara Mitchell Fales, MD to the Medical Staff. Fales, who is joining Cullman Internal Medicine & Pediatrics, received her medical degree in 2012 from The UAB School of Medicine after completing her undergradTara Mitchell uate studies in Healthcare Fales, MD Management from The University of Alabama. Fales completed her Pediatric Residency Program at The University of Tennessee Health Science Center in Memphis, Tennessee in June 2015.

Waller Receives Top Honors from AHLA for 9th Consecutive Year

industry, recently received Top Honors from the American Health Lawyers Association (AHLA) for the firm’s continued commitment to the advancement of professional development in healthcare law through its participation in the AHLA. The June 2015 issue of AHLA Connections magazine highlights Waller as the nation’s fourth largest healthcare law firm based on AHLA membership with 163 current members. This is the firm’s ninth consecutive year on the industry-esteemed Top Ten list.

Bill Clifford, MD Joins Trinity

William P. “Bill” Clifford, MD has joined the practice of Trinity Medical Clinics at Chelsea. Clifford, who is board certified in Family Medicine, received his medical degree from UAB. He completed his residency with the Mayo Clinic and William P. the University of AlaClifford, MD bama. Prior to medical school, Clifford received his Juris Doctorate degree from Emory University School of Law. A member of the Alabama National Guard, Clifford is a flight surgeon and has served in both Afghanistan and Kosovo.

Waller, one of the nation’s preeminent law firms serving the healthcare

Birmingham Medical News

SEPTMEBER 2015 • 27

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