Women in Medicine v o l u m e
In this issue: Women in Medicine Month - Physician Spotlights
Business of Medicine - Hassle Factor Log
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Wendy Parnell, MD, just completed her first year in practice.
Dallas County Medical Society PO Box 4680, Dallas, TX 75208-0680 Phone: 214-948-3622, FAX: 214-946-5805 www.dallas-cms.org Email: lauren@dallas-cms.org
DCMS Communications Committee Roger S. Khetan, MD.............................................. Chair Robert Beard, MD Gene Beisert, MD Suzanne Corrigan, MD Seemal R. Desai, MD Daniel Goodenberger, MD Gordon Green, MD Steven R. Hays, MD C. Turner Lewis III, MD David Scott Miller, MD
DCMS Board of Directors Richard W. Snyder II, MD.................................. President Cynthia Sherry, MD..................................President-Elect Jeffrey E. Janis, MD..........................Secretary/Treasurer Shelton G. Hopkins, MD.......... Immediate Past President Mark A. Casanova, MD Wendy Chung, MD R. Garret Cynar, MD Sarah L. Helfand, MD Michael R. Hicks, MD Rainer A. Khetan, MD Todd A. Pollock, MD Kim Rice, MD Christian Royer, MD
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Pr es i de nt’s Pa ge Can You Hear Me Now?
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Me mber s hi p Ma tter s Why Being a Member is Important to Erin Roe, MD
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Wome n i n Medi ci ne S potl i ght: Riva Rahl, MD
DCMS Staff Michael J. Darrouzet................... Chief Executive Officer Lauren N. Cowling................................ Managing Editor Mary Katherine Allen........................... Advertising Sales Articles represent the opinions of the authors and do not necessarily reflect the official policy of the Dallas County Medical Society or the institution with which the author is affiliated. Advertisements do not imply sponsorship by or endorsement of DCMS. ©2012 DCMS
According to Tex. Gov’t. Code Ann. §305.027, all articles in Dallas Medical Journal that mention DCMS’ stance on state legislation are defined as “legislative advertising.” The law requires disclosure of the name and address of the person who contracts with the printer to publish legislative advertising in the DMJ: Michael J. Darrouzet, Executive Vice President/CEO, DCMS, PO Box 4680, Dallas, TX 75208-0680.
Dallas Medical Journal (ISSN 0011-586X) is published monthly by the Dallas County Medical Society, 140 E. 12th St, Dallas, TX 75203.
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Bus i ne s s of Medi ci ne : Hassle Factor Log
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Wome n i n Medi ci ne S potl i ght: Geetanjali Srivastava, MD
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Wome n i n Medi ci ne S potl i ght: Wendy Parnell, MD
Subscription rates $12 per year for members; $36, nonmembers; $50, overseas. Periodicals postage paid at Dallas, TX 75260.
Postmaster Send address changes to: Dallas Medical Journal, PO Box 4680 Dallas, TX 75208-0680.
submit letters to the editor to lauren@dallas-cms. org visit us online at www.dallas-cms.org • September 2012 •
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Can You Hear Me Now? Perhaps the most transformative innovation improving health care in North Texas in years is almost upon us. In the next 3 months, the first 13-county regional, cross-system, Health Information Exchange will go on-line. The benefits of having medical connectivity and access to a patient’s complete medical history in real time in cyberspace are intuitively enormous. Can anybody say, “one-stop shopping”? Being able to gather medical information from across hospital systems and among all physicians’ offices electronically in a timely fashion will render enormous healthcare delivery dividends. For example, accessing a patient’s medical history from his internist’s office may help avoid ordering unnecessarily a repeat test. Pulling up a previous office EKG in the middle of the night and determining that those EKG changes you are seeing in the Emergency Department actually are pre-existing may save an expensive admission and nuclear stress test. It will significantly reduce the number of unnecessary redundant tests that are performed in the emergency setting because we don’t have ready access to the patient’s history. I cannot tell you how many times in my own office experience that a patient is referred for a second opinion regarding an abnormal blood test, echocardiogram or coronary angiogram, and we don’t have the pertinent records at the time of the initial office visit. The value of the visit is minimized, and often we have to schedule another appointment or telephone conference for when we have access to the information. Both the physician’s and patient’s time is wasted, and higher cost is introduced into the system from the need to schedule unnecessary clinic time and redundant tests. But more importantly, the patient is placed at risk because diagnosis and treatment plans are delayed. In this regard, an HIE can have an enormous beneficial impact on both the quality and cost of health care. Wait a minute! Isn’t that a major vision of health system reform? This is exactly the type of innovative development that Eric Topol, MD, talks about in his epic tome, “The Creative Destruction of Medicine: How the Digital Revolution will Create Better Health Care.” As I write this piece in mid-August, we are in the midst of the West Nile Virus epidemic in Dallas County. As part of DCMS’ recommendation to the Dallas County Commissioners Court in support of aerial spraying, we suggested that the County could actively monitor the area hospital EDs for unusual visits or upticks in symptoms that could be associated with the use of an aerial pesticide. An HIE would be the perfect technology to help monitor the evolution of an emerging regional health emergency such as this and coordinate an emergency response.
HIE Players and HIE Impact The HIE in North Texas will encompass 13 counties (Collin, Dallas, Denton, Ellis, Fannin, Grayson, Hunt, Johnson, Kaufman, Parker, Rockwall, Tarrant, Wise). Total patient population served in 13 counties is 6,595,234. All licensed physicians in the 13-county region will be invited to participate (that’s 11,796), as will all licensed hospitals in
President’s Page the region (137). So far 80 percent of the hospitals and 60 percent of the physicians have signed letters of agreement. The goal is to have 100-percent participation of all physician and hospital providers. The North Texas HIE is one of 16 Regional HIEs sanctioned by the State of Texas through a statewide HIE cooperative grant. The HIE in the Metroplex was created and is governed by the North Texas Accountable Healthcare Partnership (www.ntahp.org), a 501(c)3 nonprofit entity. The Partnership board is unique among healthcare cooperative enterprises in that it is populated with stakeholders representing physicians, hospitals, employers, insurance carriers, and patients (consumers) as equal partners. Through a strategy of data sharing, defined metrics and public accountability, the mission of the Partnership is to promote and reward local healthcare clinical performance that is coordinated, transparent and value-based. Fundamental to the success of this strategy is the simultaneous creation and support of the regional Health Information Exchange. The Partnership HIE will allow for the establishment of patient registries as well as point-to-point data exchange to improve real-time sharing of clinical data.
The Winding Path Toward an HIE This is an enormous project and it has undergone multiple false starts. The HIE experience in the United States is littered with the shipwrecks of failed attempts. To better understand the challenges of establishing an HIE, it is helpful to review the whimsical winding historical journey of the health information exchange in North Texas. In late 2004, Congressman Pete Sessions’ Healthcare Task Force met at Presbyterian Hospital. The conversation included a briefing about President Bush’s efforts to engage physicians and the healthcare industry into the world of electronic records. Les Secrest, MD, and Michael Darrouzet, our EVP/CEO, represented DCMS. In March 2005 Congressman Sessions wrote a letter to his advisory group to explore the introduction of a Regional Health Information Organization into the Dallas healthcare market. Later that month the task force hosted an initial meeting that included Congressman Sessions; John Gill, MD; Joel Allison, president and CEO of Baylor Healthcare System; and DCMS staff. After months of discussion, this initial effort failed primarily because of a lack of an effective governance structure and excess vendor influence. The first attempt ended. In 2006, a second effort was attempted with the formation of the North Texas RHIO Steering Committee, under Dr. Secrest’s direction. DCMS, Tarrant County Medical Society, and the Dallas-Fort Worth Hospital Council were the principles. In April 2007, just as the steering committee was preparing to transform itself into a nonprofit organization, TCMS withdrew from the project due to financial reasons. This withdrawal ended the second attempt to form a regional health information exchange, as it was deemed that without a true regional effort, the exchange would fail. In early 2008, unwilling to let the issue die and believing that physicians must take a lead role in creating an exchange, DCMS formed a RHIO Strike Team, led by Kevin Magee, MD. This effort was short-lived because of a lack of consensus between the DFWHC and DCMS about the need for an independent nonprofit. The Strike Team disbanded. DFWHC and DCMS subsequently went on their own paths toward establishing a regional exchange. DFWHC
Richard W. Snyder II, MD
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President’s Page sought a Beacon Grant but was not successful because the application was not seen to include enough stakeholders. In March of 2008, DCMS created its HIE 5 Committee. The committee experienced the most momentum of any effort to date, collecting significant financial contributions from area hospitals and hiring a consultant to write a business plan for the region. The final business plan was shared with the funding hospitals. Despite their initial buy-in, the hospitals declined to act on the plan, saying that they wanted to seek initial funding from outside sources. DCMS next sought to use Project Access Dallas as the focal point of the renewed effort to create an exchange, now called an HIE by those in Washington. (RHIO was a tainted name by now due to so many failures across the country.) In mid-2009, DCMS made a final attempt to secure funding for a physician-led HIE by requesting that private hospital systems that were partners in PAD financially underwrite the project. This request was denied. Until this point, the failed HIE experience in North Texas seemed to derive from a deficiency in at least one of four separate, but critical, components: an effective governance structure, financing, full participation of all regional partners, and involvement of all four primary stakeholder groups (physicians, hospitals, payers, and industry). In May 2009 the landscape changed. In the midst of congressional hearings about health system reform, the concept of the Accountable Care Organization was introduced. Using the ACO model as a starting point of discussion, representatives from the four stakeholder groups formed a steering committee and discussed how to address the high cost of health care in North Texas. Part of the motivation was to explore the potential of gain-sharing models and the possibilities materializing in the emerging world of capitation. DCMS’ Michael Darrouzet was named chairman of this committee. It soon will become apparent to all involved that the success of the HIE largely was a result of Michael’s keen insight, relentless nurturing and skillful stewardship of the process. Having learned from failed HIE attempts, the steering committee agreed to an organizational structure with a solid and effective governance system based on each stakeholder group having equal representation on the board. This relationship is unique in healthcare delivery models and will be key to the success of the entity. In April 2010 the steering committee agreed to form the North Texas Accountable Healthcare Partnership as a 501(c)3 nonprofit corporation in order to apply for federal/ state HIE grant funds that were allocated to Texas from federal stimulus funds. Here, three of the four elements for a successful HIE project appeared to have been met: full stakeholder participation, effective governance and an adequate start-up funding source (the feds). The regional component was satisfied by the federal requirements for application for the funding. The feds defined the counties and regions that would have to work as partners if they wanted to apply for the federal grants. On Sept. 30, 2010, the NTAHP was formed. Mr. Darrouzet was “promoted” from chairman of the steering committee to chairman of the NTAHP board, and Bryan White, former DCMS director of socioeconomics, was selected as the executive director of the HIE. The Partnership chose diabetes and congestive heart failure as the two chronic illnesses for which to develop “shared savings models.” For many months, the four workgroups met and planned “shared savings” strategies including Metrics, Care Coordination, Common Plan Designs, and Rewards.
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In November 2011 the Centers for Medicare and Medicaid Services and the state approved an amendment to the state grant award, opening funding to NTAHP totaling more than $4.9 million over the next 3 years, contingent on meeting performance goals. The NTAHP grant tied for top grant applications in the nation. I was added to the board as a DCMS representative. In March 2012 Orion Health was chosen as the HIE vendor for North Texas. This is the same vendor that the State of Massachusetts recently chose for its statewide Medicaid program. That same month Joe Lastinger accepted the position as CEO of the Partnership, and John Flores, MD, Denton County Medical Society; Matt Weyenberg, MD, Collin-Fannin CMS; and Jim Cox, MD, and Sandra Parker, MD, Tarrant CMS; were added to the board. The North Texas HIE will go “live” this fall. I have seen a demonstration of the HIE and I am very excited. The Partnership HIE also will offer the opportunity to subscribe to an on-line EMR service for a nominal fee that will satisfy CMS meaningful use requirements. This particularly will be valuable to solo or small group practices for which the economies of scale for a traditional EMR are challenging. Although the HIE has come very far and the benefits seem obvious, obstacles remain to be addressed. A major risk to the long-term success of the HIE will be the financial sustainability of the project after the federal grant monies expire. Money makes the world go round, and this is true for an HIE. However, the money saved from the reduction of unnecessary hospitalizations and redundant testing could be considerable and dwarf the cost to run the Partnership. The four stakeholder groups need to realize a financial reward for participating monetarily in the NTAHP investment. Only if all four partners participate in the reward for the risk taken can a true win-win dynamic materialize and financial sustainability be secured. Preserving the hospital participation in the project also could present a challenge. Some private hospital systems may view the North Texas Regional NTAHP HIE as a threat to their nascent HIE efforts. However, the full potential of an HIE will not be realized unless it functions across all hospital systems. If we have an HIE system that is just a patchwork of compartmentalized information exchanges, the sweeping promise and extensive benefits of a comprehensive global HIE will be minimized. Some hospital systems may also view the Partnership HIE as a threat to their individual competitive strategies, and the siloization of their patient base and physicians. An intersystem HIE of this magnitude will break down some barriers between hospital systems that otherwise would limit the outflow of physician referrals and patients (affectionately termed “leakage”), but the overriding consideration should be the net clinical benefit to the whole healthcare delivery system derived from the enhanced integrated care and cost containment. If all stakeholders maintain the primacy of the patient in this project, the NTAHP will be a stunning success. The huge winners will be all the patients in North Texas. Just as the connectivity of the telegraph and telephone linking all cities, towns and communities in America was a dramatic, transformative moment in our history, so, too, will be the NTAHP HIE linking all the physician and hospital providers in North Texas. “Can you hear me now?”
Follow Dr. Snyder on Twitter @DCMSPres!
Thursday, Sept. 27 T 806he Sh 6 - 8 p.m. 0 P ops
Go r d o n Bie r s ch B rewery & Re s t a u ra n t
ark at P La ar Da ne, Suk Lan llas ite e 125
Spruce up your referral base, network with colleagues and have fun with the Dallas County Medical Society. Light hors d’oeuvres and drinks will be served. Questions? Contact Cara, director of event planning, at 214.413.1423 or cara@dallas-cms.org.
RSV PFAX to 214.946.5805 or e-mail information to cara@dallas-cms.org. dcms member name: e-mail:
phone: yes, i will be there.
with
guest(s)
if applicable, guest name(s)
See www.dallas-cms.org for details.
save the date for the 2012 dcms member roundup friday, november 2 6 - 9 pm at eddie deen’s ranch details will be available soon!
Accountant (CPA) / Tax Services
Legal Services
Paula Allgood, CPA……Beaird Harris & Co, P.C. 972.503.1040……PaulaA@bh-co.com
Michael H. Saks……Wright, Ginsberg, Brusilow, PC 972.788.1600……msaks@wgblawfirm.com
Lori A. Eads, CPA……Bland, Garvey, Eads, Medlock + Deppe, P.C. 972.231.2503……leads@taxsmart.com
W. Darrell Armer*……Looper, Reed & McGraw, PC 214.922.8923……darmer@lrmlaw.com *Board Certified-Health Law by The Texas Board of Legal Specialization
Design / Build Medical & Dental Contractor Grady Herzog……Structures & Interiors Inc. 817.329.4241……gherzog@structures-interiors.com
Electronic Medical Records Leslie Warren……EMR Advisory Group 972.898.5671……lwarren@emradvisorygroup.com
Employee Benefits Amy Rickman……Lockton Dunning Benefits 940.384.2720……ARickman@lockton.com
Financing / Banking Gary West……BB&T 469.791.4502……GMWest@BBandT.com
Marketing / Public Relations Barbara Steckler……Concepts in Medical Marketing 972.490.7636……barbarasteckler@yahoo.com
Medical Malpractice / Commercial Insurance James Patterson, CIC, AAI……Agapé Healthcare Partners Metro 817.329.4200……jim@agapeins.com
OSHA Compliance Jessica James 469.360.1367……jsscjames@aol.com
Personnel Recruitment
Financial / Estate / Insurance Planning
Jan Harris, CPC……J. Harris Co. Personnel Services Inc. 214.369.9545……j.harrisco@verizon.net
Mark A. Trewitt, CFP®, CLU, ChFC, AEP Integrated Financial Solutions Group 972.312.1337……mark@ifsgllc.com
Practice Management / Billing / Consulting David Loomis……The Health Group 972.792.5700……dloomis@thehealthgroup.org
Healthcare Furnishings
Promotional Products / Wearables / Filing Systems
Lisa Locke……bkm Total Office of Texas, LLC 214.902.7215……llocke@bkmtexas.com
Nance Lindstrom……Safeguard Business Systems & Promotional Products 972.596.8282……rich.nance@verizon.net
Healthcare Interior Designer Laura Ginsberg……Medical Space Design, Inc. 972.566.6771…….lauraginsberg@msddallas.com
Real Estate (Healthcare) M.W. (Hugh) Resnick……Pizel & Assoc. Commercial Real Estate 972.404.0008……hugh@pizel.com
Telecommunications Charlie Hubbard, PMP……HUBCO Communications, Inc. 469.293.3081……chubbard@gohubco.com
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MEMBERSHIP MATTERS by Erin Roe, MD Dallas County Medical Society and Texas Medical Association made a big impression on me when I moved to Dallas three years ago. I came here to continue my medical training in endocrinology and diabetes at UT Southwestern and Parkland Hospital. Joining both organizations was one of the best decisions I made during my first week. I have grown to admire our medical societies’ incredible organizational focus and commitment to advocating for physicians. When Texas physicians focus on a problem, DCMS and TMA develop a polished and professional strategy that delivers that message to produce results we all can be proud of. Training in medicine today, it’s hard to escape the lament of those physicians who insist that younger physicians have missed out — that the “golden years” of medicine are behind us and we must all acquiesce to the numerous external forces that challenge our ability to deliver good care and threaten the physician-patient relationship. In DCMS and TMA, however, I have found countless physicians of all specialties and career stages and amazing staff members who refuse to resign themselves to that mentality. Their energy and desire to change and improve the system from within is a great source of inspiration. Texas physicians are lucky that our Medical Practice Act predicates itself on the primacy of the physician-patient relationship and the imperative for autonomous medical decision-making. This legislative approach to the practice of medicine is not necessarily embraced in other states. I’m continually impressed with the forethought and persistence that Texas physicians must have shown during the past decades to craft policy that protects medicine’s highest ideals. And even in the three years that I have participated, whether it’s a lobbying visit to Austin or a trip to Capitol Hill, the same tenacity of the physician lobby comes through, proudly wearing white coats, compiling and presenting insightful research, and delivering a message nuanced in the political realities of the day, but squarely focused on what’s best for patients. We certainly do not conform to the stereotypical images of physicians loudly complaining that they don’t make enough money, nor will we watch idly as change is thrust upon us. I am proud to be part of such a well-organized and visionary physician community as DCMS and TMA. When physicians come together around a cause, those organizations unify and amplify
our many voices. The sweeping medical liability reforms are only one example to the rest of the country of the potency of our physician lobby. Just as important, although receiving less attention, are our immunization programs, public health initiatives and thwarted Medicaid funding cuts that preserve access and improve the health and quality of life for our fellow Texans. In addition to the benefits inherent in membership, one of the great privileges I have had was to volunteer on the DCMS and TMA membership committees, an opportunity I hope more physicians pursue. In addition to the dutifully committed staff members, a wonderful entrepreneurial spirit permeates the committees. Dues are viewed as an active investment that the physician makes in his or her community, rather than as a payment that one is obligated to make out of a sense of “good citizenship.” This attitude moves DCMS and TMA to continually seek new and innovative ways to reach out and serve — whether through new technology in the DocBookMDTM facilitates secure physician communication. It’s fun to volunteer for an organization that has good ideas — and the vigor and initiative to get them done! Membership in DCMS and TMA has helped me feel connected and committed to organized medicine since I moved far away from my family in Ohio. As a medical trainee transitioning into practice, this connection has been pivotal in my decision to build my endocrinology practice at Baylor University Medical Center. I’m excited to put down roots and proud to call Texas my new home. Dr. Roe has been a DCMS member since 2005. She serves on the DCMS Membership/ Member Services Committee and on the TMA delegation to the AMA. She’s practices endocrinology at the Baylor Endocrine Center. Dr. Roe is married to David Roe and enjoys listening to and singing classical music, cooking and reading. She also is active in her church. endocrinology at the Baylor Endocrine Center. Dr. Roe is married to David Roe and enjoys listening to and singing classical music, cooking and reading. She also is active in her church.
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As medical director of the Cooper Clinic’s Wellness Lifestyle Modification Program in Dallas, Riva Rahl, MD, is a tremendous ambassador of what she promotes. She lives what she advocates about the importance of preventive medicine and of leading an active and healthy lifestyle.
DCMS Physician Spotlight R i va Ra hl, M D by Lauren Cowling, director of communications Her plans to be a physician started at a young age. She recalls being around age 5 when she told her mother’s friend, a physician herself, that when she grew up, she was going to be “a real doctor.” After finishing degrees in biochemistry and exercise science in 1995 from Rice University, she returned home to the San Francisco Bay area to attend medical school at the University of California at San Francisco. Her love of medicine and sports led her to pursue a career in orthopaedics, but after one round of surgery, she knew that specialty wasn’t for her. Dr. Rahl moved to internal medicine because it allows her to focus on the preventive side of medicine, and it gives her an opportunity to get to know her patients through long-term relationships. She also enjoys the cerebral side of medicine. “I wanted time with patients and I wanted to be able to talk with them,” she says. “This seemed like the best fit for me. I also enjoy figuring out problems and putting all the puzzle pieces together to find a solution.” At the Cooper Clinic, where she’s been for almost 8 years, she meets with a set number of patients each day and allots a fair amount of time to discuss a number of topics with them. This predictable schedule is helpful because Dr. Rahl is a mother to two boys, Evan, 7, and Reagan, 5. “This job is great for me,” she says. “I get to see patients grow and change, I get to teach patients how to lead a healthy lifestyle, and, for the most part, I know what my schedule is going to be every day. And it’s great because I have a job that I truly love.” Dr. Rahl credits her husband, Brian Grame, with helping her balance her busy life. Although he works full time, she says that he does more with the house and children than most stay-at-home dads do. In addition to balancing responsibilities as a physician, wife and mother, Dr. Rahl is a champion long-distance and marathon runner. While growing up in Piedmont, Calif., she participated in track and field and was the valedictorian of her high
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school class. Her academic and running achievements led her to Rice University, where she was a four-year varsity athlete in cross-country and track and field. She was a member of the 1994 Southwest Conference Champion cross-country team — a first for a women’s team at Rice and, with the breakup of the Southwest Conference in 1996, the only women’s conference championship. Upon completing medical school in California in 1999, Dr. Rahl returned to Texas for her internal medicine internship and residency at University of Texas Southwestern Medical Center at Dallas. As she began her medical career, she returned to running as a way to relieve stress and to stay healthy and active. She knew her resident’s schedule would make it difficult for her to get in as much running as she needed and wanted, so she started running to and from the hospital. Rain or shine, she ran the almost 3-mile route every day. During all those miles in every season, Dr. Rahl worried about her safety only once. The source of her fear wasn’t the deadly Texas heat or a wouldbe attacker, but a dog. Fortunately, while she was fighting off the canine, the only animal control vehicle she had ever seen during her runs was driving along the street where she was running. She and the animal control officer fought off the dog, and then he took her to Parkland. She was working at Parkland at the time, and experienced the Parkland ER firsthand, something few physicians get to do. She recalls stopping for groceries on her run home more than once. And more than once people would spot her running, grocery bags in hand, and later ask if it were her they had seen. She’d reply, “Yes, I was out running some errands.” While running those errands, she also was training for marathons and having great success. She won the Dallas White Rock Marathon in 2000 and Fort Worth’s Cowtown Marathon in 2000, 2002 and 2008. She won her most recent Cowtown just 6 months after the birth of her youngest son.
“I thought, ‘I bet I can still run,’” she says about how she decided to enter the race so soon after giving birth. And she was right — she could still run, all 26.2 miles. In 2003 Nike approached Dr. Rahl to appear in an ad campaign leading up to the Boston Marathon. All Nike needed was for her to be registered to run Boston, so she did. She then was flown to Beaverton, Ore., where she was photographed for the ads, along with running legends Joan Benoit Samuelson and Alberto Salazar. She still runs, but isn’t training for an event. She says she’s running “no more than 40-50 miles a week now.” Before she was winning conference championships in college and well before she was a marathon champion, she was a champion bird caller. Yes, a bird calling champion. When she was 17, she appeared on “The Tonight Show with Johnny Carson” in 1991 performing the call of the double-crested cormorant. She was chosen to represent her high school after winning a competition at the school. She retired from bird calling shortly after, choosing to leave like a lot of legends do — while still on top. When Dr. Rahl isn’t seeing patients, her family or long stretches of roadway, she’s preparing to speak on the benefits of leading a healthy lifestyle or considering a follow-up to her first book, “Physical Activities and Health Guidelines.” Dr. Rahl also enjoys travelling with her family and notes that her youngest son already has gold status on a certain airline. Her family recently went to London during the Olympics. Her young sons were disappointed to hear that, although Mom runs fast, she wouldn’t be running in the Olympics. But she did make an appearance at a Super Bowl. She sang the National Anthem at the 1985 game as part of the Piedmont Children’s Chorus. The chorus was founded by her mother, Susan, in 1982. The chorus, now known as the Piedmont East Bay Children’s Choir, enrolls close to 350 students, ages 4–18. Now that Dr. Rahl has given up bird calling and Super Bowl appearances, she has time to serve on the DCMS
Membership/Member Services Committee. She’s also a recent graduate of the TMA Leadership College and has served on the Dallas White Rock Marathon (now the MetroPCS Dallas Marathon) board of directors since 2010.
Dr. Rahl with her Nike ad at the 2003 Boston Marathon
Reagan, Brian and Evan Graeme with Dr. Rahl at the 2012 Olympic Games in London this summer Dr. Rahl and Reagan, after winning the Cowtown Marathon in 2008
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Dedicated to Hope, Healing and Recovery
“Hassle Factor Log”
Business of Medicine
He lp s P h y s i ci a ns Co l l ect I nsur a nce Reimbursements an d L e a d s t o Re i m bur se m e nt I mprovements compiled by Anna Acuña, Director Medical Practice Strategies
The TMA’s Hassle Factor Log offers physicians a last resort when trying to resolve claims issues, and doubles as an official record of physician office frustrations with insurance-related problems. Physicians can document the nature of the hassle, including the actions that office staff members took and the estimated time spent dealing with the problem. TMA staff goes to bat for physicians on complaints for which reasonable attempts to collect, including the appeals process, have been unsuccessful. The Hassle Factor Log program recovered a record $1.6 million in 2011 for 300 physicians who otherwise would have gone unpaid for their services. So far in 2012, Dallas County physicians have recovered about $134,368 through the program. Genevieve Davis, the TMA’s payment advocacy director, says that this low amount could be because physicians are unaware of the program. TMA uses complaint statistics to work with health plans to improve the process for both parties. The staff meets regularly with Medicare, Medicaid, healthcare payment plans, and large insurers to discuss specific problems that are brought by physicians. The information is used to resolve individual problems, effect systemic change with health plans and state agencies, and set the TMA’s legislative goals. “We have convinced some of the carriers to change a few of their more onerous judgments, such as arbitrarily paying for only one procedure for a patient when the physician has provided two or more at the same time,” Ms. Davis says. “For example, during major abdominal surgery, a physician may order a liver biopsy. However, the physician may get reimbursed only for the abdominal surgery procedure.” As a result of meetings with TMA, at least one plan has acknowledged that these are two separate procedures that require different skills, different personnel and different equipment, and now are paying for both. Improper denials and appeals still lead the list in number of complaints over the 19 years the log has been maintained. However, slow processing, data entry errors, extensive requests for medical records, bundling, and near-terminal on-hold time remain common complaints. Dallas Countyspecific issues primarily center on bundling, payment delays and refund requests. In Dallas County the top five carrier complaints from physicians are about United Health Care, Blue Cross Blue Shield, Aetna, Medicaid, and Cigna. Before submitting a Hassle Factor Log, physicians should have: 1. Documented reasonable attempts to resolve claim issues, including the appeals process unless the physician is submitting the issue as informational only 2. Clearly identified health plans and/or contractual relationships on the HFL form 3. A completed Business Associate Agreement
days after physician submitted the claim and the physician has received confirmation that the claim is being processed. TMA copies the physician on any letter it sends to a health plan regarding the Hassle Factor Log; however, it cannot guarantee response from the health plan. If an HFL is sent to a health plan that reflects incorrect coding or billing by the practice, a letter is sent to the practice explaining how to correct the issue on future claims. Processing time for HFLs ranges from 2 to 4 weeks of receipt. For physicians who want TMA to be aware of issues but are not seeking help with reimbursement, “Informational Only” submissions can be logged. These submissions are for: • Hassles marked as “informational only” • Claims being appealed with the health plan for the first time • Information submitted as a copy of a complaint filed with the Texas Department of Insurance Not all Hassle Factor Log submissions can be resolved. Submissions that did not result in reimbursements include: • Hassles that not clear, legible or understandable or that have conflicting information • Physician billing errors depicted as payer hassles • Supporting documentation not included • Claim for services older than 12 months • Claims with lack of timely followup by the physician office Attachments frequently needed to facilitate resolution include: • CMS-1500 claim forms • Remittance notices (e.g., EOBs, RAs, R&S reports) with definitions of comment indicators and/or denial messages • Copies of relevant correspondence with the health plan, including appeal and/or denial letters • Reports for proof of timely filing (e.g., batch acceptance reports from the payer or clearinghouse showing the payer accepted the claims) • Operative notes/medical records • Patient insurance identification cards • Preauthorization/referral forms Participation enhances TMA’s ability to make reimbursement less of a hassle for its members due to the robust evidence of payer issues. Physicians can mail Hassle Factor Logs to Payment Advocacy Department, Texas Medical Association, 401 W. 15th St., Austin, TX 78701; or by fax to 512-370-1632. For access to the form, go to http://www.texmed.org/template.aspx?id=2301 or e-mail Anna Acuña at anna@dallas-cms.org.
4. Reported slow-pay issues greater than 45 to 60
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Max Kalhammer, with his wife, Geetanjali Srivastava, MD, at the Maasai Mara National Reserve in Kenya
DCMS Physician Spotlight Geetanjali Srivastava, MD
by Tracy Casto, director of public affairs and advocacy Escaping the Texas summer for a bit, Geetanjali Srivastava took a long-overdue family vacation with her siblings and their families to Montreal, in honor of her mother’s 70th birthday. They toured the city for about 10 hours a day, with her mom making good use of a new pair of walking shoes. Although her family has not always lived in the same city, distance never has hindered their strong bond and closeness. Dr. Srivastava, an Indian-American, lived in Kabul, Afghanistan, until she was 9. Her parents were teachers; her father was appointed to serve as a tutor to the prince. She recalls her time in Kabul as idyllic and inspirational. “I was surrounded by people from all over the world who worked for the Peace Corps, United Nations or the World Health Organization,” she says. “I was exposed to people who were trying to change the world and not focused on accumulating wealth.” Growing up in an intellectual community piqued her interest in medicine. Social justice inspired those around her and that made a profound impact on her. She was 9 years old when the family got out of Afghanistan in July 1980. After the Russian invasion of Afghanistan, her family was fortunate to immigrate to the United States, sponsored by her uncle in Lubbock (comparisons to the Afghan landscape are inevitable). During the six months the family lived with him, he introduced them to his friends and colleagues at Texas Tech University. Dr. Srivastava’s life in Lubbock was nice and simple, but a little too conservative and provincial. She left West Texas to study philosophy (and fulfill her premedical requirements) at Bryn Mawr College, in the Philadelphia suburbs. She was drawn to the college because of its small size, emphasis on rigorous academics, and abundance of international students.
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Dr. Srivastava says she always knew she would be a physician. “From an early age,” she says, “I witnessed the respect the profession holds worldwide, the platform it gives you to affect change, and the direct, immediate impact you make on an individual life.” While she was in college, her parents relocated to Houston, and her father was diagnosed with cancer. She applied to UT Houston Medical School so she could help her parents during her father’s illness and found that their support while she was in medical school was essential. While helping with her father’s care, she learned about the healthcare system firsthand. “To experience the healthcare system as a consumer was shocking and eye-opening,” she recalls. “I think I’m a more empathetic physician because of my experience trying to navigate the complicated system of health insurance and denial of care. It also solidified my position that health care is a right and that it is unconscionable to put profit ahead of a human life.” Soon after her father passed away, she decided to get a master’s degree in public health. Her concentration of study was public health policy. She took a year off between the third and fourth years of medical school to complete the course work and wrote her thesis during her fourth year of medical school. “I always was interested in public health and that was a great motivator to become a physician, but I also was interested in ethics and policy,” she says. “I wanted to be able to have an impact beyond the individual patient, and affecting policy and law is one way of achieving that goal.” She completed her pediatrics residency at the University of Chicago Medical Center in 2001 and relocated to New York City (one month before the 9/11 attacks) for her
first job as a physician. After 2½ years of working as a pediatrician by day and moonlighting in the emergency department on nights and weekends, she wanted a change to an academic position. She accepted the opportunity to join the faculty at Temple University Children’s Medical Center in Philadelphia in the ED. Having honed in on her passion for pediatric emergency medicine and receiving encouragement from her boss and colleagues at Temple, she applied for a fellowship. She completed a three-year fellowship in pediatric emergency medicine at Children’s National Medical Center in Washington, DC. She met her husband, Max Kalhammer, while he was at Haverford College and she was at Bryn Mawr; they were acquaintances in college and had many friends in common. He had just finished working as chief planner for the Washoe tribe in Nevada when he went to DC to attend a mutual college friend’s wedding. He asked her to be his date, and she says, “It was love at second sight!” “We hit it off,” she recalls, “and then he tells me he’s going to China the next week. … He’s MOVING to China for a new job.” She told Max that she’d visit him. When she did visit several weeks later, he surprised her by accompanying her home on the seat next to her on the plane and relocating to DC. They married two years later in a traditional Hindu ceremony. She was 38; he was 37. “We are older than most newlyweds,” she laughs, “but we like to do things in our own sweet time.” The couple moved to Dallas in 2009 because they both had excellent job opportunities and because her mother and sister live in Dallas. Max, an urban planner, discovered Kessler Park when he was exploring the city. Dr. Srivastava was still living in DC when he called to tell her he had found the perfect neighborhood for them. “We were both attracted to the diversity of people who live in the area; the winding, hilly streets; and the big trees,” she says. “We also were lucky to find a lovely, modern home.” Dr. Srivastava is a pediatric emergency physician at Children’s Medical Center in Dallas and at Legacy. She’s a news junkie and loves to travel, spend time with her family, and decorate her home. She works many nights and weekends, but says that her work is her passion. Dr. Srivastava believes it is important to provide good
Dr. Srivastava in traditional Hindu dress, with her husband, Max
primary and preventive care to all Americans. She says that in Dallas, even if the underinsured and uninsured have insurance through the Affordable Care Act, the area does not have enough physicians to provide that care. “It astounds me that in Minnesota about 96 percent of physicians accept Medicaid. The national average is around 70 percent, and only about 19 percent of doctors in Dallas accept Medicaid. I don’t have a solution, but this is not acceptable or sustainable.” The issue of maternity leave is another subject that gets her fired up. She finds it unbelievable that the United States is the only industrialized nation that does not provide maternity leave. Even more irritating is that children’s hospitals across the country do not offer maternity leave to their employees. “Moms are expected to take their vacation and sick leave to take care of a newborn,” she says. “As any new mother will tell you, having a baby is not a vacation. Although I don’t have kids, I still find this offensive.” Now that she is settled in her practice and her marriage, Dr. Srivastava makes time to be active on DCMS committees. As a member of the DCMS Legislative Affairs Committee, she talks with her peers about the importance of physicians being involved in issues that affect patients.
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visit us online at www.dallas-cms.org • September 2012 •
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Letter to the Editor Physician Fees vs. Physician Services Dear Editor, There has recently been confusion about the part played by physician payment in total medical expenditures. This is not surprising because CMS bundles multiple costs under “Physician Services.” That column includes Imaging costs as well as Lab costs. In mid 2011, Jackson Healthcare, an Atlanta healthcare worker placement and temp company, reported a physician online survey which it stated showed that physician compensation was only 8 percent of healthcare spending. It has been widely quoted since. I have been unable to find it in a reviewed journal, however. What does appear to be true is that the $2.5 trillion healthcare tab is composed of no more than 20 percent “Physicians and Clinical,” of which less than two thirds is physician compensation (per: CMS “Healthcare Dollar” and CMS definitions of services and cost breakdowns). Uwe Reinhardt, in Slate, states that doctors’ pay is 10 percent of overall bill. So, the takeaway is unchanged: while, of course, all costs need to be minimized and controlled (by some as yet unknown force, breakthrough or insight), the total elimination of physicians’ fees would not get our costs close to those of other developed countries. Sincerely, Shelton G. Hopkins, MD
Most HIV positive
persons had previous visits to a medical facility where they were not tested for HIV. Routine HIV testing is an opportunity for earlier diagnosis and treatment. Learn more at
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CDC. Missed Opportunities for Earlier Diagnosis of HIV Infection --South Carolina, 1997—2005. MMWR 2006; 55(47);1269-1272
message no 5 dcms.indd 1
6/12/11 6:36:58 PM
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DCMS Physician Spotlight Wendy Pa r n el l , M D
by Tracy Casto, director of public affairs and advocacy When Wendy Parnell worked in her father’s office during junior high school, she could look out the window and see the roof of her house around the corner. Fewer than 20 years later, she’s joined her father in his fifth-floor office in Building D at Medical City Dallas Hospital. “I always knew I would be a doctor and go to medical school,” she says. Family gatherings at the North Dallas home could get confusing, with Dr. Wendy Parnell, Dr. Winfred Parnell the father, and Dr. Winfred Parnell the son and twin of Wendy. The younger Winfred Parnell works at the Dallas VA Medical Center. The twins attended Greenhill School in Dallas from grades 1–12 and then Emory University in Atlanta, where Wendy majored in neuroscience and behavioral biology. In choosing Emory, she appreciated the opportunity for research at the school and at the Centers for Disease Control and Prevention. Having family in Georgia and Florida eased the transition, as did the southern feel of the university. After completing undergraduate school at Emory, which was tremendously competitive, she was ready for a new environment and chose Temple University in Philadelphia. “I was ready for a different type of culture,” Dr. Parnell says. “Temple was a nurturing environment and more comfortable. There wasn’t the direct competition like at Emory.” The pass/fail grading system also contributed to the more relaxed environment. “We knew what our grades were on tests and papers,” she says, “but in the end, grades mattered only for a pass or fail.” She says, “The acceptance process is extremely rigorous to get into medical school, so the students who were there wanted to be there and, for the most part, are self-motivated. The students had the drive, and that was to take care of patients.” The physical environment of North Philadelphia was quite different from Emory and Atlanta. Whereas the Emory campus is situated in an upscale neighborhood, Temple is in the heart of the inner city. “You didn’t walk to your car in the parking lot alone,” she remembers. “You always called for an escort.” She and several of her friends had their cars broken into as students. “But the community loves having the medical school there because the residents know we’re there to take care of them,” she says. And the ER rotations in an inner-city hospital left never a dull moment. In choosing a specialty, Dr. Parnell first had to decide between medical and surgical. She considered internal medicine, but didn’t care for the rounding. She also didn’t like limitations of certain medical specialties. “When I saw an ill patient, I wanted to get in there and fix whatever was wrong right away,” she says. During her surgery rotation, she enjoyed urology and breast surgery, but missed the intimate patient interactions the medical specialties offered. But then she did her ob-gyn rotation. “It was a perfect fusion,” she says. “I would get to operate and have long-term relationships with patients. The idea of seeing patients from teenagers into college and then into adulthood was very appealing.” She looks forward to treating the children of the babies she’s delivering now, as her father does. After deciding on ob-gyn, Dr. Parnell’s next decision was where to complete her residency training. “I always knew I wanted to come back to Texas,” she says, so she completed a month-
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long externship at Parkland and at Baylor in Houston. “I fell in love with Parkland,” she says. “The residents seemed so confident. Managing a typical L&D board with 30 patients was just another Friday afternoon for a Parkland fourthyear. I felt they were at the level of attendings in the other places.” She recalls working long hours as a visiting medical student for her resident, Jane Yau, MD, who also is on staff at Medical City Dallas Hospital. “People would ask me why I was at Parkland at 4 in the morning as a medical student,” she says. “I just wanted to do a good job and help my extremely busy residents as much as possible.” After a few months elsewhere, she realized that the highenergy hospital was the place for her, and she took a spot at Parkland. She did her internship and residency at Parkland, where her father also had trained. Even though Parkland had the largest ob-gyn program in the country with 80 residents, Dr. Parnell felt like she knew everyone. Each month the residents were on a new team with different residents and staff. During her last year, she was a chief resident. “Coordinating a schedule for 80 residents was definitely a challenge,” she recalls, “but it also was interesting to see the faculty and resident perspective on issues, and try to get each to understand the other’s view.” At 30, she completed her residency in June 2011 and joined her father’s ob-gyn practice that August. She says that working at the practice is like coming home every day. Several of the staff members have been at the practice since Wendy was in junior high, when she spent summers filing charts at her dad’s office. “Now they ask if they can call me ‘Wendy’ or if they have to call me ‘Dr. Parnell,’” she says. “I say, ‘You’ve known me since I was little — you can call me Wendy. But they all are so respectful and call me Dr. Parnell or Dr. Wendy.” While in high school, the teenager spent several summers as a patient care assistant in the nursery at Medical City. She held and fed babies, and helped physicians do circumcisions. She worked 3–11 p.m. and on some holidays. Working in her father’s practice is going well. “It’s a positive and encouraging atmosphere,” she says. “I know they all have my best interest at heart. I interviewed with all the partners. They weren’t necessarily looking for another partner at the time, but it worked out. They felt I was a good match for the practice, and I feel truly blessed to be here.” The patients are her favorite part of being a physician. “My patients are reasonably healthy and usually have a relatively focused issue to address, so I enjoy spending time just talking to the patients and hearing about their lives.” she says. Because of the office layout, she may go an entire day without running into her father. But she knows he’s available if she needs a consult. “I have independence and treat patients my way, but I still
feel like I can ask questions,” she says. “Sometimes I may need someone to confirm my plans or listen or offer suggestions, or just to say, ‘That’s the way I’d do it, too.’” She has no shortage of physicians to consult. Joseph Carlos, MD, is a partner in the practice; he’s also her godfather. When former Parkland residency friends Drs. Winfred Parnell and Carlos began their practice in 1982, they could not have predicted that the practice would evolve to include three women physicians, one of whom was Dr. Parnell’s daughter. Wendy says that what has surprised her as a practicing physician is her lack of business knowledge. How much information did she get during training about billing and the details of running a private practice? Zero. “We got so little information in medical school and residency about the business of medicine,” she says. “Not everyone leaving residency is private-practice bound, but I think it’s important to know how to review a contract and understand how you are reimbursed for the skills you’ve invested nearly a decade of time learning.” She is thankful to have mentors such as her father and Drs. Carlos, Ramana Jones and Monica Diaz. “I can’t even imagine going into private practice alone right out of residency,” Wendy says. Also a rude awakening was the difference between the amount she bills for a procedure when assisting a surgeon and the amount she gets paid. “It’s mind-blowing,” she says. “You have two docs doing the same procedure on each side of a uterus. The assistant surgeon makes about 10 percent of what the primary surgeon makes, and the assistant is doing the same thing and spending the same amount of time. I was shocked. I can be in the OR assisting for 4 hours, and I could have made more money in a 30-minute office visit.” No longer living in the shadow of Medical City Dallas, Dr. Parnell enjoys life on the 15th floor of a high-rise in Uptown. She works out 3–4 times a week, in activities that improve
her cardio function, including “hot sweaty boot camp,” kick boxing and running. In practice for only a year, Dr. Parnell has been careful to live frugally. “A financial planner once told me to live like a resident for two more years if possible. I do splurge a little. … I’m a purse person. But I didn’t get the brand new car. I drive the same Jeep Cherokee I’ve had for years.” Dr. Parnell serves on the board of HealthPAC, the DCMS political action committee, which vets candidates for elected office. She volunteers at Healing Hands Ministries, Project Access Dallas, and as a big sister with the Big Brothers Big Sisters program. She also enjoys giving talks in the community and educating the public at health fairs, noting that her relative youth enables her to connect with an audience that can be difficult to reach.
Wendy Parnell, MD, reviews a case with her father, Winfred Parnell, MD.
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