Editors: Nutan De Joubner, M.D. | Erica Huffman, Executive Director
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Bulletin JULY/AUGUST 2018 VOLUME 48, NO. 4
CONTENTS Have you read the recent letter to doctors by the CMS administrator, Seema Verma? More change is coming for physicians trying to practice under the convoluted rules and regulations of Medicare. Physicians who participate in Medicare just endured the implementation of MACRA and MIPS, a massive restructuring of the Medicare payment system but CMS has decided that more change is necessary. As always, the changes are being promoted as something from which physicians will benefit. These changes will be an effort to rein in the excessive administrative burden by the cumbersome documentation requirements, coding rules, and quality measures placed on doctors by Medicare. There may be validity to the fact that use of Evaluation and Management (E&M) codes has turned out to be a complicated mess which puts perverse incentives in place encouraging physicians to upcode every visit in order to maximize reimbursement. In fact, when the concept of the E&M codes was first introduced, we were all encouraged and given explicit instructions on how to upcode every visit by the army of coding specialists who are now so prevalent in medicine. This coding system was always rife for misuse. Our once succinct, relevant doctor’s notes are now padded with ‘documentation,’ mostly irrelevant to us as physicians, but mandatory to CMS in order to justify a higher E&M code.
increased complexity. The new CMS rules would change the structure of the E&M codes, going from 5 levels (99211-99215) to one. There would be one code and one reimbursement fee for all follow-ups, no matter the complexity, and one code and reimbursement for new patients, no matter the time spent seeing the patient. For example, the healthynew patient with a stress fracture of the foot will apparently have the same reimbursement as the critically ill new patient with Scleroderma, interstitial lung disease and digital ulcers. We have yet to learn what the actual reimbursement fee will be. I speculate that it will be somewhere between what is presently reimbursed for a 99213 and a 99214 visit. To quote the CMS administrator in her recent letter to doctors, “We’ve proposed to move from a system with separate documentation requirements for each of the 4 levels that physicians use to a system with just one set of requirements, and one payment level each for new and established patients. Most specialties would see changes in their overall Medicare payments in the range of 1-2 percent up or down from this policy, but we believe that any small negative payment adjustments would be outweighed by the significant reduction in documentation burden.”
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Physicians feel compelled to list a multitude of diagnoses, which often make our patients appear sicker than they actually are, because managing the sicker patients allows for upcoding based on
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Matthew Furst, MD, pediatric cardiology, UF Health Theresa Roca, MD, pediatric cardiology, UF Health Matthew Steiner, MD, pediatric cardiology, UF Health Bevin Weeks, MD, pediatric cardiology, UF Health Berrin Ergun-Longmire, MD, pediatric endocrinology, UF Health James Coticchia, MD, pediatric ENT, UF Health Robert Dillard, MD, pediatric gastroenterology, UF Health Alan Sacks, MD, pediatric gastroenterology, UF Health Brent Thompson, PA, pediatric gastroenterology, Sacred Heart Medical Group Debra Cohen, MD, pediatric hematology/oncology, UF Health Jeffrey Schwartz, MD, pediatric hematology/oncology, UF Health Amanda Strobel, MD, pediatric hematology/oncology, UF Health David Shapiro, DO, pediatric infectious diseases, UF Health Edward Kohaut, MD, pediatric nephrology, UF Health Robert Huang, MD, pediatric orthopedics, Sacred Heart Medical Group Tracy Roberts, MD, pediatric orthopedics, UF Health Dana Wert, ARNP, pediatric orthopedics, Sacred Heart Medical Group Brian Donahue, MD, pediatric palliative care, Sacred Heart Medical Group Gulnur Com, MD, pediatric pulmonology, UF Health Jonathan Papic, MD, pediatric surgery, Sacred Heart Medical Group C. Gerry Henderson, MD, pediatric urology, UF Health Mark Wehry, MD, pediatric urology, Sacred Heart Medical Group Donna Williams, ARNP, pediatric urology, Sacred Heart Medical Group
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E.C.M.S. Bulletin
The Bulletin is a publication for and by the members of the Escambia County Medical Society. The Bulletin publishes six times a year: Jan/Feb, Mar/Apr, May/Jun, Jul/Aug, Sept/Oct, Nov/Dec. We will consider for publication articles relating to medical science, photos, book reviews, memorials, medical/legal articles, and practice management.
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President’s Message Continued The key phrase in this paragraph is, ‘we believe that any small negative payment adjustment will be outweighed by the significant reduction in documentation burden.’ CMS is preparing physicians for a 1-2 percent decrease in reimbursement, but I have seen estimations as high as a 9% decrease. The question is, why did most participating physicians go through the recent tortuous transition to MACRA/MIPS? It was to avoid the initial 1-2% penalty which was projected by CMS which would go to 9% over time if a doctor did not implement MACRA/MIPS. Well, it appears that those reductions are coming anyway. Even though many physicians complied to the letter of MACRA/MIPS, we will all see a reduction in our reimbursement. When will we physicians will ever learn? We have been played once again. The other suggestion by Dr. Verma is a redesign of the Merit Based Incentive Payment System (MIPS). Unfortunately for physicians participating in Medicare, CMS is not eliminating MIPS, which was the original recommendation by the Medicare Payment Advisory Commission (MedPAC.) No; instead they are preparing us for a redesign of another untested, unworkable program. We do not yet know what those changes will be but we do know that physicians will be ordered to comply under threat of increasing penalties and decreasing reimbursements.
How much more can our profession withstand before we just say “no?” Constantly changing these rules and regulations is abusive to physicians and patients. It is also denigrates our profession in a profound way. The question remains: When will physicians have had enough? Every perverse incentive and tortuous regulation of Medicare only applies to physicians who bill Medicare on behalf of their patients. If a doctor opts out and doesn’t bill Medicare, none of this applies. Did you know other perverse regulations such as Stark laws only apply to physicians who participate in Medicare? Can we ever be free of this government intrusion, this distortion of our doctorpatient relationship, and of this profound denigration of our professionalism? If so, we will be required to think differently and to act boldly. I hope you will join us for our next general membership meeting on August, 28th. I will share my experience in opting out of Medicare. I am now in my 3rd year and doing just fine. We also see an increasing number of primary doctors who have opted out of Medicare (and all 3rd parties) in the direct primary care movement. Even if you don’t think this applies to you now, it may in the future because of the nonsensical increasingly Draconian regulations of Medicare.
- Ellen McKnight, M.D.
View and opinions expressed in the Bulletin are those of the authors and are not necessarily those of the board of directors, staff or advertisers. The editorial staff reserves the right to edit or reject any submission. ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY
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Upcoming Meeting
GENERAL MEMBERSHIP MEETING 1 AMA PRA CATEGORY 1 CREDIT(S) ™ AUGUST 28, 2018 | 5:30PM TOPIC: "HOW TO OPT OUT OF MEDICARE" SPEAKER: ELLEN W. MCKNIGHT, M.D. LOCATION: HANCOCK WHITNEY BANK 940 CREIGHTON RD, PENSACOLA, FL 32504 SPONSOR: HANCOCK WHITNEY BANK
RSVP TO ERICA CALL 850.478.0706 TEXT 561.414.6113 EMAIL DIRECTOR@ESCAMBIACMS.ORG FREE FOR ALL DOCTORS THIS ACTIVITY HAS BEEN PLANNED AND IMPLEMENTED IN ACCORDANCE WITH THE ACCREDITATION REQUIREMENTS AND POLICIES OF THE ACCREDITATION COUNCIL FOR CONTINUING MEDICAL EDUCATION THROUGH THE JOINT PROVIDERSHIP OF THE MEDICAL EDUCATIONAL COUNCIL OF PENSACOLA (MECOP) AND ESCAMBIA COUNTY MEDICAL SOCIETY. MECOP IS ACCREDITED BY THE ACCME TO PROVIDE CONTINUING MEDICAL EDUCATION FOR PHYSICIANS. THE MEDICAL EDUCATIONAL COUNCIL OF PENSACOLA DESIGNATES THIS LIVE ACTIVITY FOR A MAXIMUM OF 1 AMA PRA CATEGORY 1 CREDIT(S) ™. PHYSICIANS SHOULD ONLY CLAIM CREDIT COMMENSURATE WITH THE EXTENT OF THEIR PARTICIPATION IN THE ACTIVITY.
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Announcements 2018 ECMS CALENDAR OF EVENTS How to Opt Out of Medicare Tuesday, August 28th | 5:30pm | 1AMA PRA Category 1 Credit(s) ™ | Location: Hancock Whitney Bank Sponsor: Hancock Whitney Bank
Women in Medicine Sunday, September 30th | 12:00pm Location: Painting with a Twist Sponsors: Underwood Anderson & Associates
Healthcare Economics Tuesday, October 23rd | 5:30pm |Location: V. Paul’s Dinner Sponsor: MAG Mutual Insurance Social Sponsor: Business Information Solutions, Inc. & Carr, Riggs, & Ingram LCC
Prevention of Medical Errors Tuesday, November 29th | 5:30pm | 2AMA PRA Category 1 Credit(s) ™ Location: Pensacola Yacht Club Sponsor: The Doctors Company
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2018 Resolution Local Alliances for Drug Endangered Children 2018 Resolution submitted by ECMS Delegate John Lanza, M.D. By: John J. Lanza, MD, PhD, MPH, FAAP Whereas, Existing FMA policy (P90.014) recognizes the “…importance of the physical and mental well-being of children to the future of our State…”); Whereas, Drug endangered children (DEC) are defined as children who are at risk of suffering physical or emotional harm because of illegal drug use, possession, manufacturing, cultivation, or distribution; Whereas, They may also be children whose caretaker’s substance misuse interferes with the caretaker’s ability to parent and provide a safe and nurturing environment; Whereas, In the United States in 2016, drug abuse by a parent was a factor in 34% of cases (92,000 children) where children were removed from homes; Whereas, In the State of Florida in 2017, an average of 650 children per month entered out-of-home-care due to parental drug abuse which corresponds to 47.4% of all children removed from home in our state; Whereas, The primary challenge with illegal substance abuse and DEC is in coordinating the social and political systems charged with preventing, intervening, and treating these cases; Whereas, The number, complexity, and difficult behavior-change challenges of these cases burdens practitioners including physicians and the community alike; Whereas, The best approach for addressing the needs of children in dangerous drug environments focuses on the formation of community-based partnerships that encourage private and public agency personnel from across multiple disciplines to coordinate their mutual interests, resources, and responsibilities. Whereas, The physicians who practice in our communities are a vital component of the lives of our children; Whereas, The National Alliance for Drug Endangered Children (National DEC) as well as the Florida Alliance for Drug Endangered Children (Florida DEC) provides national/state leadership in the development of programs, policies, and services on behalf of children and families who are in the cycle of substance abuse and violence; therefore be it RESOLVED, That the FMA supports the activities of the National and Florida DEC to break the cycle of abuse and neglect by empowering practitioners including physicians who work to transform the lives of children and families living in drug environments; and be it further RESOLVED, That the FMA supports the development of local DEC alliances to reach the goals of: raising awareness of the issue of drug endangered children; providing support, information, and resources to all individuals and organizations that serve and care for drug endangered children; facilitating multi-disciplinary, coordinated provisioning of services and care to drug endangered children; preventing endangerment to children in dangerous drug environments by encouraging intervention at the earliest possible point; and, developing and sustaining a network of experts and professionals including physicians who can be called upon to conduct research, evaluate practices and procedures, and provide accurate advice and information regarding the needs of drug endangered children. References P 90.014 ADVOCATING CHILDREN’S ISSUES (not available as a URL link) The Florida Medical Association (FMA) is directed to issue a press statement at the beginning of “Children’s Week” during each Florida legislative session to the effect of: “Florida has the 4th largest childhood population in the United States and the FMA encourages the Florida Legislature to strongly consider the FMA Public Policy Compendium 12 importance of the physical and mental well-being of children to the future of our State as they make decisions that impact Florida’s children.” http://www.nationaldec.org/home.html http://www.floridadec.org/ http://www.dcf.state.fl.us/programs/childwelfare/dashboard/c-entering-ooh.shtml https://www.acf.hhs.gov/media/press/2017/number-of-children-in-foster-care-continues-to-increase
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Practice Management General Practitioners and Misdiagnosed Cardiovascular Disease By Sandeep S. Mangalmurti, MD, JD As a cardiologist with a particular interest in medical liability, I was intrigued by the recent study on misdiagnosed cardiovascular disease by general practitioners in The Joint Commission Journal on Quality and Patient Safety. This study—by The Doctors Company and CRICO Strategies—found that a significant proportion of liability cases involving cardiovascular disease were due to errors of diagnosis. This is unsurprising, and consistent with previous research. The initial presentation of cardiovascular disease can be quite ambiguous. Persistent chest pain may be due to cardiac ischemia, but there are numerous benign, or non-cardiac, explanations as well. These include gastrointestinal disorders such as reflux disease or esophageal spasm, musculoskeletal diseases such as chest wall inflammation, or vascular disorders such as pulmonary embolism or aortic dissection. There are many tests that can clarify the clinical picture, but universal diagnostic testing is clearly not an option. One common way the list of potential diagnoses is culled to a more manageable level is by using the principle of pretest probability. The concept is very intuitive: The likelihood that a patient’s complaints are due to cardiac disease is strongly influenced by whether a patient has a high pretest risk of cardiovascular disease, including risk factors such as diabetes or hypertension. For example, it is very unlikely that a young woman with no cardiac risk factors would develop acute coronary syndrome. If a patient like this presents with chest pain, she should not undergo an aggressive workup to rule out that diagnosis, since that workup would almost certainly be negative. Despite these relatively straightforward algorithms, defensive medicine persists. As this study mentions, patients who are unlikely to have cardiac pathology continue to receive excessive workups. There are many likely explanations for this, one of which may a continuing fear of misdiagnosing a rare or otherwise ambiguous case, despite the low pretest probability. Nobody wants to face a lawsuit because they failed to order a test, even if the patient had no risk factors. It is possible that non-cardiologists may be even more risk averse, as they do not specialize in the evaluation of cardiovascular disease. However, the most interesting aspect of this recent study is that it suggests that perhaps the real liability danger doesn’t come from unusual or ambiguous cases, but from the relatively straightforward ones. In this study, in many of the liability cases when a cardiac illness was missed, the patient had at least one cardiac risk factor. These patients were not low risk, but at least intermediate to high risk. In such cases, cardiovascular disease needs to be considered. Sometimes even relatively easy cases can be a source of liability risk. The take-home message is that perhaps practitioners shouldn’t worry as much about getting burned by unusual or unexpected cases. Risk-stratify your patients based on their previous medical history, and focus on the fundamentals.
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Medical/Legal Sexual Harassment Allegations in Healthcare: Rising Risks Richard Cahill, JD, vice president and associate general counsel, The Doctors Company A successful and highly-respected pediatrician with an unblemished record over decades of practice learns of a HIPAA breach by a member of his clerical staff. After an investigation reveals the employee is a repeat offender, she is terminated. Imagine the physician’s reaction when the employee’s attorney not only initiates a wrongful termination suit, but also alleges retaliation, claiming the employee rebuffed sexual advances from the doctor. To gain additional leverage, the former employee’s attorney submits a complaint of sexual harassment with the medical board and has the plaintiff file a criminal complaint for sexual battery. The attorney also sends a letter to the medical executive committee of the principal hospital where the doctor admits patients, resulting in a peer review investigation. Finally, the former employee blankets social media with an aggressive smear campaign. This example demonstrates that healthcare providers are not immune from the growing number of reported incidents of alleged sexual harassment in the workplace. Accusers may be employees, patients, third-party vendors or visitors. Individuals alleged to have acted inappropriately may include co-workers, both supervisors and subordinates, professional staff—and even patients. Shortly after complaints are filed, costly and potentially embarrassing investigations are often conducted by law enforcement, human resources departments, and administrative agencies. Depending on the nature and scope of the findings, serious adverse consequences and often irreparable harm to a person’s reputation may follow, including: • Criminal prosecution. • Civil litigation with the potential for substantial damages. • Licensing board actions that may impose limitations on an individual’s continued privilege to pursue his or her profession. Adopt and Enforce Zero Tolerance Given the risks, heightened awareness, and increased scrutiny, healthcare practitioners and facilities are strongly encouraged to develop and consistently enforce a zero-tolerance policy. Protocols must be written, periodically reviewed, and updated as necessary, detailing: • The types of conduct that will not be tolerated, regardless of the identity of the alleged perpetrator. • A clear methodology for reporting claimed instances of wrongdoing. • The process to be followed in investigating complaints, and rules that should be observed to help insure that confidentiality and due process are appropriately protected. • Documentation to be completed and maintained. • The range of sanctions, up to and including termination, for both employees and patients, should the allegations ultimately be determined to be true. Staff should receive proper training as part of the on-boarding process of each new employee and on a regular basis thereafter. Offices should develop and retain attendance sign-in sheets of such training in the regular course of business to demonstrate, in the event of a subsequent problem, the good faith and due diligence as continuing efforts of the clinic, provider or facility to comply with federal and state requirements. It is recommended that healthcare facilities, clinics and other professional offices institute a process of publishing their zero-tolerance policy towards harassment. This can be achieved in employee on-boarding documentation, professional employment contracts, conditions of treatment or admission, third-party vendor agreements, website notices, and even office signage. Be Sure You’re Covered Healthcare providers are also strongly encouraged to consult with their personal or corporate attorney to understand the potential financial risks of claims involving allegations of sexual harassment or misconduct. They should then confer with their insurance agent or broker to determine pro-actively what coverages might be available in their respective states to protect the provider in the event of such a claim. Policy language and state regulatory requirements often vary from jurisdiction to jurisdiction. Most practitioners carry professional liability coverage in the event of a claim for medical malpractice. Not uncommonly, however, medical professional liability policies specifically exclude coverage for acts of sexual misconduct committed by a physician against a patient. Depending upon the professional liability carrier, the physician may be provided with a courtesy defense covering the costs of legal fees and expenses, but no payment for any indemnity incurred in the event of an adverse jury verdict. It’s also prudent to consult with insurance brokers and agents about the availability of Employment Practices Liability Insurance (EPLI). EPLI may provide coverage for certain types of workplace harassment, which may include sexual misconduct involving the policy holder and an employee. And finally, claims of inappropriate sexual behavior against a physician or other licensed healthcare practitioner may result in administrative proceedings by a state medical board, or the privileges committee of a hospital or other facility regulated by The Joint Commission. Endorsements are widely available as part of medical professional liability policies to pay legal defense costs in the event of an investigation or subsequent disciplinary hearing. ECMS | 8
Practice Management
Medical/Legal
Physician Learning Must Evolve Eric Barna, MD, associate residency program director, Inpatient Medicine, Division of Hospital Medicine/Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai Hospital In medical school, students are trained on skills that will make them better future physicians, team members and care givers. It’s a curious thing— once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skillsets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school. As a hospitalist at Mount Sinai Hospital in New York, New York, I’m part of a team that cares for moderately to severely ill patients at a major academic institution. I’m also a physician advisor, and I have the pleasure of teaching some of the youngest and brightest medical students, interns, and residents at various stages of their careers. I consider this the best part of my work, so I’m sure it comes as no surprise that I’m a firm believer in the importance of continuous learning. That’s why I was so excited when I had the chance to participate in three standardized patient (SP) encounters training designed for me and my 22 hospitalist colleagues to improve our communication skills, funded by a grant from The Doctors Company Foundation. A standardized patient encounter is essentially a live simulation in a clinical setting with trained actors. To start the simulation, a physician is given a short prompt about the patient scenario. They may also be provided with some basic information such as a diagnosis or a relevant imaging study prior to entering the room. Once the testing center provides a signal, physicians are allowed to enter the room. An introduction of our role on the medical team is provided and a discussion ensues. The actors provide relevant history, incorporate true emotional response to questioning and display any behavioral or physical prompts that a real patient would. This allows physicians to react in real time to the needs of the patient. The use of standardized patients can also be adapted to desired testing scenarios, whether in the realm of communication, clinical reasoning, or establishing a differential diagnosis. Like many hospitals, we have a program in place aimed at assessing how we educate students and younger physicians. But Mount Sinai is the first hospital in New York that has established a program designed specifically to assess and address some of the unique communication challenges we face as hospitalists to improve patient care. As hospitalists, we’ve never met patients or families before beginning conversations at critical points of care. It takes sensitivity and particular thoughtfulness to create rapport and share substantial information with a patient—without having a prior relationship. Through the training, my colleagues and I each encountered three different SPs in key scenarios: one at daily rounds, one upset over a missed diagnosis, and one at discharge, when the potential for errors and miscommunication is greatest. We were video recorded during the encounters for our personal review, and received direct feedback afterward from the patient. We discovered that we as physicians have become great at taking care of patients, but we don’t have enough opportunities to investigate which elements of our day-to-day communication need adjustment—or what good behaviors need reinforcing. It was extremely helpful for us to be able to watch the videos and ask ourselves, “Do I use medical jargon that’s hard for the patient to understand? Do I say things that aren’t warm and welcoming to the patient?” Then, by adding in patient feedback, we learned how we performed across these core domains, such as treating patients with courtesy and respect, listening skills, and explaining complex topics in an understandable way. Strengthening these individual communication skills is paramount to improving patient comprehension, which in turn can improve patient follow-though on discharge instructions and reduce risk of readmission. And as educators, our takeaways from the training can empower others in the healthcare system at large to better communicate with their patients. Mount Sinai is proud to spearhead this innovative training effort in New York. In fact, since the initial date of the training, the three modules have expanded into a program run by The Morchand Center for Clinical Competence at the Icahn School of Medicine at Mount Sinai. So far, the Morchand Center has adapted the SP methodology for hospitalists to train 1,845 additional residents in various specialties across New York City. Nationwide, the entire medical community stands to benefit from continuous physician learning and partnerships that facilitate it, like The Doctors Company, which makes trainings like this possible. At a time of tremendous change for healthcare, having a well-trained physician workforce is more important than ever before. Our patients deserve to be cared for by physicians whose knowledge evolves alongside the transformation of care delivery. Physician learning must keep pace with our industry’s transformation. By setting the bar higher for what patients should expect on a patient communication level, we increase patient safety, raise levels of patient satisfaction and drive quality care—no matter what the future of healthcare delivery looks like.
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Medical/Legal How Lawmakers Are Tackling the Opioid Epidemic By Dennis W. Chiu, JD, Government Relations Specialist When the opioid epidemic hit the news—not just in scientific journals but in the popular media as well—it spurred Congress and state legislatures to offer public healthcare policy solutions. This has resulted in increased funding for treatment, more regulations for prescribing opioids, measures to increase the availability of opioid antagonists, and a reduction in liability for the administration of opioid antagonists. Celebrity Tragedy and National Statistics In 2016, the autopsy of pop music legend Prince found that the singer died from a “self-administered” dose of the opioid fentanyl. Prince’s tragic demise was only one of many celebrity deaths attributed to opioid-related causes. Celebrity deaths brought the dangers of opioids to the public’s attention, and statistics for the general population support the perception of an opioid addiction epidemic. Centers for Disease Control (CDC) Director Dr. Tom Frieden noted: “We know of no other medication routinely used for a nonfatal condition that kills patients so frequently.”1 Between the media attention and the preponderance of evidence that opioid usage had become a major public health problem in America, legislators were spurred to address the problem. Legislation and Administrative Action Lawmakers typically attempt to solve problems in two ways: (1) providing funding for programs, and (2) enacting regulations through legislation. As an indicator of the level of concern of U.S. lawmakers, the usually gridlocked Republican Congress and Democratic President Barack Obama united to address the issue. On December 13, 2016, both houses of Congress and the president worked together to approve legislation that granted $1 billion to state opioid abuse programs. This was a sharp increase in funding from earlier in the year and from previous years. (The Senate passed the law by a vote of 94–5, and the House of Representatives passed the law by a vote 355–77.) On October 26, 2017, President Donald Trump declared the opioid addiction crisis a public health emergency via the Public Health Service Act, though minimal new funding accompanied the declaration. The White House and Congress will need to work together to increase the depleted Public Health Emergency Fund. Two states—Colorado and Indiana—have since created funding for opioid treatment pilot programs. The Maine legislature overrode its governor’s veto to ensure access to opiate addiction treatment under its Medicaid program. Delaware and New Jersey have enacted laws requiring healthcare insurers to provide coverage for opioid addiction treatment. Legislators have also passed laws regulating the prescribing of opioids. Requiring Physicians to Check Prescription Databases Prescription drug databases, originally intended to be used by law enforcement, have been widened to allow healthcare providers and prescribers to review a patient’s prescription history for signs of overprescribing or addiction. Every U.S. state with the exception of Missouri has a prescription monitoring database.2 Some states have gone even further. By 2016, 18 states had passed legislation requiring medical professionals to consult a state database: California, Connecticut, Kentucky, Maine, Maryland, Massachusetts, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, West Virginia, and Wisconsin. State laws and regulations mandating prescribers to query the database vary as to requirements, but in general, most require the prescriber to check: (1) before initially prescribing a controlled substance to a patient in an opioid treatment program, (2) in workers’ compensation cases, and (3) prior to initially prescribing or dispensing an opioid analgesic or benzodiazepine in any setting.3 Most often, the penalty for prescribers for failure to check the database is referral to the department or board that enforces violation of professional standards.4 Opioid Antagonist Access Laws and Good Samaritan Protections Legislators have also sought to decrease deaths from prescription opioid abuse by increasing access to opioid antagonists. These drugs have no abuse potential and counteract the life-threatening effects of an overdose, allowing the victim to breathe normally once administered. Previously, access to these lifesaving medications was limited because a doctor-patient relationship needed to exist for a prescription to be issued. This requirement was ineffective because family and friends are often in the best place to administer an antagonist during an overdose, but they did not have access to a prescription. In 2001, New Mexico became the first state to enact legislation increasing access to opioid antagonists. Over the past 15 years, 47 states and the District of Columbia have passed similar laws. In the 2017 legislative year, Montana, North Carolina, Nevada, Tennessee, Texas, ECMS | 10
Medical/Legal Continued from pg. 10 Virginia, Wisconsin, and West Virginia enacted laws making opioid antagonists more available. In conjunction with increasing access to opioid antagonists, many states have passed Good Samaritan laws to limit liability for healthcare professionals and “laypersons” for administering opioid antagonist medications. For immunity to apply, laws typically require that a person must have a reasonable belief that someone is experiencing an overdose emergency, must remain on scene until help arrives, and must cooperate with emergency personnel. For healthcare personnel, immunity will usually apply unless there is gross negligence in the administration of the opioid antagonist. Good Samaritan laws for the administration of opioid antagonists have been passed in 37 states and the District of Columbia. The 13 states that have yet to pass opioid antagonist Good Samaritan laws are Arizona, Idaho, Iowa, Kansas, Maine, Missouri, Montana, Nebraska, Oklahoma, South Carolina, South Dakota, Texas, and Wyoming. Florida lawmakers will consider proposed legislation, Senate Bill 458, during the 2018 legislative session. If enacted in its current form, this bill will: • Limit a controlled opioid prescription to a seven-day supply. • Limit refill or subsequent controlled opioid prescriptions to a 30-day supply. • Provide exceptions to supply limits for certain patients. • Require a prescriber to access a patient’s drug history in the prescription drug monitoring program’s database before prescribing the drug, and at least every 90 days thereafter for continuing treatment. • Require a healthcare practitioner to complete a continuing education course as a condition of initial licensure and biennial licensure renewal. In 2017, Florida House Bill 477 added synthetic opioids to the list of controlled substances. Conclusion The legislative response to the opioid epidemic includes expanding healthcare providers’ ability to access databases that track opioid prescriptions. Lawmakers are also working to ensure easier access to opioid antagonists and immunity to those who administer opioid antagonists. Legislators are also providing more public funding for existing programs for treatment of opioid-addicted patients. At this point, there is insufficient data to evaluate the effectiveness of the recently passed legislation, but lawmakers and public health advocates hope to see a decline in opioid-related deaths when data becomes available. References 1.Guideline for prescribing opioids for chronic pain [press briefing transcript]. Centers for Disease Control and Prevention; March 15, 2016. www.cdc.gov/media/releases/2016/t0315-prescribing-opioids-guidelines.html. Accessed January 5, 2017. 2.49 states combat opioid epidemic with prescription database. [transcript]. Morning Edition. National Public Radio. May 10, 2016. www.npr.org/2016/05/10/477449821/as-opioid-crisis-escalates-missouri-is-without-monitoring-database. 3.National Alliance for Model State Drug Laws. 2015 annual review of prescription monitoring programs. www.namsdl.org/ library/1810E284-A0D7-D440-C3A9A0560A1115D7/. Published September 2015. Accessed January 11, 2017. 4.Mass Ann Laws ch 94C, §24A; Md HB 437 (2016); Cal SB 482 (2016). 5.Drug overdose immunity and Good Samaritan laws. National Conference of State Legislatures Website. www.ncsl.org/research/civiland-criminal-justice/drug-overdose-immunity-good-samaritan-laws.aspx. August 1, 2016. Accessed January 11, 2017.
Foundation Foundation ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY
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Foundation Dear Physician Members; As we hit the mid-point of 2018, “Thank You” to all who have contributed to the Foundation. Whether through your time, specific contributions or by joining The 1873 Society, thanks for helping the Foundation help others. It has been a busy past few months, with the recent highlight being the initiation of the PWP (Physician Wellness Program). This was inaugurated with our June 3rd Wahoos outing and funding is well underway to allow it to become a sustainable long term entity. • • • • • •
The Physician Wellness Program - “Helping Healers Heal” - has enabled its first two physician members to initiate help in combating physician burnout. It is confidential, supportive, professionally rendered, and the first three sessions are free for Active members. Review our web site and brochures for more information. The Blood Pressure Program has distributed hundreds of cuffs to patients who cannot afford them through the four local Free Clinics. The We Care Program continues to provide needed medical care to indigent patients. The Go Senior Voucher Program continues to provide transportation vouchers for doctors’ visits. The FSU Medical Student Scholarship Program continues to be enabled through the Foundation. Pensacola State College Endowment is further enabled through the Foundation.
The 1873 Society continues to gain members. Please see additional information in this issue to help fund the Foundation’s programs. All of our programs are enabled and supported by your donations and attendance. Please consider a donation that may be sent to 6706 N. 9th Ave. #A8, Pensacola, 32504. Personally, Kurt A. Krueger, MD ECMS Foundation President
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Foundation
THE 1873 SOCIETY Since 1873, Escambia and Santa Rosa County Medical Society physicians have dedicated themselves to their patients and the people of Escambia/Santa Rosa County. To further our mission and build on the loyal support of our members, the Board of Directors approved the formation of The 1873 Society, a special recognition opportunity to formally honor physicians who contribute to our organization and have demonstrated a long-term commitment to the quality of health care and well-being of our community. As a member of The 1873 Society your good name as a physician will be honored in our community forever--entwined with the good works of the medical society in a cherished legacy. Membership in The 1873 Society is for physicians who have chosen to pledge $3,000 to Escambia County Medical Society Foundation, Inc. This can be accomplished through a single gift or a recurring gift of $1,000 over three years, THREE IN THREE! The 1873 Society members are recognized and awarded with their names permanently engraved on a traveling Wall of Honor to be displayed in the ECMS office and at ECMS and ECMSF events.
THE 1873 SOCIETY MEMBERS The individuals listed below are both founding members as well as others who have joined The 1873 Society since its founding. We thank you for joining their distinguished ranks. Joanne Bujnoski, D.O. Jack Kotlarz, M.D. Kurt Krueger, M.D. Hillary Hultstrand, M.D. Ken Long, M.D. Robert Sackheim, M.D. Ellen W. McKnight, M.D. Michelle Brandhorst, M.D. Jennifer Miley, M.D.
Who is the Escambia County Medical Society Foundation? The Escambia County Medical Society Foundation is a non-profit organization dedicated to providing healthcare services on a volunteer and funding basis through its members. The Foundation was created in 1994. The primary goal is to assure access to adequate healthcare for the medically indigent citizens of the area, to study and promote improved methods and facilities for healthcare, to pursue the protection of public health, implement the means of financing healthcare at reasonable costs to cooperate with other organizations and institutions interested in pursuing these goals, and disseminate information concerning healthcare in general. Current Foundation programs include “We Care” and “Go Seniors!” Contact the ECMS Foundation for more information | 850.478.0706 or info@escambiaCMS.org
ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY
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SOCIETY FOUND PH ATI YS O I
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ESCAMBIA CO UN TY
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Physician Wellness Program HELPING HEALERS HEAL
1120 North Palafox Street Pensacola, FL 32501
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Wellness Coaching Provider
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Dr. Rick Spencer
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The Physician Wellness Program (PWP) provides a safe harbor for physicians to receive wellness coaching to address normal life difficulties in a confidential and professional environment. Why was the program created?
A physician’s life can be difficult. Problems with the current health care delivery system, maintaining a healthy work/life/family balance, and dealing with the normal stresses of everyday life do take their toll on physicians. Often our patients turn to us for counseling and guidance, but who can we turn to when we need to talk through an issue or get some coaching on how to handle the stresses in our lives? Too often the answer is “no one,” and that is regrettable, because it is important that we be as healthy as possible in our roles as physicians. It is important that we function at our best in all areas of our lives. By addressing areas of difficulty, we can decrease our stress levels and increase our level of resilience and effectiveness.
Some examples of those difficulties include: • Burnout
• Family Issues
• Mood Swings
• Work-related Issues
• Relationship Problems
• Suicidal Thoughts
• Difficulty Managing Stress
• Depression and Anxiety
Foundation
How PWP works
The Escambia County Medical Society Foundation board has hired licensed clinical psychologist Dr. Rick Spencer who has a PhD in psychology. He will provide wellness coaching to the Escambia/Santa Rosa County Medical Society Active Members, for up to three visits per calendar year. This provider will maintain a minimal confidential paper file for each physician, but no insurance will be billed and ECMS and the ECMS Foundation, Inc. will not be given any information that would identify those who utilize the program. As such, the program is completely confidential. ECMS Foundation, Inc. will pay a monthly invoice to our psychologist based on the total number of sessions provided. ECMS membership will be verified through a monthly log provided to Dr. Spencer.
PWP benefits
• This program is a membership benefit for ECMS Active Members • Member relatives may attend coaching sessions with members in attendance • Three free in-person wellness coaching sessions each calendar year • Complete confidentiality • Convenient location • Program is funded by donations and grants
To schedule an appointment
1) Please email patrick@psyassociates.com or call (850) 434-5033 x8 2) Identify yourself as a member of Escambia County Medical Society and that you wish to utilize the Physician Wellness Program
Office hours Monday Tuesday Wednesday Thursday Friday
EscambiaCountyMedicalSocietyFoundation
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8:00 am - 5:15 pm 8:00 am - 5:15 pm 8:00 am - 5:15 pm 8:00 am - 6:00 pm 8:00 am - 4:00 pm
How to donate to the foundation...
The Physician Wellness Program (PWP) is made possible with your tax deductible donation. To donate to the PWP and make a difference for our local physicians, please mail your check made payable to the: ECMS Foundation 6706 North 9th Ave. Ste. A8 Pensacola, Fl 32504 Please put “PWP” on the memo line.
6706 North 9th Avenue, #A8 Pensacola, FL 32504
Baptist Health Care
In the Community In The Community
Baptist Hospital Inc. Among Nation’s Top Performing Hospitals for Treatment of Heart Attack Patients Baptist Hospital Inc. has received the American College of Cardiology’s NCDR ACTION Registry Platinum Performance Achievement Award for 2018. Baptist is one of only 203 hospitals nationwide to receive the honor. The award recognizes Baptist’s commitment and success in implementing a higher standard of care for heart attack patients and signifies that Baptist has reached an aggressive goal of treating these patients to standard levels of care as outlined by the American College of Cardiology/American Heart Association clinical guidelines and recommendations. “This prestigious award demonstrates our consistent commitment to providing the highest standard of care for patients with heart attacks. We are truly honored to receive this award and would like to thank our physicians, team members and our patients for trusting us while in our care,” said Safwan Jaalouk, M.D. FACC, FSCAI, Medical Director, Cardiology Consultants. Baptist Medical Group Welcomes Donald Herip, M.D., MPH, FACOEM to serve as Medical Director of Occupational Health Baptist Medical Group is pleased to welcome back triple board-certified family medicine, occupational medicine, and preventive medicine physician Donald Herip, M.D., MPH, FACOEM, to its multispecialty physician network. Dr. Herip has been selected to serve as the medical director for Baptist Occupational Health. Dr. Herip has practiced occupational health for more than 30 years and has served for over 20 years in the United States Navy. He and his dedicated staff are committed to providing exceptional occupational medicine.
Sacred Heart Health Care New CEO at Sacred Heart Tom VanOsdol has been appointed CEO of Ascension Florida, which is comprised of Sacred Heart Health System as well as St. Vincent’s HealthCare in Jacksonville. In this role, Tom serves as the CEO for all of Ascension’s Florida facilities, which include seven hospitals and regional physician networks operated by St. Vincent’s and Sacred Heart. Tom was named president and CEO for St. Vincent’s HealthCare in 2017, having come to Jacksonville in 2015 as the COO. Pediatric Orthopedic Surgeon Seeing Patients in Pensacola, Miramar Beach Dr. Tracy J. Roberts, a pediatric orthopedic surgeon, has joined the faculty of the UF College of Medicine. She will see patients in Pensacola and Miramar Beach. Dr. Roberts graduated from the UF College of Medicine in Gainesville. She completed her residency training in orthopedic surgery at UF Health Jacksonville, followed by a fellowship in pediatric orthopedic surgery and scoliosis at Alfred I. duPont Hospital for Children in Wilmington, Del. She comes to Pensacola from Shriners Hospitals for Children. New Pediatric Urologist Arrives Pediatric urologist Dr. Mark Wehry joins The Studer Family Children’s Hospital at Sacred Heart and sees patients at 1657 Trinity Drive in Pensacola and at 23 Mack Bayou Loop in Santa Rosa Beach. Dr. Wehry is fellowship trained and board certified in pediatric urology. He graduated with a master’s degree in anatomy from the University of Louisville and his medical degree from East Carolina University. Dr. Wehry received residency training in general surgery and urology at St. Louis University Hospital. He performed a fellowship in pediatric urology at Alfred I. DuPont Hospital for Children in Wilmington, Del. He is President-Elect of the Sacred Heart Medical Staff. Surgery helps patient live pain-free after years of debilitating facial nerve pain Carol Gaines still remembers how a simple act triggered excruciating facial nerve pain. “I was brushing my teeth when suddenly it felt like a firecracker went off in my mouth,” she recalled. “The pain only lasted for a few seconds, but it was the most intense pain I had ever experienced in my life.” Gaines was diagnosed with trigeminal neuralgia, a condition caused by a blood vessel irritating or compressing the trigeminal nerve. When Gaines stopped responding to pain medications, she turned to Dr. Maria Toledo, an endovascular neurosurgeon at Sacred Heart Hospital. Dr. Toledo has performed more than 150 microvascular decompressions to treat trigeminal neuralgia. During Gaines’ surgery, Dr. Toledo placed a non-absorbable, sponge-like material in her brain to create a buffer between the trigeminal nerve and blood vessel. One month after surgery, Gaines’ facial pain is gone and she is getting back to doing activities that she enjoys. ESCAMBIA COUNTY MEDICAL SOCIETY IN CONJUNCTION WITH SANTA ROSA COUNTY
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