The Journal of the Medical Association of Georgia | Vol 107, Issue 2, 2018

Vol. 107, Issue 2, 2018

Georgia Congressional leaders weigh in on health care reform

The Composite Board’s evolving role Using Georgia’s PDMP to defend opioid litigation Addressing opioid abuse on every level MAG & Gwinnett Medical Center’s ’big success‘

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TABLE OF CONTENTS VOLUME 107, ISSUE 2

18

20

28

IN EVERY ISSUE

FEATURES

3

President’s Message

7

4

Editor’s Message

The CMS Quality Payment Program for 2018

6

Executive Director’s Message

8

Georgia Congressional leaders weigh in on health care reform

14 Medical Ethics 16 Georgia Composite Medical Board: GCMB’s evolving role 22 Legal: Using Georgia’s PDMP to defend opioid litigation 26 Patient Safety: Health care delivery consolidation 30 County, Member & Specialty News 34 Perspective 36 Prescription for Life

18 GMC’s resident rotation partnership with MAG a ‘big success’ 20 Medical schools need to keep pace with changes in health care system 28 Addressing opioid abuse on every level 35 MAG MRC conducts training exercise in Coffee County

PRESIDENT’S MESSAGE

The links between health care costs, outcomes and social determinants

Frank McDonald, M.D., M.B.A.

fmcdonald@icloud.com

F

ew can argue that our health care system was in great shape when President Barack Obama signed the Patient Protection and Affordable Care Act (aka the “ACA” or “Obamacare”) into law in 2010. Our traditional employer-based system provided health insurance for most employees who, being healthy enough to work, were relatively inexpensive to insure. Tax-funded plans like Medicare and Medicaid provided insurance for the elderly, disabled, and poor.

Still, there were inequities. Between 16 percent and 18 percent of Americans did not have health insurance between the enactment of Medicare and Medicaid in the 1960’s and the passage of the ACA in 2010. In addition, commercial insurance companies did not cover pre-existing conditions in order to prevent people from waiting until they became sick to buy coverage.

Obamacare was designed to reduce the number of uninsured in several ways. This included the “individual mandate.” The thought was that by requiring every American to have health insurance, the young and healthy could subsidize the ill and elderly. Insurers were also prohibited from using pre-existing illnesses as a reason for not covering a patient or for charging them more for their policy. And Obamacare called for states to expand their Medicaid programs to provide coverage for the working poor. Finally, the ACA created a federal health insurance exchange that allowed people who didn’t qualify for Medicaid or have access to employer-based coverage to purchase individual policies. When it was all said and done, Obamacare did, in fact, cut the number of uninsured in half.

Why was it so important to reduce the number of uninsured?

The answer is that the uninsured are about five times more likely to postpone care and about six times more likely to forgo care. What’s more, the uninsured tend to seek care in expensive settings – like hospital emergency departments – and they are less likely to contribute to the workforce and more likely develop chronic illnesses. Society pays a big price for the uninsured.

Unfortunately, the ACA has been less successful in reigning in health care costs. At more than 17 percent of GDP, the U.S. has the most expensive health care in the world. In 1980, our health care costs were about 8.5 percent of GDP – the same

as Denmark, Germany, and France. While health care costs in those three countries have increased by about 33 percent, to a little more than around 11 percent of GDP, ours have more than doubled.

Perhaps a more relevant question is whether we are getting our money’s worth. In 2017, the Commonwealth Fund reported that the U.S. health care system ranked last in the world in overall performance. We had the lowest life expectancy at birth, the highest infant mortality, and a higher prevalence of chronic disease.

The data suggests that we are paying more for less. And while many assume that there is a correlation between how much we spend for health care and health outcomes, this has not panned out.

Stuart Altman, a health care economist at Brandeis University, points out that just 20 percent of health care outcomes are determined by access to care and quality of care, while 80 percent are due to social determinants – including 30 percent for health behaviors (e.g., tobacco and alcohol use, diet and exercise, and unsafe sex), 40 percent for socio-economic factors (e.g., education, employment, income, family/social support, and community safety), and 10 percent for one’s physical environment.

Note, too, that while the U.S. spends more in overall health care costs, it spends much less than its global peers when you include the costs associated with “social care.” For example, France spends 35 percent of its GDP on health care and social care combined compared to 25 percent for the U.S. When I was installed as the Medical Association of Georgia’s president in October of last year, I said that I believe physicians need to be at the forefront of health care reform. We need to be the ones who lead the efforts to design cost saving and quality measures, and we need to be the ones who are running hospitals and health insurance companies. But if 80 percent of the outcomes are outside our traditional role and reach, I believe that it is time to expand our horizon and take a more active role in addressing the social determinants of health care. www.mag.org 3

EDITOR’S MESSAGE

The Medical Association of Georgia 1849 The Exchange, Suite 200 Atlanta, Georgia 30339 800.282.0224 www.mag.org MAG’s Mission To enhance patient care and the health of the public by advancing the art and science of medicine and by representing physicians and patients in the policy-making process.

Editor Stanley W. Sherman, M.D. Executive Director Donald J. Palmisano Jr. Publisher PubMan, Inc. Richard Goldman, rgoldman@pubman.net 404.255.5603, ext. 1 Editorial Board Jay S. Coffsky, M.D., Decatur Mark C. Hanly, M.D., Brunswick Mark Murphy, M.D., Savannah Barry D. Silverman, M.D., Atlanta Joseph S. Wilson Jr., M.D., Atlanta Michael Zoller, M.D., Savannah MAG Executive Committee Frank McDonald, M.D., President Rutledge Forney, M.D., President-elect Steven M. Walsh, M.D., Immediate Past President Lisa Perry-Gilkes, M.D., First Vice President Despina D. Dalton, M.D., Second Vice President Frederick C. Flandry, M.D., Chair, Board of Directors Steven M. Huffman, M.D., Vice Chair, Board of Directors Edmund R. Donoghue Jr., M.D., Speaker James Barber, M.D., Vice Speaker Andrew B. Reisman, M.D., Secretary Thomas E. Emerson, M.D., Treasurer S. William Clark III, M.D., Chair, AMA Delegation W. Scott Bohlke, M.D., Chair, Council on Legislation Advertising PubMan, Inc. 404.255.5603 or 800.875.0778 Fax 404.255.0212 Brian Botkin, bbotkin@pubman.net Subscriptions Members $40 per year or non-members $60 per year.

Foreign $120 per year (U.S. currency only).

The Journal of the Medical Association of Georgia (ISSN 0025-7028) is the quarterly journal of the Medical Association of Georgia, 1849 The Exchange, Suite 200, Atlanta, Georgia 30339.

Periodicals postage paid at Atlanta, Georgia, and additional mailing offices. The articles published in the Journal of the Medical Association of Georgia represent the opinions of the authors and do not necessarily reflect the official policy of the Medical Association of Georgia (MAG). Publication of an advertisement is not to be considered an endorsement or approval by MAG of the product or service involved.

Postmaster Send address changes to the Journal of the Medical Association of Georgia,1849 The Exchange, Suite 200, Atlanta, Georgia 30339.

Established in 1911, the Journal of the Medical Association of Georgia is owned and published by the Medical Association of Georgia. © 2017.

4 MAG Journal

Our legislators speak Stanley W. Sherman, M.D.

M

AG provides us opportunities to meet with and get to know our elected officials. This can hopefully help us when voting for those who seek our input and advice. In April, prior to MAG’s Board of Directors meeting, there was a well-attended breakfast with some of our representatives who were introduced by GAMPAC Chair Dr. Michelle Zeanah. This included Rep. Teri Anulewicz (D-Smyrna), Rep. John Carson (R-Marietta), Rep. Brett Harrell (R-Snellville), Rep. Scott Hilton (R-Peachtree Corners), Rep. Mark Newton, M.D. (R-Augusta), and Rep. Kim Schofield (D-Atlanta).

They each gave a summary of legislation that they were involved with, and they then took our questions. They discussed 1) scope of practice issues, which they said they know will continue and 2) rural health care needs for better broadband, telemedicine, and the effects of health system mergers and 3) needs for Medicaid funding increases, but also acknowledging that waivers to increase federal funding bring problems with decreased matched federal funding over time and 4) the opioid abuse crisis and 5) the need for more care for patients with autism and dementia.

The problems surrounding the lack of insurer transparency were discussed while lawmakers acknowledged the legislative limits to change how these companies operate.

Our members suggested letting the insurance companies collect the deductibles for physicians to solve the problem of patients not paying their deductibles.

There was praise for Rep. Sharon Cooper’s blocking of bad legislation, for MAG’s support for legislation against distracted driving, and for GAMPAC and our legislative team’s efforts. During the BOD meeting, we heard a report from Rep. Betty Price, M.D. – who we can thank for her recent efforts on distracted driving, optometry and MOC bills, and who always deserves our support. Dr. William Clark introduced his guest, Ken Hodges, a candidate for judge on Georgia’s Court of Appeals.

In this issue of the Journal, we turn to a prestigious group of U.S. lawmakers that includes a senator and five representatives to inform us of their views on national health care issues. Quite obviously, the responses are split down party lines – with the Democrats supporting government solutions and interventions and the Republicans supporting private sector solutions. On the other hand, there is much agreement to preserve Medicare and Medicaid, at least in defense of these programs’ original intended purpose. Perhaps their overall agreement that the lack of insurer competition, increased insurance costs, narrowing networks, opioid abuse, and access to care in rural areas can give us hope that bipartisan solutions can occur – despite their differing views on the solutions. We certainly appreciate all of their efforts and participation in our Journal.

MAG President Dr. Frank McDonald reviews and comments on our U.S. health care expenditures. Our CEO, Donald J. Palmisano Jr., discusses health care costs and how HealtheParadigm can help us lower them. Dr. John Antalis of

the Georgia Composite Medical Board warns us about the potential changes that today’s value-based “quality measures” may bring to our traditional Standard of Care, which has only dealt with patient care and safety. The latest CMS QPP exemptions for small and solo practices are reviewed. Our MagMutual article reviews the reasons and forces behind the decrease in small independent practices in favor of large consolidated practices. Drs. Janis Coffin and Richard Self address the need to teach health care reform in medical schools, citing how closely our MIPS evaluation components are aligned with Accreditation Council for Continuing Medical Education care. Dr. Mark Murphy humorously recounts his earliest introduction to health care reform.

for substance abuse. We also congratulate Dr. Harris on her recent election as AMA’s president-elect.

AMA Opioid Task Force Chair Dr. Patrice Harris reviews the status of efforts to address opioid abuse, sources of education on this topic (to learn about a good way to meet our three-hour opioid prescribing requirements, go to www.mag.org/tai), and the need for comprehensive care

Unfortunately, in a short period of time we have lost three MAG past presidents who remained helpful and active in our organization long after their presidencies. Dr. John Watson, Dr. Bob Lanier, and Dr. Bill Hardcastle are thanked, remembered and will be missed by us all.

Our legal article from Huff, Powell and Bailey shows how PDMP use as part of our Standard of Care can prevent malpractice suits. Our ethics case from Mercer deals with hospice care and the patient’s right to stop both eating and drinking. Dr. Jay Coffsky shares some lessons that only years of professional practice, not medical school, can teach us. And past President Dr. John Harvey tells us about the Gwinnett Medical Center’s MAG Resident Rotation Program. Hopefully, this will stimulate similar programs across the state.

GAMPAC Chairman’s Circle members attend exclusive Washington, D.C. ‘Fly-In’ Members of GAMPAC’s Chairman’s Circle – who have contributed $2,500 or more in 2018 – met with U.S. Congressional leaders during an exclusive ‘Fly-In’ event that took place in Washington, D.C. on May 15-16.

The GAMPAC contingent included Thomas Bat, M.D., Snehal Dalal, M.D., Fred Flandry, M.D., Rutledge Forney, M.D., Frank McDonald, M.D., Randy Rizor, M.D., John Rogers, M.D., Christopher the left are Sen. David Perdue, Randy Rizor, M.D., Snehal Dalal, M.D., Christopher Walsh, M.D., Frank Walsh, M.D., Charles Wilmer, M.D., and From McDonald, M.D., Michelle Zeanah, M.D., Charles Wilmer, M.D., Rutledge Forney, M.D., and Fred Flandry, M.D. Michelle Zeanah, M.D. They met with Reps. Rick Allen, Drew Ferguson, Jody Hice, Barry Loudermilk, Austin Scott, Rob Woodall, Karen Handel, Doug Collins, and Buddy Carter from Georgia, Rep. Phil Roe, M.D., from Tennessee, and Sens. David Perdue and Johnny Isakson from Georgia. The group also toured the U.S. Capitol, the National Museum of African American History and Culture, and the U.S. Holocaust Museum.

“This was a really unique life experience,” says MAG Government Relations Director Derek Norton. “In addition to some great tours, our Chairman’s Circle members got a chance to weigh in on some important issues – including the VA health care system and the need for health insurance reform – with a number of lawmakers.”

The other 2018 Chairman’s Circle members include John S. Antalis, M.D., W. Scott Bohlke, M.D., S. William Clark III, M.D., Matthews W. Gwynn, M.D., Katarina G. Lequeux-Nalovic, M.D., Deborah A. Martin, M.D., Fonda A. Mitchell, M.D., John G. Porter, M.D., Keith C. Raziano, M.D., Robert D. Schreiner, M.D., Manoj H. Shah, M.D., Michael J. Sharkey, M.D., William E. Silver, M.D., James L. Smith Jr., M.D., O. Scott Swayze, M.D., Leiv M. Takle Jr., M.D., Steven Walsh, M.D., Resurgens Orthopaedics, the Georgia College of Emergency Physicians, the Georgia Society of Interventional Pain Physicians, the Georgia Orthopaedic Society, the Georgia Neurosurgical Society, the Georgia Society of Otolaryngology/Head & Neck Surgery, and OrthoAtlanta.

GAMPAC is MAG’s non-partisan political action committee. It elects pro-physician candidates at the state level. GAMPAC has more than 1,000 members.

Contact GAMPAC Manager Bethany Sherrer at bsherrer@mag.org or 404.354.1863 to join GAMPAC. Go to www.mag.org/gampac for additional information on GAMPAC.

www.mag.org 5

EXECUTIVE DIRECTOR’S MESSAGE

Better you and me than someone else Donald J. Palmisano Jr. dpalmisano@mag.org

I

n addition to its role as the leading advocate for physicians in the state, the Medical Association of Georgia is a small employer – with a staff that numbers 20, MAG can relate to the average American’s feelings of frustration and fatigue when it comes to the seemingly-endless health care debate.

This includes myriad issues, but the one problem that really stands out like a sore thumb is the glaring lack of competition within the health insurance arena – especially in rural areas, which are beginning to look and feel a lot like a single-payer system. This even though history clearly shows us that competition results in better products and services at lower cost.

Some of our larger metro areas notwithstanding, it is becoming increasingly challenging for hospitals and medical practices to keep their doors open. The only insurance plans that are available in much of rural America these days are sponsored by the government. But any physician can tell you that these plans generally don’t cover the cost associated with providing the care – which isn’t a sustainable model for any business.

This, then, undermines patient care. Patients must either see physician extenders (e.g., APRNs) or they must travel long distances to receive the care they need. And research shows that the physician extenders in rural areas are also struggling to earn enough pay.

The health insurance policy for MAG staff increased by nearly 30 percent this year. The average family policy for MAG staff now costs more than $25,000 a year.

For the first time, I’m hearing at least some employers ask whether we might simply be better off throwing in the towel and adopting a single-payer model. Others are looking for more innovative solutions.

For example, Amazon and Walmart are creating their own, inhouse health care systems. If I were a gambling man, I’d put my money on the free marketplace – but only time will tell.

The underlying messages are powerful ones either way: health care costs are too high, and we need a better solution.

I continue to believe that the single most important step that individual physicians in Georgia can take to reduce health care costs is to take advantage of HealtheParadigm, which is a physician-led health IT solution that enables physicians to create patient data reports that they can use to improve patient outcomes and fulfill today’s payer metrics.

6 MAG Journal

The macro-level premise is that overall health care costs will decrease if physicians have instant access to the patient data they need because they can avoid ordering duplicative tests.

HealtheParadigm works like a cell phone network, while your electronic medical record works like your cell phone.

Whether you have an iPhone or Samsung phone, you need access to a network like ATT or Verizon – which are agnostic when it comes to cell phone brands. In this example, Cerner, athenahealth or Epic is like your iPhone or Samsung phone, while HealtheParadigm is like the ATT or Verizon network. And HealtheParadigm works with every EHR product.

Eventually, HealtheParadigm will enable physicians in the state to connect to the statewide Georgia Health Information Network so they have instant access to a patient’s EHR – no matter where they are. Doing so will help you deliver the best possible care for your patients.

Also note that if you are in an accountable care organization or a clinically-integrated network, Healtheparadigm features “dashboards” that address public health and registries and other important metrics that will help you and your practice succeed.

Plus, Healtheparadigm creates value for physicians in every practice setting – from solo/small practices to large groups. I encourage you to call 877.921.7196 or contact Susan Moore at smoore@mag.org or visit healtheparadigm.org for additional information on Healtheparadigm.

Of course, you can rest assured that MAG’s House of Delegates will continue to consider policies that will enhance patient care and reduce costs – including whether the state’s Medicaid program should be expanded, whether insurance should be sold across state lines, and whether the Affordable Care Act should be repealed.

There isn’t any reason to panic, here, but we do need to recognize that the health care paradigm is shifting. And whether it is a small employer like MAG or your medical practice, we have to take strategic action to ensure that we remain viable in the long-term.

If we don’t, there will always be someone else who is willing, ready, and able to make these decisions on our behalf.

CMS UPDATE

The CMS Quality Payment Program for 2018

By Richard E. Wild, M.D., FACEP, chief medical officer, Centers for Medicare and Medicaid Services, Region IV

Y

Richard E. Wild, M.D., FACEP

ou just finished seeing a patient, you’re sitting at your desk, sipping a cup of coffee, asking yourself, “What’s new in year two of the CMS Quality Payment Program (QPP)?”

patients (who receive covered professional services under the Medicare Fee Schedule) per year. Only those clinicians who bill Medicare Part B under these provisions will be required to report under QPP for 2018.

In 2018, the Quality Payment Program will continue to provide you with new tools and resources to help you give your patients the best possible care.

Clinicians who are exempt from MIPS may still voluntarily report, but their score will not affect their neutral payment adjustment. Physicians who participate in Advanced Alternative Payment Models (A-APMs) by either receiving 25 percent of their Medicare payments or 20 percent of their Medicare patients in an Advanced APM are also exempt from the 2018 reporting. Clinicians who significantly participate in an Advanced APM will be exempt from MIPS payments and will instead receive an automatic plus five percent payment from CMS applied to their Medicare fee schedule payments. They will also share in the upside or downside risk-based payment amounts provided for in their Advanced APM agreements.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula and substituted the Medicare QPP. Physicians and other clinicians billing Part B services choose how to participate based on practice size, specialty, location, and patient population.

Under the changes, you have two ways to choose how you want to participate based on your practice size, specialty, location or patient population, including…

– Advanced Alternative Payment models (APMs) or – The Merit-based Incentive Payment System (MIPS) If you choose to be part of an Advanced APM through Medicare Part B, you might earn an incentive payment for participating in an innovative payment model. If you choose to participate in MIPS, you’ll earn a performance-based payment adjustment.

If you decide to participate in an Advanced APM, you may earn a five percent positive incentive payment. If you participate in MIPS, you will earn a performance-based payment adjustment between plus and minus five percent (with the possibility of up to an additional 10 percent bonus for exceptional performance).

Unlike 2017 – when all physicians in Georgia were exempt from any downward adjustment due to a statewide emergency declaration during the hurricane season – it is important to know that all eligible clinicians must satisfactorily report measures to avoid a five percent downward payment adjustment for the 2018 performance year.

For the 2018 performance year, the minimum reporting period for quality measures has been increased to a full calendar year.

Additionally, cost measures will be calculated automatically for the entire performance year (clinicians do not need to report).

Meanwhile, Improvement Activities and the Advancing Care Information reporting periods remain at 90 days. This year, CMS expanded the QPP reporting exemption to $90,000 (allowed charges for covered professional services under the Medicare Physician Fee Schedule) per year or 200 Medicare

The official www.QPP.cms.gov website is the best one-stop site for official CMS information on QPP program reporting, eligibility, MIPS, APMs, quality and other measure listings, scoring and data submission options, etc. New information is posted on the website on a regular basis, including all proposed and final changes for each year.

The most important provisions to help physicians in small or solo practices for 2018 include…

In addition to expanding the reporting exemption thresholds to $90,000 of Medicare Part B charges and 200 Medicare patients, CMS adds an automatic five bonus points to the final scores of small practices of 15 or fewer clinicians.

In 2018, small practices and solo practitioners who exceed the low volume threshold had the option to join a Virtual Group with other practices of one to ten eligible clinicians – regardless of specialty or location. This allows solo and small groups to pool resources for quality reporting and have their performance assessed as part of the Virtual Group.

Virtual groups for 2018 had to register before January 1, so practices should now plan for 2019. CMS awards small practices three points for measures in the Quality performance category that fail to meet data completeness requirements.

Small practices may also qualify for a new hardship exception for the Advancing Care Information category (electronic health records) for small practices.

Go to QPP.cms.gov for additional information or email QPP@cms.hhs.gov with questions. www.mag.org 7

Georgia Congressional leaders weigh in on health care reform

By Tanya Albert Henry

W

hen it comes to health care reform, a plethora of issues are being discussed in the nation’s capital, and the actions that lawmakers ultimately take will have a big impact on both physicians and patients in Georgia.

With that in mind, the Journal asked some of Georgia’s congressional leaders to share their thoughts on the best ways to address some of today’s most pressing health care issues.

One of the common takeaways that emerged in this process is that these legislators all agree that physicians face an administrative burden that’s too heavy – and they all said that they are striving to reduce that burden and streamline the regulatory process.

In addition to supporting organizations like the Medical Association of Georgia, they said that the most important step that individual physicians can take to effect change is to weigh in and build meaningful relationships – whether it’s writing an email or making a phone call or scheduling a face-to-face meeting. They said they want to hear from physicians – honest, real-world feedback, the good and the bad. They want to know how they can improve America’s health care system in the most effective and sustainable ways.

The congressional leaders who participated in the following Q&A include Sen. Johnny Isakson (R), Rep. Earl L. “Buddy” Carter (R, 1st District), Rep. Drew Ferguson (R, 3rd District), Rep. Jody Hice (R, 10th District), Rep. Austin Scott (R, 8th District), and Rep. David Scott (D, 13th District). It is worth noting that Rep. Carter is a pharmacist, Rep. Ferguson is a dentist, and Rep. Austin Scott owned and operated an insurance brokerage firm.

8 MAG Journal

What role should the federal government play when it comes to health care?

Sen. Isakson: The federal government’s role in health care should be limited. Free-market policies will increase choice for families and businesses and are the keys to expanding access to health insurance. I support repealing the prohibition of insurance sales across state lines, allowing small businesses to pool together to form association health plans, expanding health savings account availability, and decreasing regulations on short-term health plans.

Rep. Carter: Patients deserve the freedom and flexibility to choose the right type of care for themselves. We need to replace the top-down way of doing things and open up the U.S. health care system to innovation and market competition.

Rep. David Scott: The federal government should ensure there is a strong health care safety net in place to ensure that Americans can get care when they need it. Families shouldn’t have to choose between buying groceries and paying medical bills. Medicare, Medicaid, community health centers, and the ACA are vital parts of that safety net that I am proud to support.

Rep. Austin Scott: Federal lawmakers should enact legislation that creates a transparent and fair-competition health care landscape that empowers physicians and health care providers to innovate better patient models and drive down costs. It should also allow competition to let individuals select the health insurance plans that work best for them.

Rep. Hice: Outside of critical programs like Medicare and Medicaid, the federal government should have a limited role in health care. Congress should focus on rolling back policies

and regulations that aren’t working and on getting the federal government out of the way of the free market and private sector innovation.

What would you like to see happen and what do you think will happen on the national health care reform front in 2018 and beyond?

What are your views on the Affordable Care Act in 2018?

Sen. Isakson: In October 2017, I signed on as an original cosponsor of a short-term, bipartisan agreement known as the ‘Bipartisan Health Care Stabilization Act’ to help stabilize the individual health insurance market and to give states more of the flexibility they need and help struggling Americans who are feeling the weight of Obamacare’s requirements. I hope we can make progress on that front and pass something this year.

Sen. Isakson: The ACA has failed Georgians and the American people. Currently, 144 of Georgia’s 159 counties have only one health insurance provider, and Georgians are facing premium increases of up to 50 percent next year. We have a responsibility to do as much as we can in the short-term to stabilize and strengthen the individual health insurance market so Americans can buy insurance at affordable prices in 2018 and 2019.

Rep. Ferguson: It is clear that the ACA has failed. Premiums are rising and people have fewer choices and less access to care. In fact, most counties are down to a single insurance provider in my district.

Rep. Hice: Many Georgians were confronted with the harsh reality of the state of the ACA during the recent 2018 enrollment period. In Oconee County, Blue Cross Blue Shield has pulled out of the ACA exchanges and many folks can no longer find decent health coverage. Right now, 16 out of the 25 counties in Georgia’s 10th District have just one insurer currently offering plans. Premiums have continued to skyrocket, deductibles are still soaring, plan coverage networks are shrinking, and more insurance companies are limiting their participation in the ACA marketplaces. It’s an unsustainable situation, and it’s imperative we find a way forward.

Rep. Austin Scott: The ACA is horrible. In the district I represent, Blue Cross Blue Shield is the only exchange insurer offering coverage in every county. Through rules, regulations, and mandates, the ACA has forced consolidation of markets and providers, effectively removing competition from the industry and forcing small medical practices and physicians to sell to larger health care providers, like hospitals, creating less competition that leads to fewer options and higher prices. I fear these trends are only going to worsen beyond 2018.

Rep. Carter: The ACA is driving up costs, taking away choices, and putting bureaucrats between patients and their health care providers. I have voted to repeal this disastrous law in its entirety, and I am part of the conservative Republican Study Committee’s Health Care Taskforce that is working to identify solutions that will empower patients with more choice, lower cost, and better services. Health care delivery must come through a comprehensive approach that empowers all aspects of allied health. Although doctors will always remain in charge and are recognized as the leader of the health care team, modern health care requires the whole host of health care professionals to expand their role and increase their interaction with patients.

Rep. David Scott: Despite repeated attempts to repeal, strike down, and hamstring the ACA, it continues to insure more than 24 million Americans on the individual market and through Medicaid expansion. But with the end of cost sharing reduction payments and the repeal of the individual mandate, Congress must pass a bill to stabilize the ACA to increase insurance coverage options and bring down costs.

Rep. David Scott: It’s clear that Congress needs to come together to stabilize the individual market. I continue to support a number of policy changes, including reauthorizing federal reinsurance programs, reinstating cost sharing reduction payments, expanding the number of insured by increasing eligibility for tax credits, and ensuring states can conduct outreach about insurance options and educate individuals on how to use their insurance effectively.

Rep. Carter: We have a unique opportunity this year to address rising health care costs. The Food and Drug Administration commissioner has promised to accelerate generic drug approvals, which would add more low-cost options. I have also been working with my colleagues to bring greater transparency for pharmacy benefit managers (PBMs), including introducing legislation that will forbid PBMs from including gag clause language in contracts with pharmacies. Finally, CMS has been taking comments on how to best pass along discounts based on the lower negotiated price to patients at the point of sale.

Rep. Austin Scott: In December, Congress took steps to address the shortfalls of the ACA by repealing the individual mandate in the tax reform package. Some say this will destroy the ACA, some say it will save it; however, I don’t believe either to be the case. I believe that we must level the payment playing field so that physicians and private-owned practices are paid and reimbursed at the same rate for the same service as larger providers, like hospitals. Simply put, we must protect the independent physician’s role in medicine to improve quality and price stability in the health care system.

Rep. Hice: It’s going to take time and hard work to set the U.S. health care system on the right track. President Trump has been working to make improvements, including extensive new rules the Department of Labor proposed in January to pave the way for expanded access to association health plans. Those would allow small businesses, their employees, and the self-employed to join together as a single group to buy insurance lowering premiums and boosting competition. We are going to have to do this pieceby-piece, with many little steps and some big ones. I expect further action in the near future, such as being able to purchase health insurance across state lines. Congress needs to continue examining areas where we can reach bipartisan agreement.

Rep. Ferguson: Our nation’s health care system has long needed reforms to reduce costs and increase access to care. As a practicing dentist in West Georgia for 25 years, I saw this firsthand.

The ‘American Health Care Act’ (AHCA), which passed the House last year but failed to pass the Senate, would have been a www.mag.org 9

great first step in this process. This legislation included incentives, not mandates, to encourage Americans to have continuous health care coverage and increases choice and flexibility for consumers, allowing them to choose the health care plan that meets their needs. Significantly, the AHCA would have ensured that those who have pre-existing conditions could not be denied insurance coverage and included additional funding to ensure access to affordable coverage for all Americans, regardless of health status.

As we move forward in the health care debate, I hope that future legislation will advance the policies we laid out in the AHCA. Do you think Georgia should expand its Medicaid program?

Sen. Isakson: Georgia’s governor is best equipped to make that decision. Governor Deal has been wise to consider the risk that the federal government’s share of Medicaid expansion funding could be reduced in the future given the federal debt and deficit crisis.

Rep. Hice: Medicaid was created to provide health coverage to our most vulnerable populations, including infants and children, pregnant women, people with disabilities, and low-income seniors. I believe that Medicaid should continue to focus on those critical populations.

Rep. Austin Scott: Whenever you take people out of the private insurance market and put them into a governmentmanaged program, you increase costs for the remaining individuals and put a strain on the insurance market. If Georgia expands its Medicaid program, it runs the risk of increasing that cost burden on even more Georgians and further damaging the state’s insurance landscape. That said, I think it would be beneficial for the future of Medicaid if states were given the flexibility to develop programs that include responsible and affordable copays for Medicaid recipients.

Rep. Carter: No, Georgia should not expand its Medicaid program. Medicaid is an important program for eligible lowincome adults, children, pregnant women, early adults, and people with disabilities – covering able-bodied adults skewed the goal of Medicaid. Furthermore, states that accepted the enhanced match are finding their state budgets in debt as they struggle to balance their budgets with the steadily declining federal match.

Rep. David Scott: Absolutely. Many hardworking Georgians who make too much money to be eligible for traditional Medicaid but not enough to be eligible for a subsidy in the individual market would greatly benefit from Medicaid expansion. Additionally, states that expanded Medicaid experienced a slower rate of rural hospital closings than non-expansion states.

Is the Medicare program on solid ground/sustainable?

Sen. Isakson: We must protect Medicare, and I have been actively working on ways to preserve the program for future generations. To that end, I introduced bipartisan legislation that became law earlier this year, called the ‘Creating HighQuality Results and Outcomes Necessary to Improve Chronic 10 MAG Journal

Care Act’ to improve Medicare benefits for seniors with two or more chronic conditions. By coordinating care and focusing on prevention and keeping people out of the hospital, this reform can provide better care at a lower cost to the Medicare program. This is an important first step towards getting Medicare on a more sustainable track, and I hope Congress will continue working on bipartisan solutions.

Rep. Hice: Medicare is an important program for our seniors, but without meaningful reforms it will not be available for future generations.

Rep. David Scott: To strengthen Medicare’s financial position, we must continue Medicare reforms like those passed in the ACA, which extended solvency of the Medicare Trust Fund by 12 years and modernized the program through delivery and payment reforms. As we implement Medicare payment reforms, Congress and CMS must work closely with the physician community to ensure that any change is appropriate and not overly burdensome.

Rep. Austin Scott: Medicare and other mandatory spending programs are consuming a growing portion of the federal budget.

In the coming years, the Medicare Trust Fund will not have sufficient funds to cover projected costs because the program has not been reformed to meet the realities of the 21st century’s increased life expectancies, population shifts, and rising health care costs. We must take steps to preserve, protect, and strengthen Social Security and Medicare for current retirees, as well as protect these programs’ solvency for future generations.

Rep. Ferguson: Our current system is unsustainable, and Medicare is currently projected to be insolvent by 2029. We must put aside politics to have an honest conversation about reforming entitlement programs in our country.

Rep. Carter: The current Medicare payment system has threatened seniors’ access to quality health care for too long and they deserve a permanent solution, not just another band-aid.

Medicare is a critical program in Georgia and across the nation.

In Congress, I have worked with my colleagues to find solutions to improve benefits for patients and put the program on a more sustainable path.

Are you concerned about the health insurance industry in terms of consolidation, narrowing networks, etc. – and what role, if any, should Congress play to stabilize health insurance markets?

Sen. Isakson: Yes, and I am working toward an agreement as previously mentioned. Much more needs to be done beyond this agreement to help Georgians who have been hurt by Obamacare, but we cannot and should not make perfect the enemy of the good. Consolidation poses a threat to competition across many facets of the health care marketplace, and Congress and rulemaking agencies need to watch these trends carefully.

Rep. Austin Scott: I am very worried about the recent trends in consolidation within the health insurance industry. Leaving health insurers exempt from the antitrust laws of the country

stifles competition and gives insurers too much control in the market. My colleagues in the House and I have worked to remove this exemption by passing the ‘Competitive Health Insurance Reform Act of 2017’ by a vote of 416-7. This bill, awaiting Senate consideration, would subject health insurers to federal anti-trust laws.

Rep. Ferguson: I am very concerned about potential implications of horizontal and vertical integration in the health care marketplace and the impact of narrow networks on patients and providers in my district and across Georgia. The ‘American Health Care Act’, which passed the House in 2017 but failed to pass the Senate, would have taken important steps to stabilize the health insurance markets for Americans. Specifically, the bill included market-oriented reforms to increase choice and flexibility and lower costs for consumers. It also provided funding for states to establish high-risk pools to reduce premiums and out-of-pocket costs for individuals requiring costly care. I continue to advocate for reforms like these to lower costs and increase access to care for all Americans. I’m also proud that the House resoundingly passed H.R. 372, the ‘Competitive Health Insurance Reform Act of 2017,’ which would ensure that health insurance issuers are subject to the same antitrust and unfair trade practices laws that all businesses have had to comply with.

This bill passed the House with just seven dissenting votes, so I remain hopeful that the Senate will take it up soon. Repealing this exemption would increase competition in the marketplace and help lower the costs for consumers.

Rep. Carter: One of the greatest issues facing the health care system today is increased consolidation. Mergers and acquisitions have created large payer and provider entities that command market power. The U.S. Federal Trade Commission (FTC) and the Antitrust Division at the U.S. Department of Justice (DOJ) have closely scrutinized recent health care deals. The DOJ has recently challenged attempts at horizontal integration in the health insurance industry by blocking attempted acquisitions.

However, the dangers posed by vertical integration have not been as vigorously addressed by the DOJ and FTC. For example, a merger between CVS Health and Aetna Inc. would pose a direct threat to competition in the health care industry and would incentivize further consolidation, jeopardizing consumer choice and increasing costs for prescription medications. Consumers need relief, and further market consolidation will only worsen these rising costs.

Rep. David Scott: While consolidation is not always a bad thing, we must be vigilant to ensure that consumers do not suffer due to a lack in competition. The federal government has a long history of regulating markets to foster competition, and the federal government must continue to do so in order to drive down health care costs for all Americans.

The Department of Justice has been vigilant, and Congress must continue to provide oversight and collect information so that it can respond in the most appropriate manner when needed.

Do you have suggestions for ways to reduce prescription drug prices?

Rep. Carter: Pharmacy Benefit Managers (PBMs) have evolved from fiscal intermediaries into companies that dictate the products and providers used by patients to treat their medical conditions. It’s hard to understand what value they bring to the health care system at all. If we want to reduce prescription drug prices, we need to bring greater transparency to PBMs practice.

Rep. Austin Scott: The biggest factors contributing to the rising cost of prescription drugs are a lack of transparency in how drug prices are determined and a lack of fair competition in the pharmaceuticals marketplace. Pharmacy benefit managers are not being held accountable and due to a lack of transparency in the rebate system are able to siphon billions of dollars and pass those costs onto consumers. It is imperative we increase oversight of PBMs and closely monitor pharmaceutical industry consolidation.

Rep. David Scott: The federal government has a role to play in reducing prescription drug prices, potentially through increasing transparency, piloting payment models that pay for the value of the drug rather than per unit and changing the way federal health programs pay for prescription drugs. However, it is clear there must be buy-in from the private sector to ensure the prescription drug market is affordable and accessible for all Americans.

Do you have suggestions for ways to reduce opioid misuse?

Sen. Isakson: President Trump recently directed additional attention and funding toward this issue, and the government funding measure that was recently signed into law provides nearly $4 billion to combat the opioid epidemic harming families in Georgia and across America. Our states are taking steps to lead the way in combatting this terrible scourge, and we recently heard in our Senate committee that oversees health some of the “best practices” coming from our states. In Georgia, Attorney General Chris Carr formed the Statewide Opioid Task Force, which brings communities and stakeholders together to help combat the crisis.

Rep. Hice: The opioid crisis may have begun at home, but it’s being fueled by a massive amount of illicit drugs from overseas.

Drugs often arrive in America through the U.S. Postal Service. In September 2017, my colleagues and I on the House Oversight and Government Reform Committee – which has jurisdiction over the U.S. Postal Service – held a hearing to shine a light on how lax security standards have allowed international drug traffickers to use the mail as an unwitting courier. We need to enact commonsense solutions like the bipartisan ‘Synthetics Trafficking and Overdose Prevention (STOP) Act,’ H.R. 1057.

Rep. David Scott: It is important that there are treatments available and accessible for recovery. Additionally, Congress should encourage and fund research into opioid alternatives and the federal government should provide grants and technical assistance to ensure that prescription drug monitoring programs are userfriendly and have state and federal interoperability. www.mag.org 11

Rep. Austin Scott: While there are domestic issues that must be addressed, the crisis is further exacerbated by the illegal drug smuggling done by transnational criminal organizations. It is imperative that any health care policy change be supplemented with improved border security and drug enforcement.

Rep. Carter: While the House has passed many legislative measures to address recovery and prevention of opioid abuse, there is much more that needs to be done. We’re taking action in the Energy and Commerce Committee. I am working with my colleagues across the aisle, including legislation giving pharmacists more information on spotting falsified prescriptions, enhancing access to substance use disorder treatment through telehealth and expanding accessibility of abuse deterrent formulations.

How can we ensure that people who live in rural/ underserved areas have access to the medical care they need?

Sen. Isakson: I’ve introduced several pieces of legislation in this area. My chronic care legislation puts more money into telehealth. I also introduced the ‘Fair Medicare Hospital Payments Act’ (S.397) to correct a flawed Medicare payment formula that currently unfairly results in lower payments to hospitals in rural and lowwage areas. Finally, Congress should continue funding community health centers to provide affordable care in underserved areas.

Rep. Ferguson: We need to continue to look for innovative ways, like telemedicine, to provide meaningful care in a costeffective way.

Rep. Carter: On the Energy and Commerce Committee, I have worked with my colleagues to enhance funding for rural health care programs and remove administrative barriers preventing hospitals from focusing on care.

Rep. Austin Scott: The challenge for providers in rural and underserved areas is that their payer mix has a disproportionally larger share of no-pay patients and their services are reimbursed at a rate that is far less than the cost of doing business. In order to create more access to medical care in rural areas, we must take steps to give rural providers the tools they need to compete with providers in more densely populated areas.

Rep. Hice: At a time when many of our vitally important rural hospitals are closing their doors, we need to continue to support existing providers while looking at ways to expand the use of new methods and approaches to care like telemedicine.

Rep. David Scott: Because states that expanded Medicaid experienced a slower rate of rural hospital closings than nonexpansion states, I believe that Medicaid expansion would be a helpful step, widening the pool of potential payers. Additionally, it is clear that telehealth is a valuable resource for providing care in these areas. Congress must ensure there are proper codes and reimbursement rates for telehealth.¨

12 MAG Journal

How to contact your Congressional leaders Sen. Johnny Isakson 202.224.3643 h t t p s : / / w w w. i s a k s o n . s e n a t e . g o v / public/index.cfm/contact-me

Rep. Buddy Carter 202.225.5831 h t t p s : / / b u d d y c a r t e r. h o u s e . g o v / contact/

Rep. Drew Ferguson 202.225.5901 https://ferguson.house.gov/contact

Rep. Jody Hice 202.225.4101 Rep.JodyHice@mail.house.gov

Rep. Austin Scott 202.225.6531 https://austinscott.house.gov/contact

Rep. David Scott 202.225.2939 https://davidscott.house.gov/contact/

Go to https://www.house.gov/representatives/find-yourrepresentative to contact Georgia’s other Congressional leaders.

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www.mag.org 13

MEDICAL ETHICS

A troubling case

By Brian Childs, PhD, professor of bioethics and professionalism, Mercer University School of Medicine

A

woman in her mid-80s with advanced dementia and a failure to thrive was certified as “end stage” and moved from a nursing home to a residential hospice. Her daughter, who was from out of state, stayed with her mother during the day – fully expecting her to die within a few days.

When she was offered food or something to drink when it was placed in or near her mouth, the patient accepted it. She seemed to enjoy the feedings, especially ice cream.

While the patient never had problems swallowing in the nursing home, she did not seem to want food while she was in the nursing home – and the staff did not have the time to encourage her to eat. While her caloric input was not great, it was significant enough to support her nutritional needs.

Her daughter, who had health care power of attorney, began to object to the hospice workers offering food to her mother.

She argued that her mother would not want the food if she wasn’t demented, but since she was the daughter felt entitled to express her mother’s wishes not to have any food or drink offered.

The hospice workers felt that since the patient seemed to like the feedings, and since she did in fact finish the small meals, she was expressing a desire to eat. The daughter argued that it was only learned behavior and not indicative of any real desire to eat to relieve hunger. The daughter insisted that if food were brought into the room that she, and not a hospice worker, should administer the food.

After a week, the patient continued to eat and gained strength, so much so that she was able to sit in a chair beside her bed for a bit every day. The daughter went back to her home and made short visits over a period of a month or so. The hospice staff continued to offer the patient food – increasing the amount by a little each day – which she continued to accept.

After a month, the daughter returned to the hospice and spent an entire day and evening with her mother. She once again asked the hospice staff not to offer her mother food and drink. On a number of occasions, she said that, “This is taking too long, and all the food is doing is keeping her alive.”

The hospice workers said that with no explicit directions from the patient in the form of an advance directive, there was no clear indication that the patient – when she was in her prior lucid state – preferred not to receive food if she were in the “end stage” of life. They maintained that she accepted 14 MAG Journal

the food, seemed to enjoy it, and it would be contrary to the hospice spirit and philosophy not to offer it to her under the circumstances.



When ventilator support is withdrawn, we give patients morphine to reduce discomfort.

In this case, why not withhold feeding? In this and similar cases, it isn’t always clear that the patient is suffering (Quill et al, 2017).  It appeared to be a stalemate, so the daughter stated that she wanted to take her mother from the hospice and place her in home hospice under the daughter’s care, where there would be less interference from the hospice workers – and their unwanted offers of food and drink. The daughter and hospice workers never had any heated arguments over the care of the patient, and there was never any overt animosity. However, they had clearly reached an impasse.

The hospice workers wondered what their obligation was to the patient if the daughter took her home. Should advocating for the patient support include surrogate decision making, or should their advocacy be limited to vigorously arguing for the patient to continue to be offered food while she was in their care?

This is a real case that has been disguised. It is also the kind of case that we may be seeing on a more regular basis. Volunteer Stopping Eating and Drinking (VSED) has been getting quite a bit of attention in the literature and in the courts. A review article that was recently published in JAMA Internal Medicine (Quill et al, 2017) examines the ethical, clinical, and legal aspects of this increasingly-common choice by seriously ill and usually elderly persons who are of sound mind.

This case raises some important questions, including…

• What should one do about a patient who lacks the capacity to make medical decisions but who has a legal surrogate who

wants to make those decisions for them based on the notion of substituted judgment? In this case, the patient’s daughter claimed that as the legal surrogate she could make the decision not to feed her mother based on her knowledge of her

mother’s values and stated desires in the past.

• Had her mother been on a vent or other life support such as dialysis, we would honor her wish to have that care withdrawn since it was apparent that she was in an “end stage” condition and hospice-certified. What is the difference?

• Does it make a difference that spoon feeding is not a medical

intervention, and therefore not the same thing as life support?

• Can physicians object to this kind of request when they believe that there is a chance the patient will suffer from dehydration and insufficient nutritional intake? And isn’t this the reason we have palliative interventions in the first place?

When ventilator support is withdrawn, we give patients morphine to reduce discomfort. In this case, why not withhold feeding? In this and similar cases, it isn’t always clear that the patient is suffering (Quill et al, 2017).

What if there were an advance directive in place that said, “If I am in an ‘end stage’ condition and incapacitated, I do not want to be offered food or drink unless I can reach for it and feed myself, and I direct my health care agent to have all providers follow this wish.” I think it would be problematic

not to follow such a directive, and is there any moral difference between that and having a legal and apparently loving surrogate make the same decision without the advance directive?

It is somewhat ironic, but not unusual, that due to the concentrated and personal care that is provided in many hospice situations – and especially this one – patients live longer. But the daughter in this case claims that the care was too interventional.

Had members of the hospice staff simply offered the patient food by placing it in front of her, the daughter claimed that she would not have objected. But by placing the food in her mother’s mouth with a spoon, the daughter maintained that the hospice staff was intervening against her mother’s wishes – by way of the daughter’s substituted judgment.

In this case, we should consider every argument and counterargument. If the daughter wanted to take her mother home to die in home hospice, I believe that she had a moral case to support that decision. I also believe that, by proxy, patient autonomy should prevail in this case.¨ Our lives and practices are filled with real cases and real dilemmas. As physicians, we live in the “real” world and not a world where ideas are just that, ideas. We have to write orders and make decisions. This case is a troubling one, indeed. I welcome your thoughts and ideas at baxter_jd@mercer.edu – J. David Baxter, M.D., FACP, associate professor and Year 3 program director, Mercer University School of Medicine.

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www.mag.org 15

GEORGIA COMPOSITE MEDICAL BOARD

The Composite Board’s evolving role in value-based care

By John S. Antalis, M.D., immediate past chair, Georgia Composite Medical Board

John S. Antalis, M.D.

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the adoption and meaningful use of health information technology and the Affordable Care Act (ACA), which was designed to reduce the number of Americans who are uninsured.

The way we practice medicine has undergone rapid and dramatic changes in the last few years. The health care system is being shifted from a predominantly fee-for-service model to a one that is based on “value” in an effort to reduce costs and achieve greater efficiency. Within two years, practicing physicians will be evaluated – and compensated – based on new “quality” metrics.

MACRA includes two tracks, including the Merit-based Incentive Payment System (MIPS) and alternative payment models (APMs). I don’t address the pros and cons associated with “value-based care” in this article, but we will need to be mindful of any potential regulatory ramifications.

hen it comes to health care, federal lawmakers are now focused on policies that cut costs and waste, eliminate variations in the way patient care is delivered, and managing population health through Accountable Care Organizations (ACOs). In addition – and as the highly-contentious Affordable Care Act (ACA) has demonstrated – health care has become politicized to the extent that none of us probably imagined was possible 10 years ago. How we balance health policy and the individuality of medical practices will consequently dictate the quality of health care for the next generation of patients.

This new model will have huge implications for physicians, hospitals, government and private insurance plans – as well as state medical boards – when it comes to defining the “Standard of Care,” which is hard-wired to patient care and safety.

The dynamic shift that we have seen in health care at the national level will also present great challenges for licensing and regulatory agencies. State medical boards, including the Georgia Composite Medical Board (GCMB), do not operate in a uniform fashion. Each one has its own unique procedures.

GCMB’s mission is “to protect the health of Georgia citizens through proper licensing of its physicians and other licensed professionals named in the Medical Practice Act.” The GCMB investigates complaints, it assesses whether physicians violate the Standard of Care, and it disciplines physicians who violate the statutes of the Medical Practice Act. Until recently, the Standard of Care’s main focus has been a physician’s medical decisions, and whether they knowingly caused harm and/or failed to meet the Standard of Care.

In the last decade, there has been a slow and methodical attempt to amend the Standard of Care to include the concept of population health management. Recent examples include the Health Information Technology for Economic and Clinical Health (HITECH), whose purpose is to promote 16 MAG Journal

In 2015, the Centers for Medicare & Medicaid Services (CMS) began the process making the transition from the fee-for-service model, which CMS said is “fragmented” and expensive, to one it hopes will reduce costs and that emphasizes quality and value. Physicians, in turn, are going to be paid based on a number of new metrics that are tied to the Medicare Access and CHIP Reauthorization Act (MACRA).

The number of physicians who are in independent practice has decreased as an increasing number of physicians sign contracts with health care corporations and hospitals. Issues surrounding the Standard of Care for both independent and employed physicians will become more complicated as the rules and regulations associated with value-based care emerge.

Going forward, physicians will have to consider a wider array of factors – including “value” and “quality,” employing hospital or health care corporation standards, and patient satisfaction – when they make a clinical judgement.

The likely conundrum in the definition of the Standard of Care will be a huge challenge for state medical boards. The boards will have to determine whether a physician’s treatment of a patient falls within the current model of the Standard of Care or under the potentially new model based on “value” and “quality.” We need to work toward a consensus while the value-based system is being implemented.

I challenge physician leaders, health care policy makers, and my colleagues at the GCMB to work together to develop guidelines and a Standard of Care that we all feel comfortable with and that will enable us to continue fulfill our mission in this new era of value-based care.

If we, as physicians, fail to take an active role in this process, others will surely fill that void – and that would undermine what’s best for our patients.

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RESIDENT NEWS

GMC’s resident rotation a ‘big success’

T

welve residents have now completed the Gwinnett Medical Center’s (GMC) optional, month-long Resident Rotation Program (RRP) at the Medical Association of Georgia (MAG) since the program was created in 2016.

“From my standpoint, the program has been a big success,” reports MAG Executive Director and CEO Donald J. Palmisano Jr. “The participants have received a real-world introduction to MAG’s policy-making process, the medical profession’s advocacy efforts, and the state legislative and regulatory processes.”

Meanwhile, GMC RRP Director John S. Harvey, M.D., says that, “This program is also developing physician leaders, and it is building bridges between the resident community and the House of Medicine in Georgia.”

He adds that, “The participants have each completed a special project that is either aligned with their personal interests or MAG’s strategic objectives – like writing a policy resolution for MAG’s House of Delegates or writing a position paper on health insurance networks or making a presentation on end-of-life issues.”

Dr. Harvey, a surgeon who served as MAG’s president in 2015-2016, also notes that, “The residents are mentored by MAG staff and have the opportunity to participate in special activities, depending on the time of year. For example, they might spend time with MAG’s Government Relations staff at the State Capitol during the legislative session or they might sit in on a recording of MAG’s ‘Top Docs Radio’ show or they might attend MAG’s House of Delegates meeting.”

“It was an uplifting experience,” recalls Shoheb Ali, M.D., an internist who was the first GMC RRP participant. “The MAG rotation provides medical residents with an opportunity to connect with lawmakers to advocate for patients and physicians. By understanding the mechanics of the legislative process, we have the tools we need to author and endorse health care resolutions and vote for them to become policy at MAG’s House of Delegates. Engaging young physicians in health care legislation can spark an early interest in leadership roles and influence them to improve health care practices.”

Rishi Singhal, M.D., notes that, “My project focused on the Medicare Access and CHIP Reauthorization Act. I had the opportunity to speak with MAG leadership about the impact this legislation has on patients and physicians throughout Georgia.

I spent my time at MAG looking for ways for private practices to decrease the financial burden associated with complying with these new regulations, and I was especially fortunate to attend multiple hearings and conferences on legislation specifically impacting ophthalmology, which is my specialty.”

18 MAG Journal

Internist Haoran Peng, M.D., says that, “My MAG rotation gave me the opportunity to conduct research on state legislation that was designed to reduce prescription drug misuse. It was a great experience that really opened my eyes in terms of the critical role that legislation and regulations play in the state’s practice environment.”

Physiatrist Hannie Batal, M.D., asserts that, “The MAG rotation was an extremely worthwhile personal and professional experience, and I took advantage of the opportunity in full. I got to talk to state legislators on Physicians’ Day at the Capitol, and I got to participate in a Trauma Day event. I was also able to leverage my rotation to help sponsor a MAG House of Delegates resolution that was designed to regulate tattoo ink. For me, this was more than a just a non-clinical elective rotation…it was a developmental and educational opportunity that every resident should explore.”



“The participants have received a realworld introduction to MAG’s policymaking process, the medical profession’s advocacy efforts, and the state legislative and regulatory processes.”  Dr. Batal asks, “If we don’t get involved and represent the medical profession, who will?”

In addition to Drs. Ali, Singhal, Peng, and Batal, the GMC RRP participants have included Greg Bookout, M.D. (emergency medicine), Jake Choi, M.D. (radiology), Kelsey Guerreso, M.D. (radiology), Ben Hayes, M.D. (internal medicine), Ian McCullough, M.D. (anesthesiology), Will Nixon, M.D. (diagnostic radiology), Taylor Phelps, M.D. (ophthalmology), Michael Redmond, M.D. (psychiatry), Lawrence Williams, M.D. (internal medicine), and Brian Xavier, M.D. (radiology).

It is worth noting that Dr. Hayes won an Association of Hospital Medical Educators’ award for a white paper that he wrote on prior authorization while he went through the RRP, while Dr. McCullough helped the MAG Medical Reserve Corps secure a $15,000 grant from the National Association of County and City Health Officials.

Contact Dr. Harvey at johnharveymd@gmail.com with questions related to the GMC RRP.

Northwest Campus

ROME

The Medical College of Georgia is 190 years old and counting on you.

We hope you know that Georgia’s public medical school has a mission to educate the next generation of Georgia doctors and it has an ever-growing statewide presence to do that.

ATHENS We hope you also know the immeasurable impact that you – today’s generation of Georgia doctors – have Augusta University/ on that mission.

University of Georgia Medical Partnership

AUGUSTA Main Campus

MCG has nearly 2,500 volunteer faculty who share their time, knowledge and skill with our students. 94 percent of those volunteer faculty are you, Georgia’s physicians.

That is an exceptional benefit to your profession and to your state. You provide a scope of SAVANNAH experience to our students that helps prepare them for whatever and wherever they chose to practice. In fact, BRUNSWICK without you, one of the nation’s first medical schools simply could not educate one of the nation’s largest medical school classes.

Southeast Campus

Southwest Campus ALBANY

locations of more than 350 clinical teaching sites

We thank you.

our campus.

GEORGIA is and Georgia’s physicians our educators.

For more information, please contact Dr. Kathryn Martin, MCG associate dean for regional campus coordination, at 706-721-2812.

augusta.edu/mcg

www.mag.org 19

HEALTH CARE REFORM

Medical schools need to keep pace with the changing health care system

By Richard H. Self, M.D., M.B.A., family medicine resident, Augusta University, and Janis Coffin, D.O., FAAFP, FACMPE, chief transformation officer, Augusta University

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he policy changes that are occurring in the health care system at the national level today – including the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – came about as a result of a historical lack of system-wide accountability, be it financial or otherwise, for health outcomes, process quality, and system structure.1,2 Without a medical education complex that uniformly exposes trainees to public policy issues in proper context, the risk of inadvertently creating young physicians who are either mentally unwilling or educationally incapable of adapting to these changes in a professionally and/or organizationally healthy way becomes a serious concern.

This is especially true for GME programs, which rely on resident physicians to appropriately address increasingly complex regulatory requirements to promote superior patient care and to help maintain compliance.3 It is critical to teach and discuss the concepts of quality, value, efficiency, and clinical practice improvement under the greater scope of policy reform. This is vital in a medical education environment – before the resident is immersed in post-graduate clinical training – to help mitigate possible differences in knowledge against institutional level approaches to these topics within graduate medical education settings.4 Moreover, failing to address these issues early in the GME training process may lead to adverse patient outcomes secondary to the ignorance of system and process issues.2 Since the medical education complex represents the common pathway for U.S. medical students who enter a multitude of specialty training environments, it provides a proper and suitable venue to obtain practical knowledge of a set of core topics prior to being employed as house-staff during residency training.

Beyond the training environment Beyond post graduate training, the importance of understanding the general concepts of value, improvement, efficiency, and quality as they apply to medicine are critical to one’s professional development. Knowledge of public policy and its history helps us navigate the plethora of information that is being released about new APMs, reimbursement changes, regulatory requirements, and other policy changes that are happening at the national and organizational levels.5 20 MAG Journal

This understanding notwithstanding, many young physicians may find themselves constantly ‘scrambling’ to obtain reliable information from disparate sources about the best course of action for their practice and, be it directly or indirectly, their patients’ safety and health outcomes.



It is critical to teach and discuss the concepts of quality, value, efficiency, and clinical practice improvement under the greater scope of policy reform.  For the majority of new physicians who accept Medicare payments, understanding these core concepts is fundamental if they hope to generate the necessary financial resources and technical capacity they need to provide care for various patient populations while directly improving health outcomes and cost efficacy. In order to remain viable, the physician practices and/or organizations that are subjected to decreasing Medicare Part B reimbursements need to fundamentally understand how to optimize their performance for both their patients and payers. The alignment of reimbursements with value and quality was not unintentional, as policy stakeholders and experts have been calling for better outcomes at a lower cost for many years.5,6 Systems-based practice & new regulatory demands Many prominent stakeholders in medicine have emphasized the importance of system-based knowledge in the context of clinical practice for years. The taxonomy of the Domains of Competence (DoC) in the Physician Competency Reference Set (PCRS) specifically identifies systems-based practice as a core component of physician competency – the driver for the six core Accreditation Council for Graduate Medical Education (ACGME) educational requirements since its introduction in 1999.7,8 Considering that policy and regulatory changes are designed to address system-level issues, it becomes an increasingly-suitable vessel for launching deeper refinement

of this competency requirement – especially when it comes to patient safety and health outcomes.

Examples of systems-based practice competencies vs. MIPS evaluation domains

Also remember that physician competency is just one of the variables that contributes to optimal patient health outcomes, and using policy reform as a springboard for a discussion of the overarching health care system allows students to gain a deeper understanding of the most critical obstacles that prevent their patients from achieving optimal health outcomes within the system.

These issues can further be rooted in one of many processes that are occurring in the patient’s environment – both inside and outside of the health care delivery system. Since they have been historically considered the inherent leaders of the national health care system and patient care champions,11 it is critical for physicians to understand policy reform forces and rationales.

Subcomponent systems-based practice competencies9

MIPS evaluation components10

Work effectively in various health care delivery settings and systems relevant to one’s clinical specialty

No direct equivalent MIPS scoring component

Coordinate patient care within the health care system relevant to one’s clinical specialty

Advancing Care Information (Meaningful Use Criteria) & Clinical Practice Improvement Activity: Care Coordination

Advocate for quality patient care and optimal patient care systems

Quality (PQRS Criteria) & Clinical Practice Improvement Activity: Patient Safety & Practice Assessment

Conclusion We firmly believe that the standardized inclusion of policy reform topics in the medical education system may act as a unifying means for integrating awareness of system and process level quality and efficiency issues with traditional clinical practice if it is not haphazardly included in the curriculum.

Using the Merit-Based Incentive Payment System criteria (MIPS) created by MACRA or other related fee-forperformance (FFP) reimbursement criteria may serve as appropriate general starting points for furthering this educational goal. This is especially true as these elements are based on extensive ongoing feedback and high-quality studies performed by professional organizations, governmental regulatory entities, third party public interest groups, and clinical researchers in their respective areas of expertise.12 For educators, the best method of incorporating these topics into their lesson plans is linking core policy concepts to real-life clinical practice, such as helping to identify areas of inefficiency, devising ways to improve the quality of care that is delivered, helping to assess the level of value that is added to a patient’s care, or being engaged in a clinical improvement activity.

All of the educational components mentioned above could be taught in the medical school setting outside of the discussion of the greater national debate, but doing so might inadvertently send the message that it is “just another requirement or add-on” – without any practical meaning.

But by using health care reform legislation as a guide post, students may gain a deeper appreciation of why these topics are important to the well-being of their patients and payers – as well as any organizations that these future physicians may find themselves employed.¨

Participate in identifying system errors and implementing potential systems solutions Perform administrative and practice management responsibilities commensurate with one’s role, abilities, and qualifications

Clinical Practice Improvement Activity: Patient Safety & Practice Assessment

Incorporate considerations Resource Use (VM Criteria) & of cost awareness and riskClinical Improvement Activity: benefit analysis in patient and/ Achieving Health Equity or population-based care

References Self R.H., & Coffin J. (2016) “Finding the best MACRA rout to provider reimbursement.”

Medical Economics. Online: February 8th, 2016.

2 Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: building a safer health system (Vol. 6). National Academies Press.

1

Roberts, J. L., Ostapchuk, M., Miller, K. H., & Ziegler, C. H. (2011). What residents know about health care reform and what we should teach them. Journal of graduate medical education, 3(2), 155-161.

3

Nabors, C., Peterson, S. J., Weems, R., Forman, L., Mumtaz, A., Goldberg, R., ... & Pherwani, N. (2011). A multidisciplinary approach for teaching systems-based practice to internal medicine residents. Journal of graduate medical education, 3(1), 75-80.

4

Relman, A. S. (2009). Doctors as the key to health care reform. New England Journal of Medicine, 361(13), 1225-1227.

5

Kaplan, R. S., & Porter, M. E. (2011). How to solve the cost crisis in health care. Harv Bus Rev, 89(9), 46-52.

6

Englander, R., Cameron, T., Ballard, A. J., Dodge, J., Bull, J., & Aschenbrener, C. A. (2013). Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Academic Medicine, 88(8), 1088-1094.

7

Kavic, M. S. (2002). Competency and the six core competencies. Journal-Society of Laparoendoscopic Surgeons, 6(2), 95-98.

8

Guralnick, S., Ludwig, S., & Englander, R. (2014). Domain of competence: systems-based practice. Acad Pediatr, 14, S70-S79.

9

Merit-Based Incentive Payment System: Clinical Practice Improvement Activities Performance Category. (2016) CMS.gov. Retrieved January 05, 2018, from https://www.cms. gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/ MACRA-MIPS-and-APMs/CPIA-Performance-Category-slide-deck.pdf.

10

Reinertsen, J. L. (1998). Physicians as leaders in the improvement of health care systems.

Annals of Internal Medicine, 128(10), 833-838.

11

2016 will bring flurry of new rules and regulations affecting healthcare. (2016) ModernHelathcare.com. Retrieved January 05, 2018, from http://www.modernhealthcare. com/article/20160102/MAGAZINE/301029961.

12

www.mag.org 21

LEGAL

Using Georgia’s PDMP to defend opioid litigation

By Daniel J. Huff, Esq., partner, and A.J. Cheek, Esq., associate, Huff, Powell & Bailey, LLC A hypothetical case A motorcyclist visits your gynecologist office for her annual check-up. During her visit, she informs you that she has been experiencing chronic back pain since a motorcycle accident a few months back. As a result, you write her a prescription for tramadol and refer her to a neurologist and pain management specialist. Months later, the motorcyclist returns to your office because she believes she is pregnant. Turns out, she is. During this appointment, you ask the motorcyclist about her chronic back pain. She quickly thanks you for the referral to the pain management specialist, and proclaims she is now able to address her back pain without medication.

Nine months later, the motorcyclist gives birth to a child who is born with neonatal abstinence syndrome (NAS). You never suspected opioid use during the pregnancy, but you also never confirmed the patient’s story with her pain management specialist.

The newborn is taken under the care of maternal fetal medicine and a pediatrician. At your request, the motorcyclist enters an opioid treatment program.

A year later, it is not the motorcyclist who visits your office, but a process server carrying a medical malpractice complaint.

You learn that the motorcyclist died from opioid toxicity a few months after giving birth. Understandably, you are heartbroken, confused, and a bit scared.

Unfortunately, stories like this are becoming all too common. In fact, more Americans died of drug overdoses in 2016 than died in the Vietnam War, and experts estimate that most of those deaths were opioid overdoses.1 Litigation follows epidemics In 2016, a St. Louis jury awarded one of the first mega-verdicts in a medical malpractice case involving opioid over-prescription.2 After hearing evidence that a city employee had been prescribed more than 37,000 pain pills between 2008 and 2012 at levels above those recommended by the Centers for Disease Control and Prevention and other experts, the jury awarded $1.4 million to the patient and an additional $1.2 million to his wife.3 After finding the doctor negligent, the parties presented arguments on punitive damages. The plaintiffs’ attorney called upon the jury to “send a message from coast to coast that this is not going to happen anymore.”4 Heading the call, the jury awarded $15 million in punitive damages against the prescriber and his employer.5 While this was an exceptional case, juries across the country are voicing their frustrations with opioids through big verdicts. For example, a jury in Maine found for a

22 MAG Journal

woman who sued her physician after she suffered brain damage from temporary respiratory failure, which was allegedly caused by an overdose in her opioid medication. The jury awarded $1.9 million in damages.6 The Supreme Court of West Virginia went one step further, upholding a cause of action against physicians – not for an injury, but for simply instigating addiction.7 Four physicians and three pharmacies were sued by 29 confessed drug addicts for their addiction to controlled substances.8 This ruling is the first of its kind, but it reflects the legal attitude toward opioids.

So what is being done to protect patients and physicians from the effects of the opioid epidemic?

Georgia Acts: PDMP Georgia has attempted to assist physicians with detecting opioid abuse and commencing early intervention by providing a statewide Prescription Drug Monitoring Program (PDMP).9 The PDMP is a state-controlled electronic database that collects and analyzes prescription drug information. From its initiation, physicians were encouraged to access this database to identify problematic trends with patient prescriptions and offer early intervention.10 Even with the PDMP fully operational by 2013, opioid deaths continued to rise in Georgia.11 Many argued that without mandatory participation, harmful prescription habits – including doctor-shopping – would continue.12 On July 1, 2018, it became a requirement for all opioid prescribers in Georgia to check the PDMP when prescribing certain controlled substances, including hydrocodone, benzodiazepines and others.13 Prescribers need to check the PDMP the first time they issue such a prescription to a patient and at least once every 90 days thereafter. There are a few exceptions to this rule. Providers are not required to consult the PDMP when the prescription is for no more than a three-day supply, the patient is in a hospital or health care facility, the patient has had outpatient surgery and the prescription is for no more than a 10-day supply, the patient is terminally ill, or the patient is receiving treatment for cancer.14 Increased monitoring, documentation and reporting requirements for physicians should lead to better treatment.

The new requirements also exposed prescribers to more liability.

For example, prescribers who fail to review patients’ PDMP information will be held administratively accountable to the Georgia Medical Composite Board. The prescriber will not necessarily be held civilly liable to any person or criminally responsible for an injury or death on the basis that the prescriber did or did not review the PDMP.15 Prescribers can expect to be (continued on page 24)

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TREATING CLIENTS AS PARTNERS

concentrates its practice in civil tort litigation, focusing on the defense of persons and corporations accused of professional and products liability negligence.

“We insist that each client relationship be productive, mutually beneficial, professional and collegial,” says Scott Bailey, Managing Partner. “We treat our clients as partners. The firm continues to evolve and provide expert legal services at an exceptional value to meet the growing demands of those we serve.”

We are committed to the successful and costeffective defense of:

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www.mag.org 23

(continued from page 22)

held responsible for improper use of the PDMP system by their delegates.

The message is clear: the state of Georgia is focused on opioid prescriptions. As PDMP monitoring and reporting increases, the standard of care may necessitate interactions with the PDMP or may even require non-prescribing providers, such as pediatricians, who care for patients affected by others’ opioid use to register with and check the PDMP. Remember that the standard of care in Georgia is “reasonableness,” so isn’t it more reasonable to simply check the PDMP? How to protect yourself By the time the process server arrived at the gynecologist’s office in the hypothetical case, it was too late to cure any actions of malpractice and certainly past the point of saving the motorcyclist.

So let’s go back to the office visit. When the motorcyclist presented with complaints of back pain resulting from the wreck, an organized and thoughtful approach to treating the motorcyclist’s pain needed to be implemented. The Georgia Composite Medical Board’s (GCMB) guidelines for the use of controlled substances is a great place to start.16 In essence, these guidelines suggest that prescribers collect as much information as possible from the patient and the patient’s additional health care providers, communicate all aspects of a treatment plan with the patient and additional providers, and document each step excessively.

Regular consultation with the PDMP would have helped the gynecologist monitor the motorcyclist’s treatment and provided

evidence that he complied with the guidelines prescribed by the GCMB and the standard of care.

In the modern world of litigation, evidence of whether a physician complied with the standard of care often comes in the form of electronic medical records (EMR). As an EMR database, the PDMP provides a unique platform for documentation, communication and – in the unfortunate case of litigation – demonstrating compliance with the standard of care.

Another reality is that juries are comprised of people who are bombarded with information regarding America’s opioid epidemic and they place some of the blame on physicians. As a result, physician defendants can be unfairly labeled as “pill pushers.”

Juries will need to be educated that physicians are part of the solution, not the problem. You should utilize every resource, especially the PDMP, to defend yourself and to educate juries that health care providers have been actively working to address the opioid abuse epidemic and are helping their patients.17¨ Huff and Cheek are with the Atlanta law firm of Huff, Powell & Bailey, LLC. Huff and the members of his firm defend civil lawsuits on behalf of hospitals, physicians, product manufacturers, businesses, corporations, and other professionals. Huff and his firm try several jury trials each year. Contact Huff at dhuff@huffpowellbailey.com.

Paid editorial submission.

References German Lopez, “In one year, drug overdoses killed more Americans than the entire Vietnam War did,” www.vox.com/policy-and-politics/2017/6/6/15743986/opioid-epidemic-overdosedeaths-2016.

1

Protecting your patients, your profession & your future

Koon v. Walden, 2016 WL 3597938 (Mo. Cir.) (Verdict, Agreement and Settlement).

2

Tony Messenger, “St. Louis jury sends $17.6 million message in opioid abuse verdict,” available at http://www.stltoday.com/news/local/columns/tony-messenger/messengerst-louis-jury-sends-million-message-in-opioid-abuse/article_b7628f83-0e94-5bc7-a2a838a12ab6d7d6.html (June 28, 2016).

3

Id.

4

Id.; See also Koon v. Walden, JVR No. 1607060020.

5

Justin A. Julian, et al., “Medical-legal Risks of Prescribing Pain Medications,” www. huffingtonpost.com/entry/medical-legal-risks-of-prescribing-pain-medications_ us_59c908cee4b0b7022a646c36 (Sept. 26, 2017).

6

Id.

7

GAMPAC is your peace of mind.

Id.

8

2011 Ga. Laws 659, § 2, at 665 (formerly found at O.C.G.A. § 16-13-57 (2016)).

9

Joining MAG’s non-partisan political action committee is the best and easiest way to elect pro-physician candidates in Georgia.

Go to www.mag.org/gampac to join today.

Paid for by GAMPAC

24 MAG Journal

10

Georgia Prescription Drug Monitoring Program, GA. DRUGS & NARCOTICS AGENCY, gdna.georgia.gov/georgia-prescription-drug-monitoring-program (last visited April 20, 2018).

11

Substance Abuse Research Alliance, PRESCRIPTION OPIOIDS AND HEROIN EPIDEMIC IN GEORGIA 5 (2017), www.senate.ga.gov/sro/Documents/StudyCommRpts/ OpioidsAppendix.pdf.

12

Center for Disease Control, DOCTOR SHOPPING LAWS 1 (n.d.), www.cdc.gov/phlp/docs/ menu-shoppinglaws.pdf.

13

O.C.G.A. § 16-13-63(a)(2)(A); also see MAG Fact Sheet, www.mag.org/georgia/ uploadedfiles/MAGH.B.249PDMPFactSheet2017.pdf.

14

O.C.G.A. § 16-13-63(a)(2)(A)(i-v).

15

O.C.G.A. § 16-13-63(a)(2)(A).

16

Georgia Composite Medical Board, Guidelines for the Use of Controlled Substances for the Treatment of Pain, medicalboard.georgia.gov/sites/medicalboard.georgia.gov/files/Pain%20 Findings%20Fact%20Sheet%28v13%29.pdf; see also Center for Disease Control, Guidelines for Prescribing Opioids for Chronic Pain, available at https://www.cdc.gov/drugoverdose/ prescribing/guideline.html.

17

Xponent, Quintiles IMS; State and National Totals of Retail Filled Prescriptions: All Opioid Analgesics, 2013-2016, www.cmanet.org/files/assets/news/2017/04/ims-opioid-study-2017.pdf.

PATIENT SAFETY

Health care delivery consolidation: What it means for physicians

By Hall B. Whitworth Jr., M.D., physician consultant, MagMutual

F

or more than three decades, the number of health care providers in solo practice has steadily declined. In 1983, 41 percent of physicians were in solo practice, but by 2014 that number was a mere 17 percent. At the same time, the number of physicians practicing in groups larger than 25 has increased from five percent to 20 percent. In addition, the American Medical Association’s (AMA) 2016 biannual practice survey determined that, for the first time, more than half of American physicians did not have an ownership interest in their practice.

What’s changed and what are the forces behind this change?

These are the questions facing not only individual physicians but the health care industry at large. The majority of this change in practice group size is explained by the aggressive acquisition of physician practices by hospital systems.

In 2016, data from the AMA showed that 32 percent of physicians or their practice groups were owned by hospital systems. In 2012, it was 29 percent.

This trend has accelerated due to the result of changing payment models, the consolidation of health care delivery, and generational issues. In 2013, physician groups of nine or less accounted for 40 percent of practices; by mid-2015, this number had declined to 35 percent. At the other end of the spectrum, physician groups with more than 100 doctors have increased from 29 percent to 35 percent in the same time period. This trend impacts primary care physician (PCP) groups – where consolidation has happened faster in recent years as more PCPs join larger practice groups.

Research suggests that hospitals in many regions were concentrating on organizing their current medical practices, while also trying to align with independent practices in ways other than direct purchase. Multispecialty practices that include primary care are especially attractive for hospital acquisition, with 45 percent of such groups currently owned by hospitals.

There also appears to be a generational trend of young physicians choosing private practice less frequently. As older private practice and small group physicians retire, they’re not being replaced by younger ones. This is driven, in part, by younger physicians choosing practice environments with wage security and personal considerations – such as more predictable hours and work-life balance.

Several changes in health care delivery and market dynamics have had significant impact on these shifts in practice organization. In addition to patient care, physicians have a 26 MAG Journal

new administrative burden on them, balancing the pressures of building and maintaining a business as well as managing employees. These pressures require more time and expense, often requiring a reduction in physician compensation to hire the necessary business and administrative employees.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed in an effort to move from a fee-forservice payment model that rewards volume to a value-based payment system. MACRA allowed two pathways for physician payment: a merit-based incentive payment system (MIPS), as well as advanced alternative payment models. These changes have placed a heavy burden on smaller independent practices.

Significant reporting requirements regarding compliance, cost and quality are not only mandated for Medicare, but have been increasingly utilized by private insurers and employers. These programs require a significant increase in infrastructure to manage cost collection, management, and the data reporting – which can be overwhelming for smaller practices.



As older private practice and small group physicians retire, they’re not being replaced by younger ones.  Furthermore, there are increased demands on physicians to provide a seamless coordination of medical care in order to manage patients with increasingly-complex, chronic medical conditions. Ancillary services – including quality assurance, nursing care, and population health initiatives – are increasingly required in an effort to reduce the fragmentation of care, improve collaboration and meet the demands of health care today.

Population-based health care incentive programs require large practice populations to minimize downside risk potential to better manage the financial risk of incentive contracts.

Larger practice settings have the economy of scale – along with the resources and capital – required to help manage these administrative burdens, make business decisions, and organize care coordination. Research suggests that in four common specialties, the average physician spends 785 hours per year in administrative time to report quality measures.

These changes in both health care reimbursement and market consolidation place a greater burden on smaller practice groups, which have less bargaining power. As reimbursement declines, operational costs go up. Not only are there relative reductions in Medicare reimbursement, but also with private payers who frequently use Medicare rates as a benchmark to negotiate their own payment plan. As private health insurance payers grow larger and more powerful, and as businesses consolidate to purchase health care, they maintain greater power and control over pricing.

In addition, changes in health care reimbursement as a result of both the Patient Protection and Affordable Care Act and MACRA have reduced unreimbursed care and increased payments to hospitals. This stronger financial position has allowed hospitals to offer a wider variety of health care services, acquire more primary and specialty physician groups, and – with an expanded network – keep more patients within their own health care system.

Hospital outpatient department (HOPD) services, provided in freestanding hospital owned practices, have until recently also qualified for increased reimbursement – increasing the incentive for hospitals to acquire physician practices.

According to the Medicare Payment Advisory Commission (MedPAC), the most common type of E&M office visit payment from Medicare at HOPDs is $158, while it is just $74 at a freestanding independent physician’s office.

Similar payment discrepancies occurred with many expensive outpatient procedures. In the Bipartisan Budget Act of 2015, this disparity in payment for outpatient physician procedures was discontinued for new practice acquisitions, but it continued to be allowed for hospital owned practices that were already billing at HOPD rates.

In addition to increased acquisition of medical practices by hospital systems, some experts predict increased activity of private equity firms, which have access to large amounts of capital. Several national mergers by large corporations are now pending and await approval. This includes CVS’ agreement to purchase Aetna, which could impact primary care physicians already in competition with CVS’ retail health clinics. And United Health Group’s Optum has announced its plans to acquire a large national medical practice, DaVita Medical Group, to develop a physician-led primary and specialty care in-home, urgent care, and surgical care delivery business.

of health care, but it is likely that solo and small group practices will remain independent. Rapid changes in the health care delivery environment, however, will continue.

In addition, increased government and payer oversight will continue to require the detailed quality and outcomes accountability, information technology, and data analytics that put financial strain on smaller practices.

These changes occur in an environment where health care expenditures are demanding an increasing percentage of the nation’s gross domestic product, in some cases without clear improvement in overall health care outcome metrics.

The demands to meet these challenges have resulted in the consolidation of health care delivery into larger and larger organizations.

Let’s hope that the ultimate goal continues to be the delivery of quality and efficient health care for the individual that contributes to the wellbeing of society as a whole.¨ The information that is presented in this article is intended to serve as general information of interest for physicians and other health care professionals. The recommendations and advice that is published herein do not reflect or establish a standard of care and do not establish rules for the practice of medicine.

The publication of this information is not intended as an offer to insure such conditions or exposures or to indicate that MAG Mutual Insurance Company will underwrite such risks for the reader. Our liability is limited to the specific written terms and conditions of actual insurance policies issued.

References

American Academy of Family Physicians. www.aAFP.org. 2018. https://www.aafp.org/about/ policies/all/independent-physicianassoc.html.

Avalere Health, LLC. Physician Advocacy Institute. Implications of hospital employment of physicians on Medicare and beneficiaries. November 2017.

Casalino, Lawrence. Medical access and share reauthorization act (MACRA) and the corporate transformation of American medicine. Health Affairs. 36(5). May 2017.

Colbert, A. Straight talk from an investment banker about the challenges facing private physician groups. Becker’s Hospital Review. February 26, 2018.

Finegan, J. Regulatory changes and technology demands will drive physician practices mergers and acquisitions in 2018. FierceHealthcare. January 31, 2018.

Khullar, D. Can small physician practices survive? Sharing services as a pastor viability.

JAMA. 2018;319(13):1321–22.

Moriarty, Alanna. Our independent physician groups viable in the long run? blog. definitivehc.com. October 2, 2017.

Muhlestein, DB. Physician consolidation. Health Affairs. 2016;35(9):1638–42.

Companies outside of the health care realm are also throwing their hat into the ring. In 2017, Amazon, J.P. Morgan Chase, and Berkshire Hathaway announced their plans to develop an independent health care company for employees. There have also been discussions between Humana and Walmart that may significantly change the traditional retail store model to include health care delivery. Well-capitalized companies appear poised to expand beyond their traditional business models to capture an increasing percentage of the health care dollar.

Murphy, B. For the first time, physician practice owners are not the majority. AMA Wire.

May 31, 2017.

Many physicians and patients will continue to value the personal relationship that has always been a core component

Zinc, T. The transition of primary care group practices to next-generation models. J Am Board Fam Med. 2017;30(1):16–24.

Post, B. Economic Theory and empirical evidence on spending and quality. Vertical integration of hospitals and physicians. Med Care Res Rev. journals.sagepub.com/doi/abs/.

August 29, 2017.

Rosenberg, J. Hospital acquisition of independent physician practices continues to increase.

American Journal of Managed Care. Focus Blog. March 21, 2018.

Schneider, EC. Improved quality, control spending, maintain access. Can be Merit–Based Incentive Payment System Deliver? The New England Journal of Medicine. 2017;376(8):708–10.

Westgate, Audrey. From employment to micro-practice. Physicians Practice. Vol 24. March 11, 2014.

Woodcock, E. IPAs: Joining forces to retain independence. Medical economics practice management. http://www.medicaleconomics.com/medical-economics/news/ipas-joiningforces-retain-independence. April 1, 2015.

www.mag.org 27

OPIOID ABUSE

Addressing opioid abuse on every level

By Patrice A. Harris, M.D., M.A., American Medical Association (AMA) Opioid Task Force Chair and AMA President-elect

E

arlier this year, I received an email from the Georgia Prescription Drug Monitoring Program (PDMP) informing me that one of my patients (for whom I had prescribed a benzodiazepine) was prescribed an opioid by another physician. I contacted that physician – who left a patient’s side to take my call – and we discussed the specifics so we could both be assured that the patient’s treatment was appropriate.

This reflected an interesting “enhancement” of the PDMP to serve as a clinical support tool; I was grateful to get the alert, and the physician I spoke with was glad to have the conversation with me. At a time when tens of thousands of Americans are dying each year from opioidrelated overdoses, I am comfortable with taking extra precautions – and extra time – to ensure that an opioidbenzo combination is coordinated between physicians so we can appropriately monitor and counsel our patients.

The same urgency that is driving physicians to take extra care is also driving politicians to propose legislation to combat the opioid abuse epidemic. At the federal level, there are dozens of bills in play, and the American Medical Association (AMA) is evaluating which ones will, or will not, improve patient care.

As a Georgia physician, I am keenly aware of the new state requirement to check the PDMP for the initial prescribing of a Schedule II opioid or a benzodiazepine, as well as the new three-hour opioid prescribing CME mandate. States across the country are experiencing similar new laws, as well as others to restrict opioid prescribing.

I should also point out that opioid prescriptions in Georgia decreased by more than 14 percent between 2013 and 2017 – without a legislative mandate. Nationally, opioid prescriptions have gone down in every state since 2013, a sign of progress that is tempered by the fact that these reductions have not led to a decrease in opioid-related overdoses and deaths.

While Georgia’s PDMP can certainly be improved, physicians and other health care professionals used it nearly 3 million times in 2017 – nearly triple the rate from 2016.

And registration has more than doubled, too, from 18,048 in 2016 to more than 41,000 in 2017. The same trends are occurring nationally.

That said, there is a long way to go for PDMPs to be integrated into EHRs and for federal rules governing 28 MAG Journal

Patrice A. Harris, M.D.

electronic prescribing of controlled substances (EPCS) to be eased so that we can effectively make use of EPCS to better support patient care.

The increasing numbers of opioid-related overdoses and deaths are now being driven primarily by heroin and illicit fentanyl, though prescription opioid-related morbidity and mortality also remain unacceptably high. We must continue to press policymakers to increase access to treatment for all substance use disorders as well as increase efforts to coprescribe naloxone to patients who are at risk of overdose.

The Medical Association of Georgia (MAG) Foundation’s ‘Think About It’ initiative (www.mag.org/tai) continues to be a go-to for education and training resources for physicians in Georgia. AMA has also collated more than 300 resources from state and specialty societies on a new opioid education microsite, which is available at www.end-opioid-epidemic.org.

The prescription drug misuse epidemic will not end unless and until our patients with pain and substance use disorders receive comprehensive, high quality care. For pain, this means ensuring that we provide the highest level of compassionate care, including referrals for non-opioid care, such as physical therapy or other modalities, when appropriate. If a health insurance company requires prior authorization for a non-opioid therapy – or denies care for a non-opioid therapy – I encourage the physician to report that to Bethany Sherrer with MAG at bsherrer@mag.org.

For your patients who have a substance use disorder – or those you suspect might have a substance use disorder – we must advocate for health insurance networks to provide timely access to care. If you or your patients are forced to delay care because of prior authorization or step therapy, I also encourage you to go to www.end-opioid-epidemic.org and share your story on the ‘Share Your Story’ tab.

The AMA wants to hear from physicians about how they are responding to the nation’s opioid epidemic. By sharing your story, AMA will be a more effective advocate for you and your patients.

Editor’s notes: Dr. Harris is a psychiatrist from Atlanta and a MAG member. She was recently elected to be AMA’s presidentelect. Dr. Harris will be the first Georgian to serve as AMA’s president since 1985, and she will be the first African-American woman to hold the office. Go to www.patriceharrismd.com for her campaign website.

The AMA and MAG Urge Removing All Barriers to Treatment for Substance Use Disorder

Despite a national decline in opioid prescriptions dispensed, and an increase in the use of prescription drug monitoring programs, the nation's opioid overdose and death epidemic continues to worsen.

Deaths due to illicit fentanyl and heroin are now leading drivers of the opioid overdose and death epidemic. Now, more than ever, policymakers must join the AMA in not simply supporting increased access to treatment, but by providing the resources and effort necessary to remove barriers to highquality, evidence-based care.

Note: Data for heroin related deaths were not available until 2007.

Opioid Overdose Deaths in GA by Type of Opioid, 2000-2016 1

More people are dying from heroin and illicit fentanyl, despite a decrease in opioid prescriptions.

Evidence shows medication-assisted treatment (MAT) works.

Treatment Reduces Illicit Drug Use, Disease Rates, Overdoses and Crime. “Patients who use medications to treat their opioid use disorder remain in therapy longer than people who don’t; they are also less likely to use illicit opioids. MAT helps to decrease overdose deaths and reduce the transmission of infectious diseases, including HIV and hepatitis C.”2 FDA-approved MAT for Opioid Use Disorder includes buprenorphine, naltrexone, and methadone.

Some Payers Are Removing Prior Authorization For MAT. Several major national insurers, including Aetna, Cigna and Empire Blue Cross, said they will no longer require prior authorization for MAT for all their plans in the United States.3 If they can do it, why can’t all health insurance companies?

MAT Saves Money. “Results suggest that medication-assisted therapy is associated with reduced general health care expenditures and utilization, such as inpatient hospital admissions and outpatient emergency department visits, for Medicaid beneficiaries with opioid addiction.”4

We all have to work together. The AMA and MAG recommend: 1. Physicians should become trained to treat patients with a substance use disorder.

2. All public and private payers should ensure that their formularies include all forms of MAT, and they should remove all administrative barriers to treatment, including prior authorization.

3. Policymakers and regulators should increase oversight and enforcement of mental health and substance use disorder parity laws to ensure patients receive the care that they need.

4. We can all help put an end to stigma. Patients with a substance use disorder deserve the same care and compassion as any other patient with a chronic, relapsing medical disease.

Take action today. Join us to help end the nation’s opioid overdose and death epidemic. To learn more, visit end-opioid-epidemic.org 1. “Opioid Overdose Deaths by Type of Opioid.” The Henry J. Kaiser Family Foundation, Jan. 31 2018, www.kff.org/other/state-indicator/opioid-overdose-deaths-by-type-of-opioid/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D. Accessed on Feb. 21, 2018.

2. Substance Use Prevention and Treatment Initiative. The Case for Medication-Assisted Treatment. Feb. 1 2017, www.pewtrusts.org/en/research-and-analysis/fact-sheets/2017/02/ the-case-for-medication-assisted-treatment. Accessed February 1, 2018.

3. Madara, James L. “ Letter to the National Association of Attorneys General.” Received by The Honorable George Jepsen; Jim McPherson, Feb. 3 2017, https://searchlf.ama-assn.org/undefined/ documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2FAMA-Letter-re-AG-SChneiderman-MAT-FINAL.pdf. Accessed Feb. 21, 2018.

4. Mohlman, Mary Kate, et al. “Impact of Medication-Assisted Treatment for Opioid Addiction on Medicaid Expenditures and Health Services Utilization Rates in Vermont.” Journal of Substance Abuse Treatment, vol. 67, 2016, pp. 9–14, https://www.sciencedirect.com/science/article/pii/S0740547215300659. Accessed Feb. 21, 2018.

www.mag.org 29

COUNTY, MEMBER & SPECIALTY NEWS

COUNTY MEDICAL SOCIETY NEWS Bibb County Medical Society

by Dale Mathews, Executive Director The Bibb County Medical Society (BCMS) held a ‘Tasting of Appetizers & Craft Beers’ event in April that was hosted by BCMS member Rana Munna, M.D., and her husband, Joseph Egloff.

In addition to Dr. Munna, the event’s planning committee included Maria Bartlett, M.D., William Butler, M.D., and his wife, Tammara Butler, R. Jonathan Dean, M.D., Stephen Mallary, M.D., Christopher E. Minette, M.D., L. Arthur Schwartz Jr., M.D., and J. Eric Roddenberry, M.D. The event featured a whole roasted pig that was prepared by J. W. Griffin, M.D., and his wife, Alicja Griffin. Medical students and residents served as pourers, teaching guests about the beer and appetizer pairings.

Go to www.bibbphysicians. org or contact Dale Mathews at bibbphysicians@gmail.com for information on BCMS.

From the left are RCMS James R. Lyle Resident Research Award winners Drs. Sebastion Larion, Hoyle Whiteside, Abdalrahman Zarzour, and Angela Stephens.

30 MAG Journal

DeKalb Medical Society

by Melissa Connor, Executive Director The DeKalb Medical Society (DMS) is mourning the loss of former president and 30-year member William “Bill” Hardcastle, M.D., who had been a general surgeon in private practice in Atlanta since 1971. Dr. Hardcastle served as DMS’s president in 1983, he was a long-time member of the DMS Board of Directors, and he represented DMS at MAG’s House of Delegates meeting.

DMS President Don Siegel, M.D., said that, “We are going to miss Dr. Hardcastle, and we will remember him for his dedication and many contributions to his profession and his patients.” Contact Melissa Connor at mconnor@ pami.org or 770.271.0453 or go to www.dekmedsoc.org for information on DMS. Georgia Medical Society

by Ca Rita Connor, Executive Director The Georgia Medical Society (GMS) held its annual meeting in January. The meeting theme was ‘Does your practice want to win or are you willing to lose dollars and a lot of dollars?’ The keynote speaker was Jody Denson, the Vice President of Provider Solutions for the Kansas Health Information Network.

MAG Director of Strategic Programs and Initiatives Susan Moore was also on hand for the event. The GMS officers for the year include President Luke J. Curtsinger, M.D., Vice President and

Parliamentarian Roland S. Summers, M.D., Secretary and Chairman of the Board of Trustees William A. Darden, M.D., Treasurer Fred L. Daniel, M.D., President-Elect William H. Moretz, M.D., Historian Leslie L. Wilkes, M.D., and Historian Emeritus Thomas R. Freeman, M.D. The keynote speaker for the society’s meeting in April was Jamie Credle, the Director of the Davenport House. She gave a talk on ‘Yellow fever in Savannah 1820 with Doctor William Coffee Daniel.’ Raleigh Marcell also participated in the presentation. In May, GMS sponsored its annual high school preceptorship/ internship program, which is a collaborative effort with the Savannah Chatham County Public School System. High school seniors who have an interest in studying medicine are selected to participate in this program each year.

They shadow one or more physicians for a day. The program begins with an orientation breakfast and ends with a banquet, during which each student shares their experiences of the day.

Eleven students and 30 GMS members participated in this year’s program. Contact Ca Rita Connor at gamedsoc@ bellsouth.net with questions related to GMS. Hall County Medical Society

by Melissa Connor, Executive Director More than 40 members were on hand for the Hall County Medical Society (HCMS) meeting in April.

MAG President Frank McDonald, M.D., M.B.A., and MAG Executive Director Donald J. Palmisano Jr. gave a talk on the 2018 state legislative session, while outgoing HCMS President Kip Schultz, M.D., installed Abhishek Gaur, M.D., as the society’s president for the year. Contact Melissa Connor at mconnor@pami.org or 770.271.0453 with questions related to HCMS. Muscogee County Medical Society

by Dan Walton, Executive Director The Muscogee County Medical Society (MCMS) held its annual CME event at the Hughston Foundation in Columbus. Stephen Muse, Ph.D., from the Pastoral Institute in Columbus gave a presentation on physician burnout. The next MCMS event will take place in concert with a Columbus Lions football game on July 28. Go to www. muscogeemedical.org or call 706.322.1254 for details or to join MCMS. Richmond County Medical Society

by Dan Walton, Executive Secretary The Richmond County Medical Society’s (RCMS) February meeting featured a ‘Congestive Heart Failure Update’ by Sean Javaheri, D.O. In March, RCMS celebrated ‘National Doctor’s Day’ and it recognized RCMS administrative assistant Nancy Graham, who recently retired after more than 35

years of service. Joseph P. Bailey Jr., M.D., presented her with a plaque and a gift. MCG radiology resident Jasmine Locklin, M.D., also gave a talk on ‘Roots of Quality Improvement’ during the meeting. In April, Don Loebl, M.D., presented the fifth annual RCMS James R. Lyle Resident Research Awards – which included first place winner Abdalrahman Zarzour, M.D., second place winner Sebastian Larion, M.D., and third place winners Angela Stephens, M.D., and Hoyle Whiteside, M.D. Go to www.rcmsga.org or call 706.733.1561 for additional information or to join RCMS.

From the left are Dr. I. J. Shaker, with J. W. Griffin and Alicja Griffin at the BCMS event in April.

Dr. Joe Bailey honoring Nancy Graham for 35 years of service to RCMS.

MEMBER NEWS Former MAG President and current MAG Foundation President Jack M. Chapman Jr., M.D., was recently honored with the Greater Hall Chamber of Commerce’s Healthy Hall Awards of Excellence Program Outstanding Health Care Professional Award.

Decatur internist Gulshan S. Harjee, M.D., was recently honored with the Emory School of Medicine’s ‘Distinction in Community Service Award.’ Dr. Harjee co-founded the Clarkston Community Health Center, she serves on the boards of UNICEF’s Campaign USA and the Georgia Breast Cancer Coalition, she has conducted bone marrow drives since 1992, and she established a scholarship at DeKalb Medical.

SPECIALTY SOCIETY NEWS Georgia Academy of Family Physicians

by Tenesha Wallace, Manager of Communications and Public Health The Georgia Healthy Family Alliance (GHFA) – which is the philanthropic arm of the Georgia Academy of Family Physicians (GAFP) and a networking member of the American Academy of Family Physicians Foundation – has awarded 45 grants totaling nearly $200,000 since it launched its ‘Community Health Grant Award Program’ in 2012. The awards are made to GAFP memberaffiliated community projects that support underserved

populations and outreach programs that promote healthy practices. This year’s grant recipients have included Thad Riley, M.D., for a ‘Homebound ServicesMed Connects Prescription Assistance Project’ that helps cover medication costs for elderly and disabled patients in southeast Georgia, and Martha Crenshaw, M.D., for a ‘Physician Care Clinic’s (PCC) Chronic Disease Management Project’ project that helps uninsured patients in DeKalb County with diabetes prevention and education and supplies. Go to www. georgiahealthyfamilyalliance. org or call 800.392.3841 to support the Georgia Healthy Family Alliance with a taxdeductible donation, and visit www.gafp.org for information on GAFP. Georgia Chapter of the American Academy of Pediatrics

by Kasha Askew, Director of Membership & Education The Georgia Chapter of the American Academy of Pediatrics (Georgia AAP) president Ben Spitalnick, M.D., reports that the 2018 state legislative session produced mixed results. He says, “We were pleased to see bills on mandatory autism benefits, distracted driving, and adoption reform pass – while an APRN scope bill did not.” He adds that, “Along with our colleague societies in primary care, we had nearly 200 physicians at our Legislative Day at the Capitol in February.” AAP is working on a major initiative

to reduce gun violence – with an emphasis on children and adolescents. Dr. Spitalnick says that, “Since Columbine, 280 children and adolescents have been killed in the U.S. in school shootings. Both AAP and the Georgia Chapter believe this is unacceptable.

We will carry this forward in Georgia and undertake policy and legislative initiatives to address this issue.” The Chapter held a ‘Pediatric Infectious Disease & Immunization Conference’ in March that featured presentations

by Larry Pickering, M.D., Walter Orenstein, M.D., and Harry Keyserling, M.D. The meeting chair was Davidson Freeman, M.D. In May, the Chapter held a ‘Transitioning Youth with Special Healthcare Needs from Pediatric to Adult Care’ conference. The conference chair was Saira Alimohamed, M.D. The Chapter will host its summer CME conference – ‘Pediatrics by the Sea’ – at the RitzCarlton Amelia Island on June 13-16. The program chairs include Dan Salinas, M.D., and Patrick Frias, M.D. And on September 14-16, the Chapter will host its fall meeting, ‘Pediatrics on the Parkway,’ at the Cobb Galleria Centre in Atlanta.

The meeting chair is Judson Miller, M.D. The Chapter will also hold a gala to commemorate the 20th anniversary of the Pediatric Foundation of Georgia at the Renaissance Atlanta Waverly Hotel on September 15.

Visit www.gaaap.org or call 404.881.5091 for additional information. www.mag.org 31

Georgia Chapter of the American College of Physicians

by Mary Daniels, Executive Director The Georgia Chapter of the American College of Physicians (ACP) is pleased to announce that G. Waldon Garriss III, M.D., MACP, with the WellStar Kennestone Regional Medical Center in Marietta has been elected to serve as the Chapter’s governor-elect – which means he will begin his term as governor in April 2019. The Chapter is also congratulating Edwin Grimsley, M.D., MACP, with the Mercer University School of Medicine for receiving Mastership in the college at Convocation during ACP’s 2018 Internal Medicine meeting in New Orleans in April – as well as the 13 Georgia internists who attained fellowship at Convocation. The Chapter will hold its annual meeting at Callaway Gardens in Pine Mountain on October 12-14. Go to www.gaacp. org or contact Mary Daniels at mdaniels@gaacp.org for additional information on the Chapter.

Georgia Chapter of the American College of Cardiology

by Melissa Connor, Executive Director The Georgia Chapter of the American College of Cardiology (GAACC) will hold

32 MAG Journal

its 2018 annual meeting and scientific program at The Ritz-Carlton Reynolds, Lake Oconee in Greensboro on November 16-18. The event will feature a number of speakers and panel discussions. It drew nearly 50 exhibitors and sponsors in 2017. It is also worth noting that ACC President Mike Valentine, M.D., will speak at this year’s meeting.

Go to www.accga.org for additional information, and contact Melissa Connor at mconnor@pami.org with any questions related to GAACC. Georgia College of Emergency Physicians

Contact Karrie Kirwan at karrie@ theassociationcompany.com for information on the Georgia College of Emergency Physicians.

Georgia Gastroenterologic and Endoscopic Society

by Dan Walton, Executive Director The Georgia Gastroenterologic and Endoscopic Society (GGES) will hold its annual meeting at the Atlanta Marriott Buckhead on September 15.

It will address a number of important issues, including Hepatitis C, fecal transplant, pancreatic cysts, IBD, EMR, MIPS, pancreatitis, esophageal motility – as well as abstract presentations.

Go to www.georgiagi.org for details on registration.

Contact Stacie McGahee at smcgahee@medicalbureau. net or 706.738.3119 with questions.

Georgia Neurosurgical Society

The Georgia Neurosurgical Society (GNS) held its annual meeting at The Cloister at Sea Island in May. Go to www.ganeurosurgical. org or contact Karrie Kirwan at karrie@ theassociationcompany.com for information on GNS. Georgia Society of Dermatology and Dermatologic Surgery

Go to www.gaderm. org or contact Maryann McGrail at maryann@ theassociationcompany.com for information on the Georgia Society of Dermatology and Dermatologic Surgery.

Georgia Society of Interventional Pain Physicians

The Georgia Society of Interventional Pain Physicians (GSIPP) held its annual meeting at The Ritz-Carlton Reynolds, Lake Oconee in April. Go to www.gsipp.com or contact Karrie Kirwan at karrie@ theassociationcompany.com for information on GSIPP.

Georgia Society of Otolaryngology/Head & Neck Surgery

The Georgia Society of Otolaryngology/Head & Neck Surgery is promoting its ‘Annual Summer Meeting,’ which will take place at the Royal Pacific Resort at Universal Studios in Orlando on July 19-22. Go to www. gsohns.org or contact Karrie Kirwan at karrie@ theassociationcompany.com for additional information.

Georgia Society of Rheumatology

The Georgia Society of Rheumatology (GSR) held its annual meeting at The Ritz-Carlton on Amelia Island, Florida in June. Go to www.garheumatology. org or contact Alyson Conley at alyson@ theassociationcompany.com for information on GSR. Please submit your Georgia county medical society, member or specialty society news to Tom Kornegay at tkornegay@mag.org. Also contact Kornegay with any corrections. The Journal reserves the right to edit submissions for length and clarity. Bolding recognizes the physicians who are active MAG members at the time the Journal was prepared. Go to www.mag.org/membership to join MAG.

MAG mourns loss of former presidents Drs. John D. Watson Jr., Bob G. Lanier and William R. “Bill” Hardcastle The Medical Association of Georgia (MAG) is mourning the loss of three of its former presidents, including John D. Watson Jr., M.D. (1986-1987), Bob G. Lanier, M.D. (1994-1995), and William R. “Bill” Hardcastle, M.D. (2005-2006).

Dr. Watson graduated from the University of Arkansas for Medical Services’ College of Medicine. He had certifications in diagnostic radiology, therapeutic radiology, and nuclear medicine.

Dr. Watson and his family moved to Columbus in 1967. He led a team that was credited with introducing chemotherapy to the Columbus area.

In addition to MAG, Dr. Watson held leadership positions in a number of physicians’ advocacy organizations, including the Muscogee County Medical Society, the Georgia Society of Nuclear Medicine – which he founded, the American College of Radiology, and the American College of Nuclear Medicine.

It is also worth noting that Dr. Watson served as the president of the MAG Foundation for nearly 20 years.

Dr. Watson is survived by his wife, Margaret Watson, two children, and three grandchildren.

Dr. Lanier had a practice in Cumming for more than 30 years.

He specialized in arthritis, back disease, and rheumatology. Dr. Lanier graduated from the Medical College of Georgia, and he completed a fellowship in rheumatology at the Mayo Clinic.

Dr. Lanier was a pioneer in the electronic medical records field. He had a passion for developing new EMR software and products, and his practice was credited with being the first in the nation to submit regular production data to the Center for Medicare & Medicaid Services’ DOQ-IT program.

Dr. Lanier was a member of the American Society of Internal Medicine, the American Medical Association, the Lupus Foundation, the Georgia Society of Rheumatology, and the Gwinnett/Forsyth County Medical Society. He also served on Alliant Health Solutions’ Board of Directors. In addition to serving as MAG’s president, Dr. Lanier was the Medical Association of Atlanta’s president in 1983-1984.

Dr. Lanier is survived by his wife, Joan Rayburn Lanier, four children, and seven grandchildren.

Dr. Hardcastle had been a general surgeon in private practice in Atlanta since 1971. He graduated from Tulane University Medical School. While he was at Tulane, Dr. Hardcastle and his brother won an NCAA championship in doubles tennis in 1959. He was in the U.S. Air Force for two years, achieving the rank of major and serving a tour in South Vietnam during the Vietnam War. Dr. Hardcastle held several important leadership roles at DeKalb Medical Center during his career, including chief of staff, chief of trauma service, and chief of general surgery.

He also served as the president of the DeKalb Medical Society in 1983.

It is also noteworthy that Dr. Hardcastle won the Joseph P. Bailey Jr., M.D., Physician Distinguished Service Award in 2013.

Dr. Hardcastle was the team physician for the Marist High School football team for more than 40 years – and he was inducted into the ‘Marist Blue & Gold Athletics Circle’ in 2004.

Dr. Hardcastle is survived by three children, seven grandchildren, and his brother.

MAG’s HOD to take place at Westin on Jekyll Island on October 20-21 The Medical Association of Georgia will hold its 2018 House of Delegates (HOD) meeting at the Westin Jekyll Island/Jekyll Island Convention Center on October 20-21. This year’s HOD will feature…

• A complimentary ‘Welcome Reception’ that will take place at the Westin on the evening of Friday, October 19. All delegates and alternates delegates and sponsors and guests are encouraged to attend this event.

• A ‘Low Country Boil’ dinner that will take place on Friday, October 19 following the Welcome Reception at the Convention Center, which is adjacent to the Westin. The cost of this dinner is $56 per person (plus a $5.16 processing fee), which will include an appetizer,

buffet dinner, and two drink tickets per person.

• A formal ‘President’s Inaugural Dinner’ at the Convention Center on Saturday, October 20. This will take place following the president’s installation ceremony – and it replaces the awards dinner that has taken place in the past. The cost of this event is $75 per person (plus a $6.24 processing fee), which includes a plated dinner, two drink tickets, and table wine.

• An ‘After Party’ that will begin at 9 p.m. on Saturday, October 20 that will feature a DJ, dancing, and two complimentary drink tickets per person.

Go to www.mag.org/hod for information on registration and other details on the 2018 HOD meeting. www.mag.org 33

PERSPECTIVE

A brief, personal history of health care reform in America

By Mark Murphy, M.D. Mark Murphy, M.D.

T

he year was 1978. I was a gawky, bespectacled high school sophomore with an unruly Matterhorn of brown hair and a droopy vellum moustache. Socially awkward, I was more at home reading science fiction novels and making model airplanes than I was talking to anyone – and particularly girls – even though I had a huge crush on a gorgeous, shy, studious girl named Daphne who sat behind me in homeroom. I never volunteered for anything, except for football, which I had reluctantly tried out for despite a lack of athletic prowess only because I had promised my grandfather I would.

“Are you playing football? Because the Murphy men always play football,” Daddy Groze had said during the summer before my freshman year.

“Well, Calvary doesn’t have a football team,” I responded, secretly relieved at this fact.

As luck would have it, my school fielded a football team the very next season, sealing my fate. My only consolation was that with it being the school’s first team ever, my inherent gridiron ineptitude would be rendered less evident, absorbed into the team’s overall lack of ability. When you’re the worst player on a 0-10 football team, not many people notice.

One morning in homeroom, I was trying to sneak a sideways glimpse at the beautiful Daphne when I heard my name called.

“Mark? Mrs. Barnard wants to speak to you,” my homeroom teacher said.

Jane Barnard was a math teacher. She was not my math teacher, however, which was why it was odd that she wanted to speak to me.

Sensing trouble, I got up and was escorted into the hallway.

“Your father is a doctor, isn’t he?” Mrs. Barnard said.

I nodded.

“And I understand you’re a pretty good writer,” she added.

“I guess so,” said, staring down at my Wallabees.

“Well, I’d like your help doing research for the debate team. The topic this year is health care reform.”

I looked up. This was something my father had spoken about frequently over dinner.

“Really?” I said.

She nodded.

“They pick a single debate topic for the entire country every year.

This year, the topic is ‘Resolved: That the federal government 34 MAG Journal

should establish a comprehensive program to regulate the health care system in the United States.’ I’m sure your father has some opinions about that,” she said, grinning.

“Oh, he does,” I replied with a smirk.

My dad had voted for Jimmy Carter for president. He had even given Carter a large enough campaign contribution to get an invitation to the inauguration. But when Dad read about President Carter’s proposal for national health care reform, he responded with an explosion of expletives the likes of which I’d never heard.

“Why, Jimmy Carter’s a damn socialist!” he said, slamming his fist down on the kitchen table so hard the dishes rattled.

And that began a protracted series of nightly tirades about why “socialized medicine” would never work in this country.

I had no actual interest in health care reform, but since my father felt so passionately about it, I thought it might give us something to talk about besides football. And I emphatically did not want to talk about football.

I actually found that I enjoyed the debate team. The debate guys were all geeks like me. They liked Star Trek and model rocketry – and they were absolutely amazed that I had gone out for football.

“Are you crazy?” they said.

“Maybe,” I replied, raising a single eyebrow like Mr. Spock.

Because I played football, I was considered the coolest guy on the debate team. It was sort of like being the tallest munchkin. But like a squirrel preparing for winter, I hoarded scattered nuggets of social status anyplace I could find them.

As the region debate tournament was beginning, we found that one of our starting speakers had the flu.

“Mark, you’re going to have to fill in for David,” Mrs. Barnard said.

“I can’t!” I said, terrified.

“But there’s nobody else,” she said. “We’d have to forfeit.”

And so I debated. We ended up placing third in the state that year. I went into medicine myself and have since written dozens of articles and given many speeches on health care reform.

Ultimately, I owe all of this to Mrs. Barnard, who got me out of homeroom one bright fall morning all those years ago.

And Daphne, the beautiful girl I had such a crush on? Why, I married her.

Dr. Murphy is a Savannah gastroenterologist, a longtime MAG member, and the former president of the Georgia Medical Society.

MAG MEDICAL RESERVE CORPS

MAG MRC conducts emergency training exercise in Coffee County

M

ore than 30 members of the Medical Association of Georgia Medical Reserve Corps (MAG MRC) joined some 50 local stakeholders – including first responders and medical students – in an emergency training exercise that took place at the Coffee County Medical Center in Douglas on Saturday, March 24.

“The training scenario simulated an EF3 tornado, and our objectives included transporting and caring for wounded patients and deploying a mobile surgical hospital,” said MAG MRC Medical Director John S. Harvey, M.D., who is a general and trauma surgeon. “A number of the participants also underwent ‘Stop the Bleed’ campaign hemorrhage control training, which means that they will be equipped to help during a bleeding emergency before professional help arrives – keeping mind that a person can die from blood loss within five minutes.”

MAG MRC Regional Coordinating Physician and Douglas orthopedic surgeon Jim Barber, M.D., deemed the exercise a “huge” success. He stressed that, “The reality is that we will

have to contend with a disaster at some point, so our goal is to ensure that we are properly coordinated and trained and equipped to respond at the state and local levels.”

With the approval of the U.S. Department of Health and Human Services, the Medical Association of Georgia and the Georgia Department of Public Health developed the nation’s first medical society-sponsored statewide volunteer MRC in 2015. The MAG MRC is prepared to respond to declared emergencies in Georgia, including natural disasters (e.g., hurricanes, tornados, wildfires, blizzards, floods) and disease outbreaks. The MAG MRC supplements the official medical and public health and emergency services resources in the state. MAG MRC volunteers include both physicians and non-physicians.

Go to www.mag.org/mrc or contact Mark Reitman at 678.303.9289 or mreitman@mag.org for additional information on the MAG MRC or if you are interested in joining the MAG MRC. Go to www.stopthebleedGeorgia.org for details on the ‘Stop the Bleed’ campaign.

Members of the MAG MRC during a training exercise that took place at the Coffee Regional Medical Center in Douglas in March.

The participants practiced transporting and caring for wounded patients and deploying a mobile surgical hospital following a tornado.

A number of local stakeholders – including first responders and medical students – were also certified in ‘Stop the Bleed’ campaign hemorrhage control training.

www.mag.org 35

PRESCRIPTION FOR LIFE

Things they don’t teach you in medical school Jay Coffsky, M.D.

I

started dreaming about going to medical school when I was six years old. The good news is that I got there…I didn’t realize I would be there for more than 60 years.

The point of medical school is to learn to become a doctor.

But the truth of the matter is that there are a lot of things that they don’t – or perhaps simply can’t – teach you when you are in medical school. No matter how good the school or teacher, there just isn’t a good substitute for time and experience when it comes to becoming a real doctor.

The day one graduates from medical school isn’t the end; it’s the beginning of a lifelong process. With advances in medical care and technology, most of what is taught in medical school today will be obsolete in 20 years. This might not be unique to our profession, but I have probably accumulated about 90 percent of what I know since I graduated from medical school.

Pick your specialty or practice setting, but a good doctor never stops learning.

Here are a few important things that I have learned since I graduated from medical school…

• Some days, it all goes right. Other days, not so much. It’s not that you are that good or bad on a particular day, it just is – no matter how hard you try.

• Virtue is a great quality. Accept blame if you are in charge, even if it’s not your fault. A weak person deflects blame.

shoulders, you are either very young or lack self-awareness.

• Treat everyone – including your patients and fellow physicians and practice staff and the cleaning crew – like they were members of your family.

• It’s not always the case (trust me), but never forget that the vast majority of your patients are good people who appreciate what you do.

• Also remember that these same patients didn’t go to medical school, so take the time to make sure that they understand the words that are coming out of your mouth.

• Don’t react to another doctor’s treatment or diagnosis until you have all of the facts.

• No one cares where you went to college or medical school.

• We are all dispensable, and the sun will come up tomorrow.

• We are all dealing with personal issues, so please check your baggage at the front door.

• You aren’t always right.

• Medicine is an honorable profession. Dress like a doctor, down to your shoes.

• The last doctor a patient sees before they get better is often seen as the hero, but remember to give credit to the other doctors who played a role in the patient’s care.

• We are blessed to live in this great country.

• Humility is a great quality, too.

• They don’t teach you how to run a business in medical school.

• Never critique a co-worker in front of others. It is a terrible quality, especially if you are a leader.

• The patient often sees you and your practice staff as one in the same, so it’s important to know what’s going on at the front desk.

• Never lie or falsify a result.

• Become a good listener.

• It’s hard, but learn to apologize.

• Remember the sacrifices that your family members make along the way.

• Always introduce yourself and those you work with.

• In my religion, they take your socks off before they bury you. If we can’t take our socks – much less our wealth or knowledge or possessions – the only thing we have left is our character. Real worth isn’t measured in dollars.

• Give compliments – and be sincere.

• Respond to every phone call and email. Getting back to someone with a text or email generally only takes a few seconds.

• When you don’t know, say so. Admitting that you don’t know the answer or asking for help is an admirable quality and a sign of strength.

• You’ll make mistakes. When you do, fall on your sword.

Never try to cover up your mistakes. If you have never felt the tremendous weight of a bad outcome or a lawsuit on your

36 MAG Journal

Something else that they don’t teach you in medical school is just how difficult it will be to retire. Oh, well, time to get back to class.

Dr. Coffsky and his wife, Sandy, have been married for 58 years.

They have three children, eight grandchildren, and a greatgrandchild. Dr. Coffsky is in his 51st year at DeKalb Medical.

You can contact Dr. Coffsky at m3wejr@bellsouth.net.

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At MagMutual, one of the leading providers of medical professional liability insurance, you are more than a policyholder – you’re a PolicyOwner . As an owner, we believe you SM

should benefit from your company’s success, which is why we strive to return as much as we can back to our PolicyOwners. Over 20,000 physicians and hospitals are benefitting from MagMutual ownership, are you?

Dividends

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Owners Circle® Loyalty Rewards

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UpToDate® Access

*Dividends and Owners Circle allocations are declared at the discretion of the MagMutual Board of Directors.

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