The Journal of the Medical Association of Georgia

Vol. 105, Issue 2, 2016

The profession is changing.

Are you?

Adult immunizations Renal artery stenosis Where we practice: Athens   Legal takes on MACRA & complying with government regulations

Feel like insurance profits should go to policyholders, not stockholders?

The feeling is mutual.

Since 1982, MagMutual has been owned and led by the healthcare professionals we insure.

As a mutual, our PolicyOwners receive consistent dividends and financial rewards, plus exceptional benefits through our support programs and Patient Safety resources.

This is the reason we have grown to become the largest healthcare liability insurer in the Southeast, and leading mutual insurer in many states.

To experience the PolicyOwner difference, call 800-282-4882 or visit MagMutual.com SM

Dividend payments are declared at the discretion of the MAG Mutual Insurance Company board of directors. Since inception, MAG Mutual Insurance Company has distributed more than $136 million in dividends to our policyholders. Insurance products and services are issued and underwritten by MAG Mutual Insurance Company and its affiliates.

TABLE OF CONTENTS VOLUME 105, ISSUE 2

3

8

14

18

IN EVERY ISSUE

FEATURES

3 President’s Message

8

4 Editor’s Message 6 Executive Director’s Message 18 Medical Ethics

How will your practice change in the next five years?

11 Editorial: Health care reform’s silver lining

12 Market Analysis: Athens 24 Patient Safety: When the patient 14 Public Health: Adult makes a poor choice, will a immunization – A call for action signed AMA form protect me?

26 Legal: How to prevent compliance 16 Case Report: A unique case of renal artery stenosis and regulatory problems that could ruin your bottom line 20 GCMB: MOC – How we got here and where we are going 28 Legal: SGR to MACRA – so are we going from the frying pan and into the fire?

31 County, Member & Specialty News 35 Prescription for Life

PRESIDENT’S MESSAGE

A point of pride… and peace of mind John S. Harvey, M.D.

I

have always been proud to be a member of the Medical Association of Georgia (MAG) – but Saturday, April 30 was an especially rewarding day. It marked the culmination of a lot of hard work that involved a lot of caring, communityminded people. It was the day that MAG’s new Medical Reserve Corps (MRC) conducted a ‘Mobile Surge Hospital SetUp Training’ event at the Grady EMS Training & Education Center in Atlanta.

In addition to the training we received, the April 30 exercise was a great way for physicians who thought that they might have an interest in becoming a MAG MRC volunteer to get a taste for what they can expect to see during a real-world crisis. And, yes, we also had some fun.

MAG – along with the Georgia Department of Public Health and the Georgia State Defense Force, and with the approval of the U.S. Department of Health and Human Services – developed this, the nation’s first medical society-sponsored statewide volunteer MRC. It is also important to note that MAG formed its MRC – one of 19 MRCs in the state – as a result of an action that its House of Delegates (HOD) took in 2013, and some might recall that we officially launched MAG’s MRC at our HOD meeting in Savannah in 2015.

The MAG MRC compliments the official medical and public health and emergency services resources that are available in the state. It trains physicians to respond to declared emergencies in Georgia, including natural disasters – such as wildfires, hurricanes, tornadoes, blizzards, and floods.

It also trains physicians to respond to other emergencies affecting public health (e.g., disease outbreaks), as well as those that have the potential to compromise a hospital’s ability to respond and operate.

The MAG MRC is in the process of establishing a system to coordinate the deployment of physicians in the event of one of the aforementioned emergencies. Our units will be capable of setting up mobile hospital systems. And under extreme circumstances (e.g., a shortage of health care providers in a given

johnharveymd@gmail.com

area), the MAG MRC will be called upon to perform some of the functions that would otherwise be performed by the fulltime emergency medical response personnel in the state.

Looking into the future, the MAG MRC will conduct another portable hospital training exercise in Savannah on October 14.

This will be done in conjunction with the Georgia Defense Force and a number of state and local agencies and organizations.

The MAG MRC currently has 150 volunteers, which includes more than 80 physicians – as well as nurses, epidemiologists, law enforcement officials, firefighters, medical assistants, pharmacists and pharmacy technicians, engineers, clerks, and computer security specialists.

The MAG MRC’s top objectives for the next year include building awareness; establishing community partnerships; identifying its financial needs and funding sources; putting a leadership team and organizational structure into place; establishing policies and procedures; enhancing its recruiting, screening and selection processes; and increasing the number of physicians who serve as volunteers to 100.

Having served as a surgeon for more than 30 years, I know that we can be subjected to a wide array of emergencies without a moment’s notice. While we should never live in fear, the real key to our safety, happiness and peace of mind – whether the context is you, your family members, your practice, or your community – is to be prepared for the worst case scenario and in a constant state of readiness.

That is ultimately why we formed the MAG MRC and it is why I appeal to you and encourage you as a fellow physician to take some time and learn about how you can make a difference as a MAG MRC volunteer.

Editor’s note: Dr. Harvey serves as a unit commander in the MAG MRC. MAG MRC physician volunteers must be MAG members.

Physicians must register on the “Georgia Responds: State Emergency Registry of Volunteers in Georgia” (SERVGA) before they can serve as a MAG MRC volunteer. Go to www.mag.org/affiliates/mrc for additional information on the MAG MRC. 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 Janis S. Coffin, D.O., Augusta Jay S. Coffsky, M.D., Decatur Mark C. Hanly, M.D., Brunswick Barry D. Silverman, M.D., Atlanta Joseph S. Wilson Jr., M.D., Atlanta Michael Zoller, M.D., Savannah MAG Executive Committee John S. Harvey, M.D., President Steven M. Walsh, M.D., President-elect Manoj H. Shah, M.D., Immediate Past President Madalyn N. Davidoff, M.D., First Vice President S. Mark Huffman, M.D., Second Vice President Rutledge Forney, M.D., Chair, Board of Directors Frederick C. Flandry, M.D., Vice Chair, Board of Directors Andrew B. Reisman, M.D., Secretary Thomas E. Emerson, M.D., Treasurer E. Frank McDonald Jr., M.D., Speaker of the House Edmund R. Donoghue Jr., M.D., Vice Speaker of the House Michael E. Greene, M.D., Chair, Council on Legislation S. William Clark III, M.D., Chair, Georgia AMA Delegation 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. © 2015.

4 MAG Journal

Quality and value Stanley W. Sherman, M.D.

W

ikipedia has many definitions for “quality” and “value,” so it subsets its definitions with different contexts – such as business and service.

The website defines business quality “as non-inferiority or superiority of something,” whereas service quality is defined as “the comparison of expectations with performance in a service.” Economic value is “a measure of the benefit that may be gained from goods and services,” while marketing value is “a measure of the customer’s evaluation of benefits and cost.”

In my estimation, the words quality and value are some of the most abused and overused terms in the English language. And they are now being used to transform our health care system from fee-for-service to something less costly that bases reimbursement on achieving better quality and value.

When managed care first began, the payers described quality as adherence to their negotiated drug formulary – no matter how limited the formulary was – since it was based on their best negotiations with the drug companies and it changed frequently.

Clearly, these companies prefer the “service” definition of quality as opposed to the “business” definition that physicians use. Even if we supply the guidelines for quality, the best quality care for an individual patient is not always consistent with these guidelines, and the payers are not capable of varying from the guidelines. Many of my colleagues and I feel that even our “peer-to-peer” physician reviewers do not seem capable of doing this. If we do achieve quality measures and get a five percent bonus one year, what will stop the payers from upping the standards so that we cannot reach a bonus the next year?

When it comes to value, employers purchasing insurance feel that an appendectomy should cost the same at every hospital – a marketing value rather than an economic value definition. This implies that all hospitals and doctors are the same. If their philosophy of health care value is correct, then all cars that get us from one place to another should cost the same instead of the actual tens of thousands of dollars difference in car prices.

Would these employers support this? What if we demanded this same approach to their businesses?

One of the future medical delivery models is the “medical home.” Your first medical contact in this model will not be the highest level, longest-trained doctor; in fact it will be anyone but the M.D. How is this an improvement in quality by any definition?

One of the reasons to leave fee-for-service was that there were monetary incentives for us to order too many procedures to prevent bad illness or to find health problems early. Where is the study that shows that switching to risk-based models of health care, such as ACOs, leads to true economic value? The negative incentives to do more tests and procedures may lead to more patients getting delayed diagnoses that require more complicated therapies – perhaps a worse value.

It seems that my older patients who can afford to are moving toward “concierge care” to preserve the patient-physician relationship that they have always enjoyed rather than participate in these new approaches to their care. For those who cannot afford it and for younger patients who have only known a newer or corporate care environment,

we should call these new delivery models “cost saving systems” – and thereby quit confusing “quality” and “value” excuses for these new health care delivery systems.

I hope that you will read our feature article on practice change trends to help you predict issues that your practices may face in the near future. Dr. Frank McDonald offers his editorial comments on these new delivery systems, while MAG CEO Donald J. Palmisano Jr.’s message lets us know what our association is doing to help us succeed in the collection of data to enhance patient care and report to the payers.

Since we recently observed Memorial Day, it seems appropriate to learn from our President, Dr. John Harvey, of the progress of MAG’s Medical Reserve Corps (MRC). Dr. Andrew Herrin “jogs” us through the changes that are occurring in Athens, where he practices. Attorney Sydney Welch updates

us on the Merit-Based Incentive Payment System (MIPS) and government expectations from Alternative Payment Models (APM), while Smith Moore Leatherwood LLP warns us about some key compliance and regulatory changes. MAG requests our help opposing the insurance mega-mergers. Our medical ethics article reminds us of the art of medicine, while our articles on immunizations and renal artery stenosis remind us of the importance of the science of medicine. MAG Mutual Insurance Company informs us of what we need to do when patients leave a hospital against their physician’s advice.

Finally, Dr. Coffsky reflects on the 60 years of practice changes that he’s observed – with more to come.

I hope that you have a great summer with friends and family and, most of all, I hope that you make lots of good memories.

Medical Association of Georgia president thanks 2016 ‘Doctor of the Day’ volunteers Medical Association of Georgia (MAG) President John S. Harvey, M.D., recently expressed his thanks to MAG’s ‘Doctor of the Day’ volunteers for 2016.

Working out of MAG’s Medical Aid Station at the Capitol, MAG Doctor of the Day volunteers provide free minor medical care to legislators and their staff for one or more days during the legislative session.

MAG Doctor of the Day volunteers for 2016 included…

Becky A. Abell, M.D.

G. Waldon Garriss III, M.D.

Matthew L. Lyon, M.D.

Melissa A. Christino, M.D.

Laura Garvey, M.D.

Reginald Mason, M.D.

Daniel H. Cohen, M.D.

Richard D. Gordon Jr., M.D.

Daniel Most, M.D.

James Crownover, M.D.

Twiggy L. Harris, M.D.

W. Mark Newton, M.D.

Snehal C. Dalal, M.D.

John S. Harvey, M.D.

LaJune E. Oliver, M.D.

Shamie Das, M.D.

Rasean T. Hodge, M.D.

Ramon O. Parrish Jr., M.D.

Kelly M. DeGraffenreid, M.D.

Indran B. Indrakrishnan, M.D.

Ali Rahimi, M.D.

Andrew B. Dott, M.D.

Y. Julia Kao, M.D.

Willie Rainey Jr., M.D.

Adrian C. Douglass, M.D.

Matthew T. Keadey, M.D.

Aisha W. Redmond, M.D.

Markesha W. Fleury, M.D.

Bruce M. LeClair, M.D.

Shefali Shah, M.D.

S. Clifton Willimon, M.D.

Erica Y. Francis-Scott, M.D.

Ben Lefkove, M.D.

Stanley J. Shin, M.D.

John T. Wright, M.D.

Dr. Harvey also applauded the medical societies and health care providers that supported MAG’s Doctor of the Day program in 2016, including…

Georgia College of Emergency Physicians Georgia Orthopedic Society Georgia Partnership for TeleHealth MAG Alliance Medical College of Georgia at Augusta University Southeast Permanente Medical Group, Inc.

George Shokri, M.D. (Telemedicine) James L. Smith Jr., M.D. Carmen D. Sulton, M.D. John L. Sy, D.O. James M. Tallman, M.D. Marvin D. Tark, M.D. Earl H. Thurmond, M.D. Helen M. Ward, M.D. Thad Wilkins, M.D.

Finally, Dr. Harvey thanked nurse Ruby Butts for supporting the MAG Doctor of the Day volunteers in 2016.

“MAG’s Doctor of the Day program is a great way to remind lawmakers that physicians play a vital role in maintaining a healthy and productive workforce in Georgia,” said Dr. Harvey.

“Of course, it also reinforces MAG’s role as the leading voice for physicians in every specialty and practice setting in the state.”

The MAG Doctor of the Day volunteers were each recognized in the House and the Senate on the day they served.

Contact Liz Bullock at 678.303.9271 or ebullock@mag.org if you are interested in serving as a MAG Doctor of the Day in 2017.

www.mag.org 5

EXECUTIVE DIRECTOR’S MESSAGE

Getting from here to there Donald J. Palmisano Jr.

I

n 2015, Congress finally repealed the sustainable growth rate when it passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In doing so, lawmakers fundamentally changed the way physicians will be compensated for the care they provide – emphasizing quality over quantity.

To get from here to there, the Centers for Medicare & Medicaid Services (CMS) has developed several alternative payment models. Keeping in mind that MACRA has resulted in more than 900 pages of rules and regulations, CMS has established the Merit Incentive-based Payment System (MIPS) and a number of Advanced Alternative Payment Models (APMs).

I don’t believe that the fee-for-service component will ever be eradicated in full, but it is clear that private payers will follow suit and will be placing a far greater emphasis on quality. So my central message is that these new payment models are here to stay – and they are all data driven.

In a recent article that appeared in Modern Healthcare magazine, the U.S. Department of Health and Human Services (HHS) reported that “30 percent of all fee-for-service payments are [now] tied to alternative payment models that reward quality over quantity.”

HHS also said that “[today’s] aggressive value-based models are not as prevalent in the commercial market and that many private accountable care organizations have failed to show an improvement in quality and lowering of costs.”

This means that it will become increasingly imperative for physicians to be able to compile and submit data that demonstrates that they are indeed delivering quality care. It also means that physicians will need easy access to real-time clinical data to compete – and either thrive or simply survive.

It is consequently no surprise that for more than two years the Medical Association of Georgia (MAG) has been looking for ways to help physicians compete in the new, data-driven payment environment. You might recall from the column that I wrote in the Journal a year ago that MAG was assessing the feasibility of developing a regional health information network in conjunction with the Georgia Hospital Association and MAG Mutual Insurance Company.

The bad news is that the partnership never materialized as a result of market forces. The good news is, as they say, that when one door closes another often opens.

6 MAG Journal

dpalmisano@mag.org

I am proud to report that MAG has entered into an agreement with KaMMCO Health Solutions, which is a subsidiary of KaMMCO – a professional medical liability company – and the Kansas Medical Society, which has realized great success in this arena. This new physician-led entity will help physicians and other health care providers (e.g., accountable care organizations) “improve patient outcomes and adapt to new performancebased payment models through the use of data analytics and business intelligence tools.”

It is clear that there is a need for this kind of “actionable data analytics” solution in Georgia based on the feedback that we have received from an array of stakeholders, including independent physician associations, accountable care organizations, and hospitals. They have grown tired of health IT companies that overpromise and under deliver (i.e., they ended up with a lot of data that sat on a shelf ). Physicians want and need access to better data that they can trust and that will result in better patient outcomes.

I am convinced that this new health information exchange and population health management tool will create a lot of value for physicians and other health care providers who have remained on the sidelines because they haven’t found the right ‘fit’ given the options that are currently available in Georgia.

I am also confident that this system will help physicians obtain the data that they and their practices need to succeed in the post-MACRA world. They will be able to generate analytics to address high-risk patients and chronic disease populations while improving patient outcomes through enhanced care coordination.

Finally, I should emphasize that this new participation feebased entity will be led by a board that is composed of MAG members – which means that it will be a patient-focused, physician-led organization whose mission and values are fully aligned with ours.

I am genuinely excited about this new venture, which should be up and running in the next several months. And as a member physician, I hope that you feel some additional peace of mind knowing MAG is on the cutting edge of a technology solution that will give you more freedom to determine the way you care for your patients – regardless of your practice setting – and giving you an advantage and the opportunity to be rewarded for the excellent care you provide.

www.mag.org 7

How will your practice change in the next five years?

By Tanya Albert Henry

A

s payers move away from a fee-for-service system, physicians in Georgia – especially solo practitioners and small groups – are discovering that they need to adapt and change the practice models they employ or face the very real risk of being left behind.

Terms like “medical home” and “accountable care organization” have become a regular part of our vocabulary – and the reality is that these and other emerging practice models will become even more prevalent over the next five years as Medicare and the private payer community move to alternative payment models that are focused on improving, and measuring, the quality of patient care while reducing costs.

“Physicians will become more synonymous with health care systems, and patients will become more aligned with those systems versus individual physicians,” predicts Joseph S. Wilson Jr., M.D., MAG Mutual Insurance Company’s (MagMutual) chairman of the board and chief executive officer. “That will no doubt raise some eyebrows, but I believe there is a real opportunity to effect change that will benefit both patients and physicians.”

There might not be a consensus about the role of the private practice model five years into the future, but Dr. Wilson’s forecast provides great food for thought for every physician in the state.

The opportunity In recent years, we have seen the advent of episode-based and bundled payments, shared savings, pay-for-performance, and capitation. This has served as the genesis for accountable care organizations (ACOs) – groups of doctors, hospitals and other health care providers who provide coordinated care for Medicare patients – and the patientcentered medical home, which is a coordinated, comprehensive, 8 MAG Journal

team-based approach to primary care.

With this backdrop in mind, and along with the sweeping Medicare payment policy changes that are coming in the next several years, Piedmont Healthcare cardiologist Charles L. Brown III, M.D., believes that the pace of change will only grow faster.

He says that, “Doctors will only grow more frustrated trying to keep up with the changes that are taking place with Medicare and the other payment systems, and they will be looking for solutions to ensure they can comply with all of the new rules, which is going to be difficult.”

He also believes that the alternative for physicians who don’t want to join a system will likely be a career in concierge medicine and/or to eliminate Medicare beneficiaries from their patient mix.

While unnerving for many, Dr. Brown believes there could be a silver lining.

“The formula we use today is based on the more we do, the more we get paid,” he says. “Going forward, we will have the opportunity to be recognized and rewarded for demonstrating – in a measurable way – that we deliver great patient care in the most efficient way.”

Strength in numbers K. Douglas Smith, M.D., reports that the aforementioned payment and regulatory challenges were among the primary reasons that Northside Anesthesiology Consultants, LLC, in Atlanta was sold to a national, physician-led and managed health care management services company in 2015.

As the chair of the practice’s Department of Anesthesiology, he says that the idea was twofold, including giving Northside physicians

more freedom to focus on patient care and allowing them to get and keep the money they earn.

“Managing a practice our size becomes a little overwhelming when you are trying to care for patients and trying to learn about regulatory changes and insurance changes in between caring for patients,” says Dr. Smith, who also heads up Northside’s management committee.

“There are people with the parent company who are paid to keep up with government regulations, and our hope is that we will no longer be distracted by the billing and bill collecting process. It seemed like the right time to do this.”

He also points out that, “Size and scale matter. It’s extremely difficult for a solo physician or small group practice to hold their own in contract negotiations.”

And he predicts that, “More practices will become aligned with these larger organizations in the years to come.”

Dr. Wilson agrees, convinced that, “Physicians need to take advantage of their strength in numbers or the savings will simply go upstream.

We need to operate as a unit, negotiating as a group.”

A team-building exercise Assuming health care moves to what Dr. Wilson refers to as a “systems approach,” physicians may well have to come to grips with developing a closer working relationship with what has traditionally been an adversary in private insurers.

This alliance is being driven by payment models that reward quality of care – not to mention simple economics.

Speaker of the House of Delegates W. Steven Wilson, M.D. Every two weeks, his family practice in Warner Robins gets a packet of information from BCBSGa that flags key metrics for his patients.

“If we find out that we don’t have a lipid panel for a patient, we can get in touch with them,” Dr. Steven Wilson says. The BCBSGa alerts address key preventive care metrics, including mammograms, pap smears, and eye exams.

From his perspective, “Some might view [the BCBSGa initiative] as an intrusion – like ‘the insurance company is meddling or watching me.’ But I think it is a good thing if it helps get these patients into my office to get the care they need.”

Fusile also hopes that BCBSGa can team up with physicians on smoking cessation and other collaborative “wellness” programs.

“Patients can be skeptical when an insurance company reaches out to them with a phone call or mailing about a health care initiative,” says Fusile. “But they are generally going to be four times more likely to respond if the message comes from their physician.”

As the profession evolves into more of a systems approach, Fusile believes there will also be more transparency in the cost and quality of care.

He anticipates that, “We will get to a point in the not too distant future where we will be able to tell patients and physicians that a knee replacement will cost X at Hospital A or it will cost half of that if you go to Hospital B 10 miles away – with no difference in quality.”

Exponential [IT] change

“Whether we are working with ACOs, health care systems, or independent practices, our goal is to provide quality and value for our members,” says Blue Cross and Blue Shield of Georgia (BCBSGa) President Jeff Fusile.

Whether it is driving better patient care or reducing costs or creating greater transparency, technology will surely continue to serve as fuel for the exponential changes that we have seen in our health care system.

He places the average health care costs for an American family of four at more than $24,000 per year – while the same family’s median income is just under $54,000 a year.

In much the same way BCBSGa is analyzing patient data, physicians are using electronic medical records (EMR) to enhance patient care.

For example, Dr. Brown uses Piedmont’s EMR system to monitor every aspect of his patients’ care, including labs, x-rays and tests that other physicians who use the same system have ordered.

“It’s an unsustainable ratio,” he says. “And payers and providers recognize that we collectively have to reduce that number to be successful in the long term.”

One of the key steps that his company is taking to reign in health care costs is to try to ensure that its customers see their physicians for preventive and follow-up care.

He explains that, “Blue Cross Blue Shield can now send an alert to a doctor to let them know that their patient is overdue for an exam or that they haven’t filled a prescription so the doctor can contact the patient direct.”

He adds that, “We ultimately hope to have a liaison assigned to every practice so it would, for example, become easier to determine if a patient had been admitted to the hospital or the emergency department that week.”

Fusile recognizes that it will take some time to develop the kind of track record that’s needed to convince physicians that this approach will enhance patient care.

“If one of my patients visited an emergency department that uses our EMR system in another part of the country, I can see the record,” he explains. “This saves time and money because we can avoid repeating the same tests.”

Dr. Brown emphasizes that the next big milestone will be “interoperable systems that will enable our EMR to communicate with other EMR systems.”

It is clear, too, that telemedicine will continue to make inroads as an important part of the health care system’s portfolio. When appropriate, this technology allows patients to consult with a physician on a remote basis.

“So instead of having to take a half-day off to go to the doctor’s office, patients will be able to dial in for their appointment from their workplace using a video system that is sponsored by their employer,” Dr. Joe Wilson says.

“We are actively building trust-based relationships with a number of physicians,” Fusile says. “We then hope that we can build on that success – as doctors begin to relay their experience to other doctors.”

It might take more than five years, but he believes that “the geographic boundaries will disappear, and the challenge will be where to draw the line of when patients have to come in to the office.”

One of those physicians is former Medical Association of Georgia

(continued on page 10)

www.mag.org 9

(continued from page 9)

MAG unveils powerful data analytics tool

The big picture Dr. Joe Wilson encourages his fellow physicians to remain focused on the big picture. He says, “We need to take a seat at the table with payers and the hospitals to create the best possible system for our patients.”

He also stresses that, “Physicians will need to become an advocate for a better allocation of our health care dollars – as patients often don’t seek care until a problem arises, which requires more expensive or emergency treatment.”

And as the system strives to provide higher quality care for less money, Dr. Joe Wilson thinks that physicians should be paid on the “front end” so they can practice more preventive medicine.

“Doctors need to be in a position to say it will cost X dollars to care for patients – and if you pay me 75 percent of that, I will provide that care,” he says. “The doctors will then be able to use that money and be proactive about preventive care by hiring allied health care professionals to help. And, hopefully, that would be done for less money than the system pays now.”

Dr. Joe Wilson understands that physicians are the single most integral part of our health care system. But he believes that, “Given our leadership role, physicians need to take a more active role in shaping the future of the overall health care system.”¨

The success of the new payer models will depend on the support and guidance that physicians receive, according to an Effects of Health Care Payment Models on Physician Practice in the United States study that was prepared by the American Medical Association and RAND Corporation.

With that in mind, the Medical Association of Georgia recently launched a partnership with KaMMCO Health Solutions that will develop a health IT solution that will enable physicians to generate sophisticated patient data reports that they can use to improve outcomes and fulfill the new quality-based payer metrics.

Physicians will be able generate reports that they can use to “address high-risk patients and chronic disease populations while improving patient outcomes through enhanced care coordination.” In addition, the new tool will provide physicians with “seamless, real-time access to their patient’s full longitudinal medical record at the point of care.”

Contact Susan Moore at 678.303.9275 or smoore@ mag.org with questions.

Find the Perfect Opportunity

with EmCare

EmCare is seeking Emergency Medicine, Pediatric EM, EM Residency Program Director and Hospitalist Physicians Doctors Hospital of Augusta Augusta

Fairview Park Medical Center Dublin

Eastside Medical Center Snellville

Cartersville Medical Center Cartersville

Piedmont Fayette Hospital Fayetteville

South Georgia Medical Center Valdosta

Murray Medical Center Chatsworth

Coliseum Medical Center Macon

Smith Northview Urgent Care Valdosta

Newton Medical Center Covington

Coliseum Northside Hospital Macon

Mayo Clinic Health System Waycross

Full time, part time, per diem and travel opportunities available.

Ask about our provider referral bonus program!

SouthEastOpportunities@EmCare.com 727.437.3052 or 727.507.2526

10 MAG Journal

EDITORIAL

Health care reform’s silver lining

By E. Frank McDonald Jr., M.D., M.B.A. E. Frank McDonald Jr., M.D.

H

ealth care in the U.S. costs too much.

I heard this when I was in medical school more than 30 years ago, but I never had the tools or wherewithal to do anything about it. And a lot of really smart people have tried and failed to bend the curve, but health care costs have continued to outpace inflation year after year.

Keeping in mind that about 50 percent of our health care costs are paid by the federal government, the Centers for Medicare & Medicaid Services (CMS) is trying to effect change by moving to a payment system that is tied to the quality of care we deliver.

Of course, a fee-for-service payment method is what we are used to – what we are comfortable with. Every patient encounter is a billable opportunity. Our income is based on the number of encounters multiplied by the revenue for each encounter. To increase our revenue, we have to increase the number of encounters or increase the revenue per encounter or both.

We can increase the number of encounters by refining our patient flow process and reducing the number of no-shows.

We can increase our revenue per encounter by increasing the number of better paying encounters (i.e., procedures) and/ or by courting patients who have better paying insurance coverage.

But once we optimize both strategies, there’s no room left to increase revenue. After all, there is an upper limit to the number of patients we can see in a day. We then essentially become piece workers – albeit better paid than the ones who assemble products in a factory.

Our efforts to increase our revenue is at odds with lowering health care costs. The reality is that when the total number of procedures that are performed increases, health care costs rise.

Seeing more patients and attracting patients who have better insurance should have a neutral effect on health care costs. And capturing a larger share of the total number of procedures that are done on a nationwide basis will also increase our revenue without increasing health care costs.

I also suspect that even if health care costs do in fact level off, CMS won’t be satisfied: It will undoubtedly want to find new ways to drive even more costs out of the health care system.

In a pay-for-quality system, we get paid to keep patients well – as well as caring for them when they get sick. Since patients who are well use fewer medical resources, CMS will expect costs go down as hospitalizations and emergency department visits decline.

Given huge fixed infrastructure costs, hospitals will be hit the hardest. This is a dynamic that may serve as a driver for hospitals hiring physicians, keeping in mind that hospitals can use employed physicians to recapture dollars that aren’t spent on admissions.

While the current pay-for-quality system is both markedly flawed and limited in its scope, there is no question that it will be refined over time and one day become pervasive.

The total amount of money that is available for the health care system will be something less – and I assume that the total amount of money that is available for physicians will be something less as well.

But if we as physicians can somehow collectively find a way to dramatically reduce health care costs, the amount of money we are paid may well increase. That means we may get a larger piece of a smaller pie, though I acknowledge that is in large part out of our control.

What we can control is how well we compete within our profession. I believe that we will have the opportunity to be rewarded for achieving exemplary outcomes – and perhaps we can finally get off the high-encounter-volume treadmill.

Finally, it is exciting to know that our pay won’t have a ceiling that is defined by the number of patients we can see in a day.

Dr. McDonald is a neurologist with The Longstreet Clinic in Gainesville. He also serves as the speaker of the Medical Association of Georgia’s House of Delegates.

www.mag.org 11

MARKET ANALYSIS

Where we practice: Athens

By Andrew H. Herrin, M.D.

A

thens, Georgia. When most people hear the name, they tend to think of the University of Georgia (UGA), the home of the Bulldogs. Most doctors I meet around the state have fond memories of attending UGA as a student or having had a child attend. But what I like about Athens even more is that it is a great place to practice medicine – and a great place to run.

As I leave my house in Five Points on this breezy Friday afternoon, my work week complete, I take note of my town as I run through it. The pear trees and azaleas have peaked, but the dogwood blossoms are popping and fresh leaves are shooting from the oak and pecan trees.

College kids are driving around, waving and honking at one another.

I run past St. Mary’s Hospital, a 198bed Catholic hospital under Trinity Health. My partners at Athens OBGYN and I practice obstetrics here.

St. Mary’s is known for its stroke care and joint replacement. It has excellent nurses, a well-equipped operating room, and competent administration.

St. Mary’s Medical Group has acquired several medical practices over the years. This includes internal medicine, cardiology, family practice, general surgery, and more. The physicians seem pleased with their arrangement with St. Mary’s. Although the doctors relinquish some control over their practices, they have fewer concerns when it comes to running the practice and they experience some of the advantages that increasing the size of a practice can bring.

Next I pass Athens Regional Medical Center (ARMC), a 350bed level-two trauma center. ARMC also provides excellent services to patients and physicians. Like St. Mary’s, it owns a number of physician practices. ARMC is beginning its newest chapter, having recently been acquired by Piedmont Healthcare.

The modern practice climate has brought decreasing payments, increased difficulty negotiating with health insurance companies, and less satisfaction running an independent 12 MAG Journal

Andrew H. Herrin, M.D. practice. In Athens, as in other communities, physician practices have been forced to get bigger in order to survive.

ARMC Medical Group has 86 physicians, while St. Mary’s Medical Group has 35. My group of five joined a large OBGYN multi-practice group, Atlanta Women’s Health Group.

As I continue running down Prince Avenue, I pass the Augusta University (AU)/UGA Medical Partnership medical school.

Opened in 2010, the medical school occupies the former campus of the U.S. Navy Supply Corps School – and it has contributed mightily to the medical landscape in Athens. Many local physicians participate in medical education by serving on the staff of AU/UGA or by volunteering to teach third- and fourth-year clinical clerkships. Graduate medical education also has begun to open its wings. St. Mary’s added its first class of 10 internal medicine residents last summer, while ARMC will begin its own internal medicine residency this summer with 15 new residents.

By the time I finish my pedestrian tour of Athens, I have passed not only the hospitals and medical school, but also the University Health Center and the Clarke County Health Department. Several groups and individual private practices still call Athens home, including at least two prominent orthopedic groups and virtually all of the OB-GYNs. I arrive at home tired but satisfied that Athens continues to be an excellent center of medicine in northeast Georgia.

Good doctors will continue to be attracted to Athens not necessarily because of its two fine hospitals or its medical school or UGA or the beauty of the city. They will not come here because Athens is the ideal distance from Atlanta. (Of course, we do have easy accessibility to the advantages that Atlanta brings, but we are far enough away to sit squarely amidst a large, rural base of patients.) And they will not come solely for the great restaurants, UGA sporting events, and youthful, athletic vibe of the city.

No, Athens will remain an ideal place to practice medicine because of the fine body of physicians who live and serve their patients in the “Classic City.”

The safest place for special needs* patents with dental issues? In an O.R., of course. *Intense fears and phobias • Severe gag reflexes Medically compromised • Developmentally disabled High liability Put your patients who need it most in the absolute best of hands: Dr. David Kurtzman at his regional Sleep Dentistry practice.

• 25 years of hospital dentistry Find out more: • Hospital residency trained • General anesthesia administered by an MD HospitalDentistry.org

Multiple procedures per visit Root Canals General Dentistry Implants Surgery Perio

“The doctor’s safety net.”

Dr. David Kurtzman, DDS, FAGD 770-980-6336 | dkdds@drkurtzman.com

www.mag.org 13

PUBLIC HEALTH

Adult immunization: A call for action

By Sandra Adamson Fryhofer, M.D., MACP, FRCP

W

Sandra Adamson Fryhofer, M.D.

hen we think about vaccines, childhood immunizations may first come to mind.

The 2014 mumps outbreak in the National Hockey League1, 2 and the recent measles outbreak at Disneyland,3,4,5 however, remind us what happens when kids and adults don’t get vaccinated.

quickly volunteered to receive the three dose series of what was then a plasma-derived vaccine made from “pasteurized and inactivated” blood products of HBsAg-positive donors, not the more refined recombinant that is currently available.8 The following year, after resuscitating a patient later found to be hepatitis B positive, I was glad I did.

In July 2015, the first U.S. measles death in 12 years (an adult woman) occurred in Washington state.6 The resurgence of childhood diseases – measles and mumps – made the headlines, but this is just the tip of the iceberg.

I became a believer in flu vaccination when I came down with flu as an intern at Grady and missed a week of work. I have not missed my annual flu vaccine since then.

I also remember the days when travelers had to get a shot of gammaglobulin to prevent hepatitis A infection. The Each year, thousands of adult Americans get sick or die hepatitis A vaccine was not licensed until 1995.8 My twins from vaccine-preventable diseases. As many as 40,000 adults (now age 26) came down with chicken pox on a family are afflicted with, and as many as 4,000 adults die from, vacation – only a few months invasive pneumococcal disease  before the varicella vaccine (bacteremia and meningitis). The When you vaccinate record it became available.8 annual death toll for influenza for adults ranges from 3,000 to immediately in the Georgia Registry We’ve come a long way 49,000 people depending on the of Immunization Transactions and with adult vaccinations severity of the flu season.

There are now 13 different Adults make up about 9,000 Services (GRITS) at www.grits.state. vaccines recommended for adults of the pertussis (aka whooping by the Centers for Disease Control ga.us so it will be available to all cough) cases reported each year. and Prevention (CDC) Advisory And adults can pass pertussis hospitals and health care providers. Committee on Immunization to others, which can be a death Practices (ACIP).9 ACIP’s  sentence for babies. About recommendations have been 3,000 adults are diagnosed with acute hepatitis B each evidence-based (using the GRADE process) since October year. Approximately one million adults suffer infection 2010.10 Each year, ACIP updates its adult immunization and pain from shingles each year.7 All these diseases can schedule by collating its latest recommendations into an easybe largely prevented with appropriate immunization. to-use reference guide. The schedule includes color-coded graphics that offer vaccine recommendations based on age, Historical snapshot: The last 30 years medical, and “other indications.” Each vaccine is also paired When I finished Emory Medical School in 1983, adult with detailed footnotes that highlight nuances of vaccination vaccination was pretty simple: flu shots, pneumococcal implementation, including order, timing, and intervals vaccination for seniors, and also a tetanus (Td) booster between vaccine doses.9 every 10 years. The hepatitis B vaccine became available As the number of new vaccines that are recommended my senior year of medical school. I rotated on the hepatitis has increased, so have vaccine prices, which can be a service with John Galambos, M.D. – in my eyes, the financial barrier. Fortunately, ACIP recommendations do father of hepatology, and the real-life father of Atlanta have coverage clout with health insurance companies. gastroenterologist Michael Galambos, M.D. The Affordable Care Act mandates insurance coverage, I realized that hepatitis B was a disease I never wanted to with no cost sharing, for all Category A and B acquire. When the vaccine became available at Grady, I ACIP recommendations within one year after the 14 MAG Journal

recommendation is made. This mandate does not apply to Medicare, however.11 The 2016 adult schedule updates recommendations for the cancer-preventing HPV and lifesaving pneumococcal vaccinations. It also debuts and explains when to administer the new Meningococcal B vaccine, a topic that should be discussed with all prospective college students and their parents.9 Our adult immunization report card: Mediocre How well are we doing getting our adult patients vaccinated? The latest National Health Interview Survey (NHIS) – our national adult immunization coverage “report card” – is a continuous, cross-sectional survey sample of households throughout our country, one that includes a snapshot of vaccination coverage among adults from August 2013 through June 2014.12 Vaccine coverage rates for Tdap (tetanus/diphtheria/acellular pertussis) and herpes zoster (shingles) did show an uptick of 2.9 percent and 3.6 percent, respectively. But when considering that all adults should have a one-time Tdap booster, the Tdap coverage rate of only 20.9 percent was disappointing. Zoster can be debilitating, especially for older patients; however, the coverage rate of zoster vaccination (recommended for those age 60 and older) was only 27.9 percent. Pneumococcal disease is a leading killer of the elderly and those who are at high risk of infection, but only 61.3 percent of those 65 and older and only 20.3 percent of those with high-risk medical conditions had received it.

Everyone six months and older needs a flu vaccination every year, but only 43.2 percent of adults reported receiving vaccination against flu.9, 12 Human papilloma virus (HPV) vaccine prevents cancer. It is a prophylactic vaccine and must be given before exposure to the virus for best results.

Although the HPV vaccination’s three dose series should be routinely given during adolescents age 11-12 for best immune response, catch-up vaccination is recommended for young adult females through age 26 and for all adult males though age 21 (and for immunocompromised, HIVpositive males as well as males who have sex with other males though age 26).9, 13 HPV vaccination coverage rates for adults age 19-26 reporting receipt of at least one HPV vaccine dose was 40.2 percent for females and only 8.2 percent for males.12 These low coverage rates are disappointing. We are failing our patients. But it does not have to be that way.

A call to action Vaccines are one of our greatest public health achievements.

Adult immunization can help keep us and our patients healthy. Vaccines are not just for kids; adults need them

too. Our patients need the physicians who care for them to make this happen. Pharmacists have also stepped up to the plate as partners in this effort. You should encourage your patients to get vaccinated, and you should also update your own vaccination status. And when you vaccinate, record it immediately in the Georgia Registry of Immunization Transactions and Services (GRITS) at www.grits.state.ga.us so it will be available to all hospitals and health care providers.

Vaccination protects not only you but everyone around you. To quote fellow immunization advocates Bernie Rosof, M.D., and Bill Schaffner, M.D., “The single most important factor in promoting adult immunization is strong advocacy from a physician.”14 In other words, don’t wait.

Dr. Fryhofer is an Atlanta internist who serves as the American Medical Association (AMA) and American College of Physicians (ACP) liaison to ACIP. She also serves on several ACIP vaccine work groups for the CDC. She is an adjunct associate professor at the Emory University School of Medicine and is on the medical staff at Piedmont Hospital.

References 1

Bernstein L. How can pro hockey players on teams across the U.S. get the mumps?

Washington Post website, Available at https://www.washingtonpost.com/news/to-yourhealth/wp/2014/12/17/how-can-pro-hockey-players-on-teams-across-the-u-s-get-themumps/, Accessed on March 12, 2016.

2.

Klein J. Mumps Outbreak Prompts N.H.L. Teams to Take Precautions, New York Times website, Available at http://www.nytimes.com/2014/12/07/sports/hockey/mumps-outbreakprompts-nhl-teams-to-take-precautions.html?_r=0, Accessed on March 12, 2016.

3.

Measles Cases and Outbreaks, CDC website, Available at http://www.cdc.gov/measles/casesoutbreaks.html, Accessed on March 12, 2016.

4.

Zipprich J, Winter K, Hacker J, Xia D, Watt J, Harriman K, et al. Measles Outbreak — California, December 2014–February 2015. MMWR Morb Mortal Wkly Rep. 2015; 64(06):153-154.

5.

Kaplan K. Vaccine refusal helped fuel Disneyland measles outbreak, study says. LA Times website, Available at http://www.latimes.com/science/sciencenow/la-sci-sn-disneylandmeasles-under-vaccination-20150316-story.html, Accessed on March 12, 2016.

6.

Szabo L, Measles kills first patient in 12 years, USA Today website, Available at http://www. usatoday.com/story/news/2015/07/02/measles-death-washington- state/29624385/, Accessed on March 12, 2016.

7.

The National Vaccine Program Office, National Adult Immunization Plan, HHS.gov website, Available at http://www.hhs.gov/nvpo/national-adult-immunization-plan/index.html, Accessed on March 12, 2016.

8.

Vaccine Timeline, Historic Dates and Events Related to Vaccines and Immunizations, Immunization Action Coalition website, Available at http://www.immunize.org/timeline/, Accessed on March 12, 2016.

9.

Kim DK, Bridges CB, Harriman KH, on behalf of the Advisory Committee on Immunization Practices. Advisory Committee on Immunization Practices. Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older, United States, 2016. Ann Intern Med. 2016; 164:184-194.

Evidence-Based Recommendations—GRADE, CDC website, Available at http://www.cdc. gov/vaccines/acip/recs/GRADE/about-grade.html, Accessed on March 12, 2016.

10.

The Affordable Care Act and Immunization, HHS website, Available at http://www.hhs. gov/healthcare/facts-and-features/fact-sheets/aca-and-immunization/index.html, Accessed on March 12, 2016.

11.

Williams WW, Lu PJ, O’Halloran A, et al. Surveillance of Vaccination Coverage Among Adult Populations- United States, 2014. MMWR Morb Mortal Wkly Rep. 2016; 65(1):1-36.

12.

Petrosky E, Bocchini JA, Hariri S, Chesson H, Curtis CR, Saraiya M, et al. Use of 9-Valent Human Papillomavirus (HPV) Vaccine: Updated HPV Vaccination Recommendations of the Advisory Committee on Immunization Practices MMWR. 2015; 64(11); 300 -304.

13.

Rosof B, Schaffner W. General internists crucial to raising adult immunization rates, October 2015, Available at http://www.acpinternist.org/archives/2015/10/immunization. html, Accessed on March 12, 2016.

14.

www.mag.org 15

CASE REPORT

A unique case of renal artery stenosis

By Adrienne Repack, Natalie Sterrett, Roshan Modi, Chandan Devireddy, M.D., and Bryan Wells, M.D., Emory University Hospital Midtown

D

espite a recent increase in awareness, Fibromuscular dysplasia (FMD) often goes undiagnosed – leaving many patients untreated and at heightened risk for vascular complications. As a non-inflammatory, nonatherosclerotic vascular disease, FMD commonly leads to stenosis, aneurysms, and dissections within the affected vascular beds. It primarily afflicts women who are 20 to 60 years old.1-3 Renal and carotid arterial disease occurs in approximately 65 percent of all cases, followed by visceral arteries (nine percent) and extremity arteries (five percent).4,5 FMD affects multiple vascular beds in 25 to 30 percent of patients.4 It is essential to consider FMD in young to middle-aged patients presenting with new onset hypertension with rapid progression in severity and without traditional cardiovascular risk factors.

FMD is characterized by two unique angiographic patterns that correspond with the histologic findings.1 Multifocal (aka “medial”) FMD is by far the most common at 80 percent to 90 percent of all cases.6 A characteristic “string of beads” appears in the middle to distal third of the artery with alternating areas of stenosis and dilatation. Focal FMD is the second most common form – at five to 10 percent of cases.6, 7 In contrast to multifocal FMD, focal FMD only presents as a focal or tubular area of constriction in the affected artery.

Although the presentation of FMD is variable, as many as four percent of adult woman may be affected.3 The most common presenting signs and symptoms are hypertension, headache, and pulsatile tinnitus. Of the FMD patients in the U.S. registry, 91 percent are women with a mean age of 52 years.8 The majority of FMD diagnoses occur in middle-aged women who have a history of hypertension, dissection, or aneurysm.

Case review A 43-year-old caucasian female presented with acute onset hypertension at a routine well visit exam. The presence of an abdominal bruit prompted a renal duplex ultrasound, which revealed elevated velocities concerning for unilateral renal artery stenosis. Systolic blood pressures were significantly elevated, often greater than 200 mmHg, and the patient was started on anti-hypertensive therapy, including a calcium channel blocker (CCB) and an angiotensin receptor blocker (ARB) with limited response. A subsequent computed tomography angiography (CTA) revealed characteristic “beads on a string” and small fusiform aneurysms in the right renal artery consistent with FMD. Percutaneous transluminal angioplasty (PTA) was attempted with conservative balloon sizing due to the complex anatomy of the renal artery, but it was unsuccessful. The patient was referred to 16 MAG Journal

our institution, Emory University Hospital Midtown, for further evaluation and assessment.

Prior to her presentation, the patient was in a normal state of health with no medical conditions, though she was a tobacco user.

Lab results showed normal renal function. Headaches associated with the hypertension were noted. Her pertinent family history included a grandmother who was diagnosed with an aneurysm and a grandfather who underwent carotid surgery.

After reviewing the angiographic images, we performed another angiography with a plan for intra-arterial pressure measurements (Pd/Pa) via flow wire to determine whether a PTA was necessary.

Angiography demonstrated beading in the right renal artery and left accessory renal artery consistent with multifocal FMD. The right renal artery had marked aneurysmal change in the distal main trunk. The gradients were hemodynamically significant by fractional flow reserve (FFR). PTA was performed in the right renal and left accessory renal arteries with more aggressive balloon sizing than had been done previously. Post procedure gradients were obtained, confirming the procedure was successful with restoration of essentially normal distal perfusion pressure.

The patient was seen approximately four weeks post intervention and reported systolic blood pressure readings, which had dropped to 120-140 mmHg. In addition, the patient now required just one antihypertensive medication rather than her previous two. Regular renal artery aneurysm surveillance will be conducted with annual CTA or Magnetic Resonance Angiography (MRA).

1 3 2

Figure 1. Angiographic evidence of characteristic “beads on a string” (arrow 1) consistent with FMD diagnosis. Two small fusiform aneurysms can also be seen in the proximal and distal main renal artery (arrows 2 and 3).

Discussion Signs and symptoms of FMD include hypertension, headaches and/ or the presence of cervical or abdominal bruits (See Table 1). It is more likely in young to middle-aged women without traditional cardiovascular risk factors. The differential diagnosis includes connective tissue diseases (Ehlers-Danlos, Loeys Deitz) and vasculitis.

FMD is often realized when a secondary work-up for hypertension is performed, including a renal duplex ultrasound to uncover the source of the bruit or causes of accelerated hypertension. Similarly, a carotid duplex ultrasound should be performed in a patient with a carotid bruit, pulsatile tinnitus, or unexplained neurologic symptoms.

If a duplex ultrasound is suggestive of FMD, an angiogram (CTA, MRA, or invasive) is done to evaluate for beading to establish the diagnosis. Patients with imaging that suggests the presence of FMD should be referred to a vascular specialist for further management and possible treatment. Today’s treatment for FMD is often limited to symptom management, blood pressure medications, and careful surveillance. Experts recommend a one-time, brain-to-pelvis MRA or CTA to screen for aneurysms at the time of diagnosis.9 Knowing which vascular beds to monitor or treat is paramount to preventing further vascular events. FMD should also be considered in patients with spontaneous dissections including the carotid, coronary, and renal arteries.

Most patients, especially those with carotid involvement or a history of prior dissection, are prescribed anti-platelet medications. Those with renal artery involvement are commonly prescribed antihypertension medications with goals of blood pressure control per guideline recommendations.10 Revascularization of the renal arteries is recommended in patients with resistant hypertension or in those where PTA might cure acute symptoms such as those seen in the aforementioned case. Revascularization is rarely indicated in patients with cerebrovascular FMD, except occasionally in symptomatic patients or in those with aneurysm or dissection.11 PTA is largely accepted as the best option – but it is often not feasible.3 Outcomes of endovascular treatment of renal FMD are generally successful. An initial analysis of PTA outcomes showed an overall 88.3 percent combined cure or improvement rate in patients undergoing renal PTA for treatment of hypertension.12 Similarly, surgical revascularization has been successful in many patients.

For both types of intervention, incidents of restenosis are usually attributed to suboptimal treatment.3 However, restenosis also has been attributed to stent fracture in the renal arteries. Stenting of the renal arteries is not recommended in FMD patients, except in cases of dissection or when PTA has failed.3, 13 It is still unknown what factors cause or contribute to FMD. Several genetic theories have been proposed, including specific genes such as TGFBR1 and ACE1.14, 15 It is also possible that environmental factors contribute to the disease – as a history of smoking is fairly common in FMD patients.16 Considering that the majority of FMD patients are women, some theories include the potential role of hormones in pathogenesis.8 Future research will determine the prevalence of FMD in the general population of women and whether sex hormones play a role in the onset of the disease. Other research priorities include genetic and biological determinants, novel methods to halt

Common signs and symptoms of FMD 1. Accelerated hypertension 2. Headaches 3. Pulsatile tinnitus 4. Dizziness 5. Cervical bruit 6. Epigastric bruit Table 1.

disease progression, and determining the most effective screening protocol to prevent long-term morbidity.11 Most research comes from participating centers in the U.S. Registry for Fibromuscular Dysplasia. One of 13 sites, Emory University is now the first in Georgia to participate in the national registry.¨

References 1

David P. Slovut, M.D., Ph.D., and Jeffrey W. Olin, D.O., Fibromuscular Dysplasia. The New England Journal of Medicine, 2004(350): p. 1862-1871.

2

Luscher, T.F., et al., Arterial fibromuscular dysplasia. Mayo Clin Proc, 1987. 62(10): p. 93152.

3

Jeffrey W. Olin, D., and Brett A. Sealove, MD, Diagnosis, management, and future developments of fibromuscular dysplasia. Journal of Vascular Surgery, 2011. 53(3): p. 826-836.

4

Begelman, S.M. and J.W. Olin, Fibromuscular dysplasia. Curr Opin Rheumatol, 2000. 12(1): p. 41-7.

5

Jeffrey W. Olin, D., FAHA, Co-Chair, et al., Fibromuscular Dysplasia: State of the Science and Critical Unanswered Questions: A Scientific Statement From the American Heart Association.

Circulation, 2014. 129: p. 1048-1078.

6

Chrysant, S.G. and G.S. Chrysant, Treatment of hypertension in patients with renal artery stenosis due to fibromuscular dysplasia of the renal arteries. Cardiovasc Diagn Ther, 2014. 4(1): p. 36-43.

7

Plouin, P.F., et al., Fibromuscular dysplasia. Orphanet J Rare Dis, 2007. 2: p. 28.

8

Jeffrey W. Olin, D., et al., The United States Registry for Fibromuscular Dysplasia: Results in the First 447 Patients. Circulation, 2012. 125: p. 3182-3190.

9

Sarah C. O’Connor, H.L.G., Recent Developments in the Understanding and Management of Fibromuscular Dysplasia. Journal of the American Heart Association, 2014. 3(6): p. 1-12.

10

Weinberg, I., et al., Anti-platelet and anti-hypertension medication use in patients with fibromuscular dysplasia: Results from the United States Registry for Fibromuscular Dysplasia. Vasc Med, 2015. 20(5): p. 447-53.

11

Jeffrey W. Olin, D., FAHA, Co-Chair; Heather L. Gornik, MD, MHS, FAHA, Co-Chair; J. Michael Bacharach, MD, MPH; Jose Biller, MD, FAHA; Lawrence J. Fine, MD, PhD, FAHA; Bruce H. Gray, DO; William A. Gray, MD; Rishi Gupta, MD; Naomi M. Hamburg, MD, FAHA; Barry T. Katzen, MD, FAHA; Robert A. Lookstein, MD; Alan B. Lumsden, MD; Jane W. Newburger, MD, MPH, FAHA; Tatjana Rundek, MD, PhD; C. John Sperati, MD, MHS; James C. Stanley, MD, Fibromuscular Dysplasia: State of the Science and Critical Unanswered Questions: A Scientific Statement From the American Heart Association.

Circulation, 2014. 129: p. 1048-1078.

12

Ludovic Trinquart, C.M.-V., Marc Sapoval, Nathalie Gagnon, Pierre-Francois Plouin, Efficacy of Revascularization For Renal Artery Stenosis Caused by Fibromuscular Dysplasia: A Systematic Review and Meta-Analysis. Hypertension, 2010. 56: p. 525-532.

13

Raju, M.G., et al., Renal artery stent fracture in patients with fibromuscular dysplasia: a cautionary tale. Circ Cardiovasc Interv, 2013. 6(3): p. e30-1.

14

Stacey L. Poloskey, E.S.K., Ruchi Sanghani, Adeeb H. Al-Quthami, Patricia Arscott, Rocio Moran, Christina M Rigelsky, Heather L. Gornik, Low yield of genetic testing for known vascular connective tissue disorders in patients with fibromuscular dysplasia. Vascular Medicine, 2012. 17(6): p. 371-378.

15

A Bofinger, C.H., P Fisher, N Daunt, M Stowasser, R Gordon, Polymorphisms of the reninangiotensin system in patients with multifocal renal arterial fibromuscular dysplasia. Journal of Human Hypertension, 2001. 15(3): p. 185-190.

16

Sarah O’Connor, M., et al., Smoking and Adverse Outcomes in Fibromuscular Dysplasia.

Journal of the American College of Cardiology, 2016. 67(14): p. 1750-1751.

www.mag.org 17

MEDICAL ETHICS

Thirty years and thirty seconds: Small actions can have great consequences

By Tyler Murphy Wright, fourth-year medical student, and Richard L. Elliott, M.D., Ph.D., FAPA, professor and director, Medical Ethics and Professionalism, Mercer University School of Medicine

W

iping the sweat off my forehead with the edge of my scrub sleeve and watching my translator direct my feeble, elderly patient to the makeshift, student-run pharmacy, I reached for the bottled water at my patient care station – making the most out of my 30-second break between patients. Located in a small Korean Protestant church in Kampot Province, the poorest one in Cambodia, I tried to gather my thoughts while another student escorted my next patient from the vitals station that was run by nursing students to the blue plastic chair adjacent to the plastered wall crawling with ants. I watched as an older Khmer woman in her 60s walked slowly but with dignity toward me, not breaking eye contact for even a split-second.1

around her waist. I had noticed the rope, but I had not thought to ask my patient about its meaning. It wrapped around the patient’s waist – just above her undergarment – and it was about a centimeter in diameter with a few knots and beads tied equidistantly. When I asked about the rope, the patient’s face lit up and her body posture appeared to become more optimistic. She explained to me that she had worn this rope for more than 30 years after a village elder with special, sacred responsibility wrapped it around her for ‘protection’ during Pol Pot’s communist rule in the late 1970s.

The tradition of the ‘peace rope,’ the actual name of which was lost to me during translation, was performed by “Choum reap sor,” I said to her as I offered my ‘sampeah,’ special village elders who were thought to possess spiritual the Khmer greeting tradition in which one’s palms are characteristics that could be woven into the rope, which placed together with the fingertips pointed upward and the then provided protection from the harsh practices of the head is slightly bowed. She Khmer Rouge regime. This  sat, and my translator – a tragic time in Cambodian Cambodian medical student history, during which – helped me learn her story. millions of Khmer were She spoke of her large family, slain and families torn apart, her lifetime of farming, remained at the forefront of her childhood in Kampot many of the Khmer minds, and, of course, her medical evidenced by this peace ailments – which included rope wrapped around my poor vision, shoulder pain, patient and the ‘depression’ knee pain, and a painless I encountered in over half ‘knot’ in the soft tissue on of my patients during the the anterolateral region of medical mission trip. her right hip. Following I wondered why my patient a physical exam that was  appeared to be happy and limited to the use of my optimistic as she described the meaning of the rope around hands, a stethoscope, otoscope, ophthalmoscope, and thirdher waist. But I understood immediately when my translator year medical student brain, I determined that her ailments told me that the patient requested that I cut the rope off of her were arthritic and mildly degenerative changes – the result of waist to ‘set her free from the spirits.’ She explained that within a lifetime of farming, child-bearing, and hard work coupled the past year she had been struggling with intruding thoughts, with a diet that consisted of mostly rice and fish. The nodule nightmares, insomnia, and mental difficulty when tending on her hip felt soft to the touch, superficial, and freely to her daily tasks of maintaining her home and helping her movable. A quick discussion with my attending confirmed family. She stated that her village elders had recently ‘released my suspicion that the mass was most likely a benign lipoma, her from the controlling spirits’ and that it was now the time common among the Khmer people. for her to be ‘set free,’ symbolized by cutting and removing the During our discussion, my attending suggested that peace rope affixed around her waist.

I ask my patient about the beaded rope that she had I was faced with an ethical decision like no other in my

I was faced with an ethical decision like no other in my medical education.

Should I cut the rope as requested by the patient? Or should I defer this task to someone who was familiar with her culture and traditions?

18 MAG Journal

medical education. Should I cut the rope as requested by the patient? Or should I defer this task to someone who was familiar with her culture and traditions? The act of cutting the rope would take me less than 30 seconds, but I would be removing something that she had worn for more than 30 years, something that held a sacred meaning that I could only partially understand.

Three principles of medical ethics guided my decision.

First, I considered ‘respect for autonomy,’ meaning that my patient had the right to refuse or to choose her treatment.

In this instance, her chosen treatment was for me to ‘release the spirits’ by cutting her peace rope. To be sure I understood her request correctly, I confirmed through the translator two more times that the patient wanted me to cut her peace rope now. Moreover, it was clear based on the patient’s body language and speech tone – combined with my translator’s insistence and despite any language barriers or cultural differences that having me cut the rope now was exactly what the patient wanted.

Next, I considered the principle of ‘beneficence,’ the idea that the physician should act in a manner that benefits the patient. I initially didn’t feel like I was qualified to cut the rope because I was not a village elder and I wasn’t even an M.D. Here I was, just a third-year American medical student attempting to make a small difference in a few people’s lives in the Kampot Province of Cambodia. However, a few more moments of thought and consideration led me to believe that I lacked the capacity to truly understand what would benefit this patient. I asked the translator if the patient thought I was qualified to cut the rope and if this action would benefit the patient. My translator said yes to both.

Finally, I pondered the idea of ‘non-maleficence,’ meaning that I should refrain from harming this woman. Because she asked me to cut the rope, I felt that declining her request would cause much more harm and shame to her.

The patient appeared ready for the ‘spirits to be released,’ and she had been stretching the rope toward me eagerly, awaiting my decision.

Reaching into my medical bag, I grabbed my Leatherman® tool, flipped out the knife, and cut my patient’s peace rope.

The entire sequence of events lasted less than 30 seconds.

As soon as the rope was cut, my patient grabbed her peace rope, held it up in the air for a few seconds while saying something in the Khmer language that could not be translated, and put the rope in her pocket. She grinned from ear to ear. Her eyes watered with happiness, and she was speechless. I asked for her permission to take a quick picture with her so that I could always remember her face and her story. She agreed, we snapped the picture, and she was taken to the pharmacy to get her medications.

As I reflect on my decision that afternoon, I admit that

From the left are undergraduate student Brielle Scutt, medical student Tyler Wright (author), the patient holding her ‘peace rope,’ and a Cambodian medical student.

I will never be able to fully understand the meaning of cutting her peace rope. I am unlikely to see her again and will likely never know if I helped to ‘set her free from the spirits.’ However, I do believe that I helped her, evidenced by her emotions and by the way she walked out of the church – upright and proud.

What was learned from this? Even the smallest actions can have a lifetime of consequence. After returning to the U.S. and re-entering my teaching hospital, I have become more aware of our country as a melting pot of many cultures, ones that are often different from mine.2 Asking simple questions to my patients about their garments, their health practices, and their beliefs sometimes results in unexpected benefits for the patient and the physician. If I had not asked my patient in Cambodia about her peace rope, she might not have asked me to cut it – a loss for both of us.¨ References 1

In June 2015, Wright was a member of a 29-person medical team from Mercer University that was composed of undergraduate students, nursing students, pharmacy students, medical students, professors, and attending physicians. The third-year medical student served as a health care provider during the three-week mission trip to the Kampot Province in Cambodia. His team operated medical clinics that offered free ambulatory health care. The team saw nearly 1,700 patients – most of whom were poor and from rural areas. Wright cared for more than 180 patients under the supervision of an attending physician.

2

In preparation for this mission trip, students were asked to read Anne Fadiman’s The Spirit Catches You and You Fall Down, 1998, Farrar, Straus, and Giroux. A group met to discuss how the trip could help them become more aware of cultural differences, especially in the context of the health practices they provide.

www.mag.org 19

GEORGIA COMPOSITE MEDICAL BOARD

MOC: How we got here and where we are going

By John Antalis, M.D., Georgia Composite Medical Board

W

hen Maintenance of Board Certification (MOC) was developed in the 1970s and 80s, the intent was to enhance patient care by maintaining physician quality. The American Academy of Family Physicians (AAFP) and the American Board of Internal Medicine (ABIM) endorsed the recertification principle, but only on a voluntary basis. At the same time, many of the other 24 specialty affiliates decided not to limit board certification in this way, opting instead to use a “Board Certified for Life” classification.

John Antalis, M.D. result of the Affordable Care Act – as well as the pending health insurer mergers.

In June 2014, the American Medical Association’s (AMA) House of Delegates (HOD) voted to oppose MOC as a licensure condition. And in November 2014, the AMA’s HOD defined its principles for MOC as follows: 1. MOC should be used as a tool for continuous improvement.

2. MOC activities and measurements should be relevant to clinical practice.

In 2000, the American Board of Medical Specialties (ABMS) called for every specialty affiliate to limit board certification to 10 years – and these specialties capitulated to ABMS’ mandate to avoid losing affiliation status.

3. MOC should be based on evidence and designed to identify performance gaps and unmet needs, providing direction and guidance for improvement in physician performance and the delivery of care.

ABMS recertification requires all physicians to maintain certification by adhering to increasingly expensive and timeconsuming programs that most physicians feel do not enhance their medical knowledge. Many physicians are opting to get out of their specialty or retire early rather than complete a high stakes “all or nothing” exam. More than 150,000 physicians are currently included in the ABIM program.

4. Practicing physicians should be well-represented on the specialty boards that are developing MOC.

Then in 2002, the Federation of State Medical Boards (FSMB) became involved in recertification by supporting a basic MOC requirement for physicians to practice medicine. It wanted to couple MOC requirements with state licensure renewals (i.e., Maintenance of Licensure (MOL)). Ohio was the first state to implement this policy, which ultimately ended in failure when more than 15,000 physicians in the state – under the auspices of 15 medical organizations – united to defeat the effort in 2012.

In March 2014, a group of physicians started a nationwide online petition to return to a simpler MOC recertification process every 10 years. Signed by more than 17,000 physicians, this petition called for the elimination of all MOC requirements – including the stressful exams and the abolition of strictly ABMS board certification. The petition also called for the establishment of competing certification boards.

Physicians are concerned that if they do not maintain their MOC status they will lose potential patients who use the Internet to find a doctor. They are also afraid of limiting their career potential and advancement opportunities; losing hospital privileges; being rejected from health insurance plans; and losing status within their profession.

Compounding these concerns are uncertain payments from the Accountable Care Organizations (ACOs) that were formed as a 20 MAG Journal

5. The MOC process should not be cost prohibitive or present barriers to patient care.

6. The MOC program should not be required for licensure, credentialing, reimbursement, network participation, or employment.

7. The MOC process should be evaluated periodically to measure physician satisfaction, knowledge uptake, and intent to maintain or change practice.

8. Specialty boards that develop MOC standards should be free to approve curriculum, but these boards also should be independent of the entities that design and deliver that curriculum and should have no financial interest in the process.

The ABMS has responded to AMA and the growing number of physician complaints by agreeing to adopt AMA’s guidelines. In January 2015, ABMS urged component specialty boards to be aware of the burdens that MOC places on physician practices, as well as costs and relevance to physicians. ABMS has denied ever advocating MOC as a licensure condition, and it suggested that any MOC requirements in hospitals or third-party payers are self-imposed.

ABIM also has responded to physician criticisms of MOC by establishing the Assessment 2020 Task Force, which has recommended: 1. Replacing the 10-year MOC exam with more meaningful, less burdensome assessments.

2. Focusing those assessments on cognitive and technical skills.

3. Exploring the need for certification in specialized areas – without the requirement to maintain underlying certifications – while being transparent about specialization to the public.

In conclusion, MOC is a highly controversial topic that is far from over. There is no doubt that the current MOC format has resulted in growing anger and distress among physicians because of high exam costs, the need for preparation, the time that is demanded,

and its overall lack of relevance to their current practice.

A lot of excellent, experienced physicians are retiring early over the angst associated with recertification. Other physicians who fear exclusion have signed up for MOC out of economic necessity. It is clear that over the next several years we must reach a middle ground to ensure physician quality, while minimizing the aforementioned physicians’ concerns.¨ Dr. Antalis served as MAG’s president in 2004-2005.

GCMB seeks comments on pending rules to regulate physician advertising In another GCMB development, Dr. Antalis reports that Georgia Gov. Nathan Deal passed a bill by Rep. Trey Kelley (R-Cedartown) into law on April 26 that exempts hospitals and health systems from having to follow the influenza vaccine protocol in the state.

H.B. 1043 also has physician certification implications because it was amended to include the provisions of a bill (S.B. 385) by Sen. Judson Hill (R-Marietta) that calls for physicians to display the full name of their certifying board or that they have completed a postgraduate training program in their advertisements.

Finally, the new law requires physicians who advertise that they are certified to practice medicine in a specialty or subspecialty to 1) have completed an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) training program and 2) show proof that they have been certified by ABMS or AOA in that field and 3) pass the applicable board examination in their given specialty or subspecialty.

GCMB is in the process of developing the rules that will regulate this new law, and it is encouraging physicians to submit comments to Robert Jeffery at rjeffery@dch.ga.gov.

Atlanta TMD Dentist Mark Allan Padolsky DDS MAGD FAOS FACMS FICOI

-Dr. Padolsky taught courses for the University of Pittsburgh as well as the University of Alabama -Dr. Padolsky provides Phase I and Phase II TMD services -He is comfortable with a multi-disciplinary approach - Dr. Padolsky is accepting TMD referrals atlantatmjdentist.com Drpadolsky@gmail.com

www.mag.org 21

Years of research help create years of memories.

Northside Hospital Cancer Institute diagnoses and treats more women with breast and gynecologic cancers than anyone else in Georgia. The experienced, caring team and the survival rates are why so many women from across the country trust Northside with their cancer care. Northside helps thousands of women through their cancer journey. So they can take the first steps into their cancer free life. For help finding a cancer specialist, call 404-531-4444.

Where the Extraordinary Happens Every Day

Breast cancer can be a long journey.

For many survivors it begins here.

Northside Hospital Cancer Institute is proud to have helped so many breast cancer survivors. In fact, Northside continues to lead the Southeast in women’s cancer care, diagnosing and treating twice as many cases of breast cancer than any other program.

ADVANCED EVALUATION Every year, more than 100,000 mammograms are performed throughout Northside’s statewide network. The latest screening and diagnostic technology is available, including Computer-Aided Detection (CAD) and Breast Tomosynthesis (3D mammography), a premier technology at locations in Atlanta, Alpharetta and Cumming.

SKILLED MULTIDISCIPLINARY APPROACH Our multidisciplinary team of experts meets weekly to collaborate on cancer cases, special procedures, emerging technologies and research advancement. Northside’s team includes skilled, board certified, sub-specialized breast radiologists, medical and surgical oncologists, radiation oncologists, pathologists, genetic counselors, plastic surgeons and many other health care professionals.

CARING FOR THE WHOLE PATIENT Patients benefit from personalized and attentive resources, including individualized treatment plans and dedicated breast surgery suites. A specialized oncology dietitian and breast nurse navigators answer questions and help guide patients throughout their care. Northside’s Hereditary Cancer Program offers genetic counseling to patients, including a thorough risk assessment of genetically influenced cancers. This information helps patients and physicians better formulate a plan to detect cancer early or prevent it entirely. Through the Cancer Support Community-Atlanta and a survivors’ Network of Hope, breast cancer patients and their families are connected with specially trained volunteers and survivors, who have embraced life after facing cancer.

THE BEST HOPE FOR A CURE Highly respected among cancer care providers, Northside Hospital Cancer Institute offers the latest in breakthrough procedures, technologies and treatments. Through collaboration with the NCI Community Oncology Research Program and leading academic centers and research organizations, patients have access to exclusive clinical trials.

For more information, please contact us at (404) 531-4444 or visit northside.com/cancerinstitute.

PATIENT SAFETY

When the patient makes a poor choice, will a signed AMA form protect me?

This article is a product of MagMutual’s alliance with COPIC in an effort to bring industry-leading Patient Safety resources to MagMutual PolicyOwners.

SM

A

physician calls the COPIC risk management hotline with the following story: He was at the end of a grueling, 10-hour ER shift and his last patient was a 63-year-old female with a history of smoking and coronary disease with diffuse abdominal pain. The patient’s vitals were normal and her abdomen was diffusely tender. A workup showed a CT that was unremarkable and the white blood cell count was 12,000. Pain had continued throughout the physician’s shift, unabated by medications. At the end of his shift, the physician discussed admitting the patient – but she refused because she said she had to leave to care for her pets. After a long discussion, the patient signed an “against medical advice” (AMA) form and left the ER. The physician was advised that the patient was subsequently admitted to another hospital with an acute abdomen and ischemic colitis.

The physician called COPIC’s risk management hotline and asked if he was liable for this patient’s lack of care and if the AMA form would protect him?

What you need to know A signed informed consent or refusal such as an AMA form is the cornerstone of this case. Informed consent means that the patient made their decision after a thorough discussion with their physician (i.e., no coercion) and with a full understanding of the risks and benefits associated with that decision.

Important issues to address and document when you evaluate your patient include: 1. Is the patient competent? Does the patient have the capacity to make such a decision? Although courts have found that intoxication can impair a patient’s competence and ability to refuse medical treatment, a patient who is intoxicated does not automatically lack the competency or capacity to make medical decisions. And as noted, patients with psychiatric complaints can also be difficult to assess but do not necessarily lack the capacity to make an informed decision.

2. Does the patient have enough health literacy to understand his or her decision?

3. Does the patient understand the diagnosis and the reason for the treatment proposed?

4. Is the patient aware of alternative treatments?

5. Is the patient able to communicate his or her choice?

6. Does the patient understand the effects of his or her refusal of care?

24 MAG Journal

So when a patient makes a poor choice, will the signed AMA form protect me?

No. A signed form alone may not be enough to protect you.

However, if you properly execute the form and document the process, you are more likely to be protected.

The elements of proper execution include: 1. Document the entry into the record that describes your patient interaction and concern for the patient’s well-being.

2. Document a narrative that will show that you explained the risks associated with refusing care and the benefits and alternatives to the proposed treatments using language the patient could understand.

What you need to know There are three significant ways a properly executed informed refusal form can protect a physician from liability: 1. It terminates one’s legal duty to treat a patient.

2. It creates an affirmative defense of “assumption of risk.”

3. It establishes a record of evidence of the patient’s refusal of care.

Your duty to your patient AMA discharges like the one discussed in this case pose a classic ethical dilemma for the physician. These often expose the patient to an undertreated or undiagnosed medical problem and the complications that result from their decision to leave.

The physician wants to honor the patient’s wishes (i.e., their autonomy), but they also want to do what is best for the patient.

If a patient is deemed to have the capacity, is informed and understands the risks associated with leaving “against medical advice” but still refuses care, physicians may be protected from potential liability from adverse outcomes. A properly executed and documented informed refusal to treat form can provide vital evidence that will defend them against allegations that they were negligent in fulfilling their duty.

The Patient Safety Institute is an independent organization that was founded by MagMutual physicians to enhance the safe delivery of health care.

HUFF, POWELL & BAILEY, LLC

We treat our clients as partners working toward a common goal.

HUFF, POWELL & BAILEY, LLC

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:

•

Medical Malpractice Litigation

•

Physician Related Litigation

•

Hospital Liability Litigation

•

Premises & Products Liability

•

Pharmaceutical Litigation

•

Medical Device Litigation

999 Peachtree St., Suite 950 Atlanta, GA 30309 PH: (404) 892-4022 • FX: (404) 892-4033 www.huffpowellbailey.com

www.mag.org 25

LEGAL

How to prevent compliance and regulatory problems that could ruin your bottom line

By Maureen Demarest Murray, Esq., Smith Moore Leatherwood LLP

Y

ou work hard to earn a living – so don’t give services away by failing to pay attention to government requirements or be prepared for government audits.

Have the right qualifications

Pay attention to the basics. Be sure that you and your staff do not let licenses and credentials lapse. A fundamental requirement to receive government payments is to have licenses to provide the services being billed. Set up a tickler system to assure timely renewal. If any lapse occurs, services to government payers during that time cannot be billed or improperly submitted claims must be repaid.

Do adequate exclusion checks. It is not sufficient to rely upon employee responses. Conduct pre-employment and periodic checks of the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) to confirm that the individual has not been excluded (e.g., has been found guilty of defrauding a federally funded health care program). Be sure to obtain all names ever used and the employee’s Social Security number. Many providers have learned the hard way that the only sure confirmation is the correct Social Security number. Employment of an excluded individual must be self-reported and results in repayment of at least one and a half times the individual’s salary and benefits paid by the practice if the person does not individually bill or repayment of claims if bills for services were submitted. These requirements apply not just to direct caregivers but to any employees whose costs are included under a government claim – such as coders, billers, receptionists or transcriptionists. Do exclusion checks routinely. The government recommends monthly, but cost might make some small providers choose quarterly or semiannual checks. If you discover an employee has been excluded, the employee should be terminated or placed in a role that does not handle any activities related to patients with a government payer source.

Pay attention to the money Track and analyze claim denials. Any denial patterns could signal staff misunderstanding, repeated coding errors, or a habit of insufficient documentation. Review your claims on a quarterly basis so you can take proactive steps to correct or advocate for repayment when the claim is sufficient. Keep in mind deadlines for re-submitting claims so payment is not lost due to late timing. The government reviews data; so should you.

the service is provided to be billable, such as DME, admissions, laboratory work, physical therapy, or services performed by other providers. While other signatures may be entered after the encounter, failure to sign an order is a basis for denial of payment for the encounter. The government has become very picky about clear, dated signatures.

Be ready for the government No government inquiry is routine. Treat every government request for information as if it may become a major issue.

Obtain government credentials and any request in writing.

Clarify whether the request is civil or criminal. Be sure that you understand the request and respond fully. Request more time if needed. Consult with counsel if you have any questions. Review any patient record for completeness before providing copies.

Consider whether the record shows compliance with billing requirements or supplemental information may be relevant and appropriate. Keep copies of the request and any response.

Do your own mock audits. HIPAA audits have begun. Recent penalties have been high. For an example, go to http://bit.ly/ compliance-enforcement. Be sure that you have compliant HIPAA policies and procedures that have been updated for HITECH. Do a risk assessment of your privacy and security risks and address deficiencies. Be aware of patient access requirements and respond to patient requests for information in a timely way.

Know the limitations on copy charges. Check to be sure all needed business associate agreements are in place. Be especially cautious when electronically transmitting data on numerous patients. Use encryption – particularly on mobile devices. Randomly walk through your practice and check for privacy or security risks, such as visible patient information or patient data accessible without a password. Conduct random audits of your system for improper access. Document your efforts.

Don’t treat complaints like flies at a picnic. Unsatisfied complainers can turn to the government or even to whistleblower suits.

Investigate and respond promptly and thoroughly to complaints.

Consider complaints as possible tips on breakdowns in your procedures or implementation. Assess the underlying cause and address the issue. Give a written response to the complainer.

Document the investigation and resolution in your records.

Pay a little for prevention or a lot for the cure – the choice is yours.

Don’t let patient credit balances sit on your books. Medicare rules require physicians to refund balances that are owed to beneficiaries within 30 days. Failure to refund this money on a timely basis may result in penalties of up to $10,000 per violation and exclusion.

For more information, contact Murray at 336.378.5258 or maureen.murray@smithmoorelaw.com. She advises health care providers on regulatory, compliance and privacy issues, and she has defended health care fraud investigations.

Be sure to sign your name. Signatures are required on orders before

Paid editorial submission

26 MAG Journal

The Right Counsel Could Make All the Difference.

More tha n 30 Ye a rs ’ H e a l t h Ca re Expe ri e nce Ove r 2 0 H e a l t h Ca re A t t orneys Clie nts i n O ve r 25 St a t e s Ch a mb er s US A Top Ra nk i ng i n H e a l t h Ca re AHLA Top H onors

Toby Watt, Atlanta, GA | tobin.watt@smithmoorelaw.com | 404.962.1026

www.mag.org 27

LEGAL

SGR to MACRA – so are we going from the frying pan and into the fire?

By Sidney S. Welch, J.D., M.P.H., Cybil Roehrenbeck, J.D., and Bruce Johnson with Polsinelli PC

A

s readers will remember from the summary that was published in the MAG Journal, Issue 2, 2015, the U.S. Senate passed the most extensive piece of legislation affecting physician reimbursement in decades on April 14, 2015. And two days later, President Barack Obama signed1 H.R. 2 – the “Medicare Access and CHIP Reauthorization Act” (MACRA) – into law.

This action repealed the sustainable growth rate (SGR) formula for determining Medicare updates for physician reimbursement, and replaced it with a new system that builds on the Medicare fee-for-service (FFS) payment system to encourage participation in programs that tie care delivery to quality or value. MACRA also requires the U.S. Secretary of Health and Human Services (HHS) to streamline the Medicare Electronic Health Record (EHR) Incentive Program, the Physician Quality Reporting Program (PQRS), and the Value-Based Payment Modifier (VBM) into one program that is called the Merit-Based Incentive Payment System (MIPS).

The federal government previously had set benchmark goals for value-based payments and alternative payment models in the Medicare program. By the end of 2016, 30 percent of Medicare payments were to be tied to quality or value through alternative payment models – a number that will increase to 50 percent by the end of 2018. And by the end of 2016, 85 percent of Medicare FFS payments were to be tied to quality or value – rising to 90 percent by the end of 2018. The goals, which seemed aspirational to many stakeholders – particularly those clinicians who were already struggling to meet the growing obligations of the other CMS programs that are related to EHR and quality measurement – are now an impending reality.

On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) posted a pre-publication version of a proposed rule to change how Medicare payments for physician services that are authorized under the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).2 The rule was posted at http://federalregister. gov/a/2016-10032 on May 9 – keeping in mind that comments on the rule may be submitted to CMS until June 27. The proposed rule would establish the MIPS and the Alternative Payment Models (APM) that are required by the MACRA legislation, as well as defining the common terms that will be used under these programs.

28 MAG Journal

MACRA payment model proposals Generally speaking, MACRA offers physicians and other clinicians the choice of being subject to a quality performance score that could lead to reductions or increases in Medicare reimbursement (MIPS, as described below) or an alternative payment model (APM) that could result in a five percent annual bonus (as described below).

As noted, MIPS combines components of three existing programs, including PQRS, VBM, and the EHR incentive program (which is also called the “Meaningful Use” or “MU”). MIPS could result in potential changes in FFS reimbursement to physicians and certain other providers that is based on their performance relative to quality, resource use, clinical practice improvement activities, and the EHR meaningful use metrics. MACRA provides for positive or negative adjustments to Medicare FFS reimbursement of up to four percent beginning in 2019 and up to nine percent beginning in 2022 based on one’s performance under MIPS. The proposed rule sees a partial softening of the patient engagement scores that are required by MU. Whereas MU Stage 3 requires that five percent of patients be able to download and transmit their records in 2016 – which increases to 10 percent in 2018 – MIPS only requires doctors to have a single patient hit the measure to get credit, although physicians still get scored on how many patients access their practice’s portal. Additionally, visits via telemedicine equal an “in person encounter” for the purpose of a MIPS score.

CMS also provided proposals relative to implementation of the MACRA APM option. The proposed rule outlines the requirements that are applicable to Advanced APM under the Medicare program, and other payer Advanced APM – including commercial and Medicaid programs.

Both types of APM would require participants to: • Use certified EHR technology • Base payment on quality measures, similar to the ones that are used in MIPS • Meet defined financial risk standards that consist of a general standard or a unique standard that is applicable to medical home models (continued on page 30)

• • • •

www.mag.org 29

(continued from page 28)

Advanced APM would not be subject to the MIPS adjustments, but physicians would have the opportunity to earn bonus payments beginning in 2019 – along with potential Medicare physician fee schedule updates beginning in 2026. APM are, however, subject to financial risk.

For a medical home model APM to meet the excess of “nominal” risk standard, the total annual amount that the Advanced APM potentially owes CMS or forgoes must be at least 2.5 percent of the APM entity’s total Part A and B revenues in 2017. This increases by five percent on an annual basis in 2020 and beyond.

The proposed rule outlines financial risk standards that would need to be met for an APM to qualify as an Advanced APM. The financial risk criterion would apply to the financial risk arrangement between CMS and the APM entity. That criterion generally requires that the APM entity must bear financial risk in its arrangement with CMS, and the amount of risk must be in excess of a “nominal” amount.

The proposed rule notes that various entities that are participating in CMS initiatives would qualify as an Advanced APM based on the proposed financial risk criteria, including Medicare Shared Savings Program Accountable Care Organizations (ACOs, track two and three), NextGen ACOs, the recently announced comprehensive primary care plus program, and certain other programs that are sponsored by the Center for Medicare & Medicaid Innovation (CMMI).

Under the general financial risk standard, CMS would be able to withhold payments and use repayment obligations and other arrangements to secure payments from an APM entity (i.e., the APM’s actual expenditures exceed expected expenditures for an applicable performance period). The financial risk arrangement between CMS and medical home model APM may include these same mechanisms, plus an APM could lose the right to some or all of its guaranteed payments.

Notably, the proposed rule effectively would eliminate track one ACOs since they do not entail financial risk – leading to a prediction that many ACOs will drop out of the program since they are not recognized by the APM program. A full capitation arrangement would meet the criteria to qualify as an Advanced APM, although capitated arrangements involving Medicare Advantage organizations would not qualify for such purposes.

Under the financial risk criteria, the APM must bear financial risk that is in excess of a “nominal” amount, which was conceptually included in MACRA but not defined until the proposed rule. Here, too, the proposed rule sets forth both a general standard and a unique standard that is applicable to entities that are using a medical home model.

In addition to the open comment period that is noted above, CMS has announced that it will host three webinars and conference calls to address the MACRA rule. Additionally, the American Medical Association (AMA) has published materials to help doctors in these endeavors. And Polsinelli hosted a webinar on MACRA in June. A recording is available at www.bitly/polsinelli-webinar. These resources will be invaluable given the tight time frame to get everything in place – seven months from now and two months after the rules are finalized in late October.¨

APM financial risk requirements

The general standard bases risk as percentages of the APM entity’s assigned benchmark, while the risk percentages for medical home models are based on the medical home model APM actual Medicare Part A and B revenue. CMS views this distinction as important given the nature of medical home models (i.e., they commonly have a relatively small number of providers, more limited revenues, and limited, if any, operating experience with financial risk).

The proposed general standard provides that an APM would meet the in excess of “nominal” risk standard where: • The marginal risk that is borne by the APM entity – which is defined as the percentage of the amount by which actual expenditures exceed expenditures for which the APM entity would be liable – is at least 30 percent of the losses • The minimum loss rate – which is defined as the percentage by which actual expenditures may exceed expected expenditures without triggering financial risk – must be no greater than four percent • The total potential risk – which is defined as the maximum potential payment for which an APM entity could be liable under the APM – is no greater than four percent of expected expenditures 30 MAG Journal

Welch is the chair of Health Care Innovation at Polsinelli PC. Roehrenbeck is counsel with Polsinelli’s health care practice.

Johnson is a shareholder with Polsinelli’s health care practice.

They counsel physicians, physician practices, and health care technology clients in transactional, regulatory, administrative law, and litigation matters on a national basis. Go to www. polsinelli.com/professionals/swelch for additional information.

Contact Welch at 404.253.6047 or swelch@polsinelli.com.

References 1

https://www.congress.gov/bill/114th-congress/house-bill/2/text/enr

2

https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-10032.pdf

Paid editorial submission

COUNTY, MEMBER & SPECIALTY NEWS

COUNTY MEDICAL SOCIETY NEWS

Hall County Medical Society

Bibb County Medical Society

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

Along with Dr. Munna, the planning committee included Maria Bartlett, M.D., Margaret Boltja, M.D., W. Robert Lane, M.D., and his wife, Stacy Lane, L. Arthur Schwartz, Jr., M.D., Stephen Mallary, M.D., and J. Eric Roddenberry, M.D. J. W. Griffin, M.D., and his wife, Alicja Griffin, roasted a whole pig for the event. Go to www.bibbphysicians.org for additional information.

Coffee County Medical Society

The Coffee County Medical Society (CCMS) met in April.

CCMS President Charles Miller, M.D., says that, “We are trying to revitalize our county medical society with a series of social gatherings and parties to ramp up membership and to look at opportunities for advocacy projects at the county level as well as the state legislative level.” Contact Dr. Miller at wcmiller@ windstream.net with questions. Contact Dawn Williams at 678.303.9261 or dwilliams@mag.org to join CCMS.

Carol Collings, M.D. (in green) with Alicja Griffin at BCMS ‘Tasting of Appetizers & Craft Beers’ event in April.

DeKalb Medical Society

Go to www.dekmedsoc.org or contact Hank Holderfield at hholderfield@pami.org with questions related to the DeKalb Medical Society.

Dougherty County Medical Society

Go to www.dc-ms.org or contact Susan Workman at 229.436.8191 or dcms. director@gmail.com for information on the Dougherty County Medical Society.

Floyd-Polk-Chattooga County Medical Society

Efforts are underway to revive the Floyd-Polk-Chattooga County Medical Society (F-P-C CMS). Physicians who are interested in serving as an officer or joining the F-P-C CMS or who have questions should contact Kate Boyenga at 678.303.9263 or kboyenga@mag.org.

Georgia Medical Society

by Ca Rita Connor, Executive Director The Georgia Medical Society (GMS) hosted a meeting in April that featured talks on ‘How to live to be l00+’ and ‘Let’s make Savannah a

Blue Zone City.’ The speakers included Jacqueline Huntly, M.D., who is with the Lifestyle and Integrative Medicine Family Medicine Department at Memorial University Medical Center and who is a clinical assistant professor with Mercer University School of Medicine in Savannah, and GMS Vice President Luke J. Curtsinger, M.D. In May, GMS and the Savannah Chatham County Public School System sponsored the annual ‘High School Senior Preceptorship Program.’ Eleven high school seniors who are interested in a career in medicine got to spend a day with physicians in the area.

The event concluded with a banquet that featured reports by the students. Michael Zoller, M.D., is the program chair. Some 40 GMS members participated in this year’s program. In other news, GMS President Kelly Erola, M.D., addressed new residents at the Memorial University Medical Center in Savannah in June.

She discussed the role of GMS and the history of the medical profession in Savannah.

Contact Ca Rita Connor at gamedsoc@bellsouth.net with questions related to GMS.

by Hank Holderfield, Executive Director Medical Association of Georgia Executive Director Donald J. Palmisano Jr. gave a talk on ‘Navigating the Changing Environment of Health Care’ at the Hall County Medical Society (HCMS) meeting in May. Georgia Gov. Nathan Deal is scheduled to speak at the HCMS meeting at the Chattahoochee Country Club in Gainesville at 6 p.m. on September 15. The new members of the Northeast Georgia Medical Center staff will also be introduced at the meeting in September.

Contact Hank Holderfield at hholderfield@pami.org with questions.

Muscogee County Medical Society

by Dan Walton, Executive Director The Muscogee County Medical Society (MCMS) recently hosted a ‘Hockey Night’ for its members and their families – as they cheered on the Columbus Cottonmouths on April 2. The next MCMS event will be held at the Rivermill Event Centre in Columbus on Thursday, September 22. Physicians who are interested in joining MCMS or need additional information can go to www. muscogeemedical.org or call 706.322.1254.

Ogeechee River Medical Society

Contact Michelle Zeanah, M.D., at doctor@zeanah.com for information the Ogeechee River Medical Society. (continued on page 32)

www.mag.org 31

(continued from page 31)

Richmond County Medical Society

Troup County Medical Society

by Dan Walton, Executive Secretary The Richmond County Medical Society (RCMS) kicked off the year with a number of great talks, including a lecture on stroke and dementia prevention by David Hess, M.D., at its meeting in January, a presentation on new developments in lung cancer by Zhonglin Hao, M.D., in February, and a talk on the ‘Fountain of Youth’ by Achih Chen, M.D., in March – which was a joint meeting with the RCMS Alliance.

RCMS held its annual James R. Lyle Resident Research Awards program in April.

It received abstracts from 12 residents at the Medical College of Georgia at Augusta University. The winners included Sebastian Larion, M.D. (first place) and Justin Kennon, M.D. (second place), while the runner-ups included Randi Lassiter, M.D., and Amer Sayed, M.D. The awards were presented by the committee chair, Donald Loebl Sr., M.D. Go to www.rcmsga.org or call 706.733.1561 for additional information or to join RCMS.

Physicians who have questions about the Troup County Medical Society should contact Kate Boyenga at 678.303.9263 or kboyenga@mag.org.

Walker-CatoosaDade County Medical Society

Physicians who are interested in attending a Walker-Catoosa-Dade County Medical Society (WCDCMS) meeting or who have questions related to WCDCMS should contact Michael E. Wilson, M.D., at tenwilsons@gmail.com.

MEMBER NEWS Paul H. Earley, M.D., the medical director of the Georgia Professional Health Program (Georgia PHP), was elected to become the president-elect of the Federation of State Physician Health Programs (FSPHP) for 2016. He will serve as FSPHP’s president in 2018.

Dr. Earley has been an addiction specialist for 30 years. The Georgia PHP is

From the left are RCMS award winners Randi Lassiter, M.D., Amer Sayed, M.D., Sebastian Larion, M.D., and Justin Kennon, M.D.

32 MAG Journal

health disparities.” Dr. Mack has served as the co-director of the NCPC since June 2013.

Go to www.msm.edu for details.

Paul H. Earley, M.D.

a not-for-profit foundation that provides “initial triage, referral to treatment, and long-term monitoring services for health care professionals with substance use disorders and other mental health conditions.” It receives no state funding and “relies solely on member fees and donations, which are tax deductible.” Contact Robin McCown at 678.825.3764 or robin.mccown@gaphp. org with questions. Go to www.gaphp.org for additional information.

Dominic Mack, M.D.

The Morehouse School of Medicine has named Dominic Mack, M.D., as the new director of its National Center for Primary Care (NCPC), which is the “nation’s first congressionally sanctioned center to develop programs that strengthen the primary care system for health equity and sustainability.” NCPC’s mission is to “promote excellence in communityoriented primary health care and optimal outcomes for all Americans, with a special focus on underserved populations and eliminating

Yolanda Graham, M.D.

Cobb Executive Women (CEW) honored Devereux Georgia Medical Director Yolanda Graham, M.D., with its 2016 Woman of Distinction Award, which “recognizes a woman who has demonstrated exceptional leadership through her professional endeavors, community involvement, thereby supporting and advancing their community and respective fields.” CEW said that Dr. Graham has “received national recognition for her expertise in treating children who have been commercially sexually exploited and traumatized…[and] she has worked with the Georgia Governor’s Office to develop a statewide response to address the needs of child sex trafficking victims.”

CEW also noted that Dr. Graham has “provided clinical oversight and treatment services to residents at Angela’s House, the first safe house for exploited girls in the Southeast region.” Dr. Graham is a member of the MAG Foundation’s Georgia Physicians Leadership Academy.”

SPECIALTY SOCIETY NEWS Georgia Chapter of the American College of Physicians

by Mary Daniels, Executive Director The Georgia Chapter of the American College of Physicians will hold its annual meeting – ‘Fostering Excellence in Internal Medicine with Quality Based High Value Care’ – at the Chateau Elan Winery & Inn in Braselton on October 2123. The event will feature a hospital medicine track and faculty development sessions.

Monitor www.gaacp.org for details. Contact Mary Daniels at mdaniels@gaacp.org with questions.

Georgia Academy of Family Physicians

by Mary Claire Leverett, Manager of Communications and Marketing The Georgia Healthy Family Alliance (GHFA) – the philanthropic arm of the Georgia Academy of Family Physicians (GAFP) – was honored with the 2015 American Academy of Family Physicians Foundation Program of the Year Award for its ‘Community Health Grant Award Program.’ Since 2012, GHFA has awarded more than $100,000 to GAFP member-sponsored charitable organizations that are aligned with GHFA’s priorities, including underserved populations and outreach programs that promote healthy practices consistent with the principles of family medicine. This has included a ‘Rethink Your Drink’

obesity prevention program, and mobile mammography and women’s services for low income and uninsured patients, as well as diabetes education projects. GHFA received the award at AAFP’s ‘Family Medicine Experience’ meeting in Denver in October 2015.

GHFA’s 2016 grant recipients included Brian DeLoach, M.D., with the Hearts & Hands Clinic in Statesboro for a ‘Referrals: Specialized Lab Tests’ program, which was developed to decrease the ethnic and socio-economic disparity in health care that exists for low-income, uninsured adults who need specialized lab tests; and Martha Crenshaw, M.D., with the Physicians’ Care Clinic in DeKalb County for a ‘Chronic Disease and Diabetes Management Program’ for prevention and education classes and monitoring supplies. Go to www. georgiahealthyfamilyalliance. org/donate or call 800.392.3841 to support the Georgia Healthy Family Alliance with a tax-deductible donation. Go to www.gafp.org for information on GAFP. Georgia Association of Pathologists

by Dan Walton, Executive Director The Georgia Association of Pathologists (GAP) is recruiting new members and reminding its current members to renew their membership at www.gapathology.org.

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

Georgia Chapter of the American Academy of Pediatrics

by Kasha Askew, Director of Membership & Education The Georgia Chapter of the American Academy of Pediatrics had a great legislative session with increases in Medicaid payment rates for 26 new codes and the failure of a medical cannabis bill that would have added autism as a medically qualifying condition and a PA prescribing bill that the Chapter opposed. The Chapter hosted a ‘Pediatrics by the Sea’ meeting on Amelia Island on June 8-11. The meeting chair was Charles W. Linder, M.D., who heads up the Department of Pediatrics at the Medical College of Georgia at Augusta University. The event featured preconference seminars on developmental screening, coding, and the use of ultrasounds. The Chapter will wrap up its Pediatric Growth and Endocrinology ECHO® project in July. Farah Khatoon, D.O., a pediatric endocrinologist at Navicent Health Children’s Hospital in Macon, led the effort – which was designed to expand the capacity of primary care practices to provide evidence-based, pediatric growth & endocrinology care in Georgia. Dr. Linder and David Freeman, M.D., each recorded a rare double eagle during the ‘Jim Soapes Charity Golf Classic,’ which benefits the Chapter’s Foundation, at the Cherokee Run Golf Club in Conyers

in April. The Chapter’s fall meeting will take place at the Westin Atlanta Perimeter North on September 22-24.

The Chapter will also host a number of webinars on a range of issues – including child abuse and neglect, screening for autism, minors’ rights, and vaccine storage and handling – during the summer months. Visit www.gaaap.org or call 404.881.5091 for additional information on the Chapter.

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 Saturday, September 17.

Additional details will be posted on www.georgiagi. org as they become available.

The meeting typically offers about six CME credits – and active members can attend the meeting for free, so they should go to www. georgiagi.org to complete a membership application for the year as soon as possible if they haven’t already done so. Contact Stacie McGahee at 706.738.3119 or smcgahee@medicalbureau. net with questions.

Georgia Society of Dermatology and Dermatologic Surgery

Go to www.gaderm.org for information on the Georgia Society of Dermatology and Dermatologic Surgery. (continued on page 34)

www.mag.org 33

(continued from page 33)

Georgia Society of Rheumatology

Go to www.garheumatology. org for information on the Georgia Society of Rheumatology.

Georgia Chapter of the American College of Cardiology

by Hank Holderfield, Executive Director The Georgia Chapter of the American College of Cardiology presented the fourth annual conference for Cardiovascular Technicians (i.e., registered nurses, nurse practitioners, clinical nurse specialists, physician assistants, and clinical pharmacists) in Atlanta in March. The Chapter’s annual meeting will be held at The Ritz-Carlton at Lake Oconee on November 18-20. This nationally acclaimed meeting will feature world-class speakers and more than 50 exhibits. The Chapter’s

officers for the year include President/Governor Charles Brown, M.D., from Atlanta, Secretary/Treasurer Jeff Marshall, M.D., from Gainesville, and Immediate Past President Don Page, M.D., from Marietta. Go to www.accga.org or contact Hank Holderfield at HHolderfield@pami.org for additional information on the Chapter.

Please submit your county medical society, member or specialty society news to Tom Kornegay at tkornegay@mag. org. Also contact Kornegay with corrections, which will run in the next edition of the “Journal.” 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 to join MAG.

MAG calling for grassroots to oppose Aetna/Humana & Anthem/Cigna mergers

Medical Association of Georgia President John S. Harvey, M.D., recently addressed why he believes the pending Aetna/Humana and Anthem/Cigna mergers would have “disastrous results for patients and physicians in this state” in an op-ed that was posted on the Georgia Health News website.

Dr. Harvey is calling for Georgians to oppose the Aetna/ Humana and Anthem/Cigna mergers by sending an email to Georgia’s Department of Insurance at mergercomments@oci.ga.gov.

Go to www.mag.org/advocacy/insurance-merger to read Dr. Harvey’s op-ed and for additional information.

34 MAG Journal

MAG Alliance wins award for advocacy efforts

The Medical Association of Georgia Alliance (MAG Alliance) – which is a network of physicians’ spouses who volunteer to improve the health of all Georgians – received a LEAP Award (Legislative Education Awareness Promotion) from the American Medical Association (AMA) Alliance for its efforts to pass the Georgia Lactation Consultant Practice Act in 2016.

The AMA Alliance President Julie Newman said that, “We were all very impressed with your project and congratulate you on a successful way to affect positive change in the legislature.”

MAG Alliance President Merrilee Gober and MAG Alliance Immediate Past President Eve Tidwell will accept the award at the AMA Alliance’s annual meeting, which will take place in Chicago in June.

In a related development, the MAG Alliance issued a press release in May to applaud state lawmakers and Georgia Gov. Nathan Deal for passing and enacting the Georgia Lactation Consultant Practice Act. “Representative Sharon Cooper demonstrated great vision and leadership in introducing H.B. 649, which will create a lactation consultant advisory committee and establish guidelines to license individuals who want to be lactation consultants,” Gober said in the release. “Of course, the Medical Association of Georgia (MAG) also played a crucial role as a leading advocate for this bill.”

MAG President John S. Harvey, M.D., added that, “This legislation is consistent with a policy that MAG’s House of Delegates passed in 2012, so we were pleased to find out that Governor Deal passed this into law on April 26.”

Gober also noted that, “We are confident that this law is going to improve the health of numerous mothers and babies in Georgia. It will also provide physicians the opportunity to employ lactation consultants in their practices giving patients easy access to the service.”

The MAG Alliance supports a number of important initiatives, including the MAG Foundation’s ‘Think About It’ campaign to reduce prescription drug abuse and the Georgia Department of Public Health’s ‘SHAPE’ program to promote youth fitness. Every Georgia physician’s spouse can currently join the MAG Alliance for free. Go to www.mag.org/affiliates/magalliance for additional information.

PRESCRIPTION FOR LIFE

Goodbye, Mr. Chips Jay Coffsky, M.D. In this, one of my last articles in the MAG Journal, I reminisce about Mr. Chips – the title character of the famous British novel and films who lives through 60 or so years as a teacher and then head master at a private English academy. His story is one that is both sad and happy.

In September, I will enter my 60th year in medicine. I am now in my 50th year at DeKalb Medical. Several thousand physicians, nurses, and technologists have come and gone. None of my physician colleagues who were here when I left the Air Force to enter private practice remain. I am the last dinosaur.

The changes that I have witnessed have been fantastic on the scientific front. Yet these changes have been equally devastating when it comes to the way we interact with one another and our patients.

When I started at DeKalb, there were two “suits” – the administrator, Mr. Trasher, and the comptroller, Mr. Anderson.

Now there are hundreds.

There were no computers. The closest thing we had were adding machines and typewriters. In my reading room today I have five computers, which doesn’t even count my smart phone and tablet.

My “workstation” (never heard the word until 10 years ago) allows me to be at least four to five times more productive then before – when we handled every film and every comparison study.

When I started, gall bladder surgery required at least a week to recover in the hospital. Cataract surgery required immobilization for days and those thick glasses. A rigid colonoscopy was something you would not wish on anyone.

I would do my career over in a New York second despite what has happened to my profession. But what I abhor is that the government, the insurance industry, and technological advances have placed a “Trump-sized wall” between us radiologists and our referrals.

During the golden age, I knew every doctor on the staff. At Christmas, we literally got hundreds of goodie packages of cakes, nuts, fruits, and the like.

Now none, zilch, zero, bupkis. It’s not the food that I miss. No, it’s the absence of professional relationships. There was a genuine comraderie and fellowship that doctors shared that just isn’t there today. I occasionally go into the doctor’s lounge and don’t recognize anyone. Some of the doctors don’t even speak to one another.

There were no intensivists, hospitalists, and very few sub-specialists. In my field of radiology, I started out practicing in all areas. Now there are more than 12 fellowship specialties in radiology alone. We covered them all…we were just that much smarter.

Back in the day, almost everyone gave professional courtesy care free of charge to physicians and their families. Today, however, it’s a great challenge for a Medicare patient (even one who is a physician) to get a doctor period – let alone receiving the care free of charge.

In radiology, there were no CT scans, ultrasounds, mammograms, MRI scans, etc. I remember going to Cornell Medical in New York to see the first CT scanner. It was called an EMI after the company, Electrical Musical Instruments, that developed it. I actually met its inventor, Sir Godfrey Hounsfield.

I was recently speaking to the person who is in charge of the imaging centers for one of the largest national health and hospital organizations. He is trying to organize regional off-site image reading centers to replace multiple imaging departments.

Forget about the damage to radiologists. Can you imagine having several national or international night hawk-type centers doing imaging reports for you all day and night? If you think calling AT&T or Delta and getting someone is hard...

When I started my career in the medical profession, we did have some drugs like penicillin and streptomycin. But we did not have robotic techniques, stents, endoscopies, antibody treatments, or limited invasive procedures.

The advances in my field and most others just take your breath away when you look back 60 years. I am sure six decades from now the same will occur unless government oversight and mingling slow advances down.

When I get a physical these days, the doctor spends most of the time inputting information and looking at the computer instead of me – the patient. What the EPA has done to business, multiple government agencies are doing to medicine. I guess you can’t stop progress, if that is what it is.

My parting words to the physicians who follow in my footsteps… good luck.

Dr. Coffsky and his wife, Sandy, have been married for 57 years and have three children and eight grandchildren. He is in his 50 th year at DeKalb Medical. His email is m3wejr@bellsouth.net.

www.mag.org 35

ADVERTISER INDEX

Atlanta TMD Dentist..................................................................................................... 21 Craniofacial Pain Center of Georgia............................................................................. 13 David Kurtzman, D.D.S................................................................................................. 13 EmCare......................................................................................................................... 10 Emory Structural Heart & Valve Center.........................................................Back Cover Huff, Powell & Bailey, LLC............................................................................................. 25 MAG Mutual Insurance Company......................Inside Front Cover, Inside Back Cover Melvin M. Goldstein, P.C..................................................................................... 36 Northside Hospital................................................................................................... 22-23 PNC Bank........................................................................................................................ 1 Polsinelli........................................................................................................................ 29 Smith Moore Leatherwood, LLP.................................................................................. 27 Total Wealth Investment Firm........................................................................................ 7

The Journal of the Medical Association of Georgia A quarterly, four-color magazine from the leading voice for the medical profession in Georgia. MAG has more than 7,800 physician members. And the MAG Journal is focused on the issues that matter to physicians in the state, including state legislation, national health care reform, legal matters, practice management, and a lot more. Place an advertisement in the MAG Journal and expand your reach!

You can also reach physicians in Georgia with an ad on

www.mag.org

For additional information on advertising with MAG, contact Brian Botkin at PubMan, Inc. at 404.255.6261 or bbotkin@pubman.net 36 MAG Journal

Feel like insurance should be more transparent?

The feeling is mutual.

Since 1982, MagMutual has grown to become the largest healthcare liability insurer in the Southeast by providing PolicyOwners with enhanced products, consistent dividends, financial rewards, and a uniquely personal experience. In addition our Patient Safety advocacy, MagMutual is leading the industry call to greater transparency, as the first and only medical liability insurer to set aside millions in loyalty funds on financial statements. Will other insurers accept the challenge?

To experience the PolicyOwner difference, call 800-282-4882 or visit MagMutual.com SM

Dividend payments are declared at the discretion of the MAG Mutual Insurance Company board of directors. Since inception, MAG Mutual Insurance Company has distributed more than $136 million in dividends to our policyholders. Insurance products and services are issued and underwritten by MAG Mutual Insurance Company and its affiliates.

www.mag.org 37

404-778-5050 or 800-22-EMORY | emoryhealthcare.org/structuralheart