Kentucky Edition
March 2011
Issue Spotlight:
Pain Medicine
The Business Magazine of Kentucky Physicians
and Health Care Administrators
Comprehensive Pain Medicine (L-R)
Luis Vascello,MD Rick Lingreen, MD, Jay Grider, DO/PhD
PRST STD U.S. Postage Paid Bloomington IN Permit NO. 267
Volume 2, Number 3
Interventional Pain Specialists Inspire a New Era of Medicine New Collaborations between Primary Care and Pain Specialists Senate Bill 110 Lowers Eye Surgery Standards UK Pediatric Oncology Benefits from Student Fundraiser Colon Cancer Prevention Project
You’re never far from the best care. ®
Providing assessment, diagnosis and treatment of acute and chronic pain.
The focus of the Saint Joseph Pain and Rehabilitation Center is the practice of pain medicine dealing with the evaluation, diagnosis and application of interventional treatment for the management of pain and related disorders. Our clinic promotes the development and practice of safe, high-quality interventional techniques for the diagnosis and treatment of pain.
Profiles of Pain Problems Chronic Pain Back pain, neck pain, headaches, musculo-skeletal pain, neuropathic pain (nerve injury pain), complex regional pain yndrome/RSD, postherpetic neuralgia, pelvic pain, and other chronic problems.
Natural Treatment for Joint & Tendon Pain Relief Pain Management specialist, Luis Vascello, M.D., is offering Platelet Rich Plasma (PRP) therapy, a promising solution to accelerate
Work-Related Chronic Pain Industrial injuries, repetitive motion injuries, loss of function and impaired work capacity.
healing of tendon, ligament, or muscle injuries and osteoarthritis naturally. By using a patient’s own platelets and growth factors in PRP, the body’s healing ability improves while leading to a more rapid
Cancer-Related Chronic Pain Functional impairment due to pain, tumor related pain, opioid unresponsive pain, opioid tolerance or side effects difficulties.
decrease in pain and return to activities and sports. Find out if this oupatient, non-surgical procedure is right for your patients. Call 859.313.2212.
Acute Pain Post-operative and post-trauma pain.
Two Convenient Locations Saint Joseph Office Park, Building C 1401 Harrodsburg Road, Suite 315 Lexington, KY 40504 FOR APPOINTMENTS, CALL 859.313.2212.
Saint Joseph East • Eagle Creek Medical Plaza 120 N. Eagle Creek, Suite 101 Lexington, KY 40509 FOR APPOINTMENTS, CALL 859.967.5309.
March 26, 2011 Bluegrass Ballroom • Lexington Center
2011 Heart & Stroke Ball Chair James E.“Ted” Bassett III
Join us in honoring Ralph Hacker former “Voice of the Wildcats” & heart disease survivor.
Our evening will also feature a tribute to Sam Barnes.
of the Bluegrass
For more information visit us at www.heart.org/lexingtonkyheartball or call the American Heart Association at 859-977-4605.
March 2011 1
Letters
FROM THE DESK OF
Megan Campbell Smith, editor-in-chief This month, M.D. Update investigates developments in pain medicine and colorectal cancer screening. When we put this on our calendar a year ago, we could not have planned that this would become our most politically charged issue yet. Talk of Pill Mills and the Oxy Express dominate popular discussions of pain medicine, but in practice here in Kentucky, physicians are moving beyond the pale and into methods for delivering high-quality pain relief with consideration to the aberrant behaviors that abound in society at large. In observance of national colorectal cancer awareness month, we investigate why the state’s colonoscopy screening program is left unfunded while treatments for advanced colon cancer go on the Medicaid rolls. In an interesting aside, some of our readers may not know that Florida’s Prescription Drug Monitoring Program (PDMP), the one that Florida governor Rick Scott hopes to eliminate, has been unfunded since its authorization by Fla. lawmakers in 2008. There is a lesson here, doc. Do not assume your noble profession is above politics. And, just a few short weeks ago, our BY Megan Campbell Smith state legislature passed a new law allowing non-surgeons to perform eye surgery on unsuspecting customers. As a licensed professional myself, this new legislation causes me great discomfort. I could have never imagined that “health” and “safety” would go the way of “welfare” in political discourse. Seems like politics in Kentucky are like the weather. Got nothing to talk about? Just wait ‘til tomorrow. In the meantime, dear Reader, we invite you to share your opinion and expertise in M.D. Update Kentucky edition or online in our new M.D. Update Online edition. At www.md-update.com, we have archived issues available for your enjoyment, and we will continue to amass extended content and materials referenced in our print pages. If you like mobile apps, you will want to check out the mini editions on our Facebook page. We have heard from dozens of readers since our statewide reveal last month. Please, send us a line to tell us what you think. Best regards, Megan Campbell Smith
Submit your Letter to the Editor to Megan Campbell Smith at mcsmith@md-update.com 2 M.D. Update
Kentucky Issue Volume 2, Number 3 March 2011 Publisher
Gil Dunn gdunn@md-update.com Editor in Chief
Megan Campbell Smith mcsmith@md-update.com Associate Editor
Greg Backus gbackus@md-update.com Photographer
Kirk Schlea kirk@ md-update.com Writers
Dan Dickson ddickson@md-update.com Graphic Designer
James Shambhu art@md-update.com
Contributors:
Jackie Hamilton Patricia Cordy Henricksen Lisa English Hinkle Scott Neal George Privett, MD Woodford Van Meter, MD Ken Weaver, MD
Send your Letters to the Editor to: mcsmith@md-update.com
Mentelle Media, LLC
921 Beasley Street, Suite 210 Lexington, KY 40509 (859) 309-9939 phone and fax Mentelle Media, LLC is locally owned and operated. Mentelle Media strives to produce top quality referral and marketing resources for Kentucky’s professionals by welcoming the participation of our readers. For more information about how your business or medical practice can get involved, contact Gil Dunn at (859) 309-0720. Bulk third class mail paid in Bloomington, IN. Postmaster: Please send notices on Form 3579 to 921 Beasley Street, Suite 210 Lexington, KY 40509 M.D. Update is peer reviewed for accuracy. However, we cannot warrant the facts supplied nor be held responsible for the opinions expressed in our published materials. Copyright 2010 Mentelle Media, LLC. Contact Mentelle Media for information on obtaining reprints. Individual copies of M.D. Update are available for $7.95.
Contents cover story
2 LETTERS 5 HEADLINES 11 FINANCE 12 LAW 14 PRACTICE MANAGEMENT 19 PERSPECTIVES 31 SPECIALTIES 33 NEWS 39 ARTS
Headlines
8 Beneficiaries of Blue
Student Fundraiser Helps UK Deliver High Level of Care for Childhood Cancers
Physician Q&A
Comprehensive Pain Medicine Interventional Pain Specialists Inspire a New Era of Medicine
21 Dr. Whitney F. Jones, Founder of the Colon Cancer Prevention Project
Feature Story
By Megan C. Smith Photography by Kirk Schlea page 16
26 Leading by Example On the Cover:
Three Central Kentucky physicians, working in separate practices, meet in Frankfort to discuss their shared philosophy of interventional pain management.
Murphy Pain Center of Louisville is helping to correct Kentucky’s prescription drug problems by working with patients and primary providers in a collaboration of care and trust. March 2011 3
2011 EDITORIAL CALENDAR JANUARY
Rural Medicin e
FEBRUARY
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MARCH
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APRIL
Or thopaedics & Spor ts Medicin e
MAY
Women’s Health
J UNE
Derm atology & Plastic Surger y
JULY
Intern al Medicin e & Prim ar y Care Inter
AUGUST
Pediatrics
SEPTEMBER
Urology & Nephrology
OCTOBER
Oncology
NOVEMBER
Neuroscience
DECEMBER
Psychiatr y & Ment al Health
JOIN TH E CLUB! Cont ac
Submission Deadline: Second Friday of the month before issue
4 M.D. Update
t us today .
Gil Dunn, Publisher (859) 309-0720 phone gdunn@md-update.com Megan Campbell Smith, Editor in Chief (859) 309-9939 phone mcsmith@md-update.com mcsmith@md-updat
Headlines
Beshear Makes SB 110 Law FRANKFORT On February 24, 2011, Kentucky Governor Steve Beshear released the following statement on Senate Bill 110: “Access to quality health care is a critical issue for families across the Commonwealth. After careful consideration, along with meetings with many interested parties, today I signed Senate Bill 110 to give Kentuckians greater access to necessary eye care. A review by the Department of Medicaid finds that this legislation has little or no fiscal impact on the Medicaid budget. This bill passed overwhelmingly in both legislative chambers (81-14 in the House and 33-3 in the Senate), showing broad bi-partisan support. And finally, in order to ensure the highest degree of oversight, I will be meeting with the Board of Optometric Examiners to make sure that providers of these services undergo extensive training. I believe this new law will mean more Kentuckians can get the eye care they need.” Presently, optometrists are required to complete 15 board-approved CE hours in order to renew their therapeutic licenses.
Photo by Kirk Schlea, November 2010 March 2011 5
Headlines
Senate Bill 110 Lowers the Standards for Eye Surgery in Kentucky By Woodford S. Van Meter, MD Senate Bill 110, a proposal to give surgical privileges to optometrists in Kentucky, has flown through the House and Senate at the legislative equivalent of light speed and was signed into law by Governor Steve Beshear the day after it reached his desk. The Governor had the option of signing the bill into law, doing nothing, or allowing the bill to become law in ten days, or vetoing the bill. The physician community in Kentucky had hoped he would veto the bill, which will lower the standard of care for all citizens in Kentucky and provide a dangerous precedent for non-physicians practicing surgery outside the umbrella of the Kentucky Board of Medical Licensure. After the bill passed both chambers in the legislature, I met with the Governor in his office with Preston Nunnelly, MD, the chairman of the Kentucky Board of Medical Licensure, Cynthia Bradford, MD, professor of Ophthalmology at the University of Oklahoma and secretary for State Affairs for the American Academy of Ophthalmology, and Dean Boyd Buser of the Pikeville College of Osteopathic Medicine. Dr. Nunnelly testified that under this bill optometrists would be practicing medicine without a license outside the control of the Medical Licensure Board. Dr. Bradford reported on complications resulting from optometrists doing surgical procedures in Oklahoma. Dr. Buser said that he had seen a number of opticians and optometrists entering medical school who thought they knew all about the eye when they started, but, after they had finished four years of medical school, were amazed how little they really had known. Optometrists attend four years of optometry school after college, while an ophthalmologist after college attends four years of medical school and then four years of ophthalmology residency, during which he receives medical and surgical training on diseases and surgery of the eye at a medical center. An optometrist gets an average of 1900 hours of clinical training seeing patients, many of them normal eye 6 M.D. Update
turned down for patient safety and cost reasons. Surprisingly, the bill was kept under wraps and went to the Senate Licensing and Occupations Committee within twelve hours of its initial posting. The usual three day waiting period between posting and committee hearing was waived in both cases by the respective Senate and House Licensing and Occupation committees (which otherwise deal with air conditioning regulations and fishing licenses), with little time for evaluation by any medical groups, the public, or legislators themselves. Any piece of good legislation should stand up to minimal evaluation and scrutiny, and the clandestine course of this bill through the legislature does not pass the Woodford S. Van Meter, MD is president of the Kentucky Academy of smell test for good legEye Physicians and Surgeons. islation. The bill is dangerous, expensive, and exams for glasses. Ophthalmology resi- will likely allow optometrists to perform dents receive over 17,000 hours of clinical surgery on unsuspecting patients who don’t training in medical school and residency know the difference between ophthalmoloin a wide variety of medical and surgi- gists and optometrists. Optometrists have cal diseases of the eye and body. Medical limited surgical experience, and this legisladoctors after an ophthalmology residency tion unfortunately grants surgical privileges can practice ophthalmology in any state to all optometrists in Kentucky in front of in the union with their medical license. training and education, the reverse of what In contrast, there is no national stan- usually happens. dardized exam for optometry; the scope Problems with the bill itself abound. No optometric practice is governed by 50 consumer groups, nor any patients, have different boards of optometry in fifty dif- ever asked for or showed any need for this ferent states. The only state so far that has bill. Citizens of Kentucky are not lining allowed surgical privileges is Oklahoma in up for eye surgery, and very few ophthal1998, and since that time at least 25 other mologists have more patients clamoring states have been petitioned for laser surgical for surgery than they can handle. This bill privileges. Except for Kentucky, they were grants a wide range of surgical privileges to
optometrists by exclusion: not by listing the procedures that ODs wish to perform, but by excluding those they don’t want to perform. Consequently, as the bill is written, optometrists can inject drugs in the vitreous, perform LASEK, stick needles in the eye, administer IV sedation, and do cataract surgery with the femtosecond laser whenever it becomes available. SB 110 contains identical language to the Oklahoma 1998 bill, down to the punctuation. ODs are asking now for the same four laser privileges in Kentucky that they asked for in Oklahoma in 1998. Of note, several years after the Oklahoma bill was passed, optometrists then went back to Medicare and Medicaid in Oklahoma and demanded to be paid for a host (>100) of procedures that were not requested in the 1998 bill, yet were not specifically excluded. Since the language in the Kentucky bill reads exactly as in the Oklahoma bill, Kentuckians beware; additional privileges in the future could be a huge drain on Medicaid services. The American College of Surgeons (2007), the American Medial Association (2009), and the American Academy of Ophthalmology (2007) have all issued public statements saying that surgery, including laser surgery, because of the training involved and risk of complications, should be performed by surgeons. In response to the Kentucky bill, three additional national ophthalmology organizations, the American College of Eye Surgeons (ACES),
the Society for Excellence in Eye Care (SEE), and the American Glaucoma Society (AGS), last week issued policy statements that laser surgery should only be performed by physicians. Senate Bill 110 also allows an independent optometry board to define “the scope of optometry” in Kentucky and oversee the delineation of privileges, licensing, and scope of practice. The board decides what is included in the practice of optometry and controls all devices and medicines used for the eyes. This board works outside the Kentucky Board of Medical Licensing, so a physician who observes a complication relating to an optometrist’s treatment would have to report the complication to the optometry board, as the Kentucky Board of Medical Licensing would have no purvey. A number of complications have occurred from optometric treatment in Oklahoma including: puncturing the lens in a child while sticking a needle in the eye to relieve pressure; causing a serious corneal infection by treating corneal edema with a needle. These incidences demonstrate how this bill is dangerous for Kentucky (or any state) and has not been a panacea for Oklahoma. SB 110 will lower the standard of care for all Kentuckians by allowing optometrists, with significantly less training than ophthalmologists, to perform surgical procedures on the eye, often in unsuspecting patients. A poll
on a local radio station this week showed 70% of Kentuckians opposed to this bill. Presumably the other 30% would relish the idea of getting on an airplane with a pilot that had little experience and minimal training but a recent certificate for a weekend course. An issue that seems to make ophthalmologists and optometrists political enemies is not a turf war over privileges, but the fact that optometrists do little themselves to clarify the difference between ophthalmologists and optometrists. The optometrists in the legislative hearings when asked their names introduced themselves as “Doctor Joe Ellis” or “Doctor Ben Gaddie” while the MDs answered their names as “Woody Van Meter” or “Emery Wilson”, a feature that was apparent at both the senate and house hearings. We also heard reference to “optometry residency” rather than “optometry school”. Ophthalmologists might be more tolerant of optometrists performing surgical procedures if they thought the optometrist would first say to the patient “I am going to perform surgery on your eye and I have not been to medical school”. Then, there is at least informed consent. But we never hear that disclaimer, and any muddying of the waters between MDs and ODs serves optometrists well. Kentuckians deserve a better legislative process than this bill followed, and they deserve better eye care than this bill provides. ◆
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Dr. William O. Witt Medical Director Cardinal Hill Pain Institute March 2011 7
Headlines
Beneficiaries of Blue
Student Fundraiser Helps UK Deliver High Level of Care for Childhood Cancers When Jeff Moscow, MD, chief of Pediatric Oncology with UK HealthCare, moved to Lexington in 1997, the conditions at the clinic were, as he recalls, “less than adequate. The department was given clinic space, but we were required to raise the money ourselves to improve it.” Parent volunteers, Jennifer Mynear, cofounder and director of the Jarrett Mynear Fund, and UK Fundraising Programs director Susannah Denomme spearheaded a $2 Million fundraising effort to rebuild the UK Pediatric Oncology Clinic. Having met their bricks-and-mortar needs, Moscow, Mynear, and Denomme sought ways to fulfill the clinic’s programmatic need for more highly trained personnel in the care for childhood cancer patients. Inspired by Penn State’s THON, Mynear and Denomme helped UK students launch their own philanthropic organization to benefit pediatric oncology patients. Dance Blue was founded in 2005 and since has raised over $2.6 Million for UK Pediatric Oncology Clinic and the Golden Matrix Fund. “The students took ownership of the fundraising goal and the idea that the student community could help us take care of patients.” Moscow says he is grateful to the student organizers of Dance Blue. “I am the beneficiary of what the students do. They get the credit for this.” LEXINGTON
Personnel, Testing, Follow-Up, and Research
Fundraising by Dance Blue has enabled the hiring of two full-time dedicated pediatric social workers to help the families of the patients deal with challenges. Most of the clinic’s families come from Eastern Kentucky and are treated under
systematically assess neurocognitive functioning before and after therapy.” Moscow explains that these tests are also not reimbursed well, “but it is essential for us to be able to explain to families and teachers what deficits students have coming out of therapy and how to best deal with them so that long term outcomes are improved.” Now, all patients get CNS-directed therapy, which helps to understand what side effects the therapy had and provides tools to talk with schools Jeff Moscow, MD, about what the children may need is chief of Pediatric Oncology with UK in terms of special assistance. HealthCare. Many cancer survivors, including childhood cancer survivors, do Medicaid. There are many psycho-social not have a medical home. Moscow and financial problems associated with observes that some internists are not neceschildhood cancer. sarily aware of the long term side effects “The diagnosis of cancer in a child is of childhood cancer therapies. Meanwhile, an incredibly stressful burden for the child adult oncologists are busy taking care of and the family,” says Moscow. “The needs active adult oncology patients. of these families are great. Many of the Fundraising from Dance Blue has services that we want to be able to provide assisted in the founding of UK’s Long for them do not get reimbursed.” From an Term Follow-up Clinic, a medical home institutional perspective, helping families for survivors of childhood cancer. Young deal with the problems of their cancer does adult cancer survivors, Moscow explains, not earn income, but, says Moscow, hiring need special guidance from their pediatric people with social work skills to help the oncologists 10-15 years after their cancer. children and their families is an integral part “We have to go back into the records and of delivering the highest level of care. find out what drugs they were given and Dance Blue fundraising has also enabled at what age; what radiation exposure they UK Pediatric Oncology to implement a may have had. We have to locate these neurocognitive testing program that helps adolescents and young adults, bring them children return to learning activities after into clinic, and tell them about their completing their cancer treatments. “Many treatments, inform them of the risks of of our therapies are directed at the central treatment, screen them for things that nervous system and can result in cogni- are greater risks for them, and then try tive impairment. When we started out,” to provide them with tools for the rest of says Moscow, “we did not have a way to their lives. “This is something that is really important for high quality care. It takes a lot of money to provide these kinds of services, which earn virtually nothing in terms of clinical income. Dance Blue gives us the chance to offer the high quality of care that we could not provide otherwise.”
From an institutional perspective, helping families deal with the problems of their cancer does not earn income, but it is an integral part of delivering the highest level of care. 8 M.D. Update
Photo of Sabrina Hounshell
Students and children dance on stage during the final hours of DanceBlue 2011, which raised $673,976.60 for the UK Pediatric Oncology Clinic and Golden Matrix Fund.
UK Student Philanthropy Helps Kids with Cancer On February 19, 2011, DanceBlue committee members revealed the total funds raised at the sixth annual dance marathon to benefit the Golden Matrix Fund and the UK Pediatric Oncology Clinic. This year, 700 dancers and volunteers raised $673,976.60. DanceBlue is the LEXINGTON
University of Kentucky’s largest student philanthropy. The 24-hour no-sitting, no-sleeping dance marathon features a family talent show with children from the clinic and an emotional memorial hour to remember those who have lost their battle with cancer. The annual fundraising reveal is a much anticipated moment for many people at UK. DanceBlue began in 2006 by raising $123,323.16
Moscow believes that we must not be satisfied with how we treat childhood cancer today and leave it at that. “Dance Blue helps us staff our clinical research office so that children here have access to the latest forms of treatment for every variety of childhood cancer. Children’s Oncology Group has a number of studies involving the treatment of childhood cancers. Because we have dedicated research coordinators, we are able to participate in all of them.”
Challenges Ahead for Pediatric Oncology
According to Moscow, the forecast on federal funding for cancer research is bleak. “We seem
and has increased every year. With this year’s total, DanceBlue has contributed more than $2.6 million dollars to the Golden Matrix Fund and the UK Pediatric Oncology Clinic. Kayla Talbot, a graduate student from Albany, Ky., and DanceBlue morale team member, reflected on what DanceBlue means to her, “It is physical. It is emotional. It is an eye opening experience that affects your heart, mind and body.”
to be going into a hard time where funding is becoming more limited.” He notes that studies of childhood cancers, all of which are rare, are conducted more efficient by studying them on the national level. Federally funded research is better positioned to find treatment breakthroughs, but Moscow warns that funds are diminishing. “The climate in general these days does not favor the kind of discretionary funding that deals with such small populations and rare incidence.” For example, in the study of drug therapies for pediatric oncology, researches must choose among drugs being developed for adult oncology, where the market is vastly larger. “We pick those that seem best suit-
ed for testing in pediatric oncology,” says Moscow. “There are many new potential drugs being developed, and it is an exciting time for that reason. The challenge is to figure out which of these agents will make it through the process of being approved for adult indication and then determining which of those would be best to test in pediatric cancer applications.” This requires a lot of money and a coordinated effort. “When you get down to diseases that occur with 500 to 1,000 kids each year, you can see why drug companies do not spend 10 million dollars developing a drug for that size a population,” says Moscow. “That is just the reality of the situation. We have to take the drugs that are being developed and figure out from the biology of the tumors which ones might be the most effective.” According to Moscow, pediatric oncology is a very specialized practice where a small number of children receive intensive care for many years. “The children and their families go through a heroic struggle involving very complicated treatment plans,” he says. “This long process requires very highly trained staff and in order to provide this level of care for such an extended time we really do need the support of the community.” ◆ March 2011 9
10 M.D. Update
Finance
A Common Role Reversal: Child Cares for Parent So many of us are in the “sandwich generation”, the cohort of baby boomers who are simultaneously concerned with the wellbeing of both parents and children. Even if your parents are doing fine right now, if either or both of your parents are still alive you should consider this fact shared by one of my neurologist friends: 50% of those of us who reach age 85 will suffer some sort of cognitive impairment. That statistic alone warrants good planning. It is an important consideration not only for ageing parents, but for our own financial plans – especially since financial planners routinely plan for clients to be able to afford to live to age 100 or beyond. When we have an interview with a client, I generally ask, “Is there a possibility that you or your spouse will need to provide support for a parent?” Of course, because the conversation is about financial planning, the listener believes that I am asking merely about monetary support. Far too often, it is obvious that this is the first time
your own financial plan. The more likely case is not the sudden emergency, but the slow progressive course of ageing that results in one or both parents suffering some BY Scott Neal sort of cognitive issues that prevent them from successfully living alone any longer. What then? Viewed systemically, upon whom can elderly parents rely? Now is the time to do the planning with input from the whole family. But how does one undertake such planning? The first step is to identify and write down the goals of the elderly parents. The importance of achieving understanding and acquiescence or agreement by each family member cannot be understated. Most likely the goals of elderly parents will involve remaining inde-
The ideal scenario is to conduct all the planning prior to any sort of need, while everybody in the family is still healthy – physically and mentally. that the question has ever been contemplated. The answer is sometimes “yes” but is usually, “no.” However, when we consider our family as a system, the idea of support is much broader than simply providing direct financial support. I think that you will agree that non-financial support can certainly have a financial impact. Take for example, parents who live in a distant city. What will you do when Mom calls and says, “I have fallen and broken my hip”? Your medical-practitioner, problem-solving mind will kick into overdrive and you will quickly consider the options. Whether you travel to her, bring her to you, or find someone to be your surrogate, each of the options comes at a distinct cost to you, in lost productivity if nothing else. It is certainly a cost that any of us may be very willing to bear; but there is a cost nevertheless. This needs to be factored into
pendent for as long as possible. We have often heard it expressed in negative terms by the elder, “I don’t want to be a burden on the family.” Step two is to identify the obstacles that might get in the way of achieving any one of the goals. Step three is to find the way around the obstacles. Granted, this is easier said than done. It depends on the family, but a skilled facilitator of the process may prove to be in order. The ideal scenario is to conduct all the planning prior to any sort of need, while everybody in the family is still healthy— physically and mentally. We are told that this is an incredibly difficult discussion for the child to open. It is far better for the elder to start the conversation. If they simply won’t do that, one way to ease into it is to say, “Mom and Dad, I have been working with an advisor to develop a really good plan for my own incapacity; do you mind
if we talk about what you would want to have happen if either or both of you became incapacitated tomorrow?” You could start with the legal documents, which should be drafted by competent legal counsel. Most of the readers of this column have likely seen these documents in patient charts. Beyond the usual estate planning documents, such as a will and/or trusts, there are some documents that everyone should consider executing that address the needs of a person who is incapacitated. Durable Power of Attorney. This is a document that allows someone else to act on the maker’s behalf. To be truly effective, the documents will likely give broad powers to the person named as attorney-in-fact. That person has a fiduciary obligation to act in the maker’s best interest, but great care should be exercised in naming the person. We think it is a good idea to name a successor or two, in case the first one cannot or will not serve. It is also a very good idea to seek the person’s approval before naming him or her. The word durable means that the document will survive the incapacity of the maker. Some documents only become effective when an incapacity occurs. They can be written to take effect immediately. There are pros and cons to each and you should discuss these with your legal advisor. The Health Care Surrogate. This document names another to make health care decisions on your behalf. Consideration should be given to as to the skill and disposition of the person named to fill this role. The Living Will. This is a document that names another to make the decisions regarding life-prolonging treatment, nutrition, and hydration. Kentucky has a prescribed form for this document. Our firm uses an outline called The Map for Those Who Will Care for Me in designing the plans discussed here. We will make it available to you, free for the asking. Scott Neal, a CPA and CFP, is President of D. Scott Neal, Inc. a FEE-ONLY financial planning and investment advisory firm. He can be reached at scott@dsneal.com or toll free at 1-800-344-9098. ◆ March 2011 11
law
Physician Certification Rules Change for Home Health and Hospice with Molly Nicol Lewis Because home health and hospice care are so often ordered for patients, physicians should be aware of important new rules about how they must order these services. The Patient Protection and Affordable Care Act (“ACA”) established new rules for physician certification of patients’ eligibility for home health and hospice services that have now been fleshed out by regulations. While the long-standing requirement for physicians to order and certify the need for home health remains unchanged, new requirements affirm the role of the physician as the person who orders home health care based on the personal examination of the patient. New certification requirements for hospice patients focus on continued patient eligibility, as patients who outlive the initial prognosis of a less than six-month life expectancy must be recertified. To certify a patient for either home health or hospice, a physician must now have a face-to-face encounter with the patient.
Home Health Requirements
The new law requires that a physician who certifies a patient as eligible for Medicare home health services must actually see the patient. The new rules also allow the requirement to be satisfied if a non-physician practitioner (“NPP”), like a physician assistant or a
nurse practitioner, sees the patient when the NPP is working for or in collaboration with the physician. The new law is intended to stop practices where a home health assessment is provided over BY Lisa English Hikle the phone to a physician who does not personally affirm the patient’s condition. As part of the certification form itself or as an addendum to it, a physician must document (1) that the physician or NPP saw the patient and (2) how the patient’s clinical condition supports a homebound status and need for skilled services. The face-to-face encounter must occur within the 90 days before the start of home health care, or within 30 days after the start of care. This new requirement is meant to assure that the physician’s order is based on current knowledge of the patient’s condition. When a patient’s clinical condition changes such that the primary reason the patient requires home care changes, the original patient-physician encounter will not satisfy the requirement. Instead, another face-toface encounter is required within two weeks of the start of home care. Even with regulations, how this two-week encounter rule
will be applied is unclear. It is also important for physicians and NPPs to know that, according to agency comments, certification of a patient’s eligibility must be documented with a patient’s medical record and not on a form provided by a home health agency. The new rules also allow a physician who attended to the patient in the hospital but who does not follow the patient in the community, such as a hospitalist, to certify the need for home health care based on their face-to-face encounter with the patient in the hospital. The hospitalist may also establish and sign the plan of care. Essentially, Medicare will allow hospitalist to initiate the orders for home health services and then hand off the patient to his or her community-based physician to review and approve the plan of care. Finally, in rural areas, the law allows the faceto-face encounter to occur via telehealth in an approved originating site.
Hospice Requirements
Significant changes in the requirements for certification of a patient’s eligibility for hospice care have also been made by the ACA and through implementing regulations. To establish eligibility for hospice care, a patient must be considered terminally ill with a life expectancy of six months or less. To address concern over determinations of continued eligibility for patients who live longer than 180 days, new requirements for
To certify and recertify a patient for home health or hospice, a physician must now have a face-to-face encounter with the patient. This will be burdensome on hospice providers that do not have physicians on staff to make these face-to-face encounters. Attending physicians will be called upon to perform assessments for recertification and may be asked to make home visits considering the clinical condition of the patients. 12 M.D. Update
face-to-face encounters have been imposed. While the criteria have remained the same, the evidence required to document continued eligibility has been changed to include face-to-face encounters. For a patient to be considered terminally ill, the individual’s attending physician and the medical director of the hospice provider must certify that the individual has a life expectancy of six months or less. Thereafter, the medical director or a physician member of the hospice team must recertify that the beneficiary is terminally ill at the beginning of each 60 or 90-day eligibility periods. The ACA now requires a hospice physician or NPP to have a face-to-face encounter with every hospice patient to determine the continued eligibility of the patient prior to the 180-day recertification and prior to each subsequent recertification. The ACA also
requires that each hospice physician or NPP attest that the face-to-face encounter took place. Recertification visits by physicians or NPP must be made not sooner than 15 calendar days prior to the recertification and subsequent recertification deadline. These visit findings must be used by the certifying physician to determine continued eligibility for hospice care. These changes impose burdensome requirements on hospice providers that do not have physicians on staff to make these face-to-face encounters. Attending physicians will be called upon to perform these assessments for recertification and may be asked to make home visits considering the clinical condition of the patients. While CMS has announced a delayed enforcement of these rules until the second quarter of 2011, full compliance with the
certification requirements for both home health and hospice services is required by April. CMS expects physicians and home health/hospice providers to collaborate and establish internal processes to ensure compliance. While these changes may be considered small in comparison to other ACA changes, these are very important for physicians who are the gatekeepers for patient access to home health and hospice services. This article is intended as a summary of newly enacted federal law and does not constitute legal advice. Lisa English Hinkle is a partner of McBrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. Hinkle concentrates her practice area in health care law and is located in the firm’s Lexington office. She can be reached at lhinkle@mmlk. com or at (859) 231-8780. ◆
March 2011 13
Practice Management
Mandatory Compliance Looming Large Compliance programs for healthcare organizations will soon become mandatory as part of the Patient Protection and Affordable Care Act of 2010. While compliance programs have largely been voluntary since their inception 12 years ago, the Secretary of Health and Human Services (HHS) is required by this Act (Section 6401) to implement the requirement that providers establish mandatory corporate compliance programs as a condition for enrollment in federal programs, including Medicare, Medicaid, and CHIP (Children’s Health Insurance Program). With this mandatory requirement, the Office of the Inspector General (OIG) is charged with focusing even more aggressively on minimizing fraud and abuse. Before PPACA, mandatory compliance has only been applicable to those healthcare organizations with federal contracts exceeding $5 million or those providers and suppliers who have been sanctioned by a Corporate Integrity Agreement (CIA) as a result of
specific timelines for implementation, as well as to determine the core elements that must be included in all compliance plans. Compliance programs are not new to healthcare providers BY Patricia Cordy Henricksen and many organizations have already voluntarily adopted their own versions of compliance programs. Mandatory compliance, however, changes the playing field with the government mandating the core elements, as HHS will have the ability to direct the focus of providers specifically to include issues that the government wants addressed. HHS could add elements to include new self-auditing and self-reporting requirements, which would shift much of the burden for enforcement back to the providers.
It is clear that, with mandatory compliance looming on the horizon, providers should revisit their existing compliance programs, updating and revising them as appropriate. For those who do not yet have a compliance program, development, and implementation of a practice-specific compliance plan immediately is essential.
findings of fraud and abuse by the OIG. Mandatory compliance is meant to enable the HHS to further close the gap of fraud and abuse that is estimated to be $90 billion dollars annually. While PPACA states that any provider of medical care or services must establish a compliance program, implementation timelines are not yet defined. (Information on timelines and more is available at www.healthcare. gov/law/introduction/index.html.) The HHS Secretary is now authorized to determine the 14 M.D. Update
Failure to implement a compliance plan will obviously carry penalties but, interestingly, Section 6401 does not identify any specific penalty, although it also does not limit the ability of HHS to impose any penalties for this failure. It can readily be assumed that one penalty for failing to implement an appropriate compliance plan will result in pulling a provider’s enrollment in any government insurance reimbursement program since Section 6401 specifically creates new conditions for enrollment
with Medicare, Medicaid, and CHIP. It is clear that, with mandatory compliance looming on the horizon, providers should revisit their existing compliance programs, updating and revising them as appropriate. For those who do not yet have a compliance program, development, and implementation of a practice-specific compliance plan immediately is essential. In their original regulation promoting the adoption of compliance plans, which identified the “Seven Key Elements of Compliance Programs”, the OIG recommended these components for an effective compliance program to include:
Conducting internal monitoring and auditing
• Developing and implementing Standards of Conduct, compliance policies and procedures • Designating a Compliance Officer or contact person • Conducting thorough training and education of professionals and staff • Responding appropriately to detected offenses and developing corrective action • Developing open lines of communication • Enforcing disciplinary standards through well-publicized guidelines. With a mandate from Congress for implementation of compliance plans as a condition for enrollment in federal programs, as well as additional entities (RAC) conducting more aggressive fraud and abuse investigations, it is clear that the time to contact a healthcare compliance plan professional is now. Of course, according to the OIG, having a compliance plan and not using it is worse than not having one at all. Patricia Cordy Henricksen, MS, CHCA, CPC-I, CPC, CCP-P, PCS, is senior vice president of Soterion Medical Services and is a certified instructor of the Professional Medical Coding Curriculum for the American Academy of Professional Coders. More information is available at www.soterionmedical.com and by calling (859) 233-3900. ◆
March 2011 15
cover story
Comprehensive Pain Medicine (L-R)
Luis Vascello,MD Rick Lingreen, MD, Jay Grider, DO/PhD
Interventional Pain Specialists Inspire a New Era of Medicine
FRANKFORT
In early 2001, the US Congress declared that the decade of pain had
arrived - a movement emphasizing the education of patients and physicians as to effective options for the diagnosis and treatment of pain. Following the success of the 90’s Decade of the Brain, the Decade of Pain Control and
Research was the second congressionally-declared medical decade. The emphasis on treatment options led to the liberalized use of opioids for chronic benign pain (CBP) which, prior to these efforts, had often been reserved for acute pain and cancer pain treatment. By Megan C. Smith Interestingly, the increase in the use of opioids for CBP was not necesPhotography by Kirk Schlea sarily accompanied by a strong evidence base for how and when to use these medications. As a result, patients were often titrated to high dosages of opioids with surprisingly marginal results. This led to the observation that opioids were not effective in all patient groups and occasionally exacerbated the problem. The decade of pain is gone, but at least two hard facts linger on: Millions of Americans are in pain, and subspecialists in the discipline of interventional pain medicine are developing new tactics to combat the complex personal and societal issues in chronic pain management. Estimates vary, but somewhere between 35 and 50 million Americans experience the difficult to treat, recurring pain of disease, aging, and injury that contribute to CBP.
16 M.D. Update
on long term opioid therapy. Patients who do not show long term increases in function and decreased pain or who begin to exhibit adherent behavior with regard to their medications are carefully managed. Grider notes that often, opioids are not the first line of treatment but can be useful in a comprehensive setting. “The literature would suggest that there is little long term data to guide us to which opioid to use, what doses are acceptable, and which patients will likely benefit,” he says. “As such, the comprehensive evaluation approach is critical to determine success.” “Ultimately,” Grider adds, “it is important to note that many patients will not require or be trialed for opioid therapy as other methods of diagnosing and treating pain are effective.”
THE ERA OF PAIN MEDICINE
In the early stages of pain medicine, physicians took many approaches despite little evidence base for some procedures. Throughout the 70s and 80s, many pain medicine programs focused on a functional rehabilitation model that was often characterized by inpatient intensive behavior techniques and physical reconditioning to maximize function and decrease disability. These programs were successful from an outcomes standpoint, but many were a casualty of the reimbursement system which shifted care away from the inpatient setting. At the same time, an explosion in technology and imaging gave rise to minimally invasive interventional treatments. Many of these new treatments were offshoots of OR-based regional anesthesia techniques. Led by anesthesiologists, the practice of interventional pain medicine soon engaged the expertise of neurologists and physical medicine and rehabilitation physicians. Today, the best evidence suggests that a comprehensive approach to the patient with pain is superior to reliance upon any one modality exclusively. Patients who are only offered opioids for chronic treatment may not achieve the best results, and, conversely, not all patients respond to intervention with improved function and decreased pain. The hallmark of a quality multidisciplinary pain program will have decreased pain with improved function (as assessed by ability to participate in activities of daily). It will utilize fewer medical resources by decreasing or eliminating emergency room visits and anxiety over what are often acute flare-ups of a chronic problem. Three Central Kentucky physicians, Drs. Rick Lingreen, Luis Vascello, and Jay Grider, working in separate practices, share a philosophy of patient care. They believe that the multidisciplinary approach best meets the needs of their patients while supporting the primary care and surgeons who are referring patients. Utilizing the medical home model, they give patients an established place to turn for their pain problems while working closely with the primary care physician to create an informed and comprehensive treatment plan tailored to the individual needs of the patient.
Three Central Kentucky physicians,Drs. Rick Lingreen,Luis Vascello, and Jay Grider, working in separate practices,share a philosophy of patient care. They believe that the multidisciplinary approach to the treatment of pain best meets the needs of their patients while supporting the primary care and surgeons who refer them. The use of opioids for CBP is somewhat controversial, and while not all patients with pain would be appropriate for opioid therapy, Lingreen, Vascello, and Grider all acknowledge that in the properly selected patient opioids can be very effective. While they practice independently and therefore differently, each program carefully screens patients for effectiveness before embarking
INTERVENTIONAL PAIN THERAPY
“Intervention pain medicine has arrived,” asserts Lingreen. The independent practices of Grider, Vascello, and Lingreen are distinct in focus yet represent the wide base of comprehensive treatments comprising the discipline today. Medicine, intervention, injection, minimally invasive lumbar decompression, spinal cord stimulator, or intrathecal pumps are among the pain management options available to patients. Grider notes that each works with different patient demographics, and being able to consult one another on unfamiliar cases supports their desires to remain independent. “It is nice to have colleagues that challenge you to be the best that you can be.” Within the scope of interventional treatment are injective therapies such as lumbar and cervical epidural steroid injections, single nerve root injections, sympathetic blocks for Complex Regional Pain Syndrome (formerly Reflex Sympathetic Dystrophy or RSD), as well as trigger point therapy for myofascial pain syndromes. These treatments assist with many spinal inflammatory conditions or are often used diagnostically to determine the anatomic source of pain. “Significant numbers of patients respond to these therapies alone,” says Grider, who believes that proper physical examination of the patient is key to proper use of Interventional techniques. “I commonly see patients who have received March 2011 17
cover story lumbar epidurals, sometimes 3-4 in a series with no effect because the problem is such that an epidural is not the best choice,” he says. Implantable Pain Therapies are available for those with pain that lingers despite proper diagnosis and judicious use of injective therapy. There are many effective uses of implantable technologies that can decrease pain and increase function. For example, patients with radicular leg pain may have impressive decreases in pain with transforaminal epidural steroid injections, but because the nature of the inflammatory problem is moderate to severe, the targeted application of steroid does not itself provide lasting relief. The diagnostic response to the injection may suggest that a patient may be a candidate for spinal cord stimulation. “Spinal cord stimulation, in the properly selected patient, can have amazing results,” says Vascello. “This therapy is unique in medicine in that very few permanent procedures integrate a trial period to see how the patient interacts with the therapy. If the stimulation is not effective, the leads are removed in seconds in the office setting. A bandage is applied,” he continues, “and there is little to no recovery.” Stimulation has been successfully used for most nerve pain syndromes such as radicular pain before or after spine surgery, RSD, nerve pain after hernia surgery, and increasingly for back pain using new techniques employed by interventional pain specialists. For those who continue to have refractory pain or who have lost efficacy with oral opioids, the use of a small implantable pump to delivery pain medication directly to area of need, i.e. the spinal cord is very effective. All three physicians utilize spinal delivery of medications in their practices because “many patients are referred who have tried and failed multiple pain medications. They have few options left. This method of delivery can eliminate many of the unpleasant side effects of opioids and actually give better relief without the issues of tolerance or diversion,” says Grider. Like stimulation, a 2-4 day inpatient trial period precedes implantation of the pump to best ensure that the patient will respond well to the therapy. “Occasionally a patient will have less success than they 18 M.D. Update
initially thought during the trial, but most issues related to whether the therapy will be successful in decreasing pain come to light during the trial period,” says Grider. Functional rehabilitation, including the use of behavior techniques, is integral in the comprehensive approach to pain management. “For some patients, we are unable to significantly decrease pain despite aggressive use of our techniques and medications” says Grider. “For those individuals, it is important that we assist with their coping and support systems to ensure that we are treating the whole person.” A pain psychologist can help patients learn biofeedback techniques and identify self-limiting behaviors which will defeat the rehabilitation goals of the program. For high risk patients, such as addicted patients or patients with previous addiction problems, says Vascello, “We have modalities that they might not otherwise have access to.” Addicted pregnant patients, for example, are treated them with medicines to get them through pregnancy. Lingreen, Vascello and Grider are working on a curriculum to help primary care
pain physicians to improve the quality of life for millions of patients suffering from lumbar spinal stenosis. MILD, or minimally invasive lumbar decompression provides enduring relief for the classic patient with spinal stenosis presents to their doctor with back pain upon standing and walking. This pain is usually relieved by assuming a recumbent position or forward flexion, and upon walking the patient will develop pain or fatigue in the lower extremities known as neurogenic claudication. These symptoms are also typically relieved by rest. Lingreen, Grider, and Vascello are among a handful of US physicians utilizing the new MILD procedure. “There is growing literature which points to the safety and effectiveness of this minimally invasive approach” says Lingreen. Lingreen and Grider recently published the results of a series of over forty patients with excellent results in Pain Physician*, the journal of ASIPP. “Other than some mild soreness that lasts an average of 3-5 days, patients experienced very little in the way of after procedure effects,” says Lingreen. “Conversely, over 70 percent had significant pain relief and were able to begin walking longer distances without the use of a cart or walker.” The MILD procedure involves a minimal approach to remove small amounts of tissue from the outside surface of the bone and ligament in the lumbar spine. It takes less than an hour to do, is performed under light sedation, and has little to no recovery time. Lingreen asserts that nationally there have been Drs. Lingreen (left) and Vascello concur that functional rehabilitation, including the use of behavior techniques, is no major adverse events integral in the comprehensive approach to pain management. with therapy - suggesting its ultimate safety. “This prophysicians help situations like this. Vascello cedure is ideal for those with debilitating notes that primary care physicians are con- symptoms from spinal stenosis who are not genially oppressed by prescribing narcotics great candidates for open surgery” he says. on an ongoing fashion because they often “Often these patients have no treatment times do not want to set up the same kind options, and the results are impressive.” of compliance system. Within the last year, a breakthrough med- Pain Physician 2010; 13-555-560 ical technology has allowed Interventional ISSN 1533-3159. ◆
Perspectives 30% Cuts to Providers if Medicaid FY2011 Remains Unfunded FRANKFORT In a press release dated March 4, Kentucky Governor Steve Beshear vowed to fight cuts totaling $148.5 million to education and public safety in order to prop up Medicaid. Instead, Governor Beshear proposed transferring $166.5 million from the FY2012 Medicaid budget to FY2011, then capturing those savings through expanded managed care programs and other program efficiency measures. “Other states have implemented expanded managed care contracts that have generated savings while improving health outcomes,” said Health and Family Services Cabinet Secretary Janie Miller. “We are confident that we will replicate those results. The Cabinet is poised to act quickly and aggressively to achieve contracts with managed care organizations to capture the required savings in FY 12.” Without passage of a Medicaid bill, the only alternative would be to cut health care provider rates by 30 percent, warned Secretary Miller, which would also lead to layoffs, furloughs and reductions in health care services.
What do you think? Email your response to: mcsmith@md-update.com
Dr. Rick Lingreen performing a MILD procedure at Frankfort Regional Medical Center. © Kirk Schlea 2010. March 2011 19
Physician Q&A
Dr. Whitney F. Jones, Founder of the Colon Cancer Prevention Project Colon cancer is the second leading cause of death in the United States, and Kentucky ranks first among states in incidence of mortality from the disease. Presently, only 30 percent of preventable colon cancers are being detected at an early, treatable stage. Kentucky Colon Cancer Screening Program (KCCSP) is the state-funded program to provide access to screening colonoscopies for Medicaid and the uninsured. We have asked the CHFS for their side, but what can you tell us about the progress of KCCSP? The answer is there is no funding. We need more media asking politicians why they are not funding KCCSP. They need to ask Finance Secretary Jonathan Miller why this is not a priority since we are the number one state in the nation for colon cancer mortality. There are four things in public health that have a return on investment in terms of preventative services: vaccinations, Pap smears, anything to reduce smoking, and colon cancer screening. It is not a long list. We hear lots of excuses, ‘We’re in a recession,” or ‘We have fiscal issues,” but if you have a potential solution like colon cancer screening that saves money, it should compel you, not constrain you, to start it now. Colon cancer will not go away if you don’t look for it. What we want to know is how do we get the 10-15 percent of the uninsured to get screened so that they don’t end up on Medicaid with advanced colon cancer. If you are uninsured, 75% of the time your cancer is going to be
20 M.D. Update
advanced when it is diagnosed. If you are on Kentucky Medicaid, it is going to be 63%, if you are on commercial insurance, it is about 50%, and VA is about 40%. What factors contribute to disparities in advanced colon cancer diagnoses? One is screening. Two are risk factors or other issues in that population such as smoking and obesity, which play a role. Three is family history, which is variable. Most people who get colon cancer do not have a family history, but 20 percent do. For those people, you want to increase screening. For all those folks who are uninsured, who come into the hospital with rectal bleeding and weight loss, we see this statement ‘Please have patient and social services apply for Medicaid.’ Treating colon cancer is a $250K process. By not screening these uninsured folks and preventing these advanced cancers, we are taking colon cancer at its most expensive and least curable moment and dumping it into our public healthcare system. Fifty years ago, cervical cancer was the number one cancer and killer of women in America. The number one killer in Mexico today? Cervical cancer, because they don’t do the Pap smear. Same for India. It took the Pap smear decades to be accepted and become part of public health. How long is it going to take us to do this time around with colon cancer? What is the Colon Cancer Prevention Project’s advocacy platform? There are three components to colon
Dr. Whitney F. Jones, founder of the Colon Cancer Prevention Project
cancer screening. The first is education, knowing that you need it. Second is access, being able to be screened, and the third piece is execution. There are people who have the first two but will not do the third. We just did a study from 2008 where we asked people who had not been screened what their major reason for not being screened for colon cancer. The top two reasons, at 27% each, is ‘My doctor never told me.’ There are still physicians who do not routinely and systematically refer patients to colon cancer screening. We are working on educating those folks. There is many measures coming through Healthcare Effectiveness Data and
Information Set (HEDIS) and the governmental processes to encourage and incentivizes these folks. The second reason, also at 27%, was “I didn’t have any symptoms so I didn’t think I needed it.” That goes right back to education. Access is a smaller part of why some people did not get screened, but it is an important reason because these people have major healthcare disparities. Surgery, chemo, radiation, liver resections, $10K/month chemo. All three of these things, education, access, and execution, need to happen. Mortality and incidence rates in the last decade in Kentucky are down 16% each. That translates into about 160 fewer people per year dying from it, and 480 fewer people per year being diagnosed with it. At the same time, our screening rates have gone up. Screening in 1998 reached 34% of the population. As of 2008, we are screen-
ing 64%. We have gone from the perennial fifth worst screening rates in the nation to the 23rd best. We’ve do that without any devoted monies from the state up until this last legislative session when we got some Coal Severance tax money that went to four counties in Appalachia. Do you have recommendations for how public funding should change? We have several counties with pilot programs: Pike, Floyd, and Christian counties have active screening programs right now. Letcher and Martin will come online once their funding comes in. The Coal Severance tax pays for each of the programs except in Christian County, where they are using locally raised revenue. Nationally, public health is leading those states that have made the greatest strides. Here, we are still in the outreach and advocacy stage trying to get our public health organizations to take a
leadership role. They are engaged and participating, but I would suggest that they are not leading. This is the number two cancer killer in our state, we are the number one in the nation, and it saves money in our budget. Instead of spending money in Medicaid when they have cancer, we spend money out here to keep them from ever getting it. I wonder, where is the outrage? I think we should ask the political guys in a forum, ‘What is your position of screening colon cancer for the uninsured?’ We are also working with Kentucky Medicaid and Passport, the 18-county Medicaid HMO surrounding Louisville, because those folks have access. We want to make sure they have information and execute. Our data shows were are not screening people as effectively as we can be. Effective screening saves lives and money. Our fiscal issues should compel us, not constrain us. ◆
In response to our request for information about the funding of the KCCSP, Cabinet for Health and Family Services assistant communications director Gwenda Bond sent M.D. Update the following statement:
“In the 2008 Regular Session of the Kentucky General Assembly, legislation was enacted which provided for the Department for Public Health to develop a colon cancer screening program to address the need for colon cancer screening for the uninsured, with implementation subject to availability of funding. Due to budgetary constraints, no funds were appropriated to implement the legislation. Notwithstanding
funding constraints, the Department for Public Health has moved forward to establish a screening program protocol for use by local health departments (some local health departments are using their own resources to establish screening programs) as well as providing outreach and education in order to raise public awareness and increase the rates of colon cancer screening... In addition to the above
efforts, the Department is working with other service delivery partners such as local health departments and Federally Qualified Health Centers to provide outreach to high need populations. Finally, the Department continues to pursue grant opportunities that would enable the Department to fund colon cancer screening programs on a statewide basis. It is also noted that in
the FY 10- FY 12 Executive Branch biennial budget, $200,000 in coal severance funds were appropriated to the Kentucky Department for Local Government in FY 11 as line items for the county fiscal courts in Martin, Letcher, Floyd, and Pike Counties to support colon cancer screening and care. The Department for Public Health has provided technical assistance and outreach to these four counties in anticipation of those counties receiving coal severance funds. ◆
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Physician Viewpoint
Doctors Can Help Stem the Kentucky-Florida Drug Pipeline
22 M.D. Update
Photo by Kirk Schlea, October 2010.
By George W. Privett, Jr., MD Illicit drug use has become a topic of local concern because of the explosion of “Pain Clinics” mostly located in Central Florida, where large quantities of legal prescription drugs can be easily obtained by patients with complaints of chronic pain. These centers usually operate on a cash basis and often have their own pharmacy for dispensing the drugs. The drugs most often obtained are narcotics and anti-anxiety drugs such as OxyContin, Percocet, and Zanax, all of which have high street value. There seems to be a constant stream of carloads of people driving from Kentucky to Florida to be seen and treated in these “clinics.” Over the last 2 or 3 years, the staff of Lexington Diagnostic Center & Open MRI began to notice a pattern of receiving more and more requests from these pain clinics in Florida to authenticate MRI reports that were being provided by patients to the clinics. Our practice administrator, Deborah Winslow, reported that she was getting up to three or four calls a week for such verifications, which took a significant amount of time to respond to. She would ask that the report be faxed to us and she would compare the fax to our original. Sometimes the reports would have been altered by changing the patient’s name, date, and/or diagnosis, and we would report this to the clinic. In October 2009, she reviewed all of the requests that she had received since 2004. Sixty-one percent of those authentication requests were forged documents. For those reports which were authentic, it then occurred to us that these pain clinics were using an abnormal MRI report (usually of the spine with evidence of a disc bulge or herniation) as “hard” evidence to put in the record to support the patient’s claim of pain and to justify the prescribing and selling large amounts of narcotics. As a neurologist and neuro-imager, I knew full well that an abnormal MRI does not equate with pain and that by providing the “authentication” of the report to these clinics, we were
George W. Privett, Jr., MD is medical director of Lexington Diagnostic Center & Open MRI.
enabling these abusive and illicit pill mills. On one hand, we felt an obligation to patients who had obtained tests at our facility and were torn over providing the authentication. On the other, we did not want to be part of the problem leading to the illicit drug trade. Our compromise was to invoke the use of KASPER (Kentucky All Schedule Prescription Electronic Reporting). This reporting system is used very successfully in Kentucky and most other states, to track patients who have obtained narcotics
from several doctors and pharmacies in Kentucky. It also tracks the doctors who have prescribed them. Ms. Winslow would tell the clinic administrators that if they would obtain a KASPER report on their Kentucky patients – and if it showed no evidence to suggest drug abuse in Kentucky – then we would provide the authentication for them. Many pain clinic doctors indicated that since they were in Florida and were not Kentucky doctors, that they could not access KASPER. However, that is just not
Our practice administrator Deborah Winslow would tell the Florida pain clinic administrators that if they would obtain a KASPER report on their Kentucky patients – and if it showed no evidence to suggest drug abuse in Kentucky – then we would provide authentication of our MRI reports for them. true. When informed they could indeed sign on to KASPER, the clinic personnel refused to do so. After all, the last thing they really wanted was to know and have documented in the chart that they were providing large amounts of narcotics to drug seeking patients. This would put them out of business. In 2009, the Florida legislature passed
a bill to start a similar drug reporting system, much to the delight of Kentucky officials who would like to see a stop to the Kentucky Pain Pill Pipeline. However, in a stunning turn around, Florida Governor Rick Scott has recently cut that funding from the proposed budget for such a system, citing his opinion that Florida should not be in the business of monitoring drug use.
I would suspect that a big part of Central Florida economy is based on shady narcotic drug trade. In any event, what we can do in Kentucky to help is to be sure not to enable the Florida pill mills and Kentucky patients who are driving there to obtain narcotics or sedatives that are being used for illegal purposes. If you or your office receives a request for authentication or verification of medical records or tests from an out of state pain clinic on one of your patients, and if you are a prescriber for medical treatment of a current or prospective patient, you have the right to obtain a KASPER report on your patients who may be seeking drugs elsewhere. You can also tell any physician who calls about a patient that they can also access the KASPER system in Kentucky. ◆
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EHR Madness Event - March 24th
“Get in the Game... Embracing EHR” Two panels of experts address your concerns about EHR. Learn best practices for a successful transition.
Event Details: March 24, 2011 Crowne Plaza- S. Broadway, Lexington, KY 5:30 - 6:00 pm Heavy Appetizers & Cocktails 6:05 - 7:15 pm Panel Discussion 1 - My EHR Experience: Borders & Associates 7:15 - 7:25 pm Refreshment Break 7:25 - 7:50 pm Panel Discussion 2- Financial Perspective: Making the EHR Investment 7:50 - 8:00 pm Additional Q & A
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Reserve your Seat : Contact Jessica Pantatello 859.255. 0155 x 242 JPantatello@NetGainIT.com or visit www.NetGainIT.com
March 2011 23
Physician Viewpoint
Shocked by Passing of SB 110 Photo by Kirk Schlea, November 2010
By Ken Weaver, MD Lexington Citizens across the Commonwealth are in shock and disbelief at the passage of the bill that flew out of the Senate as SB 110, which is known as “Better Access to Quality Eye Care Act”. It was likewise expedited through the House and signed by the Governor in remarkably short order. It was not given adequate review in either chamber. In fact, it was not even vetted in the appropriate Health and Welfare committees, which deal with such issues. The absolute last thing this bill does is provide quality. To legislate the right to perform laser and scalpel surgery without medical and surgical education is absolutely wrong. Optometrists are not exposed to indepth, if any, surgical training during their four years of school. Ophthalmologists, in stark contrast, must attend four years of medical school, serve one year as an intern and, then, undergo three years of extensive and intensive residency training, including first-assisting on hundreds of surgeries and performing hundreds more under close supervision. Exhaustive written and oral testing over all phases of eye diseases and surgeries must be successfully fulfilled after training in order to become certified by the American Board of Ophthalmology. It is this process that leads to quality eye care. Merely taking a weekend course with no foundation upon which to understand
Dr. Ken Weaver, ophthalmologist, performing cataract surgery in 2010.
the information presented is ridiculously inadequate. Perhaps the most important function of being an eye surgeon is knowing when not to operate, when to expect potential complications, and how to take correc-
Kentucky legislators who voted against the SB 100, or the Better Access to Quality Eye Care Act. Senators Voting Against
Representatives Voting Against
Katie Kratz Stine Joe Bowen Mike Wilson (Julie Denton passed after unsuccessful attempt at significant amendment.)
Susan Westrom Ruth Ann Palumbo Kelly Flood Sannie Overly Mike Nemes Bob DeWeese Joseph Fischer Brent Housman
24 M.D. Update
Jimmie Lee Tom Riner Kevin Sinnette Rita Smart David Watkins Jim Wayne (Not voting were Bill Farmer, Dennis Horlander, Thomas McKee, Tanya Pullin, and Steven Rudy.)
tive measures when these do occur. As physicians, ophthalmologists are not merely treating the eye, but, rather the entire patient. We must be able to correlate the eye findings with the systemic patient and interact accordingly with specialists in all fields of medicine. Access to eye care was merely an empty ploy for this bill. There is not a single citizen up the most remote hollow in this state who is more than one hour from an ophthalmologist. Quality surgery is absolutely worth the ride. However, the majority of patients referred by optometrists to ophthalmologists for cataract and LASIK surgery are not sent to the nearest physician, but rather significantly further away to Lexington, Louisville or, even, Southern Indiana. What does that say about concerns regarding long distance travel and expense? The cry over the expense of a second co-pay for the Medicaid patient to see an ophthalmologist also falls flat. Medicaid patients’ co-pay is $2. For those who cannot afford this sum, physicians routinely write it off. Scattering scores of additional $2050K lasers across the landscape will certainly skyrocket Medicaid deficits through significantly increased usage. The state optometry board is not satisfied with getting surgical privileges, but want to have sole discretion in deciding their scope of practice. This insults the intelligence of every Kentuckian. As anyone who has read a newspaper now knows, 25 states have soundly defeated this bill for the right reasons. Only Oklahoma has allowed it to slip by, and that was 13 years ago. Not another single state had been duped into falling for the
faulty claims of this bill, until now. Over 15,000 physicians in Kentucky have dedicated our careers to providing the best possible medical care for our patients and this legislation is contradictory to everything that we know is right for patient care. We must become more active in voicing our concerns on behalf of our patients. We can begin by thanking our legislators who courageously stood up for patient safety and did not merely weakly recite the embarrassing lines: “the skids have already been greased” or “the momentum is just too great to stop this bill”. The obvious rebuttal: It is never too late or the odds to great to do the right thing. It is simply wrong to legislate surgical skills for unqualified people on unsuspecting patients. ◆
March 2011 25
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By Megan C. Smith Photography by Kirk Schlea
Murphy Pain Center of Louisville is helping to correct Kentucky’s prescription drug problems by working with patients and primary providers in a collaboration of care and trust.
Leading by Example LOUISVILLE Pain, some say, is a new vital sign. Its importance is measured not only in terms of personal health and function, but also in terms of its overall impact on medicine as it consumes healthcare resources, drives up expenses, and threatens society with its risks of addiction and aberrant behavior. Physicians face risks of their own when prescribing pain medications, and the fear of sanctions for inappropriate prescribing prevents some from prescribing for pain at all. Still, the treatment of pain cannot be ignored; it is after all the number one reason why people seek medical care. New trends are emerging that may help alleviate the medical and societal concerns over pain. Improvements in prescription drug moni26 M.D. Update
toring as well as new technologies in interventional pain medicine are demonstrating many positive effects. According to James Patrick Murphy, MD, founder of Murphy Pain Center of Louisville, new interventional pain techniques, while impressive, are only one piece of the chronic pain puzzle. He says patients need everything available to get the best outcome. “That means if they have depression, the depression needs to be treated. If they need physical therapy, we need to refer them. They may need different types of medications – not just narcotics – but those other medicines like NSAIDs that go along with them,” says Murphy. “Various interventions, surgeries, therapies, medications,
and injections - it’s the whole program together that allows somebody to function at their best.”
The Function Philosophy
While one may think that the goal at a pain center is to decrease pain, the Murphy Pain Center (MPC) emphasizes improvements in function. Often, they do go hand in hand. As the pain relief is achieved, the functioning improves. Other times, the provider has to strike a balance, or he comes to a decision point whether to continue to treat the pain. John E. Stocking, MD, anesthesiologist with MPC, believes this is an essential aspect of the practice’s pain treatment philosophy. “If you are able to decrease pain with an increase of side effects that diminish functioning, it’s just not worth it,” he says. “The person’s activity level and ability to maintain daily housekeeping or continue to perform at work are vitally important. Sometimes,” says Stocking, “by continuing to treat the pain you are taking away from something that is probably of more value to that patient.”
Because chronic pain deeply affects patients’ wellbeing, treating pain with sensitivity to patients’ needs is very important. Murphy points out that many patients arrive with pain medication goals such as never taking narcotic medications, or getting off narcotics for the first time in years. Of course, in terms of the latter physical dependency may come to bear, but says Murphy, “we can come off a lot of it and try some other things as well, not just make the success that the patients has come off of everything. “Success means that the patient’s life is better,” says Murphy. The idea, he says, is not that patients leave MPC euphoric or happy, but that they are safely getting the best results possible within the legal bounds of appropriate medications and any other treatments. “This is a pain clinic,” he says, “but really it’s a make-your-life-better clinic.”
care doctors. This pain-to-primary collaboration derives from the responsibility to prescribe appropriately. Stocking points out that an individual provider cannot meet all of the patient and society needs for pain medications, neither for pain relief nor for the appropriateness of prescribing controlled substances. Today, he says, pain treatment is a team effort between the pharmacy, physicians (both primary care and pain special-
ists), law enforcement, and the patient. Stocking recalls a time in early 2008 when follow up visits for pain medications were overwhelming the practice calendar, taking over the physicians’ time and the practice’s resources, and forcing long waits on patients with other treatment needs. They realized that if they worked more closely with primary care, they would be able to provide more of the blocks and injections that they are trained to provide
No single provider can meet all of the patient and society needs for pain medications, neither for pain relief nor for the appropriateness of prescribing controlled substances. Today, pain treatment is a team effort between the pharmacy, physicians (both primary care and pain specialists), law enforcement, and the patient.
while optimally meeting the prescribing needs as well. “Before, we took care of every patient forever,” says Stocking. “Now we work with primary care in terms of prescribing. If a patient has medication needs, we can look at starting the patient on medications and making changes. But after about a 6-month period, we probably have the patient on a good schedule of medications and any injections they might need. That is when we get them back to a primary care provider where, as part of their regular care, the primary care physician provides for their continual pain needs.” Stocking notes that it is not the case that there is a greater need for prescriptions than injections; the practice today balances both. “A pain practice brings
Changes In The Delivery Of Care
There is a new protocol at work in the medical community and at pain centers like MPC. Not only are patients given access to a full spectrum of pain relief services, but providers are now engaged in a collaborative relationship with pain patients’ primary
March 2011 27
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James Patrick Murphy, MD, founder of Murphy Pain Center of Louisville, is board certified in anesthesiology, pain medicine, and addiction medicine.
in chronic pain patients who will need medications for the rest of their lives,” he says. “Injection patients, on the other hand, come and go. If they get good relief, then they won’t need more injections, or they come back for two years. “Without primary care providers, we would eventually get to the point where we would have no time to meet the needs of new patients, causing us to filter out the injection patients,” says Stocking. “It is important that the practice of pain management fits the community.” In this vein, MPC relies on the support services available in the community for physical therapy, acupuncture, and a variety of different modalities including occupational therapy, aqua therapy, and yoga.
Addressing Primary’s Concerns
The Kentucky Board of Medical Licensure released its opinion in the Fall 2008 newsletter that, in order to meet the needs of the community, pain specialists and primary care are going to have to work together in the treatment of pain. “Primary care doctors have a real con28 M.D. Update
John Edward Stocking, MD, board-certified anesthesiologist and pain medicine physician, performs blocks and injections that provide enduring pain relief.
cern as to the appropriateness of prescribing controlled substances,” explains Stocking. “They may feel trapped between being told to address pain needs and the fear of repercussions from over-prescribing or inappropriately prescribing. That fear is driving a lot of care.” “What the KBML is saying is that if we are really going to address pain out there and give it the priority that everyone says we should, then we have to back it up by working together.” Stocking explains that after patients are reestablished with their primary care provider, MPC provides follow up or consults on medication changes whenever the primary care doctor requires, typically 6-month, a year, and as-needed. Murphy notes that MPC does not enter into the medication relationship with a new patient until they have assurance from the referring doctor that they will take the patient back in six months. MPC returns
Michael Aines, APRN, was perhaps the first nurse practitioner in Kentucky specializing in pain medicine.
the patient not necessarily on the regimen that Murphy or Stocking chooses, but rather on the regimen that the primary feels comfortable with. “One of my passions,” says Murphy, “is to make sure that other doctors feel comfortable managing pain with our help.” Murphy writes and gives talks to many physician audiences on the pain-to-primary collaboration. In the January 2010 JKMA, he published an article specifically on this point called “The Chronic Nonmalignant Pain Ladder: A Novel Approach to Prescribing Opioids for Chronic Pain.” The pain specialists, Murphy says, should be viewed by the primary provider no differently than any other specialists. “If you have chest pain, you see the cardiologist, who gives you a stent or whatever procedure and, once you’re stable, sends you back to your primary care. You still have your problem, but you no longer need the specialist.” Murphy believes that empowering primary care is the way to accomplish this. “We give the physicians a real idea
of what they should be monitoring: urine drug screens, the use of KASPER, and thorough documentation,” explains Murphy. The KBML is in support of primary care doctors treating more pain patients, to which the board now says that a letter from the pain clinic stating that the prescribed drugs are appropriate should be enough for primary care physicians to proceed without fear of the board.
The Role Of The Patient
“In this field, you really have to remember that you have two patients out there. You got the patients you’re treating,” says Murphy, “and you’ve got society. These drugs can end up in other peoples’ hands, and we have to do what you can to minimize that.” Many patients today are used to taking medicines as needed, or in the past they have been given latitude to determine for themselves when and how much of a prescription drug to take. That is no longer the case. Patients face risks with the use of con-
trolled substances. Injuries caused by abuse or misuse, including overdose or addiction, may occur. MPC imposes strict guidelines on the use of prescription pain drugs utilizing a red flag system. Talking to patients about compliance with their prescription, watching out for diversion of the drugs to friends or to others for money, pill counts, and random urine screens allow the providers to ensure that both the patient and society are protected from aberrant behavior associated with controlled substances. Murphy concurs that it is the entire community’s responsibility – police, pharmacy, providers, patients – to adhere to
Pain Medicine from the NP Perspective By Greg Backus Michael Aines, APRN, was perhaps the first nurse practitioner in Kentucky specializing in pain medicine. He started working with Dr. James Patrick Murphy in 2000. Today, most of Aines work involves follow-up visits for medication management. Kentucky’s nurse practitioners are more restricted in writing prescriptions for controlled substances than those practicing in nearby states, including Indiana. “It makes it
difficult to change things for a patient if a doctor is not available at that moment. That is one reason why we attempt to always have at least one doctor in the office at all times,” explains Aines. As an active member of the Kentucky Coalition of Nurse Practitioners and Nurse Midwives, Aines seeks to expand nurse practitioners’ ability to prescribe a variety of medications, including controlled substances, to better deal with immediate needs and emergencies. Aines relates a telling anecdote:
Murphy Pain Center clinic supervisor Debra Tichenor prepares the day’s cases with Julie Lerner, practice administrator.
“We had one patient that came to us from out of state. She was on a lot of drugs and we were slowly bringing that down. The first time I saw her she told me that she had one back surgery, but her main problem was fibromyalgia. Then she told me that she had not been able to get out of bed for a month. Why would I give her more medication if she is not functioning? I began to wean her from pain drugs. Medications should improve patients’ quality of life. If that is not the case, you are not doing them any favors by continuing the same treatment.” Aines often refers patients to occupational medicine specialists and draws on techniques from physical medicine to develop rehabilitation plans for patients.
“I am really big on yoga for patients, and we use a lot of counseling for smoking,” he says. Smokers require about 30% more pain medication than non-smokers for the same amount of relief. There is an important place for nurse practitioners in pain management. Aines notes that this requires that physicians have trust and train NPs properly. “It is difficult for a physician to see enough patients to cover overhead, especially for follow up visits,” he explains. “Nurse practitioner involvement is advantageous from a business standpoint, and it is good for the patients because we have more time to educate patients than physicians usually do. That really has a positive impact on patient outcomes.” ◆
March 2011 29
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controlled substance guidelines. But does the greater responsibility to watch out for aberrant behavior make him feel like a policeman? “I feel like a doctor, like a therapeutic person,” he says. “The drug screens that we do, I do as a therapeutic endeavor. My goal is to create boundaries so that patients know that I’m watching.” Murphy observes that while addiction among chronic pain patients is rare – somewhere between 2-6 percent – bad behavior is quite common. “People are constantly giving a pill to someone else, undertaking, or overtaking so they run out early,” Murphy explains. “What we want is for people to use the drugs the way we prescribe them because that’s the way we stay safe. “We monitor patients as a universal precaution. You cannot tell who is going to abuse the drugs. You can guess based on risk factors, but sometimes addicts or people who are diverting medicines are the best patients. They look you right in the eye and you think, ‘there is no way this person is lying to me’ because they are adept at putting on a front. Drug screens are a major component of MPC’s universal precautions. Everyone gets a drug screen at his or her first visit and then various times of the year and whenever something goes wrong, personally or medically. Patients roll dice at each visit, and if 30 M.D. Update
they roll a 2 or 12, they get a drug screen. Addiction, according to Murphy, is the right drug in the right person at the right time. Sometimes it happens when a patient turns to a drug when they lose their job or get a divorce. Murphy believes that providers serve a therapeutic role when they look for these triggers to addiction. “If we detect them early, we can intervene and save patients from a tragedy or a bad outcome,” he says. “For primary care physicians, there are guidelines that you can follow to keep your patients safe. I know it’s hard, but it can be done.” Murphy, who is triple certified in anesthesiology, pain medicine, and addiction medicine, enjoys performing the advanced techniques of interventional pain medicine as well as complementary medicine techniques like acupuncture and acupressure. He has learned a lot over the years about how to treat pain, but he warns, “Nothing is foolproof.” “We in pain medicine don’t have to get it right every time,” says Murphy, “nor should we set that standard. What we must be is thorough and appropriate, and we cannot beat ourselves up if somebody fools us. They will.” The most important thing, Murphy says, is to do right by your patients. “I know its cliché, but nobody cares how much you know until they know how much you care.” ◆
SPECIALTIES
Colorectal Cancer Screening is Working Decline in the incidence of colorectal cancer reflects an increase in screenings, though more work is still to be done. By Gil Dunn LEXINGTON The diagnostic tool of colon screening for colorectal cancer shows a direct correlation to a decline in the incidence and morbidity from colon cancer, according to results from the CDC and the Kentucky Colon Cancer Screening Project. In 1998, 34% of the at-risk, over 50 year old population was screened for colorectal cancer. In 2008, 64% of the same population was screened. During that time period, incidence of colon cancer decreased in every significant category from 1.4% to 3%. Morbidity also declined at comparable rates. Earl G. Robbins, II, MD, in solo practice at Central Kentucky Gastroenterology in Lexington, affirms the benefits of colon cancer screening. “I’ve been saying for the last ten years that colon cancer is the second leading cause of cancer death in this country. In the last year, I can now say it is third. We have never seen a decline in any cancer mortality, at this magnitude, over a relatively short period of time. It is a direct result of the benefits of colon cancer screening over a mass population,” says Robbins. The Colon Cancer Screening Project, headed by Dr. Whitney Jones (see page 20, this issue) has had a profound impact in Kentucky. “I am very proud of what Dr. Jones has accomplished in taking our cause to the Kentucky legislature,” says Robbins. Now, the need is “to continue to promote the health and financial benefits of colon cancer screening by educating our fellow physicians and the general population.” A general gastroenterologist, Robbins treats all digestive diseases, however his practice is heavily weighted by colonoscopy screening. “I estimate that 35% of my practice is dedicated to the detection and prevention of colon cancer, with the screened population primarily between the ages of 50 and 80 with an equal ratio of men and women.” Unfortunately, the at-risk population will sometimes begin screening later than
Dr. Earl Robbins is assisted by Paul Johnson, OR tech. Colonoscopy screening makes up about 35% of Robbins’s practice at Central Kentucky Gastroenterology.
“We have never seen a decline in any cancer mortality, at this magnitude, over a relatively short period of time,” says Dr. Robbins. “It is a direct result of the benefits of colon cancer screening over a mass population.” is recommended. Published data shows that colon cancer screening should begin at age 50, or earlier depending on family history. Robbins states that Kentucky has a higher incidence of colon cancer in individuals under 50 than the national average. Robbins is a Kentucky native. He grew up on a Central Kentucky farm that raised Thoroughbred and Standardbred horses. Incidence and death rates are higher in
Kentucky for many of the known risk factors including obesity, diet high in red meat and low in fiber and calcium. Other factors including the regional water and soil have been implicated. “Growing up on a farm, I know that our soil lacks selenium,” says Robbins. “Anyone who grew up in Kentucky 40, 50, or 60 years ago was probably raised on native produce, plants and livestock, which would be low in selenium. March 2011 31
SPECIALTIES
Selenium-depleted diets have been associated with cancers across the board. The early consumption of selenium depleted foods may pre-set the DNA risk factor for later in life. That may account for the high rate of colon cancer in the older Kentucky population.” Robbins says “Our ability to screen patients has improved in Kentucky in the last ten years, yet we have not seen a major change in our status as a regional population with colon cancer.” Emerging technologies for better imaging will improve early detection. Robbins notes that virtual screenings have the benefits of lower cost and no sedation. Drawbacks are the same bowel prep, gas insertion into the rectum, and radiation exposure plus the possibility of liquid or stool artifacts that indicate false polyps.
32 M.D. Update
In traditional colonoscopy, new narrow band imaging and chromo- endoscopy will improve the detection of early grandular changes to the progression of colon cancer. “The new angulation of camera by Olympus” says Robbins, “allows us to see a wider field and behind the intestinal folds.” Robbins adheres to the three part message promoted by Jones and the Colon Cancer Screening Project: provide education, access risk, and then have patients and physicians execute the plan. “While every developed nation in the world has rising colon cancer rates,” says Robbins, “none has a national colon cancer screening program. We are the only developed nation with declining colon cancer rates - and declining rapidly. In our broken health care system, there’s no question that colon cancer screening is a winner.” ◆
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CEO for Georgetown Community Hospital
GEORGETOWN Jerry Dooley has been named chief executive officer of Georgetown Community Hospital (GCH), effective February 23, 2011. Dooley had served as interim CEO for GCH since 10/28/10. Dooley has served as CEO of four hospitals during his career. He held the leadership post at Monroe Hospital in Bloomington, Ind., from May 2005 to April 2006, where he oversaw the development and opening of the 32 bed acute care facility. Prior to that, he served as CEO of Terre Haute Regional Hospital, a 284 bed hospital in Terre Haute, Ind.; Sarah Bush Lincoln Health Center, a 220 bed hospital in Matoon, Ill; and Vermillion County Hospital, a 56 bed acute care hospital in Clinton, Ind. More recently, Dooley served as CEO on an interim basis for four LifePoint Hospitals. In this capacity, Dooley provided leadership and direction for these facilities while a permanent CEO was being recruited and hired. “Jerry has proven himself to be a capable leader and administrator. I am confident that he is the right person to lead the hospital in the future and continue its successful history of serving the needs of the community,” said Dallas Blankenship, chairman of GCH Board of Trustees. Dooley holds a Masters degree in economics from Indiana State University in Terre Haute, Indiana and a Masters Degree in Hospital Administration from the University of Minnesota.
Podiatrist and Internist Join Ephraim McDowell Wound Healing Center
Carie A. Tull, DPM, podiatrist, and Dawn E. Pingleton, DO, internist, will practice at the Wound Healing Center located inside Ephraim McDowell Regional Medical Center in Danville. Dr. Tull recently completed training in wound care at Ohio State University. She finished her podiatric medicine training
DANVILLE
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Dr. Pingleton also recently completed training in wound care at Ohio State University. She finished her internal medicine training in 2005 at Pikeville College School of Osteopathic Medicine.
Carie A. Tull, DPM, podiatrist
in 1996 at Scholl College of Podiatric Medicine in Chicago, Illinois. She also completed a residency in 1997 at Central Community Hospital in Clifton, Illinois. She is board certified in podiatric medicine and surgery.
Dawn E. Pingleton, DO, internist
Kern joins Baptist Medical Associates Brownsboro Road Nancy Kern, APRN, has joined Baptist Medical Associates’ office located at 10000 Brownsboro Road. She is a 1982 graduate of the Kentucky Baptist School of Nursing, received a bachelor’s degree in nursing from the University of the State of New York in 1992, graduated from the family nurse practitioner program at Spalding University in 1995, and received her doctor of education from Spalding University in 2005. LOUISVILLE
Nancy Kern, APRN
March 2011 33
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Blum joins Baptist Medical Associates Leesgate
LOUISVILLE Jacob Blum, MD, family medicine, has joined Baptist Medical Associates’ office located at 9115 Leesgate Road. He is a 1982 graduate of the Memorial University of Newfoundland Medical School in St. John’s, Canada. He completed his family medicine residency at the University of Toronto at Sunnybrook Hospital in 1984. He graduated from the Jacob Blum, MD preventative medicine program at the Medical College of Wisconsin in 1998.
New Physician, Location for Kleinert Kutz
LOUISVILLE Kleinert Kutz has opened a new immediate hand care center in northeastern Jefferson County. The new Kleinert Kutz office will treat pediatric and adult patients and will include immediate care services for hand, wrist and arm emergencies with 12 clinical exam rooms, a minor treatment room for walk-in hand, wrist and arm emergencies, a room for aesthetic plastic surgery consultations and treatments, a cast room, digital X-ray services and hand therapy and orthotic space. The new Kleinert Kutz - Chamberlain Pointe office is located at 4642 Chamberlain Lane, Suite 202, Louisville KY 40241. Dr. Manon-Matos is a new boardcertified attending physician with Kleinert Kutz Hand Care Center. Manon-Matos, an Associate Fellow of the American College of Surgeons and a Candidate Member of the American Society for Surgery of the Hand, was born in San Juan, PR and raised in Philadelphia, PA. He received his BS in Molecular Biology Dr. Manon-Matos 34 M.D. Update
News
from Princeton University in Princeton, NJ in 2000. Afterwards, he earned an MD from Dartmouth Medical School in Hanover, NH in 2004. He completed his internship in General Surgery in 2005 at the Dartmouth-Hitchcock Medical Center in Lebanon, NH, followed by residency in General Surgery at Baystate Medical Center/Tufts University School of Medicine in Springfield, MA in 2009. He was Chief Resident his final year. He subsequently completed a fellowship in Hand and Microsurgery in 2010 at the Christine M. Kleinert Institute and the University of Louisville Hospital in Louisville, KY.
ALS/MND Association’s Forbes Norris Award to UK’s Kasarskis
Neurologist Dr. Edward Kasarskis of the University of Kentucky has received the 2010 Forbes Norris award presented by the International Alliance of the ALS/MND Associations. Kasarskis has spent the majority of his academic career at UK where he is currently vice chair of the Department of Neurology in the Kentucky Neuroscience Institute.
LEXINGTON
According to the ALS/MND Association, “It is Kasarskis’ role as Chief of Neurology at the Veterans Administration Medical Service in Kentucky which prompted his interest in ‘Gulf War Syndrome’ in returning veterans, which has resulted in his work with the Persian Gulf ALS Cooperative Study and as chair of the Persian Gulf ALS Review.” The Forbes Norris Award is presented to those who have shown significant effort in the two major areas of management of and research into ALS/MND to benefit those living with the disease. Motor neuron disease (MND) is a term used to encompass a number of illnesses characterized by progressive and rapid degeneration of motor cells in the brain and spinal cord, including amyotrophic lateral sclerosis (ALS). These diseases are generically referred to as MND in Europe and ALS or Lou Gehrig’s disease in the United States. The International Alliance of ALS/ MND was founded in 1992 to provide a forum for healthcare providers and researchers to exchange on all aspects of the disease ranging from manage-
ment of care to providing support through networking and sharing the development of ideas through good practice. The goal of the International Alliance of ALS/MND is to encourage the exchange of information between the worldwide associations. The alliance consists of more than 40 patient support and advocacy groups from more than 50 countries.
UK on YouTube: Spinal Tap Detects for Alzheimer’s
In a seven-minute video, available for viewing on the University of Kentucky’s YouTube channel, Dr. Gregory Jicha nar-
LEXINGTON
Gregory Jicha, MD, PhD, demonstrates spinal fluid donation on UK’s YouTube channel.
Edward Kasarskis, MD, PhD was honored for his work with the Persian Gulf ALS Cooperative Study and the Persian Gulf ALS Review.
rates the spinal fluid donation procedure as it is performed on him. Every 70 seconds, someone in the United States develops Alzheimer’s disease. At this time, there is no cure for Alzheimer’s, but researchers and clinicians at the University of Kentucky Sanders-Brown Center on Aging are working diligently to change that fact, even when it means putting their own bodies on the exam table to recruit both healthy research subjects as well as those with cognitive impairment. “It has been found that there are proteins associated with Alzheimer’s that are altered in the spinal fluid, but not in the March 2011 35
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blood,” said neurologist Dr. Gregory Jicha. Other researchers from the SandersBrown Center on Aging join Jicha in providing facts about Alzheimer’s disease and the importance of spinal fluid in Alzheimer’s research. “In order to obtain samples of these proteins for testing and research, we need volunteers to donate samples of their spinal fluid. This is a safe and simple procedure. To encourage others to step forward to donate spinal fluid, I decided to have the procedure done on myself with the cameras rolling,” said Jicha.
Another Big Grant for Sts. Mary & Elizabeth Hospital Emergency Department
LOUISVILLE Churchill Downs is the latest to make a large gift to the Jewish Hospital & St. Mary’s Foundation in order to support the emergency department expansion and renovation project currently underway at Sts. Mary & Elizabeth Hospital. Churchill Downs’ $10K gift is a continuation of support of the capital campaign to fund the $5.5M project. The company hosted the “Race for Excellence Leadership Breakfast” on August 11, 2010, to launch the public phase of a capital campaign to expand and renovate the emergency department at Sts. Mary & Elizabeth Hospital. The renovation and expansion plans will significantly increase the size of the emergency department at the hospital, bumping out into the existing parking lot where a new ambulance entrance will be built. Inside, the layout will be completely reconfigured to enlarge the waiting room, add a central nursing station and create all private beds--several with a specialty focus like a pediatric treatment room and decontamination suite. A dedicated space for less serious emergencies will be enhanced. 36 M.D. Update
Tom Gessel, hospital president and CEO, says “[W]e’ve developed a bold plan to dramatically increase the size and redesign the department, growing from 19 beds to a state-of-the-art facility with 34 beds and the very best in privacy, safety, quality and expedient care.” Sherri Craig, executive director of the Jewish Hospital & St. Mary’s Foundation says that over $2.5M has been raised so far.
UK HealthCare Celebrates 500th Pediatric Heart Surgery
LEXINGTON A significant milestone for the Kentucky Children’s Heart Center at Kentucky Children’s Hospital and UK Chandler Hospital occurred February 15, 2011, when Dr. Mark Plunkett performed the center’s 500th heart surgery. Plunkett, a pediatric heart surgeon, helped establish the Kentucky Children’s Heart Center at UK in July 2008.
gery, and co-director of the Kentucky Children’s Heart Center. “We have assembled an outstanding team dedicated to covering all aspects of care for these children with heart defects, and we look forward to future growth of the program.” The 500th patient, Elijah Chaney of Richmond, Ky., was two weeks old and weighed five pounds when he underwent surgery to repair his severely narrowed aorta. The surgery was performed by Dr. Plunkett and his colleague, Dr. Deborah Kozik. He was cared for by members of the Kentucky Children’s Heart Center and was discharged to home five days later. “Reaching 500 surgeries would not have been possible without the dedication and collaboration of the entire team and I am extremely proud and grateful to be a part of this group,” said Dr. Lou Bezold, the UK HealthCare chief of pediatric cardiology and co-director of the Kentucky Children’s Heart Center. “I anticipate a bright future for our program, as well as the children and families we serve.”
Jonathan Keeling, DO, Joins Lexington Clinic Dermatology
LEXINGTON Dr. Jonathan Keeling has joined the Dermatology Department at Lexington Clinic East. Dr. Keeling received his medical degree
Dr. Mark Plunkett performed the Kentucky Children’s Heart Center’s 500th heart surgery on February 15, 2011. Plunkett helped found the program in July 2008.
“We have come a long way in a relatively short time, and this milestone just highlights our progress in delivering excellent health care to the children of Kentucky,” said Dr. Plunkett, the UK HealthCare’s chief of cardiothoracic sur-
Jonathan Keeling, DO, dermatologist
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from the West Virginia School of Osteopathic Medicine. He completed a General Medicine internship at Sun Coast Hospital, part of NOVA Southeastern University, and a Dermatology residency at Wellington Regional Medical Lena Edwards, MD, internist in private practice in Center, where he acted as chief res- Lexington, contributes video to The Doctor’s Channel. ident in Dermatology. Dr. Keeling provides services in adult, adolescent, Center, is featured in a new online video and pediatric dermatology. He treats a on The Doctor’s Channel. Edwards diswide spectrum of dermatologic condi- cusses salivary cortisol testing, the use of tions including acne, rosacea, psoriasis, which is increasing for the diagnosis and various types of dermatitis, skin infec- treatment of patients with hypothalamic tions, and disorders of the hair and nails. pituitary adrenal dysfunction.
Internist Shares Expertise Online
Lena Edwards, MD, internist at Lexington’s Balance Health & Wellness
LEXINGTON
UK Chandler Hospital-Pavilion A on Track for May Opening
LEXINGTON The first two patient care floors and many of the common public spaces of
the new 1.2 million square foot University of Kentucky Albert B. Chandler Hospital will open for patients “on time and 1% under budget,” said UK executive vice president for health affairs Dr. Michael Karpf during a tour of the facility on February 23, 2011. Floors 6 and 7 will be the first to open for patient care on May 22, 2011. The 6th floor is dedicated to Neurosciences and will house a total of 24 ICU patient beds for progressive stroke care and acute care. The 7th floor will house trauma, orthopedics, general surgery, and abdominal transplants. Tower 1 on the 7th floor will feature 12 trauma ICU beds with six progressive care and 14 acute care beds. Tower 2 will feature 12 surgical and transplant ICU beds, six progressive care and 14 acute care beds. “The towers will be directly connected
INTERVENTIONAL PAIN ASSOCIATES ANESTHESIOLOGY | UK HEALTHCARE
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Good Samaritan Hospital 1st Floor | 310 South Limestone, Suite 100A | Lexington, KY 40508 | www.WildcatAnesthesia.com March 2011 37
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to UK’s Level One Trauma Center and Emergency department via oversized elevators where, if necessary, surgery can be started,” said Karpf. All patient rooms are private with bathrooms and showers fully equipped with patient lifts for patients with disabilities. In some rooms, the patient lifts extend into the bathrooms. Each room is nearly 300 sf and includes an area for family and caregivers to comfortably spend extended time. The public areas will showcase the “Uniquely Kentucky” aspect of the new hospital with landscaping reminiscent of the Bluegrass, artwork created by some of Kentucky’s most renowned artists and a 305 seat auditorium, which will host performing arts and educational lectures. “Kentuckians will have a world class hospital facility,” said Karpf. “Along with state of the art technology, we also want people to feel at home in a healing environment, enhanced by unique aspects of Kentucky landscape, limestone water features, natural
February 25,2011 at the UK Museum of Art for their enthusiastic support of the arts. According to Karpf, the new hospital is built for flexibility, function and patient safety for 100 years. The new hospital is the key to UK becoming a premier regional medical center concentrating on cancer, trauma, neurosciences, ABOVE Dr. Michael Karpf previews the Chandler Hospital Pavilion organ transplantation, and A, which will open May 15 on time and 1% under budget. pediatric subspecialties. BELOW Dr. & Mrs. Karpf with Patsy and UK president Lee Todd Partnerships with small at UK’s Art in Bloom, where the Karpfs were honored for their community and regionsupport of the arts. al hospitals will enable light, art and music. Combining these ele- Kentucky physicians to keep their patients ments into one empathetic facility has been in their own communities by using UK HealthCare physicians’ expertise. More commost rewarding for me.” In recognition of this effort, Ellen plicated cases will be referred to Lexington. The formal opening is scheduled for and Dr. Michael Karpf were honored at the 11th annual Art in Bloom event on Sunday, May 15, 2011. ◆
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Arts The Beauty of Art on a Blank Slate By Jackie Hamilton The building of the new University of Kentucky Albert B. Chandler Hospital allowed UK HealthCare to imagine the impossible and dream big — starting with a “blank slate.” Research was done and visits were made across the nation to help us create the most excellent hospital we could on all levels, truly approaching the healthcare experience differently. UK HealthCare has placed a significant importance on creating an environment in the new facility that embraces Arts in Healthcare, a diverse and multidisciplinary field that can transform the healthcare experience by connecting patients with the power of the arts. This rapidly growing field integrates the arts—including literary, performing, and visual arts and design—into a wide variety of healthcare and community settings for therapeutic, education, and expressive purposes. Studies show that integrating the arts into healthcare settings helps to cultivate a
Arts in Healthcare is a diverse, multidisciplinary field that can transform the healthcare experience by connecting patients with the power of the arts.
Nurse Bonnie by Carl McKenzie
(UK HealthCare Collection).
the architecture of the new facility. Art locations were identified throughout the space and appropriate art lighting put in place. The gallery-like presentation of the art will elevate the works to museum quality. Patients, families, and visitors will come across an individual work of art at every turn. The art and art programs will help create a unique personality and ambiance for the hospital. From the folk art collection developed to bring a sense of place, a true Kentucky experience for patients and visitors, to a four-story sculpture of Gingko tree (a nod to not only Kentucky’s history and culture, but to the plant’s medicinal roots), the arts will be an essential aspect of the overall clinical experience. The program will highlight local, national, and international artists, from different disciplines and in different media,
Stacy Daniels Land, by Mark Anthony Mulligan
healing environment, support the physical, mental, and emotional recovery of patients, communicate health and recovery information, and foster a positive environment for caregivers that reduces stress and improves workplace satisfaction and retention. The truly exciting aspect of the UK Arts in HealthCare program is its integration with March 2011 39
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ARTS
Stained Glass work by John Reyntiens
and various initiatives to enhance the healing environment. In collaboration with the University of Kentucky’s School of Music, the Arts in HealthCare program at UK HealthCare will also be able to offer the only music therapy graduate program in Kentucky. The program will bring performances to the hospital’s new auditorium. Students in the music therapy program will conduct research and utilize their skills in the clinical environment with patients of all ages and with a variety of different conditions. The music therapy program will lead the way in placing the UK Arts in HealthCare
Program at the forefront of two emerging healing modalities — music therapy and arts in healthcare. The Arts program will continue to evolve as the space is developed, but it is UK HealthCare’s intention to represent all art forms at many levels of expression. It is our hope that every person who visits can view a work or experience a performance that can alter the way they think about art and enhance the healing environment.
Jackie Hamilton is communications manager and development director for Arts in HealthCare at the University of Kentucky. She can be reached by email at jacqueline.hamilton@uky.edu or by calling (859) 257-5528. ◆
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Lena Edwards.......................................................37 Jay Grider...................................................... 16-18 Gregory Jicha......................................................36 Whitney F. Jones............................................ 20-21 Michael Karpf.......................................................38 Edward Kasarskis.................................................35 Jonathan Keeling.................................................37 Rick Lingreen................................................. 16-18 Jeff Moscow...................................................... 8-9 James Patrick Murphy................................... 26-30 Dawn E. Pingleton...............................................33 Mark Plunkett......................................................36 George W. Privett, Jr...................................... 22-23 Earl G. Robbins, II......................................... 31-32 Craig S. Roberts...................................................34 John E. Stocking............................................ 26-30 Carie A. Tull..........................................................33 Woodford S. Van Meter...................................... 6-7 Luis Vascello................................................... 16-18 Ken Weaver.................................................... 24-25
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