Volume 5 | Issue 1
Inside This Issue
January Edition 2022
Center to Study Psychedelics for Treatment of Depression, Anxiety, PTSD Launches at UT Austin’s Dell Med
A U.S. Adults’ Blood Pressure Levels Increased During The COVID-19 Pandemic See pg. 11
INDEX Legal Matters....................... pg.3 Oncology Research......... pg.4 Financial Forecast............. pg.8 Healthy Heart..................... pg.10
Why Does the Covid-19 Virus ‘Escape’ From Our Immune System? See pg. 12
s part of renewed interest in using psychedelics to treat severe mental health conditions, especially for people who have not had success with more traditional treatments, researchers at Dell Medical School at The University of Texas at Austin have launched the Center for Psychedelic Research and Therapy — the first center of its kind in Texas. The center will conduct clinical research to better understand the potential for drugs such as psilocybin, MDMA, ibogaine and ayahuasca to treat severe depression, anxiety and PTSD when used as part of treatment with a trained provider. “This research will bring further scientific rigor and expertise to study psychedelic therapy,” said center co-lead Charles B. Nemeroff, professor and chair of Dell Med’s Department of Psychiatry and Behavioral Sciences and holder of the Matthew P. Nemeroff Endowed Chair. “Recent studies have demonstrated considerable promise for these drugs when incorporated with clinical support, and this work has the potential to transform how we treat conditions like depression and PTSD, and to identify synergies between these and other well-established therapies to achieve long-term benefits for those seeking treatment.” The center’s initial focus will be on military veterans living with post-traumatic stress disorder (PTSD), adults experiencing prolonged grief disorder or depression, and those who have experienced childhood trauma.
Texas has the nation’s second-largest veteran population of about 1.6 million Americans. Central Texas alone is home to more than 250,000 vets, many of whom face lasting and difficult mental health problems related to their military service. The Mission Within and the Heroic Hearts Project, programs for veterans interested in pursuing psychedelic treatment options, will be among the center’s first program partners. This work is part of a growing effort to support novel therapies, particularly for veterans. During the most recent Texas legislative session, House Bill 1802, which was ultimately adopted, directed the Texas Health and Human Services Commission to conduct a study on the use of alternative therapies to treat veterans suffering from post-traumatic stress. Exploring the Brain’s Capacity for Plasticity In what center leaders point to as a differentiator, the research team will also explore treatments that combine psychedelic drugs with brain modulation techniques such as transcranial focused ultrasound and transcranial magnetic stimulation. Greg Fonzo, an assistant professor in Dell Med’s Department
of Psychiatry and Behavioral Sciences and center co-lead, will investigate how psilocybin and transcranial magnetic stimulation work together to provide lasting relief for stress-related depression and anxiety. “A key ingredient in how psychedelic therapies promote mental health may be their ability to enhance neural plasticity, the process that allows the brain to adapt to new experiences – which when combined with brain modulation therapies may promote maximum benefit,” Fonzo said. “The potential implications are far-reaching for people with these conditions and their families, and also for the future of mental health treatment and care.” Research funded by groups such as the Multidisciplinary Association for Psychedelic Studies (MAPS), a nonprofit research organization that has played a key role in advancing psychedelic research, has shown promise in improving the lives of people with anxiety, depression and PTSD. However, there is still a relatively limited evidence base for psychedelic therapy, Fonzo said. The center has secured funding to launch its initial work and will leverage the vast research infrastructure and expertise at Dell Med and UT Austin see Dell Med...page 14
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Legal Matters The Federal No Surprises Act – What Providers and Facilities Should Know plans. The requirements do not apply to beneficiaries or enrollees in federal programs such as Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. Beginning January 1, 2022, providers and facilities must comply with the following requirements:
By Michael P. Gennett, JD Polsinelli, PC
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he No Surprises Act of division BB of the Consolidated Appropriations Act, 2021 becomes effective on January 1, 2022 and creates requirements that apply to providers, facilities, and providers of air ambulance services, such as cost sharing rules, prohibitions on balance billing for certain items and services, notice and consent requirements, and requirements related to disclosures about balance billing protections. These provider, facility, and provider of air ambulance services requirements generally apply to items and services provided to individuals enrolled in group health plans or group or individual health insurance coverage, and Federal Employees Health Benefit
1. No ba lance bi l l i ng for outof-network emergency services Nonparticipating providers and nonparticipating emergency facilities: • Cannot bill or hold liable beneficiaries, enrollees or participants in group health plans or group or individual health insurance coverage who received emergency services at a hospital or an independent freestanding emergency department for a payment amount greater than the in-network cost-sharing requirement for such services. • Certain post-stabilization services are considered emergency services, and are therefore subject to this prohibition, unless notice and consent requirements are met.
2. No balance billing for nonemergency services by nonparticipating providers at certain participating health care facilities, unless notice and consent was given in some circumstances Nonparticipating providers of non-emergency services at a participating health care facility: • Cannot bill or hold liable beneficiaries, enrollees or participants in group health plans or group or individual health insurance coverage who received covered non-emergency services with respect to a visit at a participating health care facility by a nonparticipating provider for a payment amount greater than the in-network
cost-sharing requirement for such services, unless notice and consent requirements are met. 3. Disclose patient protections against balance billing • A provider or facility must disclose to any participant, beneficiary, or enrollee in a group health plan or group or individual health insurance coverage to whom the provider or facility furnishes items and services information regarding federal and state (if applicable) balance billing protections and how to report violations. Providers or facilities must post this information prominently at the location of the facility, post it on a public website see Legal Matters...page 14
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Oncology Research Texas Oncology Marks National Cervical Health Awareness Month
FEEL GOOD AGAIN
By Lynne Knowles, M.D., FACOG Texas Oncology Central and South Austin
O
We’re all ready to feel good again, but for our food insecure neighbors there’s no vaccine to fight hunger. The 1 in 5 Central Texas children at risk of hunger deserve a shot at a happy summer.
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January 2022
nce a leading cause of cancer death in the United States, cervical cancer diagnoses and deaths have decreased dramatically in past decades and have now leveled off, largely due to prevention and early detection through routine Pap tests. January’s National Cervical Health Awareness Month raises awareness of good cervical health and early detection. If discovered and treated before the cancer spreads from the primary site, the survival rate for cervical cancer is 92% after five years. Despite greater awareness, an estimated 1,420 Texas women were expected to be diagnosed with the disease in 2021. Therefore, it is critical that women have a regular Pap test. Almost all cervical cancer cases are caused by the human papillomavirus (HPV), a common sexually transmitted infection. Women who have had many sexual partners face an increased risk for HPV infection. However, not all women with the HPV infection will develop cancer. O t h e r risk factors for developing cervical cancer include HIV infection, AIDS, a history of Chlamydia, long-term use of oral contraceptives, multiple childbirths, or women who have had a full-term pregnancy before age 20. Women who smoke double their risk of cervical cancer compared to nonsmokers. Cervical cancer may not come with warning signs in the early stages. However, symptoms and pain may be noticed as the disease worsens. Women should consult a physician for proper testing if any of the following symptoms are present: • Abnormal vaginal bleeding • Unusual vaginal discharge • Painful intercourse • Post-menopausal bleeding • Bleeding after intercourse • Pain in the pelvic area
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• Bleeding or spotting between periods • Longer or heavier periods The Pap test is the most effective screening tool for cervical cancer. Women of average risk in their 20s should have a Pap test every three years, regardless of whether they have received the HPV vaccine. Women age 25-65 should have a Pap test and DNA HPV test every five years or only a Pap test every three years to screen for cervical cancer. The DNA HPV test, given in conjunction with a routine Pap test, may identify existing HPV infections that could lead to cervical cancer. The U.S. Preventive Services Task Force recommends another option to screen with the high-risk human papillomavirus (hrHPV) test only every five years. Physicians may recommend that women have more frequent screenings if certain risk factors are present. Women over 65 should discuss previous test results and the risks and benefits of screening with their physician. Three vaccines to prevent the types of HPV infections that cause cancer are FDA approved for females age 9-26, depending on the vaccine. The vaccines may reduce a woman’s risk of cervical cancer, but HPV
vaccines cannot protect against existing infections. Women diagnosed with cervical cancer should consult with a gynecologic oncologist and radiation oncologist to determine specific treatment needs. There are several treatment options for cervical cancer including chemotherapy, radiation therapy, targeted therapy, immunotherapy, surgery, and palliative care. Each method may be used alone, or in combination with other treatments. Researchers are making advances against cervical cancer. For now, regular screenings, awareness, and healthy lifestyle choices, such as eating well and exercising regularly, are the best tools to reduce risk.
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Why Medical Clearance is Really a Preoperative Evaluation By Debra Davidson, MJ, CPHRM Senior Patient Safety Risk Manager and David L. Feldman, MD, MBA, FACS Chief Medical Officer The Doctors Company
T
he term medical clearance is subject to debate in the medical community. Depending on how the term is used, it can have different meanings in different situations. For example, a fitness trainer might require a client to have medical clearance before beginning an exercise program, or a student athlete might need clearance before participating in sports. (For more information on this topic, see our article “Medical Malpractice and Preparticipation Sports Physicals.”) The term is often used by surgeons requesting a medical evaluation before performing surgery on a patient. In the context of surgery, a medical clearance is, essentially, considered to be an authorization from an evaluating doctor that a patient is cleared, or deemed healthy enough, for
surgeon “some realistic expectations of what complications may arise during and after surgery.… The evaluation is further helpful for determining interventions the patient can do that may lower that risk.”1 Evaluate, Communicate, and Document A preoperative medical evaluation may not be necessary for all patients having surgery. Otherwise healthy patients—often most easily categorized by the American Society of Anesthesiologists’ (ASA’s) Physical Status Classification System as an ASA I or II—don’t usually require a preoperative medical evaluation, subject to the discretion of the surgeon and/or their primary care physician. For patients with significant comorbidities (ASA III and above) the surgeon who recommends surgery refers the patient for a preoperative medical consultation. It begins with the patient’s primary care physician, who may seek additional consultation
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a proposed surgery. Arguably, clearance is an inaccurate description of what is accomplished during a preoperative medical evaluation.Dr. George Marzouka, a cardiologist who is often asked to perform preoperative cardiovascular evaluations on patients prior to elective procedures, believes that “calling a preoperative evaluation a ‘clearance,’ in fact, belittles the purpose of the assessment, and provides little in terms of meaningful information to the surgeon. It misleads patients, and possibly surgeons, by implying a sense of security that is not based on reality.” Instead, as Dr. Marzouka reminds us, “the purpose of the preoperative evaluation is to assess what medical problems are present and how those problems might affect a person’s operative risk.” It offers the patient and
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from a specialist, such as a cardiologist. It is the surgeon’s responsibility to provide the evaluating physician with up-to-date information about the patient’s medical condition, the type and expected length of surgery, the kind of anesthesia that is anticipated, how long the patient may be immobile, and details about the patient’s rehabilitation and expected recovery period. Before determining the patient’s risks for surgery, the evaluating physician considers all information and may request additional labs, tests, or other consults. It is possible that recommendations for adjustments to medical therapy may occur to help the patient get to an optimal place for
see Clearance...page 13
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Financial Forecast Outside Advisors for your Physician Practice: A Key to Success By Reed Tinsley, CPA
D
uring my years in consulting, I have found that the successful medical practices out there are the ones that surround themselves with excellent advisors. Not only do they surround themselves with excellent advisors, they utilize them at every turn. I think it’s important to have people on the outside looking in, willing to offer advice when needed. I have never seen the “perfect” medical practice – it does not exist. Why? Because we are human and as humans, we make mistakes – It’s not a perfect world we live and practice in. However by surrounding yourself with a solid team of advisors, I think you can minimize these mistakes and maintain a healthy bottom line. Every medical practice has a variety of specialized team members that handle patient intake, billing, collections, office management, and, of course, the delivery of the actual medical care itself. In the best medical practices this system is continually
refined and each member is carefully selected and trained to ensure that the practice runs as safely and efficiently as possible. What many physicians and practice managers often overlook however is the importance of the “outside” staff that supports the operations of the medical business. These outside professionals are just as vital to the success of a practice as any internal employee and must be chosen with the same degree of care. Here are, in my opinion, the key outside advisors you should surround yourself with: CPA Advisor Some will disagree but there is not much separating “tax preparers” these days. Any CPA worth their salt can prepare a good tax return. They should – it’s their job! This is a necessary skill set but in today’s economic conditions and reimbursement rates, you require more. You need a real “tax planner” — someone who is BOTH technically proficient at the paperwork and who is proactive about spotting
and suggesting ways for you to pay the minimum amount legally possible. Which category does your current CPA fall into? Make sure they are working as hard to save you money as you worked to earn it. Healthcare Consultant Advisor If your CPA does not already provide healthcare consulting services, then seek to engage such a person. What can an outside consultant do for you? First, this person acts as a resource to your practice. This person can advise you and your team on any area/issue related to daily practice management. Working in unison, there should be no practice problem that can’t be addressed and resolved. A consultant can be that set of eyes from the outside
looking into the practice. This kind of oversight is vital in today’s ever changing marketplace. Finally, working together, you and the consultant can strategize and implement ideas that will increase your bottom line. Remember there is only one financial benchmark that should matter to you – did I make more money this year than last year? Insurance Agent Insurance is your indispensible first line of defense against a variety of exposures from malpractice to data breach and even traditional life and health. In many cases these needs are served by two different agents, one who handles life insurance planning for the
is compliant with the Health Insurance Portability and Accountability Act (HIPAA) to ensure patient privacy is maintained while information is exchanged. Similarly, asthma attacks can be triggered by home conditions, including environments with smoking, pets, mold or roaches. If such conditions are identified during a clinical visit, for example, the clinician may refer the patient to a social service organization to evaluate the situation and provide a solution for the patient to address asthma triggers in the home. “The digital system we are testing will make it easy and efficient to share all this information seamlessly between health and social service providers, and help coordinate care for patients by tracking whether their
needs were appropriately addressed,” said Anjum Khurshid, M.D., Ph.D., associate professor and director of data integration in the Department of Population Health at Dell Med, who leads this work. “The system is designed to avoid adding to the burden on service providers, and to help patients navigate the health system easily.” Collaboratively Creating a Replicable Model The initiative is part of a two-year, Dell Med-led program with community partners to create a scalable, widely replicable model that can ultimately allow clinicians in and beyond Travis County more comprehensive access to relevant patient information in a seamless, secure way that does not interrupt clinical workflows.
see Financial Forecast...page 14
New Digital Tool Closes the Loop, Helps Clinicians Follow Up on Patient Care Referrals Central Texas Patients with Low Income to Benefit from Integration Of Nonclinical Info Into Medical Record
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or people with low income seeking medical care from community clinics, a visit to see a health care provider can also be an opportunity to connect with supportive social services. These critical local services – available through community organizations working beyond clinics and hospitals – provide resources such as ridesharing, food assistance and temporary housing that are key drivers to improve health. But when clinicians make social service referrals, it’s difficult to know whether patients access those services, and if so, to what extent they were helpful. In collaboration with community partners, a team of population health researchers at Dell Medical School at The University of Texas at Austin is leading the development of a two-way digital platform enabling clinicians and social service providers to close
January 2022
the referral loop by communicating whether, and how, local resources are accessed after a patient’s clinic visit. For the 56 million Americans with limited access to primary medical care, this effort will help support a system of whole-person care in which providers and support service organizations can collaborate to improve the health of individuals who are part of the most vulnerable communities. For example, a patient with diabetes who has a challenge accessing fresh, healthy foods to help control her blood sugar level may be referred by a clinic to a nearby food bank. With the patient’s consent, the new closed-loop referral system would ensure that the patient information is sent to the food bank and received back from the food bank if the needs of the patient were addressed after the referral. The system
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Physicians At St. David’s Medical Center Among First in Nation To Implant Neurostimulator Technology For Advanced Heart Failure
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octors at St. David’s Medical Center recently became among the first in the U.S. to implant a new neurostimulator technology to help treat advanced heart failure. The Barostim System is the only technology approved by the Food and Drug Administration (FDA) to use the nervous system to control heart failure and improve the function of the cardiovascular system. The system features a programmable device that is placed under the patient’s collarbone and sends electrical pulses to baroreceptors, which detect changes in pressure in the carotid artery. This triggers the baroreflex, the body’s main cardiovascular reflex, causing an autonomic, or involuntary, response to the heart. “When the device is activated, it sends impulses through an electrode to the receptors in the carotid artery,” Dr. Jeffrey Apple, a vascular surgeon with Cardiothoracic and Vascular Surgeons who performed
the procedure at St. David’s Medical Center, said. “This tricks the body into thinking that the sympathetic and parasympathetic nervous systems are working correctly. The brain then responds and sends messages to the body that the heart is working properly. This relaxes the blood vessels, slows the heart rate and reduces fluid in the body.” The therapy is designed to restore balance to the autonomic nervous system and thereby reduce the symptoms of heart failure. “This approach to heart failure is designed to improve patients’ quality of life, including those who remain symptomatic despite taking medications and have no other devicebased therapy options,” Andrea Natale, M.D., F.A.C.C., F.H.R.S., F.E.S.C., cardiac electrophysiologist and executive medical director of the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, said. “It allows them to live their everyday lives with fewer limitations.” -
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Healthy Heart New Look at Nutrition Research Identifies 10 Features Of A Heart-Healthy Eating Pattern By The American Heart Association
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he American Heart Association has outlined 10 key features of a heart-healthy eating pattern in a new scientific statement emphasizing the importance of overall dietary pattern rather than individual foods or nutrients. These features can be adapted to accommodate individual food likes and dislikes, cultural traditions and whether most meals are consumed at home or on-the-go, according to the statement, “2021 Dietary Guidance to Improve Cardiovascular Health,” published in the Association’s flagship journal Circulation. The statement reflects the latest scientific evidence on the benefits of heart-healthy eating throughout life and that poor diet quality is strongly associated with an increased risk of cardiovascular disease and death. “We can all benefit from a heart-healthy dietary pattern regardless of stage of life, and it is possible to design one that is consistent with personal preferences, lifestyles
and cultural customs. It does not need to be complicated, time consuming, expensive or unappealing,” said Chair of the scientific statement writing group Alice H. Lichtenstein, D.Sc., FAHA, senior scientist and director of the Cardiovascular Nutrition Team at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University in Boston. 10 features of a dietary pattern to promote heart health: • Balance food and calorie intake with physical activity to maintain a healthy weight • Choose a wide variety and eat plenty of fruits and vegetables to get a full range of nutrients from food rather than supplements • Choose whole grains and other foods made up mostly of whole grains • Include healthy sources of lean and/or high-fiber protein such as plant proteins (nuts and legumes), fish or seafood, low fat or non-fat dairy, lean cuts of meat and limit red and processed meats • Use liquid non-tropical plant oils
such as olive or sunflower oils • Choose minimally processed foods as much as possible • Minimize intake of beverages and foods with added sugars • Choose or prepare foods with little or no salt • Limit alcohol consumption: if you don’t drink, do not start • Apply this guidance no matter where food is prepared or consumed The dietary guidance also discusses several challenges that can make it harder to adopt or maintain a heart-healthy diet, including: • Widespread dietary misinformation from the Internet • A lack of nutrition education in grade schools and medical schools • Food and nutrition insecurity – an estimated 37 million Americans had limited or unstable access to safe and nutritious foods in 2020 • Structural racism and neighborhood segregation, whereby many communities with a higher proportion of racial and
ethnic diversity have few grocery stores but many fast-food outlets • Targeted marketing of unhealthy foods and beverages to people from diverse racial and ethnic backgrounds through tailored advertising efforts and sponsorship of events in those communities. On an individual level, the new statement reinforces a 2020 American Heart Association statement for health care professionals that encouraged routine assessment of patients’ dietary quality and inclusion of this information in the medical record so there is follow-up at the next appointment. For more information visit heart.org
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U.S. Adults’ Blood Pressure Levels Increased During The COVID-19 Pandemic The COVID-19 Pandemic Is Associated with Higher Blood Pressure Levels Among Middle-Aged Adults Across the U.S., According To New Research Published Today In The American Heart Association’s Flagship Journal Circulation.
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ccording to the American Heart Association, nearly half of American adults have high blood pressure, a leading cause of heart disease, and nearly 75% of all cases remain above the recommended blood pressure levels. Stay-at-home orders were implemented across the U.S. between March and April 2020 in response to the COVID-19 pandemic. This resulted in a shift to remote health care for numerous chronic health conditions including high blood pressure and had a negative impact on healthy lifestyle behaviors for many people. “At the start of the pandemic, most people were not taking good care of themselves. Increases in blood pressure were likely related to
changes in eating habits, increased alcohol consumption, less physical activity, decreased medication adherence, more emotional stress and poor sleep,” said lead study author Luke J. Laffin, M.D., co-director of the Center for Blood Pressure Disorders at the Cleveland Clinic in Cleveland, Ohio. “And we know that even small rises in blood pressure increase one’s risk of stroke and other adverse cardiovascular disease events.” For this analysis, researchers accessed de-identified health data from an employee wellness program (included employees and spouses/ partners) to assess changes in blood pressure levels before and during the COVID-19 pandemic. The data
included nearly a half million adults across the U.S., average age of 46 years, 54% women, who had their blood pressure measured during an employee health screening every year from 2018 through 2020. Participants were categorized into four groups: normal, elevated, stage 1 hypertension and stage 2 hypertension based on the current American Heart Association blood pressure guidelines. The researchers compared monthly average blood pressures between 2018 and 2019 and blood pressure measures in January through March 2019 to January through March 2020 (pre-pandemic). They then reviewed blood pressure changes comparing April to December 2020 (during the pandemic) to April to December 2019 (pre-pandemic). The analysis found: • During the pandemic (April to December 2020), average increases in blood pressure each month ranged from 1.10 to 2.50 mm Hg higher for systolic blood pressure (the top number
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in a blood pressure reading that indicates how much pressure the blood is exerting against the artery walls with each contraction) and 0.14 to 0.53 mm Hg for diastolic blood pressure (the bottom number in a blood pressure reading indicates how much pressure the blood is exerting against the artery walls while the heart is resting, between contractions) compared to the same time period in 2019. Before the pandemic, blood pressure measures were largely unchanged when comparing study years. see Blood Pressure...page 13
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Why Does the Covid-19 Virus ‘Escape’ From Our Immune System? New Research Discovery Could Lead to Development of Therapies To Prevent Covid-19 Virus From Proliferating In The Human Body By Gracie Blackwell
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he immune system is a complex network of cells and proteins that is designed to fight off infection and disease, especially those like the coronavirus, or SARS-CoV-2, that can cause numerous issues in the human body. Despite the immune system, many individuals are still at risk of being infected with the coronavirus, letting it replicate in the body and further transmitting to other individuals. The underlying mechanism of how SARS-CoV-2 escapes from the immune system has been poorly understood. However, researchers from the Texas A&M University College of Medicine and Hokkaido University have recently discovered a major mechanism that explains how SARS-CoV-2 can escape from the immune system and replicates in the human body. Their findings were
recently published in the journal Nature Communications. “We found that the SARS-CoV-2 virus carries a suppressive gene that acts to inhibit human gene in the immune system that is essential for destroying infected cells,” said Koichi Kobayashi, MD, PhD, adjunct professor at the College of Medicine and lead author of the paper. Naturally, the cells in a human’s immune system are able to control virus infection by destroying infected cells so that the virus cannot be replicated. The gene that is essential in executing this process, called NLRC5, regulates major histocompatibility complex (MHC) class I genes, which are genes that create a pathway that is vital in providing antiviral immunity. Kobayashi and his colleagues discovered this finding back in 2012. “During infection, the amount and activity of NLRC5 gene become augmented in order to boost our
ability of eradication of viruses,” Kobayashi said. “We discovered that the reason why SARS-CoV-2 can replicate so easily is because the virus carries a suppressive gene, called ORF6, that acts to inhibit the function of NLRC5, thus inhibiting the MHC class I pathway as well.” Kobayashi, who holds a joint appointment as a professor at Hokkaido University in Japan, collaborated with Paul de Figueiredo, PhD, associate professor in the Department of Microbial Pathogenesis and Immunology at the College of Medicine, on this paper. Kobayashi and his team’s discovery shed light on the mechanism to how SARS-CoV-2 can replicate in
the human body and can potentially lead to the development of new therapeutics to prevent the coronavirus from escaping the immune system and replicating in the body. Although the introduction of COVID-19 vaccines, such as the Pfizer and Moderna vaccines, can lower an individual’s chance of contracting the virus, there is currently no permanent therapy that can entirely prevent a human from contracting SARS-CoV-2. “We hope that this new discovery will allow us to develop a new drug that can block this gene so our immune system will be able to fight off the coronavirus for good,” de Figueiredo said.
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Clearance Continued from page 6 surgery that mitigates perioperative risks. The surgeon and evaluating physician should agree, for example, about which medications to stop preoperatively and which to continue. Anticoagulants are often an issue in surgical claims. If the patient takes anticoagulants, the surgeon and the evaluating physician should agree on the best approach given the individual’s risk factors. The evaluating physician and/ or the surgeon should also make use of a presurgical risk calculator, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator. This allows for a discussion with the patient that is specific to the procedure and includes the individual’s quantifiable risks. If it is determined that the patient can proceed with surgery, the evaluating physician should communicate the findings to the surgeon verbally and in writing. Document the patient’s medical record with the evaluation and findings and when and how they were communicated to the surgeon. Occasionally, a high-risk patient will not be able to proceed because
the risks of the procedure outweigh the benefits, even with a change in medical therapy. The reason(s) for the denial should be well documented. In those instances in which a surgical procedure is considered urgent or emergent, the surgeon will need to use his or her best judgment to determine if there is time for a preoperative medical evaluation, an assessment that would typically be performed by an in-hospital medicine physician such as a hospitalist. Malpractice Liability Considerations As with any patient-physician encounter, the preoperative medical evaluation should be carefully documented in the patient’s chart (either inpatient or outpatient, depending on the patient’s preoperative status). In some hospitals, a template is used to ensure that all systems are evaluated during this process, and the template also serves as a checklist. As mentioned previously, the decision to have the patient undergo a preoperative medical evaluation is ultimately up to the operating surgeon, though some hospitals and ambulatory surgery centers may have rules and regulations specifying when a preoperative medical
evaluation must occur. As in all medical decisions, there is always a risk of liability to both the surgeon and the evaluating physician should the patient have an adverse perioperative event. The physicians’ use of good medical judgment and documentation of these decisions in the medical record are the best defense against such a claim. This is also true when the surgeon and the evaluating physician disagree about an aspect of perioperative care or even whether the patient should undergo surgery at all. Ultimately, if the surgeon decides to proceed, he or she will need to document the reasons for choosing a course that might differ from the preoperative consultant’s recommendation. This is no different from any other physician consultation when the physician in charge disagrees with the consultant’s recommendation. Deviation from the recommendation requires documentation of the reasons for doing so. Opportunity for Partnership and Health Improvements Preoperative medical evaluations are excellent opportunities for patients to gather more information
about their health status and obtain recommendations for improved health. Remind patients to take advantage of the opportunity; a medical exam may provide an early warning sign of something serious. Avoid using the term medical clearance as it is a misnomer implying that the patient is cleared and free of risks. No patient is free of risk, however, when undergoing a procedure. The goals of the preoperative evaluation are to determine the level of risk and to identify opportunities to mitigate risk—with the surgeon and the evaluating physician working together. The decision about whether to proceed with the surgery belongs to the surgeon and the patient.
mask are important. However, the results of our research reinforce the need to also be mindful of chronic health conditions such as the worsening of blood pressure,” Laffin said. “Even in the midst of the pandemic, it’s important to pay attention to your blood pressure and your chronic medical conditions. Get regular exercise, eat a healthy diet, and monitor your blood pressure and cholesterol. See your doctor regularly to learn how to manage your cardiovascular risk factors.” The study authors are following up on these results to find out if this trend continued in 2021, which may indicate a forthcoming
wave of strokes and heart attacks. “Unfortunately, this research confirms what is being seen across the country – the COVID-19 pandemic has had and will continue to have long-reaching health impacts across the country and particularly related to uncontrolled hypertension,” said Eduardo Sanchez, M.D., M.P.H., FAAFP, FAHA, the American Heart Association’s chief medical officer for prevention. “These results validate why the American Heart Association’s National Hypertension Control Initiative (NHCI) is critically important. With a particular emphasis on historically under-resourced communities in the United States, the comprehensive
program supports health care teams at community health centers through regular blood pressure management training, technical assistance and resources that include the proper blood pressure measurement technique, self-measured blood pressure monitoring and management, medication adherence and healthy lifestyle services.”
Blood Pressure Continued from page 12 • Higher increases in blood pressure measures were seen among women for both systolic and diastolic blood pressure, among older participants for systolic blood pressure, and in younger participants for diastolic blood pressure. • From April to December 2020, compared to the pre-pandemic time period, more participants (26.8%) were re-categorized to a higher blood pressure category, while only 22% of participants moved to a lower blood pressure category. “From a public health perspective, during a pandemic, getting vaccinated and wearing a
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Dell Med
Continued from page 1 to advance its goals. “As a UT alumnus, I am proud to support such a forward-thinking team,” said Paul Barnhart III, one of the early donors supporting the center. “This work has the potential to change the paradigm in mental health and firmly stamps UT Austin at the forefront of
Legal Matters
Continued from page 3 (if applicable) and provide it to the participant, beneficiary or enrollee in a timeframe and manner outlined in regulation. 4. No balance billing for air ambulance services by nonparticipating air ambulance providers • Providers of air ambulance services cannot bill or hold liable beneficiaries, enrollees or participants in group health plans or group or individual health insurance coverage who received covered air ambulance services from a nonparticipating air ambulance provider for a payment amount greater than the in-network cost-sharing requirement for such services. 5. Provide good faith estimate in advance of scheduled services, or upon request for uninsured (or self-pay) individuals • The provider or facility must provide notification (in clear and
Financial Forecast Continued from page 8 staff and principals and another who is a property and casualty or “P&C” professional to help with liability coverage and health insurance. There are certainly many agencies that do both, but my experience with thousands of doctors leads me to believe that most are better at one or the other. I also prefer multi-line agents that have the entire universe of products available to suit my client’s needs at competitive pricing, not just one insurance carrier’s line. Attorney The plural is included because no matter what they tell you no one attorney can adequately handle all the needs that arise in a practice; lawyers are nearly as specialized as physicians. January 2022
Austin Medical Times psychiatric innovation.” Additionally, Dell Med is home to the Institute for Early Life Adversity Research, which explores the medical and psychiatric/psychological consequences of childhood trauma; the Institute for Military & Veteran Family Wellness, which conducts research, evaluation and program development to improve the lives of service members, veterans and their family members; and the Mulva Clinic for the
Neurosciences, focused on advancing patient care and neuroscience research. “Beyond the potential to improve treatments for patients, an exciting aspect of this work is the opportunity for broad collaboration across campus and with community partners,” Nemeroff said. “Engaging in this kind of work at a place like UT Austin opens up a world of possibilities.”
understandable language) of the good faith estimate of the expected charges, expected service, and diagnostic codes of scheduled services. • The good faith estimate must include expected charges for the items or services that are reasonably expected to be provided in conjunction with the primary item or service, including items or services that may be provided by other providers and facilities. 6. Ensure continuity of care when a provider’s network status changes • A health care provider or facility that ends a contractual relationship with a plan or issuer and has a continuing care patient must generally: − Accept payment from the plan or issuer (and cost-sharing payments) for a continuing care patient at the previously agreed to payment amount for up to 90 days after the date on which the patient was notified of the change in the provider’s network status. − Continue to adhere to all
policies, procedures and quality standards imposed by the plan or issuer for such items or services as if the contract were still in place. 7. Improve provider directories and reimburse enrollees for errors • Any health care provider or health care facility that has or has had a contractual relationship with a plan or issuer to provide items or services under such plan or insurance coverage must timely submit changes to the provider directory information and reimburse enrollees who relied on an incorrect provider directory and paid a provider bill in excess of the in-network cost-sharing amount. The federal No Surprises Act will effectively try to lower health care costs for consumers by prohibiting surprise billing and bill balancing by out-of-network health care providers. In certain circumstances, it will supersede state laws but it will also exist in addition to existing state laws regulating out-of-network providers where it is applicable.
A good attorney will help you with asset protection strategies, make sure your business entity is in compliance with state laws, assist with contract matters, and more importantly, someone you can reach out to for advice. Everyone needs a sounding board. Financial Planner Advisor As corny as it sounds, People don’t plan to fail, they just fail to plan. I typically find that most physicians pay more attention to their business finances than their personal finances. However, the two should go hand in hand. Want an example? You would not believe how many doctors practicing today HAVE TO WORK – they can’t retire and simply live off their retirement savings. A good financial planner will address these areas: • Are you adequately insured • Are you planning for retirement • Are you saving • Are you planning for college education
• Do you have an estate plan • Working with legal counsel, are your assets protected • Do you even have a written financial plan in place • Is there diversity in your investment portfolio A financial planner should also work with your CPA to identify opportunities to reduce taxes and allow to safely and predictably keep more of everything you earn by examining the costs and benefits of things like retirement plans and other legal tax deferment strategies. These advisors form the absolute core of any well-crafted external support team. My advice is to use them. These people are not “overhead,” but an investment in your practice. Engaging a successful team of outside advisors will make you money in the long run.
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Austin Medical Times
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WHOSE INTERESTS does your malpractice insurer have at heart?
Yet another Texas medical liability insurer has transitioned from focusing on doctors to focusing on Wall Street. This leaves you with an important question to ask: Do you want an insurer that’s driven by investors? Or do you want an insurer that’s driven to serve you—one that’s already paid $120 million in awards to its members when they retire from the practice of medicine? Join us and discover why delivering the best imaginable service and unrivaled rewards is at the core of who we are.
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Austin Medical Times
Life’s Simple
HOW TO EAT BETTER CREATE A HEALTHY DIETARY PATTERN
1
3
TIPS FOR SUCCESS WATCH CALORIES Eat only as many calories as you use up through physical activity. Understand serving sizes and keep portions reasonable.
ENJOY
COOK AT HOME
LIMIT
Take control over the nutritional content of your food by learning healthy preparation methods.
LOOK FOR THE HEART-CHECK trans fat and partially hydrogenated oils (found in some commercial baked goods and fried foods)
AVOID
2
LEARN THE SALTY SIX
READ NUTRITION LABELS Nutrition Facts
8 servings per container Serving size 2/3 cup (55g) Amount per serving
Calories
230 % Daily Value*
Total Fat 8g Saturated Fat 1g
10% 5%
Trans Fat 0g Cholesterol 0mg Sodium 160mg Total Carbohydrate 37g Dietary Fiber 4g
Learning how to read and understand food labels can help you make healthier choices. When you have more than one choice, compare nutrition facts. Choose products with lower amounts of sodium, saturated fat and added sugars.
0% 7% 13% 14%
Total Sugars 12g
LEARN MORE AT HEART.ORG/MYLIFECHECK AND HEART.ORG/EATSMART Includes 10g Added Sugars Protein 3g
20%
10% Vitamin 2mcg Heart Association, Inc., © Copyright 2019DAmerican a 501(c)(3) not-for-profit. All rights reserved. Unauthorized use prohibited. Citations available upon request.5/19 DS14545 Calcium 260mg
20%
Iron 8mg
45%
Potassium 235mg
foods that can be part of a healthy eating plan.
6%
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Limit the amount of sodium you eat each day. Learn the Salty Six. These common foods can be loaded with excess sodium: Breads & Rolls Pizza Sandwiches Cold Cuts & Cured Meats Soups Burritos & Tacos
