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Volume 11 | Issue 8
Inside This Issue
August Edition 2021
Significant Upticks in Delta Variant and Overall Covid-19 Cases in Houston By Lisa Merkl Latest Virus Genome Sequencing Results from Houston Methodist Reveal Concerning Trends
T Racial Disparities in Prostate Cancer See pg. 7
INDEX Legal Matters........................ pg.3 Oncology Research......... pg.5 The Framework.................... pg.9 Financial Forecast............ pg.10 Healthy Heart......................pg.11
he number of Delta variant COVID-19 cases at Houston Methodist has nearly doubled over the last week and is sixfold higher than in May. The most recent genome sequencing data through the end of June show the Delta variant in our patients now at 42%, up from 20% reported last week. The Delta variant has now surpassed the Alpha variant, which had been the dominant strain in Houston since March 2021, but now presently accounts for only 40% of new infections in our patients. Houston the Delta variant to be 7.5 days. Statistical plateau at 92% of all new infections Methodist has seen 139 Delta cases models predict the Delta variant will within the next couple weeks. This pattern in Houston patients is through June 28. similar to what was seen with the H o u s t o n Alpha variant here and in the UK Methodist’s team of earlier this year, and more recently infectious disease with the Delta variant in the UK. pathologists, who Couple this increase with the sequence the slight uptick we are seeing this genome of every week in overall COVID-19 cases, positive COVID-19 strain throughout Randall J. Olsen, M.D., Ph.D., and it underscores the urgency of increasing vaccination rates to the hospital system, medical director of Houston Methodist’s has calculated the see Delta..page 14 doubling time of Molecular Diagnostics Laboratory
Vaccine-induced herd immunity is our best tool and the only way to stop these variants from spreading and to prevent new variants from forming.
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Memorial Hermann Southeast Hospital Earns Magnet® Recognition See pg. 8
Know The Signs: Heat Exhaustion Can Quickly Turn to Heat Stroke
S
weating in the summer sun is one thing, overheating is another. According to an expert at Baylor College of Medicine, the main concern with heat exhaustion is that it can lead to heat stroke if symptoms are ignored. Heat exhaustion occurs when there is a moderate increase in body temperature, while heat stroke is a step further – the body can no longer control sweat and excess heat so body temperature rises even higher. Heat stroke can become fatal if not treated
immediately. “Heat stroke occurs when the core temperature of the body reaches 104 degrees Fahrenheit and changes in our central nervous system take place such as disorientation, confusion, behavioral or emotional changes or altered mental status,” said Isabel Valdez, physician assistant and assistant professor of general internal medicine at Baylor. “In some case, seizures or comas can also occur. Vital internal organs like the brain, liver and kidneys
can be damaged by heat stroke.” Symptoms The best way to prevent heat stroke is by first recognizing the signs of heat exhaustion, which include sweating, rapid heart rate, lightheadedness, headache, low blood see Heat Stroke...page 14
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Join more than 100,000 medical professionals who get free CME with Texas Health Steps Online Provider Education. Choose from a wide range of courses relevant to your practice, including short tutorials and quick courses on topics like Medicaid guidelines, ethics and mental health—available 24/7. Learn more at TXHealthSteps.com.
Content on the Texas Health Steps Online Provider Education website has been accredited by the Texas Medical Association, American Nurses Credentialing Center, National Commission for Health Education Credentialing, Texas State Board of Social Worker Examiners, Accreditation Council for Pharmacy Education, UTHSCSA Dental School Office of Continuing Dental Education, Texas Academy of Nutrition and Dietetics, Texas Academy of Audiology, and International Board of Lactation Consultant Examiners. Continuing Education for multiple disciplines will be provided for some online content. August 2021
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Page 3
Legal Matters Medicare 340B Payment Cut Déjà Vu – Part B Payment Reductions Continue
By Kyle A. Vasquez, J.D. Mary H. Canavan, J.D. Polsinelli, PC
T
he Centers for Medicare and Medicaid Services (CMS) recently released the CY 2022 Medicare Hospital Outpatient Prospective Payment System (OPPS) Proposed Rule (Proposed Rule). While the Proposed Rule contains a variety of proposed changes for CY 2022, below are key updates affecting 340B Program covered entities and some initial recommended next steps. CMS confirmed it will continue its reimbursement cuts policy for certain 340B covered entities while it awaits a ruling from the Supreme Court in the ongoing litigation brought against HHS by the American Hospital Association (AHA). CMS also signaled that while
certain 340B covered entities (rural sole community hospitals, children’s hospitals, etc.) remain exempt from the reimbursement cuts, those covered entities should continue reporting the “TB” modifier and CMS may revisit the exemption in future rulemaking. Similar to last year, CMS also continued to reference the need for consistent and reliable payments for hospitals for the remainder of the Public Health Emergency (PHE), which could mean that payment changes can be expected following the end of the PHE. Previously, HHS had been tasked with creating a remedy to make 340B entities whole after the D.C. District Court held the reimbursement cuts in 2018 and 2019 were unlawful. As part of its proposed solution, CMS issued its controversial 340B Drug Acquisition Cost Survey (Survey) to gather drug acquisition data from covered entities. CMS stated in this Proposed Rule that they had the authority to use the 2020 survey results to propose a new payment structure but believed the current payment policy is still appropriate, especially with the ongoing PHE. CMS continues to signal that its Survey data
could influence future Part B / 340B drug payment proposals. Covered entities should act now and provide comments directed at the use of CMS’s flawed Survey data. Namely, that the Survey was inappropriate, the method by which CMS sought to collect acquisition cost data was flawed, any reliance on the data would be misplaced given flaws, and results were inconclusive. Notably, although the Biden administration has made staff changes within each agency, it appears that the same CMS personnel who were involved in last year’s 340B payment section of the OPPS rule also participated in developing the Proposed Rule. While not dispositive of any issues, it’s certainly noteworthy as many industry stakeholders question why
the Biden Administration didn’t back down from payment cuts implemented under the prior administration. Part B 340B Drug Payment Rates for Urban Hospitals Ultimately, CMS did not propose any changes to payment for 340B drugs. The same payment policies implemented in 2018 and expanded upon in 2019 will continue throughout 2022 unless the Supreme Court rules in favor of covered entities or CMS alters course in its CY 2022 Final Rule. CMS will continue to pay covered entities ASP minus 22.5% for separately payable, non-pass through 340B drugs. Rural sole community see Legal Matters...page 12
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Seven Tips for Telehealth Clinical Documentation By Sue Boisvert, BSN, MHSA Patient Safety Risk Manager II The Doctors Company
T
he standards of care for telehealth are identical to those for onsite medical care: Medical and dental professionals must practice with the same level of skill and expertise as qualified practitioners in the same specialty under the same circumstances. State regulations and associated rules define what constitutes telehealth, third-party payer contracts outline medical necessity expectations and the services that qualify for reimbursement, your organization’s policies and procedures define practice expectations, and case law clarifies the interpretation of all these standards. Clinical documentation plays a significant role in demonstrating regulatory compliance, establishing medical necessity for billing, and supporting your defense in the event of a professional board complaint or medical professional liability claim.
August 2021
The following seven tips outline unique considerations for documenting telehealth care: 1. Modality. Specify clearly in the medical record what modality of telehealth is being used. Examples include “secure interactive audio-video session using Skype,” “medication management visit conducted by telephone,” or “asynchronous diagnostic test follow-up by portal/text/email.” 2. Geography. Note the patient’s physical location and geography. For example, including “at her home in Tennessee” is important for billing purposes and for determining venue in the event of a regulatory or professional liability action. Also include the provider’s location (“clinic name and city” or “home office and city”) in the documentation. 3. Informed consent. Advise patients before asking them to consent to treatment by telehealth—about the unique risks of a telehealth visit, including the
potential for technical difficulties, information security concerns, and the potential for converting the visit to an in-office visit based on the patient’s needs. In the progress note, include a summary of the discussion and the patient’s decision, as well as a copy of the signed form if used. Find our sample Telehealth Informed Consent form on our Informed Consent Sample Forms page. 4. Identity. Confirm the identity of new patients by asking them to hold a photo ID close to the camera. Document confirmation
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of patient identity. Patients also have the right to ask for provider identification. 5. Appropriateness. Determine quickly if the patient and environmental conditions are appropriate for a telehealth visit. Some patients may not be appropriate based on their cognitive status. If the patient is unable to answer questions or provide an accurate history and no support person is available, the visit may need to be rescheduled. Documentation in this situation see Telehealth...page 14
Houston Medical Times
Oncology Research Applying Sunscreen – You’re (Probably) Doing It Wrong By Andrew Jackson, M.D., Texas Oncology
A
ugust in Texas means the arrival of 100-degree temperatures and a reminder to pay close attention to skin cancer prevention. The danger of the abundant sunshine we encounter in our ‘wide open spaces’ state is unmistakable: more than 4,200 Texans will face melanoma this year. Using sunscreen is essential to sun protection, but the bad news is that when it comes to applying sunscreen, many of us are doing it wrong. The good news is that doing it right can be summed up in two words: use more. Sunscreen works for a limited time. You should reapply sunscreen every two hours or according to the directions on the product label, but more frequently if you’re swimming or sweating a lot. Water-resistant
sunscreens need to be reapplied every 40 or 80 minutes, according to the product label. Experts recommend using a broad-spectrum (protects against both UVA and UVB rays), water-resistant sunscreen with a sun protection factor (SPF) of at least 30. FDA rules on product labeling prohibit sunscreen being labeled as “waterproof,” “sweat proof,” or “sunblock,” serving as important reminders that one application of sunscreen is not enough. Skin damage from the sun takes many forms, including sunburns, wrinkles, and several types of skin cancer. According to the Skin Cancer Foundation, 20 percent of Americans will develop skin cancer by the age of 70, and those with five or more sunburns are twice as likely to get melanoma. Protecting yourself from sun damage prevents annoyances like sunburns now, and complications like skin cancer later. As the summer heats up, here’s what Texans need to know about sun safety:
Page 5
Be Sun Smart Anyone can get skin cancer, and everyone can take steps to reduce skin cancer risk. While some risk factors like family history and naturally fair skin cannot be changed, exposure to UVA and UVB rays can be limited. Avoid being outdoors in sunlight too long, particularly in the middle of the day when UV light is strongest, and avoid indoor tanning. Protect your skin and use sunscreen as directed. Check for A, B, C, D, and E Check any moles or changes on your skin against these symptoms, and if they match, consult a dermatologist. • Asymmetry: One half of the mole is different from the other in size, shape, or color. • Border: The edge or border of the mole is not smooth. • Color: The color of the mole contains various shades of tan, brown, black, and in some instances red, white, or blue. • Diameter or Dark: A lesion that is darker than others, regardless of size. Skin cancer melanomas are usually larger than six millimeters in diameter, but they can be smaller.
• Evolving: The mole changes over time or develops new symptoms, such as bleeding, crusting, or itching. Think Beyond Sunscreen To stay safe outside, cover up! Always use sunscreen, even on hazy or cloudy days, since UVA and UVB rays can still penetrate clouds. But there’s more to sun protection than slathering on sunscreen. Wide-brim hats, sunglasses with UVA and UVB blocking lenses, long-sleeved shirts, and long pants or skirts can all help protect your skin. Simple preventative steps now can help protect against more serious complications later. Be smart while enjoying the summer sun and keep your skin safe.
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Houston Medical Times
New Laboratory Study of Five Ebola Vaccines Provides Data on Features and Functions Of Vaccine Protection
A
new study published in Science Translational Medicine reports on the Ebola vaccine-mediated protection of five mucosal vaccine vectors based on the human and avian paramyxoviruses. The study comprehensively characterized the antibody response to each vaccine, identifying features and functions that were elevated in survivors and that could serve as vaccine correlates of protection. The multi-year study, led by Alexander Bukreyev, PhD, of the University of Texas Medical Branch (UTMB) Galveston National Laboratory looked at whether all the vaccines conferred protection and produced robust antibody responses. The team also explored 139 different immune and vaccine response parameters to see which ones were responsible for improving the “quality of survival.” “Testing during outbreaks is
difficult because of their sporadic nature, and yet much needs to be studied in order to determine the most effective vaccine for combatting this disease. Establishing the signatures of vaccine-generated immunity remains crucial for vaccine design, assessment and application,” said Bukreyev. Research Scientist Michelle Meyer, PhD, of UTMB served as lead author of the paper, Ebola vaccine-induced protection in non-human primates correlates with antibody specificity and Fc-mediated effects, which reports the efficacy results of the vaccines in cynomolgus macaques challenged with EBOV. The five mucosal vaccines tested differed in the degree of protection against death and disease, ranging from disease-free survival to only partial protection. Meyer notes vaccines need to do more than allow for survival, with an ideal result being to arrest virus replication and abate disease. To
evaluate antibody features that are relevant and potentially predictive of protection, the team employed a survival index in the analysis which incorporated several parameters of EBOV disease to allow for correlations with improved infection outcomes. “Through in-depth characterization of the antibody response, we found that even though all vaccines express the same antigen, they differed in multiple aspects, with the correlates of protection appearing to be unique to the vaccine platform. Our analysis defined RBD-specific antibodies and Fc-mediated immune
functions as contributing factors to improved survival,” said Meyer. The lack of correlation with neutralizing antibody titers suggests that the conventional means of predicting efficacy does not apply to all vaccines. During the most recent ebola outbreaks in Sierra Leone and the Democratic Republic of Congo, more than 300,000 people were vaccinated. Deciphering the immune responses to vaccination that correlate with protection is imperative to predict efficacy of vaccines in humans, says Meyer.
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Racial Disparities in Prostate Cancer Explained at Genomic Level Study Finds Substantially Different Biological Characteristics in the Tumors Of African American Men, Pointing to a Possible Contribution to Higher Prostate Cancer Death Rates By Lindsey Hendrix
I
t’s been well documented that African American men are more likely to be diagnosed and ultimately die from prostate cancer. Although the cause of this disparity is often attributed to cultural and socioeconomic factors that lead to poorer health outcomes among African Americans, a researcher from Engineering Medicine (EnMed) at Texas A&M University recently found substantially different biological characteristics in the tumors of African American men that he believes also contribute to the disparity. He said the findings provide compelling evidence that clinical therapies and treatments should be tailored to patients based on their race.
“Racial disparities are quite prevalent in health care,” said Kamlesh Yadav, PhD, instructional associate professor for EnMed. “The findings from most of the existing onco-genetic studies are not directly extrapolatable for tumors in all the races. Analyzing genetic drivers of tumors in various races and the clinical outcomes associated with cancer therapy have immense clinical value as we can now tailor therapeutics that would work better for one race versus other.” Yadav worked with a team of researchers at the Mount Sinai Health System in New York City to conduct a retrospective analysis of 1,152 patients who had undergone surgery for prostate cancer. The review included 596 African American men
and 556 men of European descent who had clinical-genomic information available to review. The researchers found that the tumors from men in two groups had distinctly different genomic profiles that would affect a health care professional’s plan for managing and treating the cancer. Specifically, the researchers found that tumors in African American men had higher expression of genes related to immune response and inflammation, and lower expression of DNA mismatch repair genes. Yadav says this means that African American men would benefit more from radiation therapy and platinum-based chemotherapy than their European counterparts. “Cancer is a genetic disease,” Yadav said. “This study has cemented
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the understanding that beyond socioeconomic differences, certain genetic factors drive racial disparities observed in prostate cancer. Understanding these genetic factors would benefit patients in getting personalized cancer treatment.” Yadav said EnMed is poised to developing machine-learning algorithms that will help professionals deliver more personalized medicine. “EnMed is at the cusp of not only making remarkable strides in helping uncover these differences but also with the help of our clinical partners, taking the findings to the clinic,” he said.
August 2021
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Houston Medical Times
Memorial Hermann Southeast Hospital Earns Magnet Recognition
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emorial Hermann Southeast Hospital has received one of the highest national honors for nursing excellence a hospital can receive. The hospital announced today that they have achieved Magnet recognition as a reflection of its nursing professionalism, teamwork and superiority in patient care. The American Nurses Credentialing Center’s Magnet Recognition Program® distinguishes organizations that meet rigorous standards for nursing excellence. With this credential, Memorial Hermann Southeast Hospital joins the global community of Magnet-recognized organizations. Just a small, and select group of U.S. health care organizations have achieved Magnet recognition. “Our goal is to provide the highest quality of care to our community and Magnet recognition helps to affirm that we are doing so,” said Mary Carrillo, Chief Nursing Officer of Memorial Hermann Southeast and Memorial Hermann Pearland Hospitals. “This honor is tangible evidence of our nurses’ commitment to providing the very best
August 2021
care to our patients on a daily basis. We have a tightknit team between our two campuses and we will continue to pursue and maintain Magnet recognition well into the future.” Research demonstrates that Magnet recognition provides specific benefits to health care organizations and their communities, such as: • Higher patient satisfaction with nurse communication, availability of help and receipt of discharge information. • Lower risk of 30-day mortality and lower failure to rescue rates. • Higher job satisfaction among nurses. • Lower nurse reports of intentions to leave their positions. The Magnet Model provides a framework for nursing practice, research, and measurement of outcomes. Through this framework, ANCC evaluates applicants across a number of components and dimensions to gauge an organization’s nursing excellence. The foundation of this model comprises various elements deemed
essential to delivering superior patient care. These include the quality of nursing leadership and coordination and collaboration across specialties, as well as processes for measuring and improving the quality and delivery of care. Memorial Hermann Southeast Hospital, which includes Memorial
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Hermann Pearland Hospital and Memorial Hermann Convenient Care Center in League City, is home to the most comprehensive, high quality care available for residents of Houston’s Bay Area, Pearland, and Brazoria County.
Houston Medical Times
Page 9
The Framework “Topping Out” Ceremony for New O’Quinn Medical Tower Marks Historic Milestone for Baylor St. Luke’s Medical Center
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ith the hoisting of a commemorative steel beam covered in hundreds of hand-written signatures, Baylor St. Luke’s Medical Center celebrated the completion of the concrete structure in the ongoing construction of the O’Quinn Medical Tower at the McNair Campus. The traditional “topping out” ceremony was attended by hospital leaders and board members from St. Luke’s Health, Baylor St. Luke’s Medical Center and Baylor College of Medicine, along with a host of individuals involved in this historic project, which, when completed in 2023, will greatly expand medical services and outpatient care to residents of Greater Houston. “Today we celebrate the rebirth of the iconic O’Quinn Medical Tower, as part of the continued development of our new medical campus,” said Doug Lawson, Ph.D., CEO of St. Luke’s Health. “The completion of the tower’s structure is a significant milestone as we move toward advancing our
position as a high-performing health system within Texas.” The event, which also marked the next phase of construction on the Medical Tower, was also attended by key individuals from HKS Architects, Harvey Builders and other organizations working on the project. Their signatures were among the hundreds of hospital employees and leaders who traditional “topping out” ceremony was attended by hospital leaders and board members from St. Luke’s Health, Baylor signed the commemorative The St. Luke’s Medical Center and Baylor College of Medicine, along with a host of individuals involved in this historic project. beam for posterity. The new 12-story O’Quinn Medical Tower at Baylor St. Luke’s College of Medicine. forward to the continued expansion.” - McNair Campus will be the new “The new O’Quinn Tower and The expanded cancer center clinical home for the Dan L Duncan its designation as the clinical home of will offer radiation therapy and other Comprehensive Cancer Center. The Baylor’s Dan L Duncan Comprehensive diagnostic and treatment services, as Center is nationally ranked for cancer Cancer Center will be an important well as multiple specialized oncology care by U.S. News & World Report and milestones in Baylor’s mission,” said clinics and an infusion center. The is one of only three National Cancer In- Dr. Paul Klotman, president, CEO and new tower will also house multiple stitute-designated Comprehensive executive dean of Baylor College of outpatient services including radiology, Cancer Centers in Texas, a Medicine. “The McNair Campus is the see The Framework...page 12 designation it earned through Baylor hub of our clinical activity, and we look
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Page 10
Financial Forecast The Most Difficult Part of a Financial Planner’s Job
hile medical professionals may deal on a more regular basis with “life or death” issues, such situations can span across many different professions – including financial services. A long-time client contacted me the other day. Because I was expecting another call, I made the conversation brief and asked how my assistant could help him. His answer shocked and saddened me when he said, “I don’t think they can help me with this.” He went on to tell me he was in hospice. And just like that, thoughts of the 26 years he and I had worked together flooded my mind.
saying good-bye to someone who has become your friend over the years – and in some cases, even like family. While most people don’t like to think about it, death is a part of life. Yet, everyone deals with it in their own way. Given that, I think what is important here is to ask the people we care about how we can help them during this time. As a CFP, I know there are some important areas that should be taken care of, but that may be overlooked given their more pressing focus on the physical and medical-related needs. For instance, what loose ends do they need to tie up? Should they satisfy their annual required minimum distribution(s) from retirement and/ or IRA accounts now? Are there any funeral arrangements that still must be planned or funded? What about details for their eulogy and the outfit they want to be buried in? What about assets or personal
As a CERTIFIED FINANCIAL PLANNER, I help clients with a variety of issues. While most things have to do with monetary objectives, the majority of these are surrounded by emotional factors. For example, generating ongoing retirement income so people can feel confident about their finances and therefore, they can focus on spending more time with their loved ones. If I asked people to guess what the hardest part of my job is, I’m not sure that losing clients is the first thing that would come to their minds. Rather, they might say the most difficult components of any financial advisor’s duties may be: −− Securing new clients −− Dealing with different client personalities −− Ensuring that investments and strategies fit clients’ objectives −− Helping clients make good decisions when the market is volatile But the reality is that the toughest part of being a financial planner is
items they want to pass on to loved ones? Should some of these be gifted while the individual is still alive so that they can see the excitement on the recipients’ faces? In some instances, early birthdays or holiday celebrations may be in order. Because all situations are different, not all strategies will be right for everyone. But as difficult as having some of these conversations can be, they are well worth it as the next steps can be extremely meaningful for all involved. If anyone will struggle financially upon your passing, this should be addressed in your financial plan. And, if you already have a plan in place, you should consider reviewing it on a regular basis to make sure it is up to date. Working with a CFP practitioner to see whether or not your financial plan has all of the bases covered, including those that deal with transition, is highly recommended. That way, you can be more assured that things move forward the way you intend them to.
By Grace S. Yung, CFP Midtown Financial Group, LLC
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Page 11
Healthy Heart 13 Things Primary Care Clinics Can Check to Help Preserve Brain Health By The American Heart Association
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rimary care clinics can play an important role in preserving patients’ brain health using the American Heart Association’s Life’s Simple 7 as a guide, as well as addressing 6 other factors associated with cognitive decline, according to an American Stroke Association/American Heart Association Scientific Statement. Preserving brain health in an aging population is a growing concern in the U.S. An estimated one in five Americans 65 years and older has mild cognitive impairment, and one in seven has dementia. By 2050, the number of Americans with dementia is expected to triple, the statement authors note. Life’s Simple 7 focuses on seven lifestyle targets to achieve ideal cardiovascular health: managing blood pressure, healthy cholesterol
adulthood.” According to the statement: • Recent data show that hypertension, diabetes and smoking in adulthood and middle-life increase the odds of cognitive decline in middle-age and accelerate cognitive decline in older age. • People with dementia experience lower quality of life, and caregivers - typically family members - experience high rates of psychological stress and physical ill-health. Dementia is more costly than heart disease or cancer, with worldwide costs estimated at $818 billion in 2015. • Professional guidelines also recommend routine screening for depression and counseling patients to focus on healthy eating and exercising a minimum of 150
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levels, reducing blood sugar, increasing physical activity, eating better, losing weight and not smoking. The statement suggests primary care professionals also consider assessing risk factors to optimal brain health, including depression, social isolation, excessive alcohol use, sleep disorders, less education and hearing loss. “Studies have shown that these domains are impacted by factors that are within our control to change,” said Chair of the scientific statement writing group Ronald M. Lazar, Ph.D., FAHA, the Evelyn F. McKnight Endowed Chair for Learning and Memory in Aging and director of the Evelyn F. McKnight Brain Institute at the University of Alabama at Birmingham School of Medicine. “Prevention and mitigation are important, because once people have impaired cognition, the current treatment options are very limited. Prevention exists along the health care continuum from pediatrics to
minutes a week. • Lack of access to primary care services may be a barrier to prevention. Even with the Affordable Care Act, an estimated 15% of Americans adults still lack health insurance, and 25% of Americans do not have a source of primary care. “Many people think of high blood pressure, Type 2 diabetes and other risk factors as affecting only heart health, yet these very same risk factors affect our brain health. Patients might be more likely to pay attention to the importance of addressing modifiable risk factors if they understood the links,” Lazar said. “I’ve given lectures, and what people tell me is, the one thing they do not want to lose during the course of their lives is their mind.” To learn more about AHA’s Life’s Simple 7 visit heart.org.
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August 2021
Houston Medical Times
Page 12
Legal Matters
Continued from page 3 hospitals, children’s hospitals, and PPS-exempt cancer hospitals would continue to be excepted from this reimbursement cut and would continue to be reimbursed at ASP plus 6%. Update on Ongoing Litigation – American Hosp. Assoc. v. Becerra In the latest on the case, an appeals court ruled in favor of HHS, stating that the Secretary had the authority to make the 340B reimbursement cuts. AHA appealed to the Supreme Court, which agreed to hear the case to determine if
the Secretary has the statutory authority to make such substantial changes to Part B reimbursement for 340B drugs. Additionally, the Supreme Court requested HHS and AHA to address whether AHA’s challenge is valid based on an OPPS statutory provision which purports to limit judicial review of certain agency determinations. The Supreme Court is expected to hear the case during its next term, which begins in October. Key takeaways for 340B Program
Covered Entities: • Submit comments to provide input regarding use of the Survey data and to outline the impact CMS’s continued payment reductions have on covered entity communities. Comments must be submitted by 5 p.m. EST on September 17, 2021. • Continue to report JG/TB 340B drug modifiers and budget for ASP minus 22.5% reimbursement for 340B drugs for CY 2022 until the Supreme Court rules on the case or
CMS alters its course. • Monitor billing/coding compliance relative to 340B drugs as failure to utilize appropriate modifiers can lead to overpayments and duplicate discounts (in the Medicaid context). • Document files relative to the financial impact of the payment cuts for purposes of proving damages, if needed.
said Liz Youngblood, president of Baylor St. Luke’s. “By consolidating complementary services into one single location, we are elevating the patient experience of providing and receiving care and making it more convenient for our patients to receive the high-quality care they deserve.” The O’Quinn Medical Tower
is part of the expanding McNair Campus, which will boast more than 400,000 square feet of space to support and provide personalized care to patients and families. The campus will eventually include another hospital bed tower and ambulatory care center. The McNair Campus sits directly adjacent to the planned site of TMC3, the new
37-acre campus that will be located between Old Spanish Trail and the Brays Bayou. The new campus boasts a convenient location with ample parking and easy access to Highway 288, positioning Baylor St. Luke’s with the newest ambulatory diagnostic and treatment facility.
The Framework
Continued from page 9 endoscopy and an ambulatory surgery center. Among the new services expected to be offered at the new tower are a Pain Center and a Women’s Center for diagnostic breast imaging. “At Baylor St. Luke’s, we challenge ourselves every day to deliver exceptional, compassionate care while creating a positive experience for our patients and their families,”
WHAT WE OFFER:
• Integrating the Montessori method into the public school curriculum • Currently offering Pre-K thru 4th • Open enrollment until positions fill
• Comprehension Stem Program • Character & Leadership Development • High Tech – 7 computers per classroom
2319 N. GRAND BLVD., PEARLAND, TX. 77581 www.hmps.net | 281-485-2500 August 2021
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Houston Medical Times
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How One Houston Practice Transformed Its Pain Management Protocol by Offering a Non-Opioid Option With Commentary from Dr. Stefan Kreuzer, Orthopedic Surgeon, and Dr. Chauncey Jones, Anesthesiologist, Inov8 Surgical In Houston, Tx
F
or patients heading into orthopedic surgery – especially joint procedures like knee and hip replacements – pain is often top of mind. Opioids are the current standard of care for managing pain following these procedures; however, they are often associated with several side effects including nausea, constipation, dizziness, and even addiction and dependence. Considering non-opioid options could be a component to help turn the tide in America of opioid misuse. For nearly two years the team at INOV8 Surgical in Houston has worked to incorporate a multimodal pain management approach, including non-opioid options, to provide a positive recovery experience for patients while simultaneously decreasing opioid use after surgery. INOV8 Surgical is recognized as being one of the only Ambulatory Surgery Centers (ASC) in the area with demonstrated experience incorporating this non-opioid approach. Houston Medical Times spoke with two clinicians from the ASC to share their pain management protocol, how it has revolutionized the patient experience, and why they have incorporated it into all total joint procedures. Dr. Stefan Kreuzer, founder and orthopedic surgeon at INOV8 Surgical: Our practice is unique in that we approach all total joint procedures with a strategic, team-based mentality, which has been critical to the success of the center. We cross-train all nurses, anesthesiologists, surgeons, and recovery teams on our multimodal protocol, which includes various non-opioid options to manage pain, to ensure there is a continuity of care for each patient. This integrated effort, coupled with an emphasis on preoperative patient education and follow up, has allowed INOV8 Surgical to see extremely impressive results in improving patient recovery while decreasing opioid prescribing after surgery. Dr. Chauncey Jones, anesthesiologist at INOV8 Surgical: Our anesthesiology team works very
closely with the entire team of surgeons, nurses, and providers to ensure our approach to pain management is executed effectively. Our involvement spans from patient evaluation a nd education prior to the day of surgery, to early postoperative ambulation, discharge, a nd subsequent follow-up. This allows us to continually assess and optimize our protocol as partners. A key ingredient to our multimodal approach has been Dr. Stefan Kreuzer Dr. Chauncey Jones a non-opioid option called EXPAREL® (bupivacaine liposome injectable negative side effects of these powerful twitching, blurred vision, itching, and rapid heartbeat. suspension). EXPAREL is a medications. For more information, please EXPAREL can cause a temporary long-acting local anesthetic that is loss of feeling and/or loss of muscle injected into the surgical site during visit www.EXPAREL.com/safety. movement. How much and how long the procedure to provide pain relief Indication for the first few, and typically most EXPAREL® (bupivacaine liposome the loss of feeling and/or muscle painful, days after joint replacement injectable suspension) is indicated movement depends on where and how surgery. This is imperative, as the for single-dose infiltration in patients much of EXPAREL was injected and 24-48 hours post-surgery are the most aged 6 years and older to produce may last for up to 5 days. critical in terms of any rebound pain postsurgical local analgesia and in EXPAREL is not recommended to be or potential readmission. Because of its adults as an interscalene brachial used in patients younger than 6 years effectiveness, we now use EXPAREL plexus nerve block to produce old for injection into the wound, for in all total joint procedures, which has postsurgical regional analgesia. Safety patients younger than 18 years old reduced our average length of stay and and efficacy have not been established for injection near a nerve, and/or in pregnant women. sends patients home the same day– a in other nerve blocks. Tell your health care provider feat which used to be unheard of for Important Safety Information patients undergoing joint replacement EXPAREL should not be used if you or your child has liver disease, in obstetrical paracervical block since this may affect how the active surgery. ingredient (bupivacaine) in EXPAREL Dr. Kreuzer: We have anesthesia. performed over 800 same-day In studies in adults where EXPAREL is eliminated from the body. discharge total joint procedures using was injected into a wound, the most EXPAREL should not be injected into an EXPAREL-based multimodal common side effects were nausea, the spine, joints, or veins. The active ingredient in approach. It has been instrumental constipation, and vomiting. EXPAREL can affect the nervous in improving the patient experience. Through our evolving practice, we In studies in adults where EXPAREL system and the cardiovascular system; have seen that satisfied patients with was injected near a nerve, the most may cause an allergic reaction; may well-managed pain are more likely common side effects were nausea, cause damage if injected into the joints; and can cause a rare blood to get home quicker and experience fever, and constipation. a better overall recovery. We look In the study where EXPAREL was disorder. forward to continuing to provide our given to children, the most common Sponsored by Pacira patients with innovative methods side effects were nausea, vomiting, BioSciences, Inc. that advance their care, while constipation, low blood pressure, low minimizing opioid prescribing and the number of red blood cells, muscle medicaltimesnews.com
August 2021
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Houston Medical Times
Delta
HOUSTON
Continued from page 1 reach herd immunity, as experts say it’s the only way to stop these variants from spreading and to prevent new variants from forming. We have seen a 41% increase in COVID-19 patients at Houston Methodist in the last two weeks. As of July 7, there were 127 Covid-positive patients admitted as inpatients in our hospitals, increased from Sunday’s 107 and last week’s 86. Research shows the vaccines work well against the Delta variant and almost all infected patients
are unvaccinated. While some new studies say the vaccines used in the U.S. have reduced efficacy against infection with Delta, they remain highly effective in preventing serious illness and hospitalization. This is proving to be the case in Israel. Bottom line, Houston Methodist is urging the unvaccinated in the community to get shots as soon as possible, and if they do not, then they should continue practicing the COVID-19 prevention measures of
masking, social distancing, avoiding large crowds, maintaining hand hygiene and other best practices to protect themselves and their loved ones against Delta.
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Continued from page 1 Valdez recommends drinking water early on in the day and during your time in the heat. Sports drinks also are an option to replace electrolytes that are lost in sweat but should be supplemented with water. “Fluids with electrolytes are very helpful but not necessary,” Valdez said. “If you are going to be outdoors for extended periods, acclimatize yourself to the heat by spending only a few hours outdoors at first and adding more time in the outdoors over a span of two weeks.” It is also important to be aware of your environment. High humidity may contribute to heat exhaustion, so do not forget to wear cool clothing and take breaks from the heat. Those most at risk for heat
exhaustion include children, the elderly, those who are overweight and young athletes, especially football players who wear heavy equipment. Valdez adds that some common over-the-counter and prescription medications such as antihistamines, diuretics, anticonvulsants and anti-depressants also may increase the risk of heat exhaustion. “If you have to work or train in the outdoors and are concerned for the risk of heat exhaustion, reach out to your medical provider to review your medications and create a plan that suits your needs to keep you healthy during the heat,” Valdez said.
family members may be present, or the patient may be a minor. For example, document “visit conducted with child sitting on mother’s lap.” Clinical assistants, students, or a scribe may be present on the provider’s side. An interpreter may assist from a third location by video or telephone. Include documentation of all participants. 7. Assisted assessment. Plan in advance and provide instructions for patient assistance, such as for patients who will obtain and report their own vital signs (including weight, blood pressure, pulse, and temperature). Document the information in the medical record as “patient provided.” If
patients also assist in various aspects of physical examination, document the details as “patient assisted.” For more information on patient-assisted assessment, see our article “Strategies for Effective Patient-Assisted Telehealth Assessments.” Following these seven tips can help you ensure that your telehealth documentation is patient centered, comprehensive, and effective. You can also benefit from familiarizing yourself with the regulatory and payer requirements specific to your practice location(s).
Telehealth
Continued from page 4 might include “the visit was rescheduled at the patient’s request because her husband could not be available.” Evaluate and address distractions in the environment. Carefully document the patient assessment and environmental conditions as well as any actions taken and recommendations made. For more information on addressing patient distractions, see our article “Telehealth’s Newest Safety Risk: Distracted Patients.” 6. Others present. Document the record with the name and relationship of everyone who is present on the patient’s side of the interaction and the names and roles of everyone present on the provider’s side. The patient’s August 2021
Director of Media Sales Richard W DeLaRosa Senior Designer Jamie Farquhar-Rizzo
Heat Stroke
pressure and muscle cramps. Valdez adds that symptoms like nausea, vomiting or diarrhea should not be ignored. “Not only are these signs of heat exhaustion, but they can also make it difficult to recover from heat exhaustion when you are trying to rehydrate,” she said. If heat exhaustion is suspected, Valdez advises to find a place to rest, drink water and move to a cooler environment. If a person becomes confused and has an elevated body temperature of greater than 104 degrees Fahrenheit, they should be taken to the emergency room. Prevention While a quick reaction is good, prevention is better. The first way to prevent heat exhaustion is to hydrate.
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Houston Medical Times
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Is it time for insurance that’s
FOCUSED ON YOU?
With yet another of Texas’s largest medical liability insurers selling out to an investor-owned company, it’s time to ask yourself, “Do I want an insurer founded by and for physicians that’s guided by my peers? Or do I want a profit-focused insurer that’s driven by investors?” 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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Houston Medical Times
Making small changes every day can add up to big improvements in your overall health. Life's Simple 7 outlines a few easy steps you can take to live a healthier lifestyle. Two of these steps, Get Active and Eat Better, can help jump-start your whole health journey. Making choices that help you eat smart and move more can also help you lose weight,control cholesterol, manage blood pressure, reduce blood sugar and stop smoking. 1, 2, 3
GET ACTIVE Try to get at least 150 minutes per week of moderate aerobic exercise or 75 minutes per week of vigorous exercise (or a combination of both), preferably spread throughout the week. Even short 4 bursts of exercise can be beneficial, and all those little steps will lead to big gains in the long run.
EAT BETTER Eat a colorful diet full of fruits, vegetables, whole grains, low-fat dairy products, poultry, fish and nuts. Try to limit sugary foods and drinks, fatty or processed meats and salt. 1
LOSE WEIGHT Maintaining a healthy weight is important for your health. To lose weight, you need to burn more calories than you eat. Learning to balance healthy eating and physical activity can help you lose weight more easily and keep it off. 5
CONTROL CHOLESTEROL Cholesterol comes from two sources: your body (which makes all the cholesterol you need) and food made from animals. Eating smart, adding color and moving more can all help lower your cholesterol! 2, 6
MANAGE BLOOD PRESSURE Blood pressure is the force of blood pushing against blood vessel walls. Sometimes the pressure in arteries is higher than it should be, a condition known as high blood pressure. Stress and poor diet have both been linked to high blood pressure, so it’s important to be well and eat smart to help positively influence your blood pressure numbers. 1, 7
REDUCE BLOOD SUGAR Blood glucose (aka sugar) is an important fuel for your body. It comes from the food you eat, so it’s important to eat smart. Cut bout added sugars by checking nutrition facts labels and bingredients, limiting sweets and sugary beverages, choosing simple foods over heavily processed ones and rinsing canned fruits if they are in syrup.1 And you can move more, because moderate-intensity aerobic physical activity can also help your body respond to insulin.8
STOP SMOKING Not smoking is one of the best things you can do for your health. Smoking damages your circulatory system and increases your risk of multiple diseases, but the good news is that your lungs can begin to heal themselves as soon as you stop. Moving more can help you on your journey, since physical activity can help you manage stress. 9
1. Van Horn, L., Carson, J. A. S., Appel, L. J., Burke, L. E., Economos, C., Karmally, W., . . . Kris-Etherton, P. (2016). Recommended dietary pattern to achieve adherence to the american heart Association/American college of cardiology (AHA/ACC) guidelines: A scientific statement from the American Heart Association. Circulation, doi:10.1161/CIR.0000000000000462 2. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: The evidence. CMAJ. 2006;174(6):806 3. Van Horn, L., Carson, J. A. S., Appel, L. J., Burke, L. E., Economos, C., Karmally, W., . . . Kris-Etherton, P. (2016). Recommended dietary pattern to achieve adherence to the American Heart Association/American College of Cardiology (AHA/ACC) guidelines: A scientific statement from the American Heart Association. Circulation, doi:10.1161/CIR.0000000000000462 4. U.S. Department of Health and Human Services. (2018, November) Physical Activity Guidelines for Americans, 2nd Edition 5. Hill, J., Wyatt, H.R., Peters, J. (2012). Energy Balance and Obesity. doi.org/10.1161/CIRCULATIONAHA.111.087213 6. Third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III) final report. Circulation. 2002;106(25):3259-3260. 7. Gianaros, P. J., Sheu, L. K., Uyar, F., Koushik, J., Jennings, J. R., Wager, T. D., . . . Verstynen, T. D. (2017). A brain phenotype for Stressor
‐Evoked blood pressure reactivity. Journal of the American Heart Association, 6(9) doi:10.1161/JAHA.117.006053
8. Benjamin, E., Blaha, M., Chiuve, S., et al. Heart disease and stroke Statistics—2017 update. Circulation. 2017;CIR.0000000000000485 9. Silverman, M. N., & Deuster, P. A. (2014). Biological mechanisms underlying the role of physical fitness in health and resilience. Interface Focus, 4(5), 20140040. doi:10.1098/rsfs.2014.0040 ©2018 American Heart Association
August 2021
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