Louisiana Medical News October 2013 by FW Publishing

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SOU TH LOU ISIANA ED ITION

On Rounds Physician Spotlight

Insurance Marketplace Comes in, Glitches and All By TED GRIGGS

Dr. John A. Bolin A local legend

Necessary Provider Hospitals Don’t Meet Medicare Distance Requirement Only four of Louisiana’s 27 Critical Access Hospitals would qualify for the additional payments the Medicare program offers if required to re-enroll, according to the U.S. Department of Health and Hospitals Office of Inspector General ... page 6

Louisiana’s Health Insurance Marketplace will be up and operating by the Oct. 1 deadline, but consumers and small businesses, and possibly healthcare providers, can expect some glitches. “This is so complex that it is going to be very, very difficult for even agents to advise folks correctly on what they should do or should not do,” Insurance Commissioner Jim Donelon said. On the plus side, healthcare providers may have an easier time dealing with the insurance marketplaces than the newly enrolled members, said B. Ronnell Nolan, president and chief executive officer of Health Agents for America. In theory, the provider will input the patient’s information, and the marketplace will verify that the person is eligible, Nolan said. “It’s supposed to be seamless and easy,” she said.

Nolan said the U.S. Department of Health and Hospitals will be given six months to repair any glitches or make fixes to the marketplaces. Everyone eligible isn’t going to sign up on Oct. 1. But HHS will be able to handle any issues that arise between then and the next expected flurry of enrollment around Jan. 1. The agency will have to make any final adjustments to the marketplaces before March 31. Still, there is undoubtedly going to be a lot of consumer confusion. The federal government says everybody has to have insurance, and people will have the opportunity to buy coverage through the marketplaces or outside them. But it’s important to remember that the subsidies will only be available for customers who purchase coverage through the mar(CONTINUED ON PAGE 10)

MENTAL HEALTH

Research Uncovers New Clues to the Causes of Schizophrenia Genome-wide study discovers new variants, pathways By CINDy SANDERS

An insidious condition, schizophrenia is estimated to occur in about 1 percent of the population worldwide. Characterized by a breakdown in thought processes, the mental illness has been described for centuries through accounts of individuals suffering from delusions, paranoia and hallucinations. The chronic, debilitating disorder takes a heavy toll not only on affected individuals but also on their families and society as a whole. An early onset disorder, many patients are first diagnosed during the late teens

or early adult years and struggle throughout their lifetime to manage symptoms. “It’s a horrible disorder,” stated Patrick Sullivan, MD, director of the Center for Psychiatric Genomics at the University of North Carolina School of Medicine. “It’s a huge, huge public health problem, and it’s one where the scientific discussion has been dominated on partial informa(CONTINUED ON PAGE 12)

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Louisiana Medical News

Physician Spotlight

Dr. John A. Bolin A local legend

By BARBARA MCCONNELL

It has been 46 years since Dr. John Bolin’s 1967 graduation from the LSU School of Medicine, followed by a one year internship at New Orleans Charity Hospital and residency in the LSU Medical School Surgery Program. He has triumphed, survived and re-invented himself more than once to change with the times and the challenges of life. And recently, perhaps in the most daunting and ironic twist, he is himself a prostate cancer patient going through treatment, while continuing his work operating on women with breast cancer. “Now that I have had cancer, I can really identify with the women I treat. The hot flashes from taking hormone shots as part of my own treatment, and the associated weight gain without increased eating, are really terrible! What is unnatural for me, is natural for them as women and I never realized to what extent before. I have learned to appreciate that,” Bolin stated. There was a lack of intellectual and financial opportunities while growing up in the very small town of Singer, Louisiana near deRidder, but playing basketball in high school and then college at Northwestern State University is where he learned that hard work and persistence were needed to get where he wanted in life. “Shooting basket after basket in that hot, lonely gymnasium all by myself, sometimes up to 300 baskets at a time, was a hard lesson but that’s what it took,” he reminisced. He was not planning on being a doctor; instead he had a ‘calling’ to be a Baptist minister. But it was at Northwestern that he learned that he had a natural ability in science, and it didn’t hurt that his uncle, Arthur Chopin, head of the chemistry department at LSU, had influence with the medical school. “I may have had help getting into medical school, but that sure didn’t keep me in,” he stated in the soft-spoken drawl punctuated with a slight grin and melodious chuckle that is his manner. And he did well. He was Outstanding Resident twice in a four year surgical residency. In 1972, after requests by then Governor Edwin Edwards for him to be the new medical staff director and help re-open Charity Hospital in Lake Charles, Bolin said it was a short-lived ‘disaster,’ and he never wanted to get involved in the politics of medicine again.

The Hamilton Group – twice In 1973, around the end of the conflict in Vietnam, though Bolin wanted to sign up for military duty after his residency, the

government had signed him up already for The Army Reserves until age 35. With that resolved, a prestigious group of physicians in Lafayette, Louisiana, The Hamilton Group (THG), asked him to join them as a general surgeon, which he did from 1973 to 1989, after obtaining his board certification in surgery. In 1977, he went to The Lahey Clinic in Boston for a mini-fellowship in colorectal surgery, which he performed along with general surgery upon his return to Lafayette. He was still part of THG when they affiliated with Hospital Corporation of America (HCA) in the 1980’s as well as the new hospital that HCA built, now Regional Medical Center of Acadiana. Bolin left THG to learn about women’s breast cancer with Dr. Robert Elliott

at the Elliott Mastology Center in Baton Rouge in 1989-1990. “Dr Elliott was way ahead of his time with this clinic, where everything was under one roof: mammo, ultrasound, stereotactic. We saw many many patients. I remember one day we had 100, where I saw 40 and he had 60.” Returning to Lafayette for a short second tour with THG, Bolin then wanted to open a breast center similar to the one in Baton Rouge, and HCA helped him do that with the Southwest Regional Breast and General Surgery Center. But along the way, fate intervened again, and in 2000 at age 59, he had a massive heart attack, ‘the widow maker,’ in fact. Though lucky not to have sustained extensive heart damage, his days as a general surgeon, taking call, long hours, day

and night surgery, were over. However, after recovering, he continued to perform breast cancer surgery, which for him was much less strenuous, and he has been doing so for almost 25 years. Working part time now, nine days a month, Bolin said retirement is probably in a year, which is disturbing to his patients. He has a very loyal following because he says that once a woman has had breast cancer, they are followed forever and they become like family. A philosophy for his patients? “Believe in your physician; get support from family and/or friends; and have a strong belief in a greater being or God. And in life, add love what you do.” He is now part of the Women’s MultiSpecialty Group on the campus of Women’s and Children’s Hospital. The practice consists of four doctors – three breast surgeons and a urogynecologist – with a fifth doctor in imaging just down the street. Bolin’s office is packed with autographed pictures of sports stars in boxing, football and many autographed baseballs! “I have hundreds of signed baseballs at home, and three rooms of collectibles; some I bought, many given to me, names like Mantle, Gehrig, Ali,” he attests. From the pictures hanging everywhere inside and outside his office, you see what else is very important to him: rose growing, pets, golf, fishing, his church and family – his wife and two children and numerous grandchildren. Bolin said he is most proud of being past president of the Lafayette Parish Medical Society, and his promotion of continuing medical education in Acadiana.

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Louisiana Medical News

OCTOBER 2013 • 3

Tides Medical Launches Wave of New Products By LISA hANChEy

A mutual interest in nautical products served as the inspiration for Tides Medical, a Lafayette, La.-based manufacturer and distributor of regenerative medicine products. Dr. Isabella Sledge and medical device salesman Joe Spell started discussing their love of boats over a friendly business dinner in Boca Raton, Florida. At the time, Lafayette native Spell was a sales rep for a large orthopeIsabella dic company working Dr.Sledge in east Texas and looking to move back home. Sledge, an internist with over fifteen years of outcomes research experience, was practicing north of Boston and looking to do something Joe Spell different. Eight years ago, Spell moved back to his native Lafayette to start his own distribution company. In 2010, Spell and Slege formed Tides Medical, recently opening an office at 1819 W. Pinhook Road, Suite 109 in totally refur-

bished offices. Spell serves as CEO, while Sledge is vice president of data services. Dr. Isabella Sledge, is an internist with over fifteen years of outcomes research experience. “We have a number of ongoing studies documenting the efficacy of our products for patients. Our plan is to continue to grow this evidence base so we can effectively promote the appropriate use of these products in patient care,” said Sledge. About a year ago, Sledge’s husband John opened an orthopedic practice in Lafayette, allowing Isabella to move down from Boston and operate alongside her business partner. Officially headquartered in Lafayette, Tides Medical manufactures and distributes orthopedic implants and biologic products used for bone and tissue repair and wound healing. Tides’ moniker derived from two sources –Spell and Sledge both hail from tidal regions (Spell from the Gulf Coast and Sledge from the Atlantic Ocean), and all of Tides’ products bear nautical rope names. Examples include Trefoil (biologics), Cinch (wrappable bone allograft) and Hitch (osteoconductive sponge). Tides Medical’s mission is to bring the highest quality innovations in the orthopedic and wound care field to the

Physicians’ health Foundation oF louisiana

market through its national distribution network and solid relationships built on a foundation of personal customer service. “Our focus on physician–directed technology assessment has allowed us to bring several innovative devices to market quickly and to provide an ongoing pipeline of exciting products,” Spell explained. Tides’ FDA-approved, U.S. manufactured products include implants for cervical and lumbar surgeries such as interbody spacers, anterior lumbar buttress plates and the Spider Cervical Plate System. The latter provides the surgeon with a simplified implantation process through straightforward instrumentation and a proven one-step locking mechanism. “One of the things we like about pedicle screws is that ours are incredibly strong,” Spell explained. “They test out very well. It is simple, user-friendly and reproducible for surgeons.” In 2013, Tides launched its new line of biologic products, Trefoil BiologicsÔ. These products include bone putty, bone chips and wrappable bone allograft that speed healing following surgery or traumatic bone injuries. These bone grafts provide structural stability and serve as a scaffold for new bone formation, increasing the likelihood of a successful outcome for the patient. Trefoil Biologics follows in the wake of Tides’ successful line of amniotic tissue products launched in 2012. One, an absorbable patch, AmnioHealÔ, is used to speed the healing of wounds, tissue, and nerve repairs. It has also proven successful on difficult-to-treat radiation side effects, battlefield injuries, severe burns, and diabetic skin ulcers. In addition, there is an injectable formulation that has been developed for treating tendon injuries such as tennis elbow and rotator cuff tendinitis. Both products are produced from amniotic tissue harvested during planned c-section births. The tissue is then sterilized to remove any potentially infectious material and processed so that the tissue can be handled and placed in the affected area. “These are kind of unique products

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Louisiana Medical News

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for us,” Spell explained. “They are used for about 150 different applications, from spine surgeries to treating burns and treating wounds, scar management and sports injuries.” Strong data in medical literature supports the use of amniotic tissue for eye, orthopedic, obstetric, dental, urologic, cardiac, and neurological surgeries. Tides Medical promotes the development of further evidence on its products’ safety and efficacy by supporting clinicians in their efforts to carry out additional clinical studies. “We have a number of ongoing studies documenting the efficacy of our products for patients,” Sledge explained. “Our plan is to continue to grow this evidence base so we can effectively promote the appropriate use of these products in patient care.” Currently, Tides Medical’s products are manufactured elsewhere. That could change early next year, when Tides anticipates manufacturing proprietary products. Tides Medical contracts with approximately 200 sales associates from across the country. As its Lafayette headquarters nears completion, the company anticipates adding about 40 employees locally. Recently, the company hired Doug Payne as vice president of product development. Payne will direct the development of a proprietary line of spinal implants that will be launched in late 2013 or early 2014. A major area of growth for Tides Medical’s amniotic products is for professional and amateur athletes. Tides has sponsored several professional athletes who have had injuries treated with the injectable formula, including Wesley Sun Chee Fore, owner of CrossFit Lafayette, who placed thirteenth in the CrossFit Regional competition in 2012. Another sponsored athlete, Freddy Krueger, is a championship water ski jump record holder. He is featured on the cover of the July/August issue of Water Ski Magazine. On Sept. 28, 2013, Tides Medical will be sponsoring the Louisiana Night Jam, a water sport festival hosted by Bennett’s Water Ski and Wakeboard School in Zachary, La. Tides Medical will be showcasing its Trefoil Biologics line and revealing designs for its line of spinal implants this fall at the North American Spine Society annual meeting. Tides Medical will have a booth at the event from October 8-11 at the Convention Center in New Orleans, La.

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Louisiana Medical News

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Necessary Provider Hospitals Don’t Meet Medicare Distance Requirement By TED GRIGGS

Only four of Louisiana’s 27 Critical Access Hospitals would qualify for the additional payments the Medicare program offers if required to re-enroll, according to the U.S. Department of Health and Hospitals Office of Inspector General. Hospitals can be certified as CAHs by meeting a variety of requirements, including being located 35 miles from other hospitals – 15 miles if the facilities are separated by a two-lane highway – and being in a rural area. Up until 2006, states could permanently exempt CAHs from the distance requirement by designating them “necessary provider” CAHs. The Inspector General has recommended the Centers for Medicare and Medicaid Services ask Congress to remove that exemption. If that happened, instead of being paid 101 percent of reasonable costs for treating Medicare patients, 23 of Louisiana’s CAHs would get the same reimbursements as their counterparts in more heavily populated areas. Without the additional payments, some of the rural hospitals would close, and patients in those areas would suffer, said Rebecca Bradley, associate vice president of Rural Health Programs for the Louisiana Hospital AsRebecca sociation. Bradley “It would be a roll of the dice. If you just look at what their Medicare margins are right now, they’re all on razor-thin budgets,” Bradley said. Many of the rural hospitals have limited cash reserves. Even with the CAH reimbursements, the best those providers can hope for is a 1 percent profit margin on Medicare patients. It would be really hard for rural hospitals to survive the transition from CAH payments to the Prospective Payment System, the fee schedule under which other hospitals operate. “So we would be very nervous about these hospitals being able to survive that transition phase,” Bradley said. The rural hospitals fortunate enough to have cash on hand could survive the payment transition. But there’s no guarantee they would continue operating longterm. The smaller hospitals would have to take aggressive steps in order to compete in the marketplace and keep their doors open, she said. Right now, the rural hospitals are safety-net providers, and the areas they serve may not have other healthcare resources if those hospitals close. The Critical Access Hospital certi-

fication was created to insure that rural patients could access hospital services. The designation was created after Congress passed the Balanced Budget Act in the 1990s, switching rural hospitals to the Prospective Payment System and inadvertently forcing many of the facilities to close. Rural hospitals typically care for high numbers of Medicare patients, but their overall patient volumes are so low that it’s difficult for them to cover their overhead costs, Bradley said. There are more than 1,300 CAHs in the United States. These hospitals provided care for roughly 2.3 million Medicare beneficiaries in 2011. Medicare and Medicare patients paid around $8.5 billion for that care. The Office of Inspector General says nearly two-thirds of CAHs would not meet the location requirements if required to reenroll in Medicare. Medicare and Medicare members could have saved $449 million if CMS had decertified Critical Access Hospitals that were 15 miles or closer from the nearest hospital in 2011, according to the Inspector General’s report. That works out to an average of $860,000 per decertified hospital. But CMS doesn’t have the authority to decertify most of the CAHs because most of them are “necessary providers.” Bradley said the projected savings are a tiny fraction of the total spent each year on Medicare. The Louisiana Hospital Association and several of the hospitals’ chief executive officers are working to educate members of the state’s Congressional delegation about the issue. The topics of those talks include the importance and history of the Critical Access Hospital Program, why the state originally designated those hospitals as necessary providers, and what the impact would be if those facilities lost their CAH status. “Beyond that it’s going to take an act of Congress, literally, so we’re just keeping our eye out for any tentative legislation and working with the National Rural Health Association and the American Hospital Association to just kind of stay out in front of any piece of legislation that might be dropped,” Bradley said. However, Bradley said it’s unlikely that kind of legislation would surface before the next presidential election. “Thankfully at this point we have so many issues that outweigh this one at the federal level right now,” she said. “People are very hesitant to pick up anything that’s got healthcare on it and carry that bill, and especially if what you’re saying is going to decimate rural areas nationwide, which this one would if they tried to do it.”

What You Need to Know NOW about the CHNA Deadline By DAVID A. WILLIAMS

Within the numerous parts of the Affordable Care Act, there are still many areas of implementation and enforcement that are unclear. In the confusion, hospitals may have missed or are in danger of missing important deadlines like the Community Health Needs Assessment (CHNA). Nonprofit and dual status hospitals must submit a CHNA before the end of the fiscal 2012 year. Here’s an overview of what you need to know, along with tips on how to begin structuring your CHNA assessment to become a strategic tool you can use to better serve parts of your community that fall through the cracks, as well as to set budgeting priorities for the next few years. 1. If you are a dual status hospital (a governmental organization that is by statute not required to file a 990) and do not file a 990, you must still complete a Community Health Needs Assessment before the end of the fiscal year. The penalties for not submitting are uncertain, but it seems logical to assume that revocation of a hospital’s tax exempt status could be at stake as well as a $50,000 penalty. 2. The fact that the IRS has not yet revealed its mechanism for dual status

hospitals to submit the assessment does not exempt nonprofit and dual status hospitals from completing the CHNA. 3. The CHNA process takes several weeks from conceptualizing to staffing, information gathering to analysis, and report preparation. The report needs to include an action plan for addressing areas in your community that are underserved and have disproportionately high health issues 4. Think strategically about the CHNA. Under the Affordable Care Act, a Community Health Needs Assessment is required to be completed every three years. Taking the time to put a good process in place gives you a solid template for conducting CHNAs going forward. But the CHNA can actually be a very helpful strategic tool to take the temperature of the community; find out where you are having successes like a decrease in diabetes, which lets you know your program is working. Or you could find out infant mortality rate has risen, so a different approach is needed to help the community in that area. By treating the CHNA as more than a compliance requirement, there is an opportunity to move more swiftly from a reactive status to a proactive status that can get ahead of serious health trends.

Addressing population health management is a vital concern for hospitals. The reimbursement system for Medicare is shifting from a fee-for-service environment to an outcomes based delivery model. Other payors may adopt this approach moving forward, therefore, status quo is not a strategy for hospitals. The CHNA is a great tool to aid in the culture shift required to move away from the reimbursement platform that exists today. Here are key process suggestions to get the CHNA process started at your hospital: • Develop your supervisory team. Often the hospital administration, under direction from its board, is tasked with taking point on the CHNA. The first priority is to develop a needs listing that identifies both signs of wellness and areas of concern in the community you serve. Review existing programs with an eye for refocusing resources to meet the most critical needs. • Develop your CHNA implementation team. Include a broad representation of residents, agencies, and medical personnel that are knowledgeable about your community and will dedicate the time and effort to make the CHNA a success.

• Design the infrastructure necessary to manage the process, and to collect and analyze data. An evidencebased approach is necessary to meet compliance. • Establish a plan for gathering primary and secondary data. Primary data on your community provides an opportunity to identify health trends that need to be addressed. Methods used to collect primary data include postal surveys and web-based surveys, videography, observation, focus groups, and face-to-face interviews. Secondary data is information used to prepare quantifiable benchmarks. Examples of secondary data include demographic data about the growth rate of the community population, family income trends, area employers, vital statistics about incidence rates, prevalence rates, mortality, morbidity, and outcomes. Good sources for secondary data include Centers for Disease Control, State Department of Health, and U.S. Census Bureau. • Set up a process to analyze the data. Prepare charts that include benchmarks that show how your community stacks up against state and national benchmarks in key areas of wellness and disease. • Prepare a report that includes the (CONTINUED ON PAGE 8)

Louisiana Medical News

OCTOBER 2013 • 7

Stacking the Deck Part 1

One COM’s winning approach to retaining medical graduates By LYNNE JETER

When leaders at the Florida State University College of Medicine (FSU COM) began crunching numbers, they were pleasantly surprised to learn that roughly two of three medical graduates are practicing medicine in-state, even if they completed residencies elsewhere. “We were concerned it was a fluke and hoped the trend kept up,” said Michael Muszynski, MD, dean of the FSU COM Orlando regional campus, and associate dean of clinical research. “Five years later, it’s holding steady between 60 and 64 percent.” State lawmakers ap- Dr. Michael Muszynski proved the opening of the FSU COM in 2000, after the Board of Regents denied requests in the late 1990s, stating more doctors weren’t needed. The charter class graduated in 2005. As of May, 82 of 135 FSU COM graduates who have completed residencies are practicing medicine in Florida (61 percent). Of those, 70 percent (57) are in-state primary care providers (PCPs) and 16 percent (13) are practicing in rural, medically underserved areas of the state. “The reasons why our statistics are much better than the standard 30/60 percent split – that is, 30 percent of graduates from traditional-based medical schools typically return to the state after complet-

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ing residency and 60 percent stay where they did their residency – is because of the foundation we laid with our mission statement, which was created by us from the very start,” said Muszynski. “We wanted the foundation firmly established so that whoever inherited the program from the pioneers who started the school wouldn’t be able to vary from the mission.” First, FSU COM stacks the deck on the front end through a holistic application approach, focusing on applicants who want to live and practice medicine in Florida. Second, the college follows a community-based medical school model during students’ clinical years, where they connect one-on-one with physicians in the community. And third, medical school faculty makes it fun and interesting to be a community-based doctor with a mentoring system that maintains contact with students during school and afterward. “We put a great deal of thought into how our approach might work,” said Muszynski. “We knew we had to make an impression on medical students when they were making choices about their careers. And it’s working. The only thing that surprised us was how well it’s worked. We would’ve been happy with a 40 to 50 percent return, but 60 to 65 percent is astounding.”

Deck Stacking Rather than reviewing only grades and scholastic ability, the FSU COM application review board selects students with attributes that mirror the school’s mission. “We quickly discovered that students who stated upfront their agreement with our mission had experience supporting that mission alignment,” said Muszynski. “For example, we noted that many appli-

cants from smaller towns and smaller high schools were involved in a meaningful way with their community and seemed more likely to maintain that mission. We made no apologies for those identifying descriptors.” For several years, FSU COM only accepted in-state applicants. Now, approximately 5 percent of approved applicants cross state lines to attend. Still, the board remains very selective. All factors considered equal between two applicants – one from a rural area and an urban applicant – the rural applicant may be get a slot above the urban applicant, said Muszynski. “A student from a rural area is more likely to align with our mission just because of their setting,” he explained. “But the rural applicant who didn’t do much extracurricular-wise, where the urban applicant worked with the underserved, then it’s different.”

Middle Ground To keep the in-state return mindset strong, the FSU COM uses a communitybased curriculum to place third and fourth year medical students in the field. “Community-based curriculums have been talked down by some schools,” said Muszynski. “We contend its equal worthiness. We focus on producing physicians who can care for patients in community settings, and a community-based curriculum is central to the process.” For example, FSU COM has a unique apprenticeship model. Students aren’t assigned to hospitals, wards or residency teams. Instead, they’re assigned to a physician practicing in the community who has been trained to be an educator. That physician typically receives $2,000 a month on a contract basis. As a result of this model, the FSU COM has no full-

Stage 3 To further strengthen community ties and the job placement network, Florida Hospital recently provided a $2 million gift to establish the Florida Hospital Endowed Fund for Medical Education to help the FSU COM support its educational mission. “Our mission aligns strongly with Florida Hospital’s except that we’re not a faith-based school; we’re public,” said Muszynski. “These students are highly sought after, and relationships end up being life-long. We have 16 graduates already practicing in Central Florida. You might think: only 16? But it’s impressive when you consider the number of graduates during our ramp-up years between 2005 and 2010, and those who are just finishing 5-year residencies. We’ve now created a number of scholarships to encourage students to return.”

What You Need to Know NOW YYo urr PPaarr neH care ou tt nn eresrisniH aleta hlctah re about, continued from page 7 Your Partners in Healthcare

EDWIN G. PREIS, JR. EDWIN G. PREIS, JR. L. LANE ROY L. LANE ROY ROBERT M. KALLAM ROBERT M. KALLAM EDWIN G. JR. FRANKFRANK A. PICCOLO A.PREIS, PICCOLO LANE ROY JOHN L. M. RIBARITS JOHN M. RIBARITS ROBERT M.LANDRY KALLAM CATHERINE M. LANDRY CATHERINE M. FRANK A. EDWIN G. PREIS, JR. JAMES A.PICCOLO LOCHRIDGE, JAMES A. LOCHRIDGE, JR. JR. L. LANE ROY JOHN M. RIBARITS CHARLES J. BOUDREAUX, JR. CHARLES J. BOUDREAUX, JR.M. ROBERT KALLAM CATHERINE M. LANDRY DAVID L. PYBUS FRANK A. PICCOLO DAVIDJAMES L. PYBUS A. JR. DAVID M.LOCHRIDGE, FLOTTE JOHN M. RIBARITS DAVIDCHARLES M. FLOTTE J. BOUDREAUX, JR. LEAH NUNN ENGELHARDT CATHERINE M. LANDRY L. PYBUS LEAH DAVID NUNN ENGELHARDT JAMES EDWARD F. KOHNKE IV A. LOCHRIDGE, JR. CHARLES J. BOUDREAUX, JR. DAVID M.E. FLOTTE JOSEPH LEE IIIIV EDWARD F. KOHNKE DAVID L. PYBUS LEAH NUNN ENGELHARDT JENNIFER A. WELLS JOSEPH E. LEE III DAVID EDWARD F. KOHNKE IV M. FLOTTE JONATHAN L. WOODS LEAH NUNN ENGELHARDT JENNIFER A. WELLS JOSEPH E. LEE ALEXANDER III EDWARD F. KOHNKE IV M. BENJAMIN JONATHAN L. WOODS JENNIFER A. WELLSJOSEPH E. LEE III KEVIN T. DOSSETT M. BENJAMIN ALEXANDER JONATHAN L. WOODS JENNIFER A. WELLS KENNETH H. TRIBUCH JONATHAN L. WOODS ALEXANDER KEVINM. T.BENJAMIN DOSSETT CARL J. HEBERT M. BENJAMIN ALEXANDER KEVIN DOSSETT KENNETH H.T.TRIBUCH MICHAEL B. NORTH KEVIN T. DOSSETT KENNETH H. TRIBUCH CARL J.MARJORIE HEBERT C. NICOL KENNETH H. TRIBUCH CARL J. HEBERT MATTHEW S. GREEN CARL J. HEBERT MICHAEL B. NORTH MICHAEL B. NORTH MICHAEL B. NORTH EZRA L. FINKLE Fully Staffed MARJORIE C. NICOL MARJORIE NICOLMARJORIE C. NICOL JEAN ANN C. BILLEAUD MATTHEW MATTHEW S. GREEN MATTHEW S. GREEN JOHNS. F.GREEN COLOWICH Practice Group Healthcare EZRA L. FINKLE EZRA L. FINKLE EZRA L. FINKLE KRISTOPHER STOCKBERGER JEAN ANN BILLEAUD JEAN ANN BILLEAUD 337.237.6062 JEAN ANN BILLEAUD JOHN L. ROBERT, III JOHN F. COLOWICH F. COLOWICH KRISTOPHER STOCKBERGER WILLIAM W. FITZGERALD JOHN JOHN F. COLOWICH Charles J. Boudreaux, Jr. KRISTOPHER JOHN L. ROBERT, III Medical Malpractice and Professional CAROLINE T. STOCKBERGER WEBB KRISTOPHER STOCKBERGER WILLIAM W. FITZGERALD JOHN L. ROBERT, III MANDY A. SIMON Head of Healthcare Charles J. Boudreaux, Jr. Liability JOHN WILLIAM L. ROBERT, III MedicalDefense Malpractice and Professional ~ CAROLINE T. WEBB ~ Risk Management W. FITZGERALD NATHANIEL C. PITONIAK A. SIMON Charles Head of Healthcare Practice Group WILLIAM W. FITZGERALD J. Boudreaux, Jr. Medical Malpractice and Professional CAROLINE WEBBMANDY NICOLE M.T. BOWEN Defense ~ Risk Management ~ Liability NATHANIEL C. PITONIAK Charles J. Boudreaux, Jr. Practice Group Regulatory Healthcare Compliance ~ HIPAA ~ CAROLINE T.A. WEBB MANDY SIMON Head of Healthcare ANDREW B. BROWN NICOLE M. BOWEN Healthcare Compliance ~ HIPAA Regulatory Defense ~ Risk Management ~~ Liability NATHANIEL PITONIAK MANDY A. SIMON ANDREW B. BROWN THOMAS H. C. PRINCE Head of Healthcare ~ General Commercial and EMTALA Practice Group THOMAS H. PRINCE NICOLE M. BOWEN NATHANIEL C. PITONIAK RACHAL D. CHANCE EMTALA ~ General Compliance Commercial and Healthcare ~ HIPAA ~ Regulatory Practice Group RACHAL D. CHANCE ANDREW BROWN II CRAIG R.B. BORDELON, Business Transactions Healthcare NICOLE M. BOWEN Business Transactions Healthcare THOMAS PRINCECRAIG R. BORDELON, II JARED O.H. BRINLEE ~ General Commercial and EMTALA JARED O. BRINLEE ANDREW B. BROWN RACHAL D. CHANCE and CHRISTOPHER M. LUDEAU Contracts andContracts CHRISTOPHER M. LUDEAU THOMAS H. R. PRINCE CRAIG BORDELON, II Healthcare Business Transactions KELLYE E. ROSENZWEIG KELLYE E. ROSENZWEIG RACHAL D. CHANCE JARED O. BRINLEE and Contracts CRAIGCHRISTOPHER R. BORDELON, II M. LUDEAU E. ROSENZWEIG Lafayette ~ New Orleans ~ Houston JAREDKELLYE O. BRINLEE CHRISTOPHER M. LUDEAU www.preisroy.com KELLYE E. ROSENZWEIG

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time faculty for years 3 and 4, with the exception of the campus dean. The approach also includes a geriatric rotation component to spark interest in caring for older patients. FSU COM has also established a strong student advisor network. Each student is assigned to a community advisor on an 8-to-1 ratio. Students are counseled not only about their careers, but also life in general, volunteerism, and the delicate yet very important work/life balance that perplexes many physicians. Advisors are overseen by a dean or associate dean, depending on the campus, on a 20-to-1 (students-to-dean) ratio. “That low of a ratio in the U.S. rarely exists,” emphasized Muszynski.

Louisiana Medical News

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health priorities identified by the CHNA. Share it with the community and prepare an action plan to address any healthcare gaps. If you treat the CHNA as a checkthe-box requirement, then you’ll have a nice statistics report you can file. But when done correctly and strategically, the CHNA truly does provide an opportunity for hospitals to proactively budget resources for a multi-year plan that meets the specific health needs of the community of residents it serves. David A. Williams, CPA, MPH, FHFMA leads healthcare reimbursement and advisory services at HORNE LLP. For more than 25 years David has focused on the healthcare industry serving hospitals, outpatient centers, home healthcare agencies, skilled nursing facilities, assisted living centers, rural health clinics and mental rehabilitation centers. From offices across the Southeast, HORNE serves healthcare clients across the nation. Visit www.horne-llp.com for more information.

A New Gold Standard?

Washington University team performs ﬁrst incisionless procedure for treating esophageal achalasia in St. Louis By LyNNE JETER

An incisionless procedure first performed in St. Louis at Washington University’s 7th Annual GI Live Conference in July may very well represent a new gold standard for treating esophageal achalasia. “This is the closest we’ve gotten to the Holy Grail dream of incisionless surgery, where the patient goes to sleep, wakes up, feels no pain and has no side effects or complications,” said surgeon Michael Awad, MD, PhD, FACS, associate dean of medical student education, program director of general surgery, and director of the Washing- Dr. Michael Awad ton University Institute for Surgical Education. “We’re not totally there yet, but we’re very, very close.” Awad and interventional gastroenterologist Faris Murad, MD, assistant professor of Dr. Faris Murad medicine, and director

Current Gold Standard for Treating Esophageal Achalasia The Heller myotomy is most commonly used to treat achalasia, a dysfunction of the lower esophageal sphincter (LES), which fails to relax properly, making passage to the stomach difficult for food and liquids. Initially performed by Ernest Heller in 1913, the procedure, now performed laparoscopically, involves cutting the LES muscles. The myotomy only cuts through the exterior esophagus muscle layers that are squeezing the muscle, leaving the inner mucosal layer intact.

of endoscopic ultrasound at Washington University, performed the area’s first POEM (Per Oral Endoscopic Myotomy) procedure on July 19, on a 54-year-old female who awoke early the next morning ready to go for a run. “We said, ‘no, you can’t do that yet,’” recalled Murad, with a laugh. Immediately after completing the procedure, Murad and Awad could see how well the patient’s esophagus opened. “Other than minor bleeding and some CO2 that leaked into her abdomen, the case went great,” said Murad. “We’d practiced it and really understood the game plan.”

When checking on the patient postoperatively that evening and the next morning, Awad was pleased to learn the patient had zero pain from the procedure. She only expressed slight discomfort from the postoperative barium swallow study and the IV in her arm. “We wrote her (a script for) IV pain medication,” he said. “She didn’t use it once. We’d also written (a script) for Tylenol, but she didn’t take even one Tylenol. That’s almost unheard of after a procedure like this.” Within a couple of days, the patient returned to her daily routine. “She’s noticed a huge difference,” said Murad. “We’re thrilled with her outcome so far.”

The Long Preparation Murad and Awad began preparing for the introduction of the incisionless procedure to St. Louis two years ago, when they first heard about POEM being introduced in the United States. Worldwide since 2010, some 1,400 POEM procedures have been performed. Nationally, there have been only 200 POEM cases, mostly at two locations. The largest POEM center in Portland, Ore., accounts for roughly half of them. Awad trained with Lee Swanstrom, MD, FACS, of The Oregon Clinic in Portland, who was the first doctor to perform natural orifice surgery in the United States. The second largest center is Chicago; roughly 35 POEM procedures have been performed at NorthShore Hospital, and perhaps 25 cases at Northwestern Memorial Hospital. “One of the first times POEM came up in the U.S. was two years ago at a Society of American Gastrointestinal and Endoscopic Surgery (SAGES) conference in San Diego,” said Murad. “I was presenting at the conference and had heard discussion about POEM, but it was the first time I’d seen video and learned more about it. A consensus meeting discussing (CONTINUED ON PAGE 11)

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Louisiana Medical News

OCTOBER 2013 • 9

Insurance Marketplaces, continued from page 1 ketplace, Donelon said. There will also be two marketplaces, one for consumers and one for small businesses. Subsidies are available for people who earn up to 400 percent of federal poverty levels, or roughly $92,400 for a family of four. “That’s going to be a lot of people,” Nolan said. Some 963 plans filed to sell health insurance in Louisiana in 2014, Nolan said. She is not sure which of those companies or rates have been approved for the Louisiana Health Insurance Marketplace. A number of larger insurers have said they will participate in the exchanges, including Blue Cross and Blue Shield, Coventry Health Care, Vantage, Humana

and the Louisiana Health Cooperative. Each of those insurers is likely to offer different health plans at different levels of coverage. The plans can offer bronze, silver, gold and platinum plans, as well as catastrophic coverage for those under 30. “Blue Cross might have 20. Vantage might have 10, and Coventry might have 10. There could be a lot of different things to choose from,” Nolan said. A number of firms are also expected to offer dental coverage through the exchanges. All those coverage options mean consumers will need help making a good decision.

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In mid-August, the federal government awarded four “navigator” associations in Louisiana around $1.8 million to help consumers with the marketplaces. The groups are Southern United Neighborhoods, a charity founded in 2010, $486,123; Martin Luther King Health Center Inc., a Shreveport nonprofit, $81,066; Southwest Louisiana Area Health Education Center, founded in 1991, $1.1 million; and Capital Area Agency on Aging, District II Inc., $100,000. In addition, at least 250 health insurance agents have taken the 8-hour course to be certified as healthcare reform specialists. Consumers and small business owners should make sure they talk to someone who’s educated and knowledgeable about the health plans, Nolan said.

“The premium’s the same (on the marketplaces), regardless of whether you use an agent, a navigator, or you do it yourself. It’s going to be the same. It doesn’t matter,” Nolan said. Although the marketplaces were touted as a source of more affordable coverage, things may not work out as planned, Nolan said. Some industry members expect rates could be as much as 40 percent higher. If so, then even the people with subsidies might not be able to afford the coverage. Going without insurance coverage will cost individuals $95 the first year. By the third year, the penalty will jump to $695. And Nolan said there may be other complications. The subsidies are advanced to insurers on behalf of consumers who qualify. The subsidy amounts are based on the previous year’s income. So a welder who made $12,000 the year before and then makes a lot more money because he works a lot of overtime may end up having to repay part of his subsidy. Some people are going to have sit down and figure out if it’s worth their while to make more money. “It’s scary that you even have to have those thoughts. But that’s the new way we’ll go forward as far as healthcare is concerned,” Nolan said.

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Louisiana Medical News

Simplifying Systems Securing SSOs

By LYNNE JETER

For many organizations, single signon (SSO) technology is simply a tool to increase efficiency. But in the healthcare setting, it’s a differencemaker. Expedited access to patients’ health records allows caregivers to make quicker decisions about treatment options and medications. As disparate systems Dean Wiech continue to be pervasive, with records in multiple environments, an SSO tool easily allows users access to all systems by using just one login credential. SSO simplifies user interaction, and when done properly, may act as a catalyst to improve workflow and documentation.

“Virtually everything is digital and stored electronically,” said Dean Wiech, a national leader in IAM (identity and access management) healthcare technology. “The real issue becomes making sure the appropriate people have access appropriate to their position or department in hospitals. For example, role-based access control – when a user is granted position into the network and applications – allows staff to have the ability to see information appropriate to them. You don’t want a nurse in the maternity ward to have the ability to see what’s going on the respiratory floor.” Single sign-on security has been a grave concern of CIOs, noted Wiech. “An employee could walk away from a monitor and leave a session open that anyone else could walk up and see,” he explained. “There are some great tools on

the market to fix the issue; single sign-on is just a part of it.” Wiech, also managing director of Tools4ever, a supplier of software and integrated consultancy services involving IAM, pointed to one solution: an enterprise-level SSO that uses badge readers and Follow Me, a tool particularly helpful for physicians making their rounds. “They log into a terminal server and the session goes up so they can go from machine to machine without waiting for any application to open,” he said. “It remains open through the terminal service environment.” Time options for inactive screens to automatically close a session range from 30 seconds to 1 minute, configurable to the hospital’s requirements. “Since information began converting to electronic, the ability to view it has

become more widespread,” he said. “You may have 10 to 15 nurses on a floor, and you run the risk of a digital file being exposed.” In Orlando, for example, a low-level hospital clerk misused his newly discovered access to emergency room medical charts by routinely scanning them for automobile accidents and pocketing money for every lead he gave a local attorney. “For that reason, role-based access control is another tool that ties into single sign-on,” said Wiech. “If proper controls had been put in place during that employee’s hire, he never would’ve had access to the system. You really need an application that takes a look at different types of data elements needed, and configure and maintain that person’s access to the network, data and applications appropriately.”

usually approach disease of the GI tract with keyhole surgery. We’ve been trying for years on a national level to make our procedures less invasive, and a huge jump was made 20 years ago with the advent of laparoscopic and minimally invasive surgery. It was a huge advance toward less pain, faster recovery, and fewer complications for patients.”

“in-you-way”) to keynote the July 19 St. Louis Live Endoscopy Conference and also proctor the first POEM case at Washington University. “It’s too early for us to know long-term outcomes, but right now they’re matching laparoscopic outcomes,” said Murad. “As our understanding of the procedure improves, it might lead to better long-term outcomes.” Is the POEM procedure the new gold standard for esophagus achalasia? “That’s the hope,” said Murad. “We don’t have quite enough evidence yet to say that, but it’s emerging, and very promising. However, this particular procedure requires a great deal of technical expertise and a lot of specialized training. It won’t be done in all corners yet.”

A New Gold Standard? continued from page 9 the best approach to POEM with preliminary data and other details was very enlightening. POEM has been slow to take hold in the U.S. because so much goes into it, and the procedure takes highly skilled people.” In St. Louis, a collaborative approach was taken with minimally invasive surgery and interventional endoscopy. This col-

POEM Procedure for Esophageal Achalasia Symptoms: Weight loss, chest pain/ heartburn, regurgitation. Preoperative examination: Esophageal manometry, barium swallow study, blood test, and x-ray exam of chest and abdomen. POEM surgical steps: 1. With the patient in the operating room under general anesthesia, an endoscopy of the upper gastro-intestinal tract is performed to determine the length of the required incision of the muscle layer. 2. After the injection of a saline solution is made under the mucosa, a “mucosal incision is created which allows the endoscope to enter the submucosal space”. 3. A submucosal dissection is then performed down the esophagus to the top of the stomach. After creating the tunnel in the submucosa, the inner muscle layer is cut along its length. 4. The mucosal entry is closed by clips that will eventually fall off. Possible postoperative symptoms: Fever up to 101 degrees, chest pain due to the muscle layer incision performed, and throat discomfort. Day after surgery: A barium swallow study to confirm that the mucosal incision is tight and not leaking.

laboration paired surgical experts in performing laparoscopic Heller myotomy, with interventional endoscopy and an esophagologist. Awad and Murad co-directed the start of the POEM program at Washington University. Because the POEM procedure pairs specialists in surgery and GI, Murad and Awad began concentrated efforts to expedite bringing the POEM procedure to St. Louis. “POEM is a convergence of disciplines, with both specialties focusing on the GI tract,” said Awad. “Traditionally, the approach to those disorders has come from different angles. GI approached it through use of medications and limited therapeutic maneuvers (injection of Botox and balloon dilation). On my end, we

Lagniappe During the preparation phase, Awad and Murad connected with Haruhiro Inoue, MD, a professor at Showa University Northern Yokohama Hospital and Digestive Disease Center in Japan, who has performed 423 POEM procedures. The timing worked well for Inoue (pronounced

SOURCE: Showa University Northern Yokohama Hospital.

Louisiana Medical News

OCTOBER 2013 • 11

LSMS

Making Louisiana a Better Place to Practice Medicine Since 1878

A New Health Insurance Marketplace Means Questions by LSMS Communications, Publications, and Social Media Manager Joshua Duplechain Changes abound in the Health Insurance Marketplace, and the Louisiana State Medical Society wants to help the community with questions it might have.

How Do the Health Plans Vary in Cost?

Recently, the Centers Joshua Duplechain for Medicare & Medicaid Services published a helpful guide to the changes in health insurance that became effective October 1. With their help, let’s take a look at the major questions consumers might have.

Whom Does the Marketplace Help? In short, the uninsured. The marketplace is meant mainly for those individuals who want to buy healthcare coverage for either themselves or their families. Those who have insurance through their employer or a government program need not concern themselves.

Why Would a Healthy Person Need Insurance?

No one plans on becoming sick or hurt, but most people eventually need healthcare. For example, three days in the hospital run, on average, $30,000. Fixing a broken leg can cost up to $7,500. Having healthcare coverage protects an individual from unexpected medical expenses.

Can Someone With a Medical Condition Buy Insurance?

Yes. Insurers can’t deny an individual coverage because he or she has a medical issue, nor can they charge that person more than someone in good health. Also, once that individual has insurance, medical care begins immediately.

What Does the Marketplace’s Health Insurance Cover?

All of the health plans provide a package of 10 essential benefits, including emergency services, hospital care, lab services, prescription drugs, doctor visits, preventive care, etc. Some plans offer additional coverage for things like dental or vision care. The benefits are similar to what is typically covered in an employerprovided plan.

Some marketplace plans have lower monthly premiums but charge more outof-pocket when individuals require care. Other plans charge higher premiums but cover more medical expenses. The individual decides how he or she wants to balance their premium costs with their out-of-pocket costs. For example, if you see your doctor often and take a number of prescription drugs, a platinum or gold plan may be better for you. If you don’t, a silver or bronze plan may be more practical. You will see the differences in premiums and out-ofpocket costs when you shop for a plan.

How Does Someone Shop for Insurance in the Marketplace?

By filling out an application and finding out how much you can save on monthly premiums and out-of-pocket costs. Most people who apply will qualify for lower costs of some kind. Specific information is available at healthcare.gov.

Where to Go for Help in Applying and Enrolling?

Online at healthcare.gov, by phone at 1-800-318-2596, or in person. The website and toll-free call center can direct you to the benefit counselors in your area.

Where Can Someone Shop and Enroll, and When Does Coverage Start?

Open enrollment began October 1 and runs through March 31, 2014. Health plans and prices are available now. Coverage begins January 1, 2014.

What if Someone Doesn’t Have Coverage in 2014?

The new healthcare law requires people who can afford it to take responsibility for their health insurance by getting coverage or paying a fee. Without insurance, the individual bears the full brunt of any medical bills, which could lead to heavy debt.

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12 • OCTOBER 2013

Louisiana Medical News

Research Uncovers New Clues, continued from page 1

tion.” He added, “People have done the best they can with what information they have. We’ve been debating the cause of schizophrenia for the better part of a century now.” On Aug. 25, Sullivan and colleagues helped Dr. Patrick move that conversation Sullivan forward with the online publication of a new genome-wide association study (GWAS) in the journal Nature Genetics. “This is the largest published study we’ve done in the field,” noted the lead author who also serves as a professor in the departments of Genetics and Psychiatry and UNC. Collaborators in the study include co-authors from the Karolinska Institutet in Sweden, the Stanley Center for Psychiatric Research at the Broad Institute of MIT and Harvard, and the Mount Sinai School of Medicine in New York. “We discovered there were 22 places in the genome, 13 of which to our knowledge had never been described before, and each is a clue about the cause of schizophrenia,” Sullivan said of identifying nearly two dozen locations in the human genome that are involved in the disorder, including one that has previously been implicated in bipolar disorder. “If finding the causes of schizophrenia is like solving a jigsaw puzzle, then these new results give us the corners and some of the pieces on the edges,” he stated, adding the number of genetic variants probably numbers in the thousands. “These 22 are the tip of the iceberg.” The study was based on a multistage analysis that began with a Swedish national sample of 5,000 schizophrenia cases and 6,200 controls followed by a meta analysis of previous GWAS studies and then a replication of single nucleotide polymorphisms (SNPs) in 168 genomic regions in independent samples for a total of more than 59,000 people included in the research. The results underscored two takeaways for Sullivan. The first, “We need to do more studies urgently. We’re actually quite encouraged and believe larger studies of this type will lead to more knowledge,” he said. The second, “The

Are You CONNECTED?

early results we have here certainly indicate two different biological processes are involved.” The research uncovered two distinct pathways that might be associated with the disorder — a calcium channel and microRNA 137. Calling the calcium channel, which includes the genes CACNA1C and CACNB2, the ‘queen of the channels,’ Sullivan explained there are a number of FDA-approved calcium channel blockers on the market today that are used for a variety of conditions ranging from hypertension and angina to migraines. Stressing that it was much too early to draw conclusions, Sullivan said the findings at least indicate the calcium channel might be an area that deserves further attention from those studying schizophrenia. Hypothetically, he continued, calcium channel blockers might be found to have unexpected efficacy in schizophrenics. “That’s something that needs to be evaluated in a careful, rigorous way,” he said, again cautioning against jumping too far ahead. The second pathway includes its namesake gene MIR137, which is a known regulator of neuronal development. Sullivan noted more than a dozen other genes are also known to be regulated by MIR137, as well. Schizophrenia has long been known to have a strong genetic component. While it occurs in about 1 percent of the general population, the disorder is found in about 10 percent of people with a firstdegree relative diagnosed with schizophrenia. The National Institute of Mental Health notes the highest risk for developing the illness — 40 to 65 percent — occurs in an identical twin of an individual with schizophrenia. Yet, most scientists believe genetics is only one component in developing the disorder, which probably has environmental triggers, as well. While Sullivan said each different approach to solving the enigma of schizophrenia is important, he noted the genetic approach offers a strong foundation for discovery. “We can measure the DNA part of people particularly well these days,” he said. “Our study is a step forward in understanding the genetic basis of the disorder. This is really, truly nice progress.” He added the new findings provide “a couple of good strides forward” even though an endpoint isn’t yet in sight. “But for researchers and scientists, it shows us a bunch of things we’ve never seen before … and that’s pretty cool.” And Sullivan expects more information to be forthcoming. “What’s really exciting about this is that now we can use standard, off-the-shelf genomic technologies to help us fill in the missing pieces,” he said. “We now have a clear and obvious path to get a fairly complete understanding of the genetic part of schizophrenia. That wouldn’t have been possible five years ago.”

Happy, Safe Workforce Prerequisite for Patient Safety Report Emphasizes Impact of Workplace Culture on Patient Outcomes By CINDy SANDERS

If the workforce ain’t happy … ain’t nobody happy. This spring the Lucian Leape Institute at the National Patient Safety Foundation (NPSF) released a report, Through the Eyes of the Workforce: Creating Joy, Meaning and Safer Health Care, that underscored the fundamental importance the workplace environment plays on patient safety. The result of two roundtables on the topic, the report contends patient safety is inextricably linked to healthcare workers’ own sense of safety and well being since providers who feel disrespected or threatened are more likely to make errors and less likely to follow institutional protocols. Julianne Morath, RN, MS, president and CEO of the Hospital Quality Institute based in Sacramento, Calif., coled the roundtables with former U.S. Treasury Secretary Paul O’Neill, Julianne now CEO of Alcoa. A Morath founding member of the Lucian Leape Institute, Morath was the inaugural recipient of the John M. Eisenberg Award for Lifetime Achievement in Patient Safety from NPSF and is a noted author and speaker on the topic of safety and workforce improvement. Going into the roundtables, Morath said the working hypothesis was, “A workforce, no matter how committed and skilled, cannot create a culture of safety unless they themselves are free from harm and disrespect.” This hypothesis was borne out during the discussions that included the experiences and opinions of frontline practitioners, leaders of healthcare organizations, scholars, and representatives of government agencies and healthcare professional societies. Morath said, “It became very evident through the course of the roundtables that we have a long way to go in healthcare workforce safety.” When workers live in a constant state of risk, they become blind to that risk and resigned to their situation, Morath said. “It’s a dangerous place to be if you think this is as good as it’s going to get no matter what you do,” she noted. When a workforce reaches this state, Morath continued, the workers won’t speak up or speak out. Yet, the evidence clearly shows having a culture that allows for effective assertion … or a ‘stop-the-line conversation’ … is a prerequisite for patient safety. Morath, who served as chief quality and patient safety officer at Vanderbilt University Medical Center at the time of the roundtables, said her co-leader O’Neill

has often made the statement that every person in a workforce should be able to answer affirmatively to three essential questions: 1. Am I treated with respect and dignity by everyone? 2. Do I have the support and training tools to do my job? 3. Am I recognized and thanked for my contributions? Unfortunately, ‘no’ is too often the answer to those questions. “It was jarring to find not only was there a lack of respect … but even worse, there was a culture of disrespect in many of our healthcare organizations that was tolerated,” she said of the group’s findings. “We have a somewhat historic and toxic culture where the hierarchy has to do with positional titles and the number of degrees,” Morath added. Vulnerabilities in the system include accepting emotional abuse, bullying and learning by humiliation as ‘normal,’ performing demanding tasks under severe time constraints due to the production and cost pressures that dominate today’s healthcare landscape, and having a higher rate of physical harm than such high-risk industries as mining, manufacturing and construction. This culture of fear and intimidation takes away the joy and meaning from work that most healthcare employees chose for the very purpose of helping others and making a difference. “While this report is concerning, it’s also hopeful,” said Morath, noting there were also examples of healthcare workplaces that are getting it right … at least most of the time. New healthcare models that rely heavily on teamwork are also helping make cooperation part of the landscape. “It really requires an appreciation and respect for everyone’s contribution in a team to deliver high quality, safe care in this complex environment in which we work today,” she noted. The report asserts joy and meaning are created when the workforce feels valued, safe from harm and part of the solutions for change. The Mayo Clinic and Virginia Mason Medical Center are two examples that Morath said stood out for their culture of respect. She also said Hospital Corporation of America (HCA) has an exemplary employee safety and security initiative.

To create safe, supportive work environments, healthcare facilities must become high-reliability organizations with a fundamental precondition that employees are their most valuable assets and that the health and well being of those employees is a non-negotiable priority. The report outlined seven strategies to move the needle toward becoming this type of an effective organization. 1. Develop and embody shared core values of mutual respect and civility; transparency and truth telling; safety of all workers and patients; and alignment and accountability from the boardroom through the front lines. 2. Adopt the explicit aim to eliminate harm to the workforce and to patients. 3. Commit to creating a high-reliability organization and demonstrate the discipline to achieve highly reliable performance. 4. Create a learning and improvement system. 5. Establish data capture, database and performance metrics for accountability and improvement. 6. Recognize and celebrate the work

and accomplishments of the workforce regularly and with high visibility. 7. Support industry-wide research to design and conduct studies that will explore issues and conditions in healthcare that are harming the workforce and patients. “It sounds deceptively simple, but it’s about and individual and collective commitment to continual learning, continual improvement, and continual engagement,” said Morath. “When you start, you’re never finished. This is a commitment … a long term commitment.”

Through the Eyes of the Workforce To download the full report and related materials, go online to www.npsf.org. Click on “About Us” and select the Lucian Leape Institute at NPSF. From there, choose the LLI Reports and Statements link under “Related Pages.”

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OCTOBER 2013 • 13

Legislative Affairs

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The Louisiana Health Care Commission last met on Friday August 23, 2013. The Health Care Commission is under the auspices of the Department of Insurance. Leah Barron, vice chairman, gave the opening remarks and introduced new members of the Louisiana Health Cindy Bishop Care Commission. Darie Jordan, legislative coordinator for the Louisiana Department of Insurance, gave a legislative review of the 2013 Regular Session of the Louisiana Legislature. Ronnell Nolan, President and CEO of Health Agents for America gave a presentation about Navigators. Navigators are part of the Affordable Care Act and will facilitate enrollment and help people figure out what plans they are eligible for. Navigators are not allowed to sell anything or receive a payment from insurance companies. They also can make referrals to Department of Health & Hospitals. Navigators are paid for by the federal government. They will have to adhere to strict security and privacy standards. Navigators will be required to obtain twenty hours of training to be certified by the federal government and are subject to criminal penalties for violations of privacy or fraud statutes and must register with the Department of Insurance. According to Centers for Medicare and Medicaid, a navigator will spend about one hour with a client and should be paid about $20 per hour. A mid-level project leader will be about $29 per hour and a senior level executive will earn $48 an hour. Navigators will “hang out” in church picnics, beauty salons and go door to door. Navigators will be listed on the CMS website Louisiana was awarded $1.77 million for 2014 for navigators. This is one-time money. The following organizations were awarded contracts. • Southern United Neighborhoods received $486,123 and will work in Arkansas, Louisiana and Texas. • The Martin Luther King Health Center Inc. located in Shreveport received $81,066 and will participate in educational health fairs. • Southwest Louisiana AHEC was awarded $1,099,985.20 (swlahec.com) Capital Area Agency on Aging was awarded $100,000 and will help individuals and small businesses enroll in the marketplace. Carol Guidry with the Louisiana Department of Insurance said that to receive email updates, anyone can sign up at www. healthcare.gov

Private Hospital Partnerships Phyllis Peoples, President and CEO, Terrebonne General Medical Center addressed the Commission

about the public-private partnership with Ochsner Foundation. She thanked the Commission for the invitation to speak. She said that from a community perspective this is a unique opportunity. She said that TGMC worked with Department of Health & Hospitals and LSU on this partnership. Mike Hulefeld, Ochsner Foundation said that the transition has been quite an effort. Ritchie Dupree, also with Ochsner, spoke about Graduate Medical Education (GME) and that 95 percent of the Leonard Chabert team have applied for jobs and most were accepted as new employees. Steve Russo, executive counsel to the Department of Health and Hospitals, said that a Cooperative Endeavor Agreement was executed to transfer operation of Earl K. Long Memorial Hospital to OLOL in November 2013. The CEA was amended to accelerate the transition of inpatient services and include the transition of outpatient clinics on April 15, 2013. Russo said that partners have been identified, including but not limited to: • New Orleans - LA Children’s Medical Center • Baton Rouge - Our Lady of the Lake • Houma - TGMC and Ochsner Health System (Southern Regional Medical Corporation) • Shreveport - Biomedical Research Foundation • Monroe - Biomedical Research Foundation • Alexandria - Christus / Rapides Independence - Lallie Kemp will remain a public state run hospital The following hospital closures have been approved by the LSU Board of Supervisors: • Earl K Long Medical Center • W.O Moss Regional Medical Center Russo said that CMS has approved state plan amendments for the OLOL public/private partnership. He said that DHH expects to receive the rest of the approvals in the next few months. David Hood asked Calder Lynch to ask Department of Health & Hospitals to provide estimates of the cost savings as a result of the public private partnerships. Calder said he would ask the Department of Health & Hospitals to provide this information to the Louisiana Health Care Commission. The next meeting of the Louisiana Health Care Commission is October 25, 2013 Legislative Affairs content is provided by Checkmate Strategies, publisher of Health Care Information Services. All content © Checkmate Strategies and Louisiana Medical News, LLC. For more information, readers may contact Cindy Bishop at 225.923.1599 or P.O. Box 80053, BR, LA 70598, or send email to destiny362@aol. com. Our website is www.checkmatestrategies.com

New Pill Mapping Index Becomes iPhone App for Clinicians by Jane

Ehrhardt

Birmingham-based MedSnap will soon make it easy for clinicians to almost instantaneously and accurately identify most pills presented by patients. “This will allow the ER or physician or home healthcare worker to quickly assess the brown bag full of pills the patients bring with them,” says Patrick Hymel, MD, chief executive officer and co-founder. To use the pill-mapping program, the clinician places the pills or Patrick capsules on a special tray Hymel, MD about the size of a smartphone, and then snaps a photo with their iPhone. Within seconds, a screen pops up listing the pills by name and strength, their usages and interactions, plus any disease interactions. Any missing meds or any creams, lotions or injected medications, like insulin, can be added manually. “What the patient assembles on their own is much more likely to be the truth than what they write down,” says Hymel, who comes from an emergency medicine background. MedSnap can help ERs avoid unnecessary admissions. “If you can establish the source of a patient’s problem as medication-related, it’s a call to their physician rather than an admission,” Hymel says, adding that adverse drug events and non-adherence are the number one cause of preventable readmissions. A mammoth goal, MedSnap’s pill mapping index (PMIX) aims to cover the most popular 2,000 pills. “The top ten prescribed pills represent a very, very large percentage of all pills prescribed. So if we get even the top 1,000, the program’s going to know most of the pills out there,” Hymel says. Currently MedSnap’s PMIX has tapped into the volunteer services of more than 500 healthcare providers to submit images of pills from all sorts of angles and lighting situations. Samford’s pharmacy

Special tray improves accuracy in identifying pills.

school is an avid supporter. “Those students come from a mindset of crowd-sourcing and like to tackle a mission,” Hymel says. “We were so impressed with their enthusiasm, we thought why not open it to everyone.” So far, no one with the right iPhone has turned down their invitation to participate. Any interested clinicians with the right phone can sign up at medsnap.com. Hymel says a pill’s color, shape and size “gets you 80 percent of the way in pill mapping, and the rest is the imprint and other proprietary things.” But color presents the prime challenge. “What is a white pill in yellow light? it’s yellow,” he says. “You need white balance to understand what the exact color is you’re looking at. It’s a surprisingly complicated problem.” Before MedSnap, the FDA had the best pill-mapping database, but it differentiates between only nine color categories. “What if you look at an orange pill that’s between yellow and orange? The FDA didn’t have a color for that. We differentiate between over 900 types of color,” Hymel says. The solution for the color problem and to allow multiple pills to be identified

at once lies with the special tray. “The tray surface keeps the pills within the camera frame and forms a grid to let us assign which pixels to which pill,” Hymel says. With the tray, the MedSnap app holds a 96 percent accuracy in identifying the right pill. “That takes enormous technological achievement,” Hymel says. With the right data, they will be able to

push that to 99 percent. “Especially with the white rounds, which are incredibly dangerously similar to one another.” Currently thirteen full-timers and eight part-timers work six days a week on testing the program. With the steady growth of their PMIX database, MedSnap plans to launch the subscriptionbased app this March. Individuals will pay $69.99 per year per phone, plus $20 to $30 for the tray with no usage limit. A licensing fee can be arranged for large practices and hospitals based on volume. Initially, the app will work only on iPhone 4S and 5. “Eventually we’ll have it on Droids, but that’s a lot more difficult, because the vision system is very precise and requires consistency in the operating system and the hardware,” Hymel says. “With iPhones, you know the OS doesn’t need to interact with a different camera system when you move it from a Motorola to a Samsung.” Ultimately, MedSnap will be tweaked to also help individuals identify and keep their medications straight. “If I can’t tell the difference between two white rounds at forearm’s length,” Hymel says, “think how hard that can be for a 70-year-old.”

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OCTOBER 2013 • 15

In the News General Health System Announces New CEO BATON ROUGE – Baton Rouge General/General Health System’s Board of Trustees announced its new President and Chief Executive Officer, Mark Slyter, FACHE. The 44-year old executive comes to Baton Rouge General with more than 17 years of progressive healthcare experience as a leader in nationally recognized not-for-profit hospital systems throughout the South, including Baptist Health Systems-Jackson, Mark Slyter MS, Baptist Health Sys-

tem-Jacksonville, FL and the Greenville Hospital System-Greenville, SC. Mark is making the transition from his current role as President and CEO of Baptist Health Systems, a multi-hospital system including its flagship 650-bed regional tertiary medical center. “Baton Rouge General’s Board leadership was committed to identifying a CEO who would embrace and elevate the culture of excellence our team has worked so hard to develop. Mark Slyter’s down-to-earth, diplomatic personality combined with his CEO experience in leading successful, collaborative teams on the journey of patient-centered, evi-

denced-based healthcare performance, were naturally fitting for Baton Rouge General and our community,” noted Janice Pellar, Acting Chair, Baton Rouge General/General Health System Board of Trustees. With a masters in health services administration from the University of Kansas, a fellowship from the American College of Healthcare Executives and a doctorate in progress in health services administration (University of Alabama, 2016), some of Slyter’s most notable achievements surround rigorous Lean Six Sigma patient care quality and performance improvement and innovative, evidenced-based

leadership initiatives. Slyter, born and raised in Augusta, Kansas, a small town near Wichita, earned an undergraduate degree in Exercise Physiology and a masters in health services administration from the University of Kansas where he also played football for the Jayhawks. Mark attributes his appreciation for family values, faith and hard work as well as his love of playing sports and music to his parents. His father was a high school football coach and talented craftsman, and his mother, a math/computer science teacher and pianist.

Sound Physicians to provide hospitalist services for CHRISTUS Health hospitals in Texas, Louisiana TACOMA, WA- Sound Physicians, a leading hospitalist organization focused on driving improvements in quality, satisfaction and financial performance of inpatient healthcare delivery, announced an agreement to provide hospitalist services for seven CHRISTUS Health hospitals throughout Texas and Louisiana. The Louisiana sites include CHRISTUS St. Frances Cabrini Hospital in Alexandria, CHRISTUS St. Patrick Hospital in Lake Charles, and CHRISTUS Highland Medical Center in Shreveport. “We are looking forward to partnering with CHRISTUS Health and increasing our strong regional presence in Texas while expanding our services to Louisiana,” said Robert Bessler, MD, CEO of Sound Physicians. “We are eager to bring our performance focus and physician leadership to these CHRISTUS Health hospitals.

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16 • OCTOBER 2013

Louisiana Medical News

BATON ROUGE- The Louisaina Hospital Association has added a new section to its http://www.lhaonline.org website. The section, “Enrolling Patients in the Marketplace”, is designed to provide information regarding the Individual Mandate to acquire health insurance, details on who is eligible for coverage through the Marketplace, and the background on Louisiana’s Federally-Facilitated Marketplace. The LHA has also included the contacts for the organizations that have received Navigator grants from the Centers for Medicare & Medicaid Services (CMS) as well as those Federally Qualified Health Centers that received funds to help enroll their clients in the Marketplace. Hospitals will also find the links to apply to become a Certified Application Counselor Organization and the requirements to do so. Once certification is obtained from CMS, employees are eligible to enroll in the online training to become Certified Consumer Assisters and will then be able to assist patients with enrollment in the Marketplace.

In the News

(L-R): Drs. Darrin Breaux, Evens Rodney, Nakia Newsome, Venkat Surakanti Lance LaMotte and Brian Swirsky.

Cardiology Presence Expands in Baton Rouge General’s Heart and Vascular Tower

BATON ROUGE – Interventional cardiologist Lance LaMotte, MD, FACC, and invasive cardiologist Nakia Newsome, MD, recently joined Baton Rouge Cardiology Center’s physician practice location in Baton Rouge General’s Heart and Vascular Tower on the Bluebonnet campus. Joining BRCC physicians Drs. Darrin Breaux, Evens Rodney, Venkat Surakanti and Brian Swirsky at the practice location in the Heart and Vascular Tower, Baton Rouge General welcomes Drs. LaMotte and Newsome to its campus community. With the recent multi-million dollar expansion of its heart and vascular services and its growing community of heart, vascular and cardiothoracic physician tenants, Baton Rouge General brings together comprehensive heart and vascular services all under one roof. The General’s heart and vascular enhancements include an expanded surgical space equipped with an innovative hybrid OR build-out. Compared to traditional surgery space, the General’s hybrid room uniquely allows for the simultaneous IT integration of sophisticated diagnostic technologies, precise imaging capabilities and multiple surgical therapies – with the goal of maximizing treatment options for cardiac and vascular procedures. Nationally recognized for excellence in heart and vascular care as Baton Rouge’s only Joint Commission “Top-Performer” Hospital for Heart Attack and Heart Failure and the city’s only A-rated hospital for patient safety by the Leapfrog Group two years in a row – Baton Rouge General is committed to providing the most comprehensive, high quality heart and vascular care for the community.

(L-R): Pictured in front of a rendering of the new Cancer Center is: Dr. Tom J. Meek, Jr., Mary Bird Perkins Board Chair; Charles Freeburgh, Our Lady of the Lake board member, Donald Daigle, OLOL board chair; Terrie Sterling, OLOL chief operating ofﬁcer; Donna Saurage, MBP immediate past chair; Dr. Maurice King, MBP medical director; and Todd Stevens, MBP president and chief executive ofﬁcer.

Mary Bird Perkins – Our Lady of the Lake Cancer Center begins Renovation and Expansion BATON ROUGE- Mary Bird Perkins – Our Lady of the Lake Cancer Center has announced a significant renovation and expansion initiative, including onsite and offsite campus facilities. The more than $23 million construction project is currently underway and includes modernizing building systems and expanding areas for additional and enhanced services. “This is about providing the highest level of comprehensive care for patients and their caregivers through aligned outpatient and inpatient cancer services. Upon arrival, we want every patient to immediately sense that the entire experience is designed with their needs in mind, first,” said Todd Stevens, president and CEO of Mary Bird Perkins Cancer Center. Stevens also noted that all Cancer Center services will continue as normal during the renovation period; team members are working to ensure patient safety and comfort throughout the process. The renovation project is scheduled for completion by late 2014.

Louisiana Medical News

OCTOBER 2013 • 17

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In the News Patient’s Compensation Fund Elects Ofﬁcers BATON ROUGE- Officers were elected at the Patient’s Compensation Fund Oversight Board meeting on Sept. 5. Clark Cossé, representing hospitals, was re-elected as the chair; Vincent Culotta, Jr., representing physicians, was re-elected as vice-chair; and Kent Guidry, representing all other providers except nursing homes, was re-elected Secretary. As of June 30, 2013 the fund stood at $827 million, while liabilities are actuarially estimated to be $787 million. The PCF reported this fact to Commissioner of Insurance Jim Donelon has, who expressed interest in the solvency of the PCF.

Mohs Surgeon Joins Dermatology Associates of Southwest Louisiana LAKE CHARLES- Lee Miller, MD, a board certified dermatologist specializing in Mohs micrographic surgery, is now practicing medicine with the Dermatology Associates of Southwest Louisiana. Dr. Miller, a Lake Charles native, is a gradu- Dr. Lee Miller ate of Barbe High School. He completed his undergraduate studies in biological engineering at Louisiana State University and received his medical degree from Louisiana State University School of Medicine in Shreveport, where he also completed an internship in internal medicine. He performed his residency in dermatology at Wake Forest Baptist Health in Winston Salem, N.C., where he served as chief resident. He most recently completed a fellowship in procedural dermatology at Scripps Green Hospital in La Jolla, Calif. Dr. Miller is the only Mohs surgeon in the area. This specialized surgical technique is used to remove skin cancer. The procedure offers the highest cure rates for common types of skin cancer and allows the physician to preserve more healthy tissue around the lesion than any other method. He will also perform general dermatology as well as some cosmetic dermatology. Dr. Miller and his wife Amy, also from Lake Charles, are expecting their first child this fall. He is excited to be back in his hometown and is looking forward to giving back to the community as well as getting out on area waterways to fish and water ski.

O’Connor Recognized by Emergency Nurses Association GONZALES- Tammy O’Connor, RN, Director of Emergency Services for St. Elizabeth Hospital in Gonzales, Louisiana, was presented with the Mae Webb Excellence in Emergency Nursing Award by the Louisiana Council of Emergency Nurses at its annual conference held in Baton Rouge on August 16, Tammy O’Connor 2013. The distinction was 18 • OCTOBER 2013

Louisiana Medical News

given in recognition of her ongoing contributions to emergency nursing. Among several contributions to the field of emergency nursing noted, O’Connor’s efforts at making the St. Elizabeth Hospital Emergency Department a safe place to work through the implementation of a Workplace Violence Prevention, her efforts at maintaining outstanding throughput times, and an emphasis on promoting staff education related to emergency nursing including her efforts at encouraging all staff registered nurses to obtain certification in emergency nursing, were cited. In addition, O’Connor was recognized for consistent maintenance of both employee and patient satisfaction. Both have been above the 90th percentile or above for the past six years. “Tammy is an outstanding attribute

to our organization, both personally and professionally. Her work over the past several years to improve the level of service provided in our emergency department, in and of itself, is commendable. But, Tammy’s efforts to improve emergency services across the state by sharing her time and talents through the Louisiana Nurses Association makes her truly deserving of this award,” said St. Elizabeth Hospital Vice President of Patient Care, Yvonne Pellerin. The Mae Webb Excellence in Emergency Nursing Award is named in honor of Louisiana’s Emergency Nurses Association founder and honors a member of the organization who has consistently demonstrated excellence in emergency nursing and who has made significant contributions to the profession of emergency nursing and to the Louisiana ENA.

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Louisiana Health Care Quality Forum Schedules Fall Summit

BATON ROUGE- The Louisiana Health Care Quality Forum will host its fall summit, “Health Care Reform and You: Professional Viewpoints,” on Oct. 31 at the Marriott Hotel in Baton Rouge. The fall summit will provide insight from various stakeholders on the impact of health care reform in Louisiana. Sheila P. Burke, Senior Public Policy Advisor with Baker Donelson’s Washington, DC, office, will serve as the keynote speaker. In addition to her role at Baker Donelson, Burke serves as a faculty member at the John F. Kennedy School of Government at Harvard University where she teaches a health policy course and co-directs a public policy simulation exercise. She is also a faculty research fellow at Harvard’s Malcolm Weiner School for Social Policy, a Research Professor at the Public Policy Institute and Distinguished Visitor at the O’Neill Institute for National and Global Health Law at Georgetown University. Her distinguished career includes 19 years on Capitol Hill where she served as Deputy Staff Director of the Finance Committee, Chief of Staff to Senate Majority Leader Bob Dole, and Secretary of the Senate. In these roles, she was involved with numerous legislative issues including those related to Medicare, Medicaid, Maternal and Child Health programs, welfare reform, budget reconciliation and previous legislative efforts to reform health care. Burke’s career also includes a seven-year tenure as Deputy Secretary and Chief Operating Officer of the Smithsonian Institution with responsibility for the overall operations of the 19 individual museums and galleries, the National Zoo and nine research facilities. The fall summit will also feature Quality Forum Board Member Donna D. Fraiche, Esq., attorney with Baker, Donelson, Bearman, Caldwell & Berkowitz, PC, who will lead a panel discussion among David Callecod, President and CEO of Lafayette General Health System; Ray Peters, Vice-President of Roy O. Martin Lumber Company and President of the Quality Forum Board of Directors; Vincent Culotta, M.D., President of the Louisiana State Medical Society; and Carol Solomon, President and CEO of Peoples Health. Mike Bertaut, Health Care Economist with Blue Cross and Blue Shield of Louisiana, will be the closing speaker. Sponsorship opportunities are also available for the event. Sponsor levels include Platinum ($5,000), Gold ($3,000) and Silver ($1,500). For information about the features of each sponsorship level or to request additional information about how to become a sponsor, contact Cynthia Michael via email at cmichael@lhcqf.org, or by phone at 225.334.9299. To register to attend the event, visit http://lhcqf.org/2013-fall-summit

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