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PHYSICIAN SPOTLIGHT PAGE 2
Samuel Brown, MD ON ROUNDS
Search Underway for UMMC’s Next Leader Top post at Mississippi’s academic health center attractive to many Mississippi’s healthcare community should know by early spring who will be stepping into leadership at the state’s academic health center ... 5
AMA’s Telemedicine Push Evolution improves health outcomes, accelerates medical education change, and enhances physician satisfaction and practice sustainability In June, the American Medical Association (AMA) adopted a resolution addressing telemedicine as a key innovation in support of healthcare delivery reform ... 9
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Going Smoke-Free
Mississippi physicians lobby for smoking ban, aiming for 20,000 online petition signatures By LyNNE JETER
Several years ago, a single mother of two schoolchildren making a living as a Waffle House waitress frequented an emergency room on the Mississippi Gulf Coast, where emergency medicine specialist Steven Demetropoulos, MD, worked. Second-hand smoke in such a tight, enclosed space had given her persistent upper respiratory problems – wheezing, shortness of breath, and bronchitislike symptoms. Yet she made good tips, enjoyed repeat customers, and couldn’t afford to make a job change. “What I saw happening to this young lady, who didn’t smoke and had to choose between her health and the ability to put food on the table for her family, precipitated my involvement in this smoking ban,” said Demetropoulos, of Pascagoula, immediate past president of the
Mississippi State Medical Association (MSMA), and a staunch supporter of the state association’s Physicians for a Smoke-Free Mississippi initiative that launched Oct. 3. “I happened to see her two or three times in a row, and she never could get over those respiratory problems associated with secondhand smoke. The symptoms weren’t going to clear until she got out of that environment. I thought, it’s a shame that somebody like this woman doesn’t have a voice in policy matters, so I thought maybe I could do something about it. We worked to get our community smoke-free, then we thought: why not make the state smoke-free? It would immediately reduce medical costs and dramatically improve the health of our citizens.” Smoke-free Air Petition Drive The MSMA, representing 4,700 physicians and their pa(CONTINUED ON PAGE 8)
‘How Do We Pay for Healthy?’ Preventive care approach calls for transforming delivery model By LUCy SCHULTZE
Mrs. Jones wakes up in the morning and steps on her bathroom scale. She’s gained three pounds since yesterday. The scale’s Bluetooth capability relays that information to her doctor’s office, and half an hour later, her phone rings. It’s the nurse, calling to let her know the doctor is adjusting her medication today to help bring down her fluid levels. “That’s when we’ll have arrived, because all of a sudden, we’ve kept Mrs. Jones out of the hospital today,” said Timothy H. Moore, president and CEO of the Mississippi Hospital Association (MHA). “But, in some form or fashion, we’ve got to pay the doctors to do that.” It’s a challenge that seems so simple on its surface — to apply our modern healthcare capabilities toward not just helping people get better, but keeping them well in the first place. (CONTINUED ON PAGE 6)
Timothy H. Moore
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PhysicianSpotlight
Samuel Brown, MD By LUCY SCHULTZE
In the realm of robotic surgery, Jackson OB/GYN Samuel Brown, MD, has gone from skeptic to full-fledged prophet. “Once I saw the capabilities of robotic surgery and the significant increase in dexterity it gives you, I was sold at that point,” said Brown, who specializes in minimally invasive gynecologic procedures as part of Jackson Hinds Comprehensive Health. “To me, now, when I do an open procedure, it seems very barbaric,” he said. “It just doesn’t seem right for the patient when there are other alternatives.” That was not a conviction Brown held early on in his career, after his training at Vanderbilt University Medical Center in Nashville, Tenn. “I trained in laparoscopic procedures and did a lot of minimally invasive hysterectomies and other surgeries, but initially I didn’t want to learn robotic surgery,” he said. “Today, it’s the focus of my practice because of all the advantages it provides.” Brown estimates he has been involved in more than 1,000 robotic surgery cases over the course of the past five years. That includes his part in training more than 80 physicians across the country in techniques for using the da Vinci® Surgical System. “As physicians increase their volume and do more cases, they will become more confident in doing more difficult cases,” he said, noting the American Association of Gynecologic Laparoscopists’ 2012 state-
ment that OB/GYNS who cannot perform laparoscopic hysterectomies should refer their patients to someone who can. “There is a push not to open people — to either do laparoscopic or vaginal procedures,” Brown said. “At some point, there should be no more open cases for hysterectomies.” While Brown continues to provide obstetrical care to patients, he is sought after for his surgical expertise in performing difficult hysterectomies, endometriosis resection, and minimally invasive surgical procedures.
In the case of obese patients, Brown said, too many OB/GYNs choose laparoscopic or even opensurgery techniques. “Don’t be afraid to operate on those patients robotically,” he said. “They are the ones who will benefit the most — even more than patients with a normal BMI. “People are afraid to operate on obese patients. But with open surgery, the patients are at higher risk for respiratory complications, pulmonary complications and wound infections. Robotic surgery has many advantages for them, including reducing pain and allowing patients to be ambulatory very early in the process.” From the physician’s point of view, Brown said, penetrating a thicker abdominal wall to perform robotic surgery on obese patients does not increase the difficulty of the procedure. “In my experience in doing surgery on these patients, I’ve found they are actually easier to operate on, because of the larger surface area you have to work with,” he said. “I’ve had patients weighing upward of 400 pounds for robotic hysterectomies and have not had any complications with my larger patients.” The outcomes of such procedures are the subject of an article Brown is currently working on, focusing on obesity and robotic surgery. He is also preparing a paper on using robotic surgery as a diagnostic and curative tool for endometriosis. In the case of endometriosis resection, Brown’s experience in robotic surgery gives him a comfort level in performing
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the challenging procedure. “In removing endometriosis, you are very close to very vital structures,” he said. For hysterectomies, Brown recently introduced the single-site procedure at Central Mississippi Medical Center. It allows the uterus to be removed through a one-inch-long incision in the belly button, as opposed to through multiple incisions. Using the robot, the procedure takes just 15 to 20 minutes, and most patients are able to leave the hospital after an overnight stay. Brown credits his CMMC team with enabling robotic surgery procedures to be completed swiftly and smoothly. “It’s imperative for a smooth operation to have a good team, and this one is excellent,” he said. “I’m excited about the future and moving this program forward.” On the horizon are plans to establish at CMMC a Center of Excellence for Minimally Invasive Gynecology, an effort for which Brown serves as director. A native of South Carolina, Brown earned his undergraduate degree at South Carolina State University. He worked toward a PhD in analytical chemistry before launching into medical school at Meharry Medical College in Nashville. He completed his residency at Vanderbilt. Brown came to Mississippi in 2004 to join fellow Meharry alumnus Paul Rice, MD. When Rice scaled back his practice a couple of years later, Brown began seeing many of Rice’s patients and took on all of his surgeries. The group was in private practice when Brown joined it and has since become part of Jackson Hinds Comprehensive Health. Brown’s office is located on the CMMC campus. He also holds privileges at affiliated institutions River Oaks Hospital and Woman’s Hospital in Flowood. In addition to teaching other physicians how to use the da Vinci device, Brown hosts residents from Meharry College who come to him for a one-month rotation. For Brown, the choice to make his home in Mississippi has been affirmed over his 10 years of practice in Jackson. “I love it here; I’m not going anywhere,” he said. “The cost of living is not high, and the people are great. But it pains me to see so many obese people here, because they’re in such a prison. I counsel my patients to do some kind of physical activity every day.” Outside of work, Brown focuses on spending time with his family and enjoys cycling on the Natchez Trace. He is also an amateur photographer with a penchant for capturing glorious sunrises. His wife, Shannon, owns the Ridgeland lingerie boutique Laces by Lexi. They have three children: Samuel, 17; Alexia, 14; and Antonio, 3.
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HEALTHCARE Leadership Solutions BY BEVERLY SMALLWOOD, PHD
The Price of Not Nice: Part 4 A call to action
Editor’s note: This column is the final installment of a four-part series on healthcare leadership solutions. As the data presented in Part 3 of this series have shown, astronomical human and financial costs accrue to the failure to act in order to correct and prevent disruptive physician attitudes and behaviors. Hospitals, medical practices, and other healthcare organizations cannot afford to fail to be proactive in assuring that their physicians are not exhibiting “abusive behavior that interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care” (disruptive behavior definition by Federation of State Medical Boards). In addition to having the courage to hold the physician accountable for unacceptable emotional and interpersonal behavior, it’s in the best interests of all to provide assistance and resources needed to help them understand the negative impact they are having and to learn to behave more effectively. What are the components of an ef-
fective model of prevention and intervention? First, the healthcare organization must have the systems and skills in place to both prevent problems and to intervene when they occur. Leaders must become educated in the specialized skills required to deal with a physician with disruptive behavioral habits. The organization should also cultivate ongoing relationships with trusted resources who can comprehensively assess the sources of a physician’s problematic attitudes and behaviors within the realistic context of the healthcare environment. Such professional coaches should also have the skills, experience, and compassionate courage to educate, coach, and inspire the doctor to make a real change in the disruptive behaviors. More specifically, the following components of the plan of action are essential. Code of Conduct The Joint Commission requires explicit performance standards of behavior and competence, credentialing, and disciplinary processes. Specifically, the Joint Commission leadership standard – Lead-
ership LD.03.01.01 – requires hospitals to have a code of conduct policy in place to address disruptive behaviors and a process in place to manage disruptive individuals. All physicians should acknowledge the code of conduct in writing before being granted clinical privileges. However, simply having these standards in place is not enough. Monitoring Healthcare organizations must pay attention! A pattern of complaints by patients or others and confidential evaluations by colleagues and coworkers should never be ignored. Hickson and colleagues reported from their research that the analysis of patient complaints can identify doctors with interpersonal problems and predict the likelihood of malpractice litigation. Four or more complaints about a particular physician over a six-year period creates a 16 times greater likelihood of that person having two or more risk management files opened than were physicians with no complaints. Evaluations by department chairs, executive boards, and peers can also flag
and lead to the addressing of disruptive and dangerous behaviors. Department chair observations and confidential peer evaluations can bring to light disruptive behaviors, communication skills, emotional reactions, office management, and collegiality. Department Chair/Executive Board Response It then becomes the responsibility of the department chair or executive board to promptly respond to the deficiencies. If there’s an indication that patient welfare is in danger, immediate action should be taken to limit practice during assessment and rehabilitation. If the physician refuses to accept education, treatment, monitoring, or necessary restrictions of practice, or if the interventions fail, the physician must promptly be referred to the state medical board for disposition. The problem is, good physicians and even good managers often don’t possess the leadership skills for knowing how to approach the physician in question. As stated in an earlier column, they may (CONTINUED ON PAGE 6)
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Practice Management Legislative Issues 2015 By HAROLD INGRAM
Three medical-related issues will likely be on the legislative forefront for 2015 – continued implementation of the Affordable Care Act (ACA), performance penalties, and SGR Medicare payment reductions – that can have a significantly negative impact on physicians’ revenue. As the ACA continues to unfold, 2015 will see the implementation of employer mandates, which may have employers looking for different ways of offering health insurance to employees, if at all. The expansion of health insurance exchanges is likely to encourage the narrowing of insurance networks. As insurers begin restricting enrollment, physicians may be required to choose sides, aligning themselves with selected area hospital systems. Non-traditional alliances among large groups, hospital systems, and even commercial enterprises may also evolve. And there will be pressure to continue to change payment methodology to focus on outcomes rather than payment based on the number and type of procedures performed, like fee for service. The upcoming year will also include the potential for reduced revenue because of Medicare “payment adjustments.” Providers will have to meet PQRS (Physicians
Quality Reporting System) and meaningful use requirements to avoid penalties. Also, beginning in 2015, all providers will be subject to a Value-Based Payment Modifier that will affect Medicare payments in 2017. The variable benefit modifier is different from the PQRS and meaningful use adjustments since, in addition to quality measurements, it examines costs associated with patient care and patient satisfaction. Unless Congress acts before the end of March, SGR (Sustainable Growth Rate) reductions will significantly reduce Medicare reimbursement. As seen many times in the past, temporary “fixes” have delayed the application of the SGR reductions by freezing payments at current levels or occasionally providing only a nominal increase for a few months, when it has to be addressed again. It’s likely that another temporary fix will occur in the first quarter of 2015. Nationally, uncertainty surrounds the legislative activity for the next two years. At press time, the Nov. 4 mid-term elections are still a couple of weeks away. Projections seem to indicate a strong likelihood that Republicans will gain control of the Senate. If that’s the case, it’s also likely a number of bills will be introduced to chip away at the Affordable Care Act
(ACA). Although some Republicans are calling for the repeal of the entire act, it’s unlikely that a full repeal will happen. Should the Democrats retain control of the Senate, it will probably lead to more gridlock and inaction. In addition to challenges to incumbents wishing to return to the Capitol, key congressmen are retiring. The change in makeup of the House and Senate, whether Republicans gain control of the Senate, means that committee appointments will change. This is unfortunate for those calling for reform of the Medicare SGR, part of the Medicare reimbursement formula. The current Congress has made a great deal of progress in trying to reform the Medicare payment structure eliminating the SGR, with both bi-partisan and bicameral support. During “lame duck” sessions, which take place between November elections and the time when new members of Congress are sworn in, significant legislative activity rarely takes place. However, the Medical Group Management Association (MGMA), which has played an integral
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part in encouraging the development of the current legislation to reform the Medicare payment system, may make a push to encourage action by its 33,000 members to call for action on SGR legislation before the end of the year. If SGR legislation isn’t possible during this upcoming “lame duck” session, the process will basically have to start over. MGMA has also indicated support for the Flexibility in Health IT Act (H.R. 5481) or “Flex-IT” Act that’s been introduced in the House. This bi-partisan bill addresses difficulty in meeting meaningful use criteria. Currently, providers are required to meet meaningful use requirements for an entire year. This bill would reduce the reporting period from one year to three months, giving providers time to make necessary adjustments during the year and still qualify as successfully meeting the criteria to avoid payment penalties. At the state level, there will more than likely be a renewed push for “any willing provider” legislation. The crux of this legislation would be to force insurance companies operating within the state to allow any physician to become a network member if the physician desired to do so and met network participation requirements. The intent of this legislation is to counter the possibility of narrower insurance networks that may limit participation in underserved areas of the state. During the 2014 legislative session, “any willing provider” legislation was introduced, but didn’t make it to the floor for a vote. At that time, Gov. Phil Bryant indicated he would establish a study committee to look at legislation for the upcoming session. A push to weaken the very strong immunization laws currently on the books in Mississippi is also anticipated. As more people question the efficacy of immunizations and have questions about potential immunization side effects, there’s concern that legislation will be introduced to give individuals more freedom to choose or refuse immunization. The Mississippi State Medical Association (MSMA) indicated several other issues it would like to see addressed. These include placing a ban on texting while driving and legislation aimed at reforming the current mental health system. Additionally, MSMA will be working to secure additional Graduate Medical Education (GME) funds from the state since national funds are drying up. Active constituent involvement makes a difference. Contacting congressmen and legislators can impact the success or failure of legislation affecting the practice of medicine. As a current State official once said, it only takes four or five constituent calls to move him to look at and possibly act on an issue. Harold Ingram is CEO of PerforMax Medical Management in Metro Jackson, and legislative liaison for MGMA of Mississippi.
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Search Underway for UMMC’s Next Leader Top post at Mississippi’s academic health center attractive to many By LUCY SCHULTZE
Mississippi’s healthcare community should know by early spring who will be stepping into leadership at the state’s academic health center. The University of Mississippi is currently seeking a successor for James Keeton, MD, Vice Chancellor for Health Affairs and dean of the School of Medicine. Keeton has set his retirement date for June 30. A 17-member search committee is on track to deliver the names of its top two or three candidates to UM Chancellor Dan Jones, MD, by February. “In seeking the next leader of this institution, we are looking for someone who will think not just about healthcare but about health,” said Patrick O. Smith, PhD, a psychologist who serves as chief faculty affairs officer for UMMC and chairs the search committee. “It’s important to find someone who can actively seek partnerships among physicians around the state and all the providers who are intertwined in the health of the state of Mississippi,” Smith said. The good news: There’s plenty of interest. The top post at the University of Mississippi Medical Center is one that is attractive even to sitting deans at other medical schools, Smith said, noting that UMMC’s organizational structure is different from that of most institutions. “Of the 141 schools of medicine in the United States, there are only about 20 schools in which the dean of the school of medicine is also the vice chancellor or president/CEO of the entire institution,” he said. “Our organizational structure is considered to be the future of academic health science centers, so many people are very attracted to a position like this.” The institution itself also holds attractive qualities, Smith said. “We are the only academic health center in the state of Mississippi. We have good financial stability, and we serve some 3 million people in this state,” he said. “We also have a population that really needs our help. All those are factors or features that have led a lot of top-talented, future-oriented leaders to be interested in this position.” The successful candidate will assume the reins from Keeton, who has held the post since 2009. Keeton succeeded Jones as vice chancellor, first on an interim basis when the latter was tapped as UM chancellor. Then, when both top candidates from that search withdrew their names at the last minute, Jones asked Keeton to stay on. While the odds are slim that such a scenario could occur again, Smith said the search committee is working to ensure early and open communication as it begins interviews. “I think the most important thing we’re doing in the process is being very candid and transparent to candidates mississippimedicalnews
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The next leader of the University of Mississippi Medical Center will take the reins of a $1.6 billion enterprise engaged in health professions education, research and patient care. UM Chancellor Dan Jones, MD, is expected to name the next UMMC vice chancellor and medical school dean in the spring for a tenure to begin July 1, 2015.
about the institution and the process,” he said. The next vice chancellor will arrive as construction is underway for UMMC’s new $74 million School of Medicine facility. In addition to the planning and funding of that project, Keeton’s tenure has also seen the arrival of the Affordable Care Act and associated changes to the healthcare system. Under his leadership, UMMC has implemented a $90 million electronic health record system and recruited more than 30 people to senior leadership positions. At UMMC, the vice chancellor essentially acts as the chief executive of a $1.6 billion enterprise engaged in health professions education, research and patient care. The Medical Center encompasses six health sciences schools with more than 2,900 students and employs more than 9,600 people. To locate its JNLMSMed-2 next leader, the search JNLMSMed-2
committee convened in late spring and has since been working with Ira J. Isaacson, MD, MBA, from the healthcare executive search firm Phillips DiPisa in Atlanta. By early fall, the committee had begun to evaluate the credentials and experience of each candidate in the consultant’s pool. A smaller group of candidates would be invited to take part in boardroom meetings, after which the top candidates would be invited for a campus visit. The top candidates’ names will be made public at that point. “We will invite these individuals to our campus, and they will meet with a large number of leaders on the campus as well as before the campus community in a larger setting,” Smith said. “Our goal is to end up with two or three candidates that we think could take on this responsibility, and we’ll provide those names to Dr. Jones for his consideration.” The selection will be made by Jones, with the approval of the Mississippi Insti-
tutions of Higher Learning Board. In addition to the candidates’ qualifications and experience, the search committee aims to gauge each candidate’s motivation, disposition and leadership skills, Smith said. “They have to be strategic thinkers,” he said. “They have to have skill sets in philanthropy. They have to be a good spokesperson for the institution to external partners. They have to be someone who can promote creativity and innovation, and someone who has a growth mindset. “And they have to have authenticity, integrity and a commitment to something bigger than themselves.” When it comes to applying the priorities of UMMC faculty to the search process, the committee has had as a resource the results of the Faculty Forward Engagement Survey. That survey, by the Association of American Medical Colleges, was completed in 2009 and 2011 at UMMC and is currently underway again. “We are the first institution in the United States that will have completed this three times,” Smith said. “It tells us how well the faculty is satisfied with the institution and what they expect within our leadership. So instead of looking at anecdotes, we’re able to look at an aggregate of faculty data over time to find out what they’re expecting for the institution and for their specific departments. “In fact, we have plans to expand the Faculty Forward project to all the schools on the campus with support from the AAMC.” As it weighs both internal and external candidates for the post, the search committee has also been discussing the principle of unconscious bias and giving members the tools to measure their own bias and ensure each voting member is applying a fair approach.
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‘How Do We Pay for Healthy?’ continued from page 1 Yet achieving that reality will require nothing less than redefining what exactly healthcare providers are paid to provide. “How do we pay for healthy?” Moore challenged. “Changing the model to deliver healthcare differently — to focus on prevention — isn’t a complicated thing in my mind. But we must figure out how to pay providers for that care — because currently, we’re incentivizing them to care for people when they get sick.” Correcting that contradiction is at the heart of the MHA’s agenda for the 2015 session of the Mississippi Legislature, which convenes on Jan. 6. The MHA has spent the past year working to deliver on a promise it gave legislators during the previous session: To bring them a “playbook” for developing this new healthcare model and explain how it would work. “We believe the delivery model of healthcare is going to change — ‘from volume to value,’ as they say,” Moore said. “That means we’re going to have to be more proactive about how we deliver healthcare. We must define how, particularly in our rural communities, hospitals can be more proactive in improving the culture of healthcare in their communities. “How do we take a more proactive role in catching congestive heart failure early — before that patient has to spend three or four days in the hospital to get their fluid (level) down? How do we control hypertension and diabetes, and make sure that individuals who are less fortunate have the resources to stay out of more expensive healthcare settings? “All of that could be real easy. But there has to be a simultaneous transition in how providers are paid to keep people well.” Toward that end, the MHA last
spring gathered a steering committee of physician leaders and administrative personnel from across the state to begin developing a new model to present to legislators. To help guide the project, MHA contracted with Evolent Health of Arlington, Va., which brought in additional support from Boston-based Spring Consulting Group. Manatt Health Solutions has been providing additional guidance in legal and regulatory requirements, while Health Catalyst of Salt Lake City has been contributing data analytics. “Trying to get timely data in the state has been extremely difficult,” Moore lamented. “There’s a huge data set to consider as we look at different populations and apply certain treatment protocols and algorithms that would help keep a high percentage of them from going into any kind of health crisis.” While the consulting groups have worked to find similar solutions in other states, Mississippi is different because it’s one of a handful of states that hasn’t expanded Medicaid under the Affordable Care Act (ACA). Pushing for expansion is not part of the MHA’s current agenda. “We would love to work toward covering more lives in the state of Mississippi,” Moore said. “But our state leadership has made that decision, and we respect it.” Regardless, he said, the consulting groups are looking at how Mississippi may benefit through the ACA from certain state waivers, such as those that reward healthcare innovation. Within the state, MHA’s process of developing the new plan has engaged a wide range of provider groups, from behavioral health to long-term care to physician leaders. Insurance companies are also part of the conversation, Moore said.
Visit the MHA website at mhanet.org in January to view the full report.
“From a hospital standpoint, we haven’t been pleased with the way managed care has been delivered in the state,” he said. “As we look at the feasibility of a new model, we believe other options should be considered — but also, that managed care may be part of the solution. “Still, ultimately, a provider-led model will be much more efficient and a higher-quality model than a managedcare model.” For providers, the ongoing transformation of healthcare in America offers both an opportunity and a responsibility, said Lee Greer, MD, a Tupelo-based geriatric medicine physician. “My sense is that providers really are being asked to lead this transformation,” said Greer, a member of the MHA steering committee. “When I look around nationally, healthcare providers are being asked to create value while driving down
The Price of Not Nice, continued from page 3 dread the physician reaction and even fear personal and organizational reprisal. The development of the practical leadership skills that enable physician leaders and department chairs to deal with such delicate situations is absolutely essential to the health of the healthcare organization. Comprehensive Assessment Too many Boards have fallen into the trap of simply sending the physician off to “anger management” (whatever that is) or one-size-fits-all “charm school.” These are big mistakes. Anyone in healthcare knows, treatment without diagnosis is malpractice! A physician improvement plan must be based on a comprehensive assessment by a qualified professional who not only is competent in “people issues,” but also who understands organizations in general and the healthcare environment in particular. Since the problems in ques-
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costs. That’s the right spot for us to be in, because we’re the ones who can make the best decisions for our patients.” Greer said he often points to the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign as an example of such an initiative. That effort has invited all specialty groups to define five common care approaches within their field that should be questioned before being prescribed or performed. The goal is to encourage physicians to avoid costly tests, medications and procedures when they do not adhere to evidence-based standards. “Following the same principles within our state can allow us to provide the right care at the right time and in the right place,” he said. “We as providers can help guide our legislative leaders and others in making the best choices for the patients we take care of.”
tion are emotional and interpersonal in nature, an ideal team member in this improvement process would be a psychologist or other behavioral specialist who also is experienced in leadership development and organizational dynamics. The assessment process should be multi-faceted. Prior to beginning the intervention, the improvement plan should be tailored and personalized after the careful evaluation of the physician’s behaviors, attitudes, and needs. The coaching process should involve face-to-face interviews with the client physician; consultations with executives, physician leaders, and other staff as appropriate; the completion of validated assessment processes; mutual creation of clearly-defined goals; and coaching sessions over time; and on-the-job assignments. Throughout the implementation process, accountability in collaboration with organizational leaders is a must. (Request a more detailed description of the coaching process from the author.) To sum up, physicians play not only a critical role in medical outcomes, but their personal and interpersonal habits impact the entire healthcare environment. When doctors treat others with disrespect, callousness, or hostility, this negativity ripples throughout the healthcare system. The result is poison to patient satisfaction and retention, employee satisfaction and retention, and medical outcomes. In addition to the human costs, the financial impact of disruptive physician behaviors is astounding. Hospitals and other healthcare organizations cannot afford not to address the problems. Investing in programs that give such doctors professional feedback, systematic opportunities to learn and change, and accountability for improvements is a fiscally wise and humanly caring course of action. Beverly Smallwood, PhD, is a psychologist with more than 30 years’ experience coaching physicians and executives, and also developing healthcare leadership teams. Request “The Price of Not Nice” white paper, or talk with Smallwood about leadership team needs by email via Bev@DrBevSmallwood.com
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An Epidemic of Undertreatment in Patients with Aortic Stenosis Closing the Gap with Creative Clinical Initiatives By ANTOINE KELLER, MD, FACS
Cardiovascular disease (CV) kills more people than all types of cancer combined and while deaths caused by CV have declined steadily over the last two decades, the incidence of valvular heart disease has increased and is expected to double over the next 20 years. Aortic stenosis (AS) is the most common heart valve problem in the United States, affecting an estimated 3.4 million people, and as with many cardiovascular syndromes, the prevalence of AS increases with age. It has been estimated that approximately 2 percent of people over the age of 65, 3 percent of people over age 75 and 4 percent of people over age 85 have clinically significant aortic valve stenosis. The first wave of “Baby Boomers” has now reached 65 years of age and the prevalence of AS is on the rise. Indeed, the incidence of AS is expected to double in the next 20 years. A recent report by the L.E.K. Consulting estimated that there are 320,000 people over age 65 in the United States who have
severe AS and meet indications for aortic valve replacement. The 2014 ACC/AHA Guideline mandated treatment for severe AS is aortic valve replacement, however, only about 19 percent of patients who meet guidelines ever receive appropriate surgical therapy. The classic signs and symptoms of AS are angina, syncope and congestive heart failure. Once patients develop one of these symptoms, this indicates a critical point in the natural history of AS. Referral to a cardiovascular health professional with advanced training in the care of patients with valvular heart disease is essential to obviate further progression of disease and potential adverse outcome. Fully 50 percent of untreated symptomatic patients with severe AS will die within two years of being diagnosed. Many times, however, the signs and symptoms are more subtle; perhaps a progressively declining capacity for work or activities of daily living, increasing requirement for rest during the day, or frequent weak and dizzy spells. Additionally, patients will often modify their lifestyles to accommodate their symptoms.
For example, whereas a patient would previously mow their lawn with a push mower, they may move on to a riding mower because cutting the grass with a push mower caused them to have chest pain. While these are relatively non-specific signs and symptoms, if your patients have any of them (especially in the presence of a heart murmur) you should have them evaluated by a physician with expertise in the diagnosis and treatment of valvular heart disease. Recent studies from the Mayo Clinic and other centers have shown that early intervention in the form of aortic valve replacement is advantageous even in patient with severe aortic stenosis who are asymptomatic. Patients who receive aortic valve replacement for severe AS before their hearts show signs of dysfunction can have a life expectancy equivalent to unaffected age matched patients, with much lower risk of complication or death than those patients who do exhibit ventricular dysfunction prior to surgery. Specially trained cardiothoracic surgeons can now perform aortic valve re-
placement through very small incisions (2-3 inches) and are indeed able to replace the aortic valve using percutaneous techniques. New transcatheter technology also allows physicians to replace heart valves through very small incisions in the groin without having to open the chest. This technology has the potential to change the paradigm for treating aortic stenosis. Almost all patients with isolated aortic stenosis are candidates for minimally invasive approaches and this strategy has become the standard of care in many communities. The advent of trans-catheter aortic valve replacement has ushered in a new era of evaluation and treatment for “high risk” and “in-operable” patients with severe AS, and many more patients are now being considered for aortic valve replacement. As the population is aging, the prevalence of AS, and consequently the utilization of aortic valve replacement, and the cost of treating AS are expected to dramatically increase. A recent analysis of Medicare data (CONTINUED ON PAGE 8)
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Going Smoke-Free, continued from page 1 tients, is aiming for at least 20,000 signatures on its statewide signature drive by year-end. The petition will be presented to legislators at the onset of the 2015 legislative session to reflect the degree of support from Mississippians. “Many people have asked why we’re ‘wasting’ our political capital on an issue like this,” said Demetropoulos. “If we as doctors aren’t the ones standing up to say, Dr. Steven ‘here’s how we can im- Demetropoulos prove the health of Mississippians,’ who will? Besides, if we can persuade legislators to pass a smoking ban statewide, it’ll be the best health initiative in decades.” Specifically, the smoking ban pertains to commercial spaces, including bars, casinos, restaurants and workplaces. “We’re focusing on enclosed spaces,” he said. “The ban wouldn’t apply to courtyards in restaurants or open outdoor spaces in commercial venues.” In 2010, Mississippi led the nation in new local smoke-free laws. Now, 84 municipalities have adopted smoke-free ordinances. As a result, it’s reduced the 25 percent higher incident rate of cardiovascular disease that comes from secondhand
smoke, and decreased the state’s asthma prevalence rate. “Studies of the effects of secondhand smoke three years after Hattiesburg and Starkville adopted smoke-free ordinances showed that heart attack rates for nonsmokers in Starkville dropped 28 percent, and 13 percent in Hattiesburg,” said Demetropoulos. “However, even if all Mississippi municipalities adopt smoke-free ordinances, it would only represent 45 percent of the state because it’s so rural.” Pushback Despite a big smoke-free push in 2013, efforts for Mississippi to become the 23rd smoke-free state have been hindered, primarily because of pushback from casinos uninterested in a smoke-free environment, and state lawmakers who smoke. On the Mississippi Gulf Coast, one sole gambling boat – Palace Casino in Biloxi – advocates a smoke-free environment. “We continue to advocate for smokefree casinos in Mississippi,” said Demetropoulos. According to Americans for Nonsmokers’ Rights, casinos have up to 50 times more cancer-causing particles in the air than highways and city streets clogged with diesel trucks in rush-hour traffic. Ventilation doesn’t solve the problem because
SIGN THE PETITION: http://smokefreeairms.com/support/
casino workers, even in “well-ventilated” areas, have cotinine, or metabolized nicotine, levels up to 600 percent higher than employees in other smoking workplaces during a work shift. Studies also show that smoke-free casinos have no difficulty attracting new customers, there’s no adverse effect on total gaming revenues. And consequently, smoke-free policies decrease turnover and reduce overall healthcare costs. “Making casinos 100 percent smokefree is the only way to completely protect customers and workers from the dangers of secondhand smoke,” said Demetropoulos, adding that he’s also heard from restaurant owners who say “if everyone complies, and they’re competing on a level playing field, they have no trouble going smoke-free.” Dr. Claude Other groups have Brunson joined MSMA in its concerted lobbying effort for a smoke-free state: Mississippi Department of Health (MSDH), Mississippi Hospital Association, state chapters of medical specialty
associations, and the Partnership for A Healthy Mississippi. According to the MSDH Office of Tobacco Control, nearly 5,000 adults die annually from health issues related to smoking, and nearly 200,000 children are exposed to secondhand smoke at home. MSMA President Claude Brunson, MD, encourages all physicians, medical office staff and patients to sign the petitions online via a special link (see below). He pointed out that MSMA studies show 82 percent of Mississippians, including a majority of smokers and nearly 1,000 restaurant owners statewide, favor a state law prohibiting smoking in most public places. “Every signature counts,” said Brunson. Demetropoulos told WLOX-TV, the ABC and CBS affiliate for the Mississippi Gulf Coast, that pushing for the passage of a statewide smoking ban is the single most important thing physicians can do to improve the health of Mississippians. “That’s a pretty strong statement,” said Rick Williams, general manager of WLOX-TV. “We support the physicians’ petition drive and hope the state legislature will listen to the doctors.”
An Epidemic, continued from page 7 indicated that medical management of AS may cost the healthcare system more than $1 billion annually highlighting the poor outcomes associated with medical management of elderly patients with AS. While the clinical benefits of aortic valve replacement in patients having acceptable risk for surgery are irrefutable, timing of intervention, significance of symptoms in the pathophysiology of disease, and the best course of treatment for low risk patients remain vigorously debated. There is very little debate, however, about the fact that the changing paradigm for taking care of patients with AS has benefitted immeasurably from a multidisciplinary approach that includes simultaneous input from cardiologist, cardiac surgeons, diagnostic radiologists and critical care specialists.
Multidisciplinary treatment spaces, such as the St. Dominic’s Heart Valve Clinic have allowed patients and their families to receive the benefits of advanced technology, and cutting edge therapy in a collaborative environment that allows a non-linear treatment paradigm aimed at fitting the best multidisciplinary treatment approach to each individual patient, as opposed to committing the patient to one discipline or the other. Antoine Keller, MD, is a native of Louisiana. He earned his medical degree at Duke University School of Medicine where he graduated with honors and completed his general surgery internship, residency and research fellowship at Tulane School of Medicine. His thoracic and cardiovascular surgery residency was completed at the Carolinas Heart Institute (Sanger Clinic). Keller is board certified in cardiovascular and thoracic surgery. He is author or co-author of more than 40 scholarly publications, presentations, book chapters and abstracts, and has participated in countless experimental and clinical studies.
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AMA’s Telemedicine Push Evolution improves health outcomes, accelerates medical education change, and enhances physician satisfaction and practice sustainability By LYNNE JETER
In June, the American Medical Association (AMA) adopted a resolution addressing telemedicine as a key innovation in support of healthcare delivery reform. Timing of the resolution melds with legislative advocacy action being made at the local, state and national levels as telemedicine goes mainstream. Among the high points: a universallyaccepted telemedicine payment model, licensure portability, ethical guidance, clinical concerns and recommendations. “The umbrella of the reason and purpose of the resolution is that we recognized the technology of telemedicine was a very important tool we could use to take better care of our patients,” said AMA President Robert Wah, MD. “Underneath that umbrella, we firmly believe this technology shouldn’t Dr. Robert necessarily replace faceWah to-face interaction between the physician and the patient. We view face-to-face interaction as the highest quality action to have with a patient because there’s so much detail and information that comes out with direct interaction with our patients. We recognize that in some cases, after a patient-physician interaction has been established, telemedicine can be very helpful. In some instances, such as urgent matters requiring a consult, the technology may be used without an initial face-to-face interaction. But we still believe strongly that face-to-face is optimal for our patients.” Licensure Requirements In its resolution, the AMA made it clear that the physician providing telemedicine should be licensed in the state the patient resides. “We believe it’s important for physicians and patients to be treated within the parameter of local regulations and laws, which differ widely across the country,” said Wah. “We want to respect those differences and not try to supersede them via the use of telemedicine. For instance, if I as an OB-GYN am going to prescribe birth control for a patient under the age of consent, some states require a parent to be notified. The best way to comply with local regulations and laws is to make sure the physician is licensed in the state he’s using telemedicine.” Background In 1996, the Institute of Medicine (IOM) released the nation’s first commississippimedicalnews
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prehensive report on telemedicine, “Telemedicine: A Guide to Assessing Telecommunications for Health Care.” Despite the evolution of the practice, there remains no consensus on the definition of telemedicine and telehealth, often viewed as interchangeable terms. Instead, three broad categories of telemedicine technologies are defined as: store-and-forward, remote monitoring, and (real-time) interactive services. Regardless of the verbiage, “the evolution of telemedicine impacts all three strategic focus areas of the AMA: improving health outcomes, accelerating change in medical education, and enhancing physician satisfaction and practice sustainability by shaping delivery and payment models,” said Charles F. Willson, MD, a pediatrician from Greenville, NC, and presenter of the Report of the Council on Medical Service that preceded the AMA’s adoption of the resolution on telemedicine. Payment Reform In the report, Willson addressed how coverage of and payment for telemedicine has varied widely after the passage of the Balanced Budget Act of 1997 and the Telemedicine Communications Act of 1996 enabled payment for professional telemedicine consultation in 1999, and how inconsistencies remain to create barriers to the further adoption of telemedicine as public and private payers have continued to develop formal mechanisms to pay for telemedicine services. “Each year, Medicare pays approximately $6 million for telemedicine services,” according to the report, “In 2009, there were approximately 40,000 telemedicine visits, involving some 14,000 Medicare beneficiaries. That same year, 369 practitioners, including physicians, provided 10 or more telemedicine services to Medicare beneficiaries – most of which were mental health services. “Psychiatrists, psychologists and clinical social workers comprised 49 percent of the practitioners who provided 10 or more telemedicine services in Medicare. While physician assistants, nurse practitioners and clinical nurse specialists accounted for 19 percent of such practitioners, family medicine and internal medicine physicians accounted for 7 percent.” The District of Columbia (DC) and 46 states offer some form of Medicaid payment for telemedicine services. Also, 19 states and DC have adopted laws mandating that private payers cover telemedicine services, as defined by various states. “When any developing therapy or
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Tax Time: Getting Your Financial House in Order By CINDy SANDERS
After the sticker shock that accompanied last year’s tax code regulations, many will be happy that 2014 is going out on a quieter note. However, there are still some changes and lingering questions about a number of extenders that could adversely impact your bottom line on both a personal and professional basis. Tony Jones, CPA, a tax services manager for HORNE LLP, said many high-earning individuals are still adjusting to the major changes in 2013 that included higher rates on net in- Tony James vestment income and the additional Medicare tax. “’13 was also the year that personal exemptions and line item deductions phased out for high income taxpayers,” he added of the resurfacing of tax rules for individuals with an adjusted gross income over $250,000 and married couples with AGI over $300,000. “In Tennessee, the sales tax deduction is pretty important to us, and that has not been extended … yet,” he said in early November, adding the extender could be approved before the end of the year. “It’s also important to Florida and any state that doesn’t have a state income tax,” he continued. In addition to the sales tax deduction, Jones said accountants had their collective eyes on a number of other extenders included in separate U.S. Senate and House
bills. The general consensus was that no decision on the fate of these extenders would be made until after the November elections. This year, all 435 seats in the House of Representatives and one-third of the seats in the Senate were in play. Retirement Funds Jones said most physician practices still operate on a cash basis and are still making a profit. To avoid higher corporate tax rates, it’s quite common to distribute ‘leftover’ cash to partner physicians in the form of a bonus where it will be taxed at the individual rate. “There is one deduction they can accrue and pay later, and that’s retirement plans,” Jones noted. “You get a deduction for the money that goes into retirement plans. Then you don’t have to pay taxes on any of that until you do pull it out … and hopefully, by then, you’re in a lower tax bracket.” For those who wish to take advantage of the tax benefits that come with funding a retirement plan, Jones said there are several options. The easiest is to put money in a traditional or Roth IRA, but that limits an individual to $5,500 for the year ($6,500 for those aged 50 or older). “If they want to save more, they need to look at another type of retirement plan where they can put away up to about $55,000 depending on the vehicle,” he said. Jones continued, “It’s too late to put a 401K plan in place for ’14, but if they don’t already have one, they (physician practices) should definitely think about it in 2015.
AMA’s Telemedicine Push, continued from page 9 technology in medicine becomes mainstream, we want to make sure there’s a payment for the benefit that gets accrued by using the technology,” said Wah. Case Studies Highlighted in the AMA’s Report of the Council on Medical Service are two case studies resulting from telemedicine outreach and research efforts: The University of Virginia (UVA) Center for Telehealth across the UVA Telemedicine Partner Networks includes 118 sites offering telemedicine services in more than 40 specialties and sub-specialties. The center has provided more than 33,000 patient encounters in Virginia,
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and provides more than 30,000 teleradiology services annually. The Arkansas ANGELS (Antenatal & Neonatal Guidelines, Education & Learning System) provides patients with round-the-clock and telemedical support at approximately 30 telemedicine sites statewide to address high-risk obstetrical care needs. In 2012, Arkansas ANGELS reported 5,221 telemedicine visits, 2,062 telemedicine obstetric ultrasound visits, and 130 fetal echocardiogram visits. Also the same year, 1,629 colposcopy exams were performed, which identified 303 women with high-grade lesions requiring treatment and five diagnosed with cancer. “We made a strong statement in our resolution to lobby for continued research on the most optimal way to use telemedicine and integrate it into our current delivery system to take better care of our patients,” said Wah. “I don’t have specific thoughts about how that research would proceed. Yet, as with any therapy or technology that I use to care for my patients, I’m always looking for ways to improve that care.”
Section 179 Depreciation “In the past several years, a business could expense up to $500,000 of new, fixed asset purchases during the year,” Jones said. On top of that, he continued, “They could also expense 50 percent of new equipment purchases … a 50 percent bonus depreciation.” That, however, has changed dramatically. “In 2014, that $500,000 limit dropped to $25,000, and that 50 percent bonus depreciation is not in effect either at this time,” Jones said, adding the bonus depreciation extender could well be reinstated when Congress reconvenes after the elections. “We hope they’ll reinstate it, but we don’t know for sure.” Jones went on to explain what the limit changes might look like for a physician practice. Using a hypothetical example, he said if a physician had a net income of $450,000 in 2013 and purchased a piece of equipment with a price tag of $400,000, the doctor could effectively drop his or her net income to $50,000. Then, using the bonus depreciation rules, that remaining $50,000 could also be expensed out to pull the taxable amount down to zero. “But in 2014, in that same scenario of $450,000 net income, you could only take $25,000 plus regular depreciation off the top,” Jones said, adding the tax burden would be much higher this year. (Note, there are also rules that come into play pertaining to annual dollar thresholds that are not included in this simplified example). If the bonus depreciation extender is ultimately put back in play, then the physician could deduct another $200,000 tied to the new equipment purchase plus normal deprecation and the $25,000 covered under 179 depreciation. Although, the latter scenario is clearly preferable, Jones pointed out that with or without the bonus depreciation, physicians should expect to pay more in taxes for 2014 than would have occurred under the much more generous 2013 rules. For those who have purchased new equipment this year or are planning to do so by Dec. 31, it will be particularly important to follow any last minute changes to the bonus depreciation extender. As for the bottom line, Jones noted, “In 2013, there were so many changes. In 2014, there hasn’t been quite as much. It’s pretty much more of the same.” Jones is based in the Jackson, Tenn. office of HORNE, one of the top 50 accounting and business advisory firms in the country with offices in Alabama, Louisiana, Mississippi, Tennessee and Texas.
CORRECTION: In our October issue on page 10 we captioned John Anderson as Joe Anderson. We apologize for any inconvenience.
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SOUTHCOMM Chief Executive Officer Chris Ferrell Interim Chief Financial Officer Glynn Riddle Chief Marketing Officer Susan Torregrossa Chief Technology Officer Matt Locke Chief Operating Officer/Group Publisher Eric Norwood Director of Digital Sales & Marketing David Walker Controller Todd Patton Creative Director Heather Pierce Director of Content / Online Development Patrick Rains Mississippi Medical News is published monthly by Medical News, Inc., a wholly-owned subsidiary of SouthComm, Inc. ©2014 Medical News Communications.All rights reserved. Reproduction in whole or in part without written permission is prohibited. Medical News will assume no responsibilities for unsolicited materials. All letters sent to Medical News will be considered Medical News property and therefore unconditionally assigned to Medical News for publication and copyright purposes.
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GrandRounds Hattiesburg Clinic Spine Center Welcomes Meyers Adam D. Meyers, CNP, recently joined Hattiesburg Clinic Spine Center as a nurse practitioner. He earned his Bachelor of Science in nursing through Chamberlain College of Nursing in Downers Grove, Ill., and his Master of Science in nursing from University of Mississippi Medical Center in Jackson, Miss. Meyers is board certified by the American Nurses Credentialing Center. He is a certified Adult Gerontology Acute Care Nurse Practitioner. He joins Richard E. Clatterbuck, MD, PhD; Jack Kruse, MD, DMD; Elizabeth B. McCrary, CNP; and Brandi K. Rawls, CNP.
thology. He is a graduate of The University of Tennessee College of Medicine in Memphis, Tennessee. He was Fellowship trained in Blood Banking at St. Luke’s Episcopal in Dr. Charles Slonaker Houston, Texas. Dr. Slonaker completed his Pathology Residency at St. Luke’s Episcopal and The University of Tennessee College of Medicine. He has been practicing on the Gulf Coast for over 30 years. Dr. Slonaker served as Secretary-Treasurer from 2012 to 2014.
Joseph Bosarge, MD, was elected Secretary-Treasurer. He was appointed to the Medical Staff in 2009. Dr. Bosarge is Board Certified in Internal Medicine, Pulmonary Medicine and Critical Care. He received his medical doctorate, PhD and Fellowship trainDr. Joseph ing at the University of Bosarge Mississippi Medical Center in Jackson. Dr. Bosarge completed his Internal Medicine Residency at the Mayo Clinic in Jacksonville, Florida.
Coast Cardiovascular Associates now Seeing Patients at new location in Cedar Lake-Biloxi Memorial Physician Clinics is pleased to welcome Cardiologists Paul Mullen, MD; Antoine Rizk, MD; and Wakkas Tayara, MD and Nurse Practitioners Elizabeth Crosby and Lezlie Mathews to our healthcare system. They are now providing cardiology services as a Memorial Physician Clinic at two locations: 1391 Broad Avenue, Gulfport and their new location in Cedar LakeBiloxi at Memorial Physician Clinics.
Hattiesburg Clinic Gastroenterology Welcomes Goebel Michael A. Goebel, MD, recently joined Hattiesburg Clinic Gastroenterology. Dr. Goebel earned his medical degree at Louisiana State University Health Sciences Center in Shreveport, La. He completed an internal medicine internship and residency at Wake Forest University Baptist Medical Center in Winston Salem, N.C., and a gastroenterology fellowship at Ochsner Medical Center in New Orleans, La. Dr. Goebel is board certified by the American Board of Internal Medicine. He is a fellow of the American College of Gastroenterology and a member of the American Gastroenterology Association, American Medical Association, American College of Physicians and the Louisiana State Medical Society. Dr. Goebel joins Kevin B. Barker, MD; Kevin P. Blanchard, MD; E. Howell Crawford, Jr., MD; Jacob M. Feagans, MD; Sean D. Fink, MD; Gregory R. Owens, MD; Joseph P. Phillips, MD; Melinda “Mindi” J. Bennett, CNP; and Susan R. Oglesbee, CNP.
New Memorial Medical Staff Officers Assume Positions Memorial Medical Staff Officers were elected in September and began serving their terms October 1. They will serve through 2016. Alton Dauterive, MD, was elected Chief of Staff. Dr. Dauterive is a Fellow of the American College of Surgeons who was appointed to the Medical Staff of Memorial Hospital in July of 1986. He is a graduate of Tulane School of Medicine in New Orleans, LouiDr. Alton siana. He completed his Dauterive Internship and Residency at Charity Hospital in New Orleans and his Fellowship in Vascular Surgery at LSU School of Medicine. Dr. Dauterive served as Vice- Chief from 2012 to 2014. Charles Slonaker, MD, was elected Vice-Chief of Memorial Medical Staff. Dr. Slonaker is Board Certified in Blood Banking, Clinical Pathology, and Anatomic Pamississippimedicalnews
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An ER designed with seniors in mind. Now at two area hospitals. Going to the emergency room is a stressful experience at any age, but particularly for seniors. That’s why Central Mississippi Medical Center and Crossgates River Oaks Hospital have introduced an environment just for patients 65 and older. Senior Track ER features: • Designated parking • Nurses specifically trained in geriatric emergency care* • Patient rooms with softer beds and easy-to-operate call buttons • Separate waiting areas, and wheelchairs for easy transportation • Nutrition, physical therapy and medication screening To learn more, visit CentralMississippiMedicalCenter.com or CrossgatesRiverOaks.com.
601-825-2811
601-376-2807
If you are experiencing a medical emergency, call 911. * CMMC: Geriatric Emergency Nursing Education * Crossgates: Nurses Improving Care for Healthsystem Elders program offered by the New York University College of Nursing
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