St Louis Medical News April 2015

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PHYSICIAN SPOTLIGHT PAGE 3

Andria Ford, MD ON ROUNDS

Correcting Irregular Heartbeats More Successfully St. Anthony’s is first in Missouri to add Topera Mapping System

By JULIE PARKER

What Does UnitedHealth’s Latest Move on Hysterectomies Mean?

Nation’s largest health insurer stiffens rules on hysterectomy coverage UnitedHealth Group, the nation’s biggest player in the health insurance market, recently announced a policy change to narrow the rules on hysterectomy coverage ... 4

Just in time for Valentine’s Day, the Heart & Vascular Institute at St. Anthony’s Medical Center gave its patients a gift of a more successful treatment option for atrial fibrillation (AFib) and other arrhythmias.

The Topera 3D Mapping System opens up treatment options for patients who previously would have been difficult to treat.

“In instances of cardiac arrhythmias, the problem is electrical, not anatomical, and the electrical source can be different in every patient,” said Gregory Botteron, MD, a clinical cardiac electrophysiologist (EP) with St. Anthony’s Heart Specialty Associates, whose first case with the new diagnostic tool was successfully completed on Feb. 13 at the Heart & Vascular Institute. “This system provides the first opportunity to look at each individual patient’s AFib and understand the areas more responsible for keeping the patient in AFib. By better pinpointing these areas, long-term outcomes will substantially improve.”

The Topera system consists of the FDA-cleared (CONTINUED ON PAGE 8)

Dr. Greg Botteron performs an ablation to treat AFib on March 21, 2014.

A Collective Voice for Independent Physicians Implanting “The Bullet” Leadless Pacemaker

SLPA aims to demonstrate quality medical care, cost-effectiveness

By LUCy SCHULTZE

Mercy Hospital St. Louis is only Missouri hospital in national clinical trial for patients with bradycardia Another great medical accomplishment is taking place in the heart of St. Louis ... 5

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stlouismedicalnews

Dr. Scott Hardeman

Talk of controlling healthcare costs may make physicians bristle. But from the perspective of Scott Hardeman, MD, the real question is not whether medicine must become more cost-effective. It’s who ought to be defining that value.

Amplifying the voice of physicians – and therefore patients – in the debate over healthcare is the goal of a new network of independent St. Louis-area physicians

Now Available!

that’s come together since 2012.

The St. Louis Physician Alliance (SLPA), for which Hardeman serves as chairman of the Board of Managers, has reached a membership of more than 900 physicians. It recently received approval as a Medicare Shared Savings Program Accountable Care Organization (ACO).

In an age when many physicians see little alternative to becoming employed by a hospital, the SLPA envisioned (CONTINUED ON PAGE 8)

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PhysicianSpotlight

Andria Ford, MD

Moving quickly at Barnes-Jewish Hospital

By LUCY SCHULTZE

As significant as the symptoms of stroke can be when they set in, equally striking is the power of swift intervention in restoring a patient’s normal function.

That duality — and the challenge to hone protocols toward ever-swifter interventions — is a driving force in the practice of Andria Ford, MD, a Washington University neurologist and stroke specialist at Barnes-Jewish Hospital.

“Those initial symptoms can be utterly disabling,” she said. “But the patient’s disability in the long term can be greatly diminished by early intervention.

It all depends upon what happens in those first few hours and how well you can restore blood flow to the brain when you act very quickly.”

Working to make stroke interventions as effective as possible for patients at BJH has been a focus of Ford’s practice since she joined the Wash U faculty in 2008.

In addition to training residents and seeing stroke patients herself, she also coordinates the response protocols that stroke team members follow when a patient arrives in the emergency room. The process of adjusting those protocols in recent years has shaved more than a few minutes off the average treatment time, making BJH one of the fastest stroke centers in the nation.

“One of the biggest changes we have made has been to streamline the choreography of how a patient is moved from room to room after they arrive in the ER,” Ford said. “We realized we were wasting time. Rather than moving the patient from place to place, we needed to bring the care to the patient.”

Previously, patients started out in a trauma bay for evaluation, then were taken to the CT scanner to check for bleeding in the brain and returned to the trauma bay. Now, emergency medical responders know to roll a stroke patient directly from the ambulance to the CT scanner. The hospital’s stroke team goes to the patient in the CT room to evaluate the patient and, if the stroke is deemed recent enough, administers tPA to help dissolve the blood clot and restore blood flow to the brain.

“When we first went through protocol improvement a few years ago, we reduced from 60 minutes to 39 minutes the time between when a patient arrives at our hospital door and when they receive the tPA medication,” Ford said. “Since we’ve now begun taking them straight to the CT scanner, we have likely improved our times even more.”

The chance to affect changes that will significantly improve patient outcomes is what drew Ford to the field of neurology and to stroke care in particular.

“I’ve also had several family memstlouismedicalnews

.com

bers who have had strokes,” she said.

“One minute, they’re living a totally normal life, and the next minute, they can be very disabled by a whole variety of symptoms, including weakness and language problems.

“But since there is such a great opportunity to make an impact through early intervention, we have the chance to help address a very common problem and make a real difference in preventing longterm disability.”

A native of Oklahoma City, Okla., Ford studied biomedical and electrical engineering for her undergraduate degree at Duke University in Durham, N.C. Interested in the technical aspects of the field but drawn more to work with people and patients, she opted for medical school.

She completed her studies at the University of Oklahoma School of Medicine in Oklahoma City, then came to Wash U for a residency in neurology. She remained at Wash U for a combined clinical and research fellowship in cerebrovascular disease before joining the faculty.

“I’ve always had an interest in research and wanted to be on the cutting edge of whatever I specialized in,” Ford said. “That’s why I was really looking for an outstanding academic center and teaching hospital. I didn’t want to be too far from home either, so Wash U wasn’t a difficult choice.”

Today, Ford is involved in a range of research projects, including one focused on the challenges of treating patients for whom the time of stroke cannot be easily determined.

“Up to one-third of patients have unwitnessed strokes or wake up with stroke symptoms,” she said. “For that population, we are left with our hands tied, because we can only provide tPA if we know they were last normal within four and a half hours.”

Giving tPA to someone whose stroke has been going on for longer than that can cause serious side effects like bleeding in the brain, making the patient’s condition worse rather than better.

In order to better assess how recently a stroke happened, Ford’s current study tests outcomes when patients with unwitnessed stroke are taken straight to the MRI scanner as soon as they arrive at the hospital.

“We can use the MRI findings to judge how long the stroke has been going on,” she said. “If it looks like the stroke

had a recent onset, perhaps right before the patient woke up, then we can give them tPA and are likely to improve their long-term outcomes.”

Ford is also enthusiastic about recent studies for which results were shared at the American Heart Association and American Stroke Association’s International Stroke Conference in February.

“Several recent clinical trials have demonstrated the benefit of what we call acute stroke intervention, in which a neuro-interventionalist threads a catheter into the blood vessels of the brain and uses a device to remove the blood clot causing the stroke,” she said. “If you can do that fast enough, you have a much greater chance of a good outcome than if the patient has not received the intervention.

Previously, we had little to offer these patient with such large, disabling strokes, but now we can intervene with these newer devices which are much more effective than previous devices.”

Since even such advanced interventions depend on speed to be effective, Ford said the most important thing providers can do is continue drilling patients to recognize the symptoms of a stroke.

“If physicians and their staff can teach their patients about the symptoms of stroke, they can get to the hospital quickly within the treatment window,” she said.

“When patients arrive early, there’s much more we can do to help them.”

Outside of work, Ford focuses on her family, which includes her husband, Nitin Anand, a pulmonary critical care intensivist at Missouri Baptist Medical Center; and two children, Ketan, 3, and Surina, 1.

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What Does UnitedHealth’s Latest Move on Hysterectomies Mean?

Nation’s largest health insurer stiffens rules on hysterectomy coverage

By JULIE PARKER

UnitedHealth Group, the nation’s biggest player in the health insurance market, recently announced a policy change to narrow the rules on hysterectomy coverage.

Even though the insurer’s plan to impose tighter restrictions on the use of the morcellator has garnered the most attention – many hospitals ceased using the laparoscopic surgical device after the FDA reported in April 2014 the fast-spinning blade can actually spread uterine sarcoma in some women undergoing hysterectomies – the squeeze is also being felt on the performance of hysterectomies in general.

UnitedHealth (NYSE: UNH), the insurer of 40 million patients based in Minneapolis, Minn., now requires specific authorization before most types of hysterectomies are performed. Only vaginal hysterectomies – the least invasive and inexpensive option – done on an outpatient basis are exempt. The policy doesn’t affect hysterectomies performed in cancer treatment. Approximately half a million hysterectomies are performed annually in the United States.

Before UnitedHealth announced its policy decision, Anthem was the only major commercial insurer requiring pre-authorization for hysterectomies.

Cigna and Aetna haven’t indicated they will follow suit. An Aetna spokesperson said the decision is “best left up to the physician and patient based on clinical circumstances,” a position also adopted by the American College of Obstetricians and Gynecologists (ACOG).

Days after UnitedHealth’s announcement, ACOG members buzzed about the issue at an ACOG national leadership conference.

“It’s been good fodder for discussion, though we’re taking it very seriously,” said Ravi Johar, MD, an OB/GYN from St. Louis, Mo., past president of the St. Louis Metropolitan Medical Society. “For UnitedHealth to reverse course, no one knows exactly what it means.”

Johar, council chair of the Missouri State Medical Association, said OB/ GYNs are certainly accustomed to the pre-certification process.

“We’ll do what we’ve always done,” he said. “We’ll discuss with patients all of the options and go from there. The decision is between the patient and physician.

My job is to provide the best medical care possible. How that affects them financially is a big impact, but it’s not my area of expertise.”

UnitedHealth is a good weathervane in the post Affordable Care Act era, with its combination of market power, community support, and access to exceptional data, said Jay Wolfson, DrPH, JD, Distinguished Professor of Public Health, Medicine and Pharmacy at the University of South Florida (USF) Morsani Dr. Jay College of Medicine.

Wolfson “In this case in particular, it’s important to recognize that UnitedHealth, over the past couple of years, has been the most aggressive of the health insurers in tightening up their markets,” he said. “They began eliminating a

lot of physicians and hospitals from their panels in many communities.”

For example, said Wolfson, cancer and children’s hospitals were removed from UnitedHealth’s list of risk providers, based on the argument of cost being significantly higher at those healthcare facilities than others.

“Procedures in hospitals like MD Anderson, Sloan Kettering and Moffitt may cost 50 percent more than non-specialty, community facilities,” he said. “That’s to be expected because they’re teaching hospitals.”

Wolfson also pointed out that UnitedHealth acquired Optum, a healthcare technology firm established in 2010, which he considers one of the “best staffed analytic division of third parties.”

“Optum focuses on quality, outcome and cost-effective analyses of United’s (and other available) databases” said Wolfson. “Their research translates into what, to whom and how much United will pay.”

That influence has infiltrated the healthcare industry in many ways. In January 2013, while outsourcing work with Optum before bringing the firm in-house, UnitedHealth Group’s Center for Health Reform and Modernization proposed the use of predictive modeling software, particularly in Medicare and Medicaid programs, as tools for care management and information security as a possible solution to both healthcare fraud and preventable hospitalizations.

“As part of the ACA, they’ll continue to drill down and drive down costs and utilization and attempt to be as directive as they can to their patients, physicians, hospitals … to optimize cost, utilization

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and safety while also reducing liability,” said Wolfson.

Some hospital systems are adopting a tough stance against UnitedHealth’s culling process and policy changes they view as unfavorable.

“Three years ago, BayCare (Health System, Tampa Bay’s dominant nonprofit hospital chain), went up against UnitedHealth over reimbursement issues,” noted Wolfson. “Unlike most standoffs, there was no last minute negotiation and 450,000 members in Tampa Bay had to change hospitals and physicians because BayCare stood its ground against this healthcare delivery powerhouse.”

Wolfson also sees a trend of separate policy issues, in part led by UnitedHealth, that are shaking up the medical device manufacturing industry and the pharmaceutical sector.

“Until recently, pharmaceutical companies have had a tremendous influence in medical schools and communities concerning what medications physicians prescribe,” he said. “Now some medical schools across the country like ours have gone ‘drug-free’ and no longer allow pharmaceutical reps to teach in our classrooms or offer ‘educational’ program lunches.”

The same cycle holds true for manufacturers of medical devices, Wolfson said.

“The device manufacturing industry has also heavily affected medical practice,” he said. “Their significant influence is waning.”

In response to UnitedHealth’s policy change on hysterectomies, medical schools will place a stronger emphasis on technical skills to perform vaginal hysterectomies.

“We’ve developed a generation of surgeons who don’t know how to do vaginal surgery, quite frankly,” said Neil Finkler, MD, an OB/GYN in Orlando and CMO at Florida Hospital Orlando.

“So many physicians stopped using vaginal hysterectomies and it’s not being taught very much,” Wolfson added. “Our younger medical students don’t have the skills. It’s easier to use a device, which generates more revenue and becomes a standard. Most clinicians interviewed say it’s safer, less complications, but it’s not done because it’s just not being done. That’ll change.”

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Implanting “The Bullet” Leadless Pacemaker Mercy Hospital St. Louis is only Missouri hospital in national clinical trial for patients with bradycardia

By JULIE PARKER

Another great medical accomplishment is taking place in the heart of St. Louis.

Mercy Hospital St. Louis is the first and only hospital in Missouri to implant the Nanostim™ leadless pacemaker as part of the national LEADLESS II Clinical Trial being conducted by St. Jude Medical.

The implantable cardioverter defibrillator (ICD), nicknamed “the bullet” for its size smaller than a triple-A battery, was developed for patients with bradycardia.

It’s the world’s first retrievable, nonsurgical pacing technology – and a significant quality of life booster for its patients.

“The Nanostim is a huge development for patients with rhythm disorders,” said Amit Doshi, MD, a cardiac electrophyiologist (EP) at Mercy Clinic Heart and Vascular, and principal investigator for the clinical trial at Mercy Dr. Amit Hospital St. Louis. “It’ll Doshi eliminate many of the typical activity restrictions and ultimately allow our patients to get back to a more active life.”

Implanted via the femoral vein with a steerable catheter, the Nanostim leadless pacemaker provides physicians at Mercy with a less-invasive approach, compared to traditional pacemaker procedures that require more extensive surgery.

The capsule-like device has a helical screw on one end to allow fixation into the heart muscle and a docking station on the other end to allow tethering of the device, which is fully retrievable and may be eas-

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ily repositioned during the implant procedure and later retrieved, if needed.

“Nanostim will serve a wide range of patient populations,” said Doshi, “but will be especially helpful for patients who have had infection issues, have trouble with veins – like dialysis patients – and those who don’t need pacemakers with several different wires.”

Because the Nanostim leadless pacemaker eliminates the need for an invasive chest incision and cumbersome wiring, it enhances patient comfort and possibly reduces complications, including device pocket-related infection and lead failure.

“The technology is pretty astounding,” said Doshi, noting that Mercy per-

forms more than 3,200 cardiac procedures annually; nearly one in four involves pacemaker implantation. At press time, nine Nanostim procedures had been successfully completed. “It’s going to be on the forefront of new technology in the next five years.”

In February, the St. Louis Dispatch featured the leadless pacemaker clinical trial at Mercy and Marilyn Gould, who was 69 when she suffered a heart attack and stroke in 2013. Diagnosed with bradycardia, she had a temporary traditional pacemaker implanted at another hospital.

When infection set in and the leads significantly limited her movement, the pacemaker was removed. She remained weak

until Stephen Pieper, MD, a cardiologist at Mercy Clinic Heart and Vascular, recommended her for the Nanostim clinical trial.

Gould, skeptical at first, became a trial participant when J. Mauricio Sanchez, MD, implanted the leadless pacemaker in January. She was elated at the drastic improvement in her quality of life.

“For patients with a high risk of infection and limited access to the vascular system, leadless is a great option,” said Sanchez. “The only thing patients have after the procedure is a groin stick, which can heal much more quickly than an open procedure placing a pacemaker.”

The LEADLESS II pivotal trial – a prospective, non-randomized, multi-center, international clinical study designed to evaluate the safety and effectiveness of the Nanostim leadless pacemaker in qualifying U.S. patients – is expected to enroll approximately 670 patients at 50 centers.

The first successful implants of the leadless pacemaker took place in December 2012 in a series of 11 patients at Homolka Hospital in Prague, Czech Republic. The feat marked an important milestone, noted Drew Hoffmann, CEO of Nanostim Inc., maker of the medical device.

The device received CE Mark approval two years ago, and is being implanted in the United States as part of the FDA-approved investigational study.

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Marijuana, Medicine & Addiction A conversation with ASAM President Dr. Stuart Gitlow

By CINDY SANDERS

With three states plus the District of Columbia sanctioning recreational use of marijuana and virtually all other states either allowing for or considering decriminalization and/or medical use of the drug, the great marijuana debate has become a legislative hot topic over the last three years. For Stuart Gitlow, MD, MPH, DFAPA, however, talk of medical benefits associated with inhaling the plant is just smoke and mirrors.

Gitlow, who concludes his term as presiDr. Stuart dent of the American Gitlow Society of Addiction Medicine this month, said there are two major issues with the drug … addiction and toxicity. The double board-certified psychiatrist, who has a private practice in Rhode Island, is concerned by the possibility of adding marijuana to the mix of alcohol and tobacco as yet another substance with the potential to do more harm than good.

The Drug

Marijuana refers to the dried leaves, flowers, stems and seeds from the hemp plant Cannabis sativa, which contains

the mind-altering chemical delta-9-tetrahydrocannabinol (THC), along with other compounds. The National Institute on Drug Abuse (NIDA) has found marijuana to be the most common illicit drug in America and one for which usage is on the rise. The national organization stated marijuana’s popularity, particularly since 2007, has coincided with a diminishing public perception of the drug’s risks.

However, at the same time risk perception has been declining, the drug’s potency has actually been on the rise. In looking at the amount of THC in marijuana samples confiscated by the police, the THC concentration averaged close to 15 percent in 2012 as compared to around 4 percent in the 1980s, according to the NIDA fact sheet on marijuana.

Gitlow agreed, saying, “The marijuana that is available today is much different, much more potent, than the marijuana that was available in the ‘60s.

More research needs to be done to see if there are even more long-term issues with this more potent form.”

Addiction

Gitlow noted marijuana works like any other addictive drug. “There’s not debate at all within the medical community that it’s addictive … that’s a given,” he said. “It’s like any other psychoactive

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drug … it’s not addictive to the majority of those using it once or twice.” However, he continued, “There’s no way of knowing if a person is going to have a problem with the drug until they try it … and then they are playing Russian roulette.”

Gitlow explained, “Addictive disease is not about the drug, it’s about a brain abnormality. It exists before somebody picks up the drug.” The three factors required for addiction, he said, are a genetic abnormality, environmental trigger and the drug. “Addictive disease is in only, give or take, 15 percent of the population.”

He added popular consensus is that about 9 percent of adults and 17 percent of adolescents who use marijuana become addicted. In addition, NIDA’s marijuana fact sheet noted addiction rates jump in daily users, with as many as 25-50 percent becoming addicted.

Toxicity

“There’s a second issue with marijuana, and it’s independent of addiction.

Marijuana has toxic ramifications,” Gitlow said. “Marijuana makes you stupid,” he stated bluntly. “It lowers IQ. It causes slowing of the processing speed. It causes abnormalities of attention and focus. It basically dumbs you down, and it does that more or less universally.”

When marijuana is smoked, the THC passes quickly from the lungs into the bloodstream and to the brain. THC targets cannabinoid receptors, which have a higher density in areas of the brain that influence pleasure, memory, concentration, coordination, thinking and time perception. Additionally, THC’s chemical makeup is similar to a naturally occurring brain chemical called anandamide. That similar structure lets THC be ‘recognized’ by the brain, allowing the outside compound to alter normal brain communication.

Of major concern is the affect marijuana has on brain development when used heavily among adolescents. A recent study showed marijuana users who began in adolescence had fewer connections in the areas of the brain that control memory and learning. A large, long-term New Zealand study found those who began heavily smoking marijuana in their teens lost an average of eight IQ points between ages 13 and 38. However, that impact on IQ wasn’t replicated in the study among those who didn’t begin smoking until adulthood.

NIDA also cited issues with cardiopulmonary and mental health. Gitlow said, “There’s a five-fold increase in psychotic disorders among those who use marijuana as compared to those who don’t.”

Alcohol vs. Tobacco, Marijuana

Last month, results of a new study stating marijuana is 114 times less lethal than alcohol made the media rounds and became fodder for late night comics. Gitlow said comparing the two is like com-

paring apples and oranges. “They affect different parts of the brain,” he said.

Gitlow also noted it is possible to ingest enough alcohol in one sitting to kill you, which isn’t really true of marijuana or tobacco. “So I could make the argument that cigarettes are safer than alcohol,” he said. However, there aren’t many physicians recommending a patient give up the occasional glass of wine and take up smoking tobacco instead.

“We’re not prohibitionists,” Gitlow continued. “No one at the American Society of Addiction Medicine says alcohol should be banned, but all these drugs collectively are an enormous burden on the American public from an economic and health-related standpoint.”

Considering the dangers of tobacco and alcohol, Gitlow said he couldn’t fathom why, as a country, we would want to add marijuana to the mix. “Why would we want to make our burden worse?” he questioned.

Possible Benefits

Gitlow reiterated his frustration at claims of marijuana being a medical marvel. “There is no medical purpose. No one has ever proven through a double-blinded trial a medical benefit of marijuana.” He continued, “That’s not to say there aren’t components within the plant that might not have medical application.”

However, Gitlow said breaking down the more than 100 components in marijuana would require scientific investigation just like any other drug in this country seeking approval from the Food and Drug Administration. He added marijuana lobbyists bringing anecdotal evidence to legislators interested in the bottom line doesn’t constitute a thorough research endeavor.

NIDA’s viewpoint is similar, noting that so far clinical evidence does not show the therapeutic benefits of marijuana outweigh the health risk. In it’s assessment of the drug, the national organization stated, “To be considered a legitimate medicine by the FDA, a substance must have welldefined and measurable ingredients that are consistent from one unit (such as a pill or injection) to the next. As the marijuana plant contains hundreds of chemical compounds that may have different effects and that vary from plant to plant, and because the plant is typically ingested via smoking, its use as a medicine is difficult to evaluate.

“However, THC-based drugs to treat pain and nausea are already FDA approved and prescribed, and scientists continue to investigate the medicinal properties of other chemicals found in the cannabis plant – such as cannabidiol, a non-psychoactive cannabinoid compound that is being studied for its effects at treating pain, pediatric epilepsy, and other disorders.”

With the increased attention being given to marijuana around the country, it’s a safe assumption that opponents and proponents will continue the debate. stlouismedicalnews

.com

Gearing up for ICD-10

CMS confirms Oct. 1 switch; healthcare consultant offers cautionary notes

By JULIE PARKER Successful completion of a full week of end-to-end testing of the new ICD-10 coding shows the healthcare industry is ready for the next step toward total conversion from ICD-9 coding, Marilyn Tavenner,

former administrator of the Centers for Medicare and Medicaid Services (CMS) said before her departure from the federal agency earlier this year.

To promote the healthcare industry’s smooth transition from ICD-9 to ICD10, CMS is conducting a comprehensive program of testing. In the first full week of testing -- from Jan. 26 to Feb. 3 – CMS received nearly 15,000 test claims from 660 providers.

“Testing allows us to identify areas of improvement, and we’ll work with outside entities and stakeholders to improve those very small deficiencies identified,” she said at the time. “And we’ll continue to do testing, especially in those areas we identify as needing improvement.” Tavenner added, “Because ICD codes are required on medical bills, we want healthcare providers to be confident they can submit Medicare claims and get paid as the nation switches to ICD-10.”

CMS also identified a point that’s prompted some confusion among the healthcare community. Acting Administrator Andy Slavic has reiterated ICD-9 coding is to be used for services provided before the Oct. 1 deadline; ICD-10 coding will be used for services provided on or after Oct. 1. Prior to Oct. 1, ICD-10 can be used only for test purposes. However, once we hit Oct. 1, 2015 only ICD-10 can be used for services rendered on or after that date. But claims submitted after Oct. 1, 2015, for services provided before that date, must still use ICD-9 codes.

Margie Maley, BSN, MS, coding educator and consultant with KarenZupko & Associates Inc., a national consulting firm based in Chicago, said she’s strongly advising clients that bill directly to Medicare to apply for end-to-end testing.

“If you don’t get accepted for end-toend testing, at the very least conduct acknowledgement testing,” she said, noting that applications for the next available endto-end testing (mid-July) became available on all carrier websites (MACs) on March 13.

“Medicare is only accepting up to 850 providers per testing week, so act fast,” urged Maley. “Even our orthopedic clients who must deal with the greatest increase in ICD-10 codes and reorganization have jumped onto the testing bandwagon successfully.”

Maley pointed out that claims testing highlights more than ICD-10 issues.

“Medicare says that 6 percent of testing errors were due to ICD-10,” she emphasized. “Yet more than twice that – 13 percent – were due to provider-preventable errors, such as incorrect NPI or submitter ID, or invalid place of service or HCPCS codes.”

Carrier software bugs are also being caught in the testing phase. stlouismedicalnews

.com

“A lot of this is just the nature of software development … not necessarily a coding issue,” Maley said. “Everyone is creating new features to deal with ICD-10 and they need to be tested so bugs are caught and fixed before the deadline. So make sure your practice is part of the testing process.

You never know what you might learn about your own processes.”

CMS is clearly ready for ICD-10, emphasized federal officials.

“And thanks to our many partners —

spanning providers, health plans, coders, clearinghouses, professional associations and vendor groups — the healthcare community at large will be ready for ICD-10 on Oct. 1,” Tavenner promised before stepping down. “I appreciate the tremendous efforts and achievements of health professionals as we work together to realize the benefits of ICD-10 and other advances toward the ultimate goal of improving the quality and affordability of healthcare for all Americans.”

For healthcare providers unable to complete the necessary systems changes to submit claims with ICD-10 codes by Oct. 1, CMS has provided free billing software via MAC websites.

This billing software has been updated to support ICD-10 codes to offer submitters an ICD-10 compliant claims submission form; coding assistance isn’t provided. Alternatively, all MACs websites provide internet portals; a subset of those portals offer claims submission.

EVERY PATIENT IS UNIQUE. Saint Louis University Physicians know this. That’s why we have teams of specialists to listen to, treat, and care for patients. And why our physicians began combining traditional medical imaging with 3D printing. The result puts a custom-made, true-to-life model in our surgeons’ hands before any incisions are made. It’s a part of Informed Medicine – our philosophy that reconnects the science of medicine, with the soul of it.

See how informed medicine makes a difference at SLUCare.edu

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A Collective Voice for Independent Physicians, continued from page 1 part of its role as providing a means and an advantage for physicians seeking to maintain their independent practices. The SLPA’s model for a Clinically Integrated Network (CIN) involves sharing data that can demonstrate the clinical and financial value of physician-led care.

Hardeman is a St. Louis-based ENT specialist with Sound Health Services PC. He graduated from the University of Missouri-Kansas City School of Medicine and completed post-graduate training at Saint Louis University in the Department of Otolaryngology Head and Neck Surgery.

How has the SLPA developed so far?

“Our organization is still in its infancy, but we’re building a model for a Clinically Integrated Network and building our IT infrastructure to be able to look at aggregate claims and electronic health record data. This will let us develop our own parameters to demonstrate to both patients and payers that we, as independent providers, can provide the most highquality, cost-effective care.

“We represent a broad group of physicians who come from all the medical and surgical specialties, and we are working with United Surgical Partners International to help us. Those of us left in the St. Louis marketplace are pretty hungry to try to stay independent. But it takes a lot of resources to build something like this.”

What has it been like to try to communicate these goals to physicians in the St. Louis area?

“It has been challenging. We felt, for the first 18-24 months as we were speaking with physicians in the process of developing this network, that it was similar to pushing a giant snowball up a hill. Then at some point, we reached a critical mass — and now it’s as if we’ve topped the hill and are running ahead with that giant snowball chasing us. At that point many providers started calling, wanting to join

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the organization.”

“The hard part initially was just getting them to understand what it means to join a CIN. Private practice independent physicians are pretty wary at this point.

We’ve seen so many of our colleagues get integrated in to large hospital systems and things not work out for them. We had to let physicians know: This is not a model that would constrain their practice. What we’re sharing is clinical data through a robust IT program that can illustrate the quality of care we provide and its costeffectiveness.”

“As we grew, we also added two important groups of employed physicians in the area who recognized the value of our efforts and bring important medical specialties and management capabilities to the table. The Saint Anthony Physician Organization has one of the premiere groups of primary care providers managing thousands of Medicare Advantage patients in St. Louis. The SLUCare physicians bring both academic rigor and important hospital-based subspecialists so that we can offer a full range of services through our network.”

An important part of our development has been developing relationships and trust across all of our partners to allow each to succeed in their own practice as well as coordinate care for their patients who often need services from multiple physicians in our network.

“The other side is that we’re starting to get in front of the payers now as a unit. We have a governmental ACO model with plans to develop a commer-

cial ACO. When you go to an insurance company and say, ‘Our network of physicians has the data to demonstrate our costeffectiveness over another group’ — they take notice pretty quickly.”

How does your organization stand to provide an alternative for young physicians who assume becoming employed is the only way to go?

“The best way we can demonstrate that choice to younger physicians is sustain a thriving group of independent physicians practicing quality medicine and the infrastructure to support new physicians just entering practice.

“A lot of the hospitals around here have teaching programs, and I do believe there is a push to get physicians out of medical school and residency into these hospital environments. There’s really no business education that takes place during residency. You have to really be on your game to want to go out and hang up your shingle. The complexity of the business of medicine combined with the debt load that many physicians enter the workforce with make the risk of independence frightening.”

“These young physicians come out of training with a quarter-million dollars or more in debt. The hospitals can woo them out of residency and offer them good pay. Whether that environment ultimately leads to personal satisfaction and professional autonomy depends on a lot of factors. An independent doctor succeeds or fails on his or her own efforts, em-

ployment arrangements can be subject to forces well beyond the physician’s control.

In my experience, that can be a difficult dynamic.”

How has your own practice managed to stay independent?

“Our group, Sound Health Services, formed 11 years ago — initially under some pretty heavy pressure, as the insurance payers came through with an aggressive policy of decreasing reimbursement rates. We started down a year long path and ultimately formed our organization by merging several thriving smaller practices in to one entity. We started out with just nine doctors. Today we have 25.”

“Our goal has really been to create a high quality, large, single-specialty group that had a global geographic stamp. We did it to bring down our expenses and to achieve success through enhanced contracting.”

“Established physicians should have the option to remain independent as we have. Younger physicians leaving residency should also have that option. However, at the end of the day, I really believe the future of healthcare lies with the doctors, both independent and employed, who want to provide quality care for their patients in a cost-effective way. While the current trend is certainly toward growing employment, eventually, I think the pendulum will swing back the other way. The SLPA network offers a model to demonstrate the benefit of a robust group of independent physicians and our hospital-based partners.”

Correcting Irregular Heartbeats, continued from page 1 RhythmView™ workstation and FIRMap™ catheter, used in tandem for the identification and localization of the sustaining mechanisms of cardiac arrhythmias – AFib, atrial flutter, atrial tachycardia, and ventricular tachycardia – to provide a graphical display of the right and left atrial electrical activity for the best view of full-chamber, continuous electrical activity, even in the most complex cardiac arrhythmias.

“This technology will allow us to effectively treat a larger population of patients,” said Botteron, who completed his internship, residency and dual fellowships to specialize in curative ablation therapy in St. Louis. The only EP in the metro area trained to use the Topera system, he was brought to Dr. Gregory St. Anthony’s in 2010 to Botteron improve and enlarge the institute’s ablation program. St. Anthony’s committed to an investment of roughly $25,000 a month for the Topera system.

“We believe it shows the commitment of our new Heart & Vascular Institute at St. Anthony’s to improve the heart health of our community.”

St. Anthony’s CMO David Morton, MD, an interventional cardiologist who

joined the healthcare system’s medical staff in 1987, agreed.

“Any time we believe there’s technology that could benefit our patients, either by performDr. David ing procedures more Morton safely, or in a way to gain a better result for our patients or provides us with a better overall approach, we want to make sure we’re offering it to all of our patients,” he said.

Morton emphasized the one-time procedure may cure a majority of heart patients with arrhythmias and therefore dramatically reduce the number of hospitalization days and readmission/reprocedure rates.

“Having the technology to help a patient avoid subsequent procedures is quite worthwhile,” he said.

The third largest medical center in the St. Louis metro area, St. Anthony’s serves nearly 1 million residents in the counties of St. Louis, Jefferson, Franklin, Saint Francois, Sainte Genevieve and Washington in Missouri, and Monroe, Randolph and St. Clair counties in Illinois. The nearest medical centers with the new diagnostic tool are located in Chicago and Indianapolis, Ind. Here’s how the Topera system works:

A catheter is used to capture electrical potentials from the endocardium, which may then be used in conjunction with the workstation to create activation maps to facilitate the diagnosis of cardiac arrhythmias.

The catheter “basket,” which conforms to the shape of the heart chamber, consists of 64 evenly space electrodes distributed among eight splines.

The workstation includes a panoramic contact-mapping catheter designed for treating complex arrhythmias and associated heart anatomy in hardto-reach areas, such as locations near the distal and proximal ends of the basket. Previous basket catheters were often “blind” to those areas, Botteron pointed out.

The spline design assists with the even deployment of electrodes across the chamber, avoiding the “spline bunching” that historically has been associated with basket catheters. Radiopaque marker bands on the splines facilitate the positioning of the catheter and the localization of sources identified on the workstation.

“A very large, randomized trial using the technology showed a good long-term outcome, better than patients treated in a traditional manner by catheter ablation,” said Botteron. “The results were significant and confirmed this approach is better long-term.” stlouismedicalnews

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Survey Says … A Digital Disconnect Exists Between Patients, Practices

By CINDY SANDERS

Patients increasingly want to access online services to enhance convenience and communication with providers, according to a recent national survey conducted by TechnologyAdvice Research. Yet, the majority of respondents in the “2015 Trends in Patient Engagement” survey said a number of digital solutions that would be helpful are not offered by their primary care practices.

“Only 19 percent said their physician offered online appointment scheduling,” noted Cameron Graham, survey author and managing editor for TechnologyAdvice, a company that conducts research and analysis of IT products in a number of industries including healthcare. “Only 17 percent said their physician offered online bill pay.”

In addition to scheduling and payment functions, Graham said viewing test results or diagnoses online also ranked high among survey participants. However, only 27.8 percent said their physician proCameron vided that option. GraGraham ham pointed out all three of the most desired digital services are fundamental patient portal features. With that in mind, he continued, “There’s a big discrepancy between what patients report having access to and the EHR adoption rate among physicians.”

Graham said electronic health record adoption rates are in the “high 70s, low 80s” by office-based physicians in the United States. “A lot of those systems should have online appointment and bill pay capabilities,” he said, adding some of the older systems might not have those options but virtually all newer products offer robust patient portal resources.

“I think one of the big takeaways is that the patients don’t seem to be aware of the tools their physicians probably have,” he said. The other option, Graham continued, is that offices have these capabilities but are not using them. Either answer could spell trouble for practices.

“When we asked how important these services were when people were choosing a physician, 60.8 percent said it was ‘important’ or ‘somewhat important,’’ Graham said. “If physicians are offering these indemand digital services, a more proactive approach to promoting them is needed and could create an advantage in attracting and retaining patients.”

Graham added he also believes physicians need to more fully embrace digital services. “Patients value them a lot. Physicians think of them as an extra or add-on.”

With meaningful use requirements staged to increase health information exchange and promote patient engagement, Graham noted the effective use of patient portals could help practices hit the necessary stlouismedicalnews

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benchmarks to access incentives.

However, he noted, there probably won’t be a ‘one size fits all’ solution when it comes to patient engagement. “We did find age played a role in which services patients wanted their physicians to offer,” he said.

Not surprisingly, the demand was much higher by younger adults than in the senior population. “Among the 25- to 34-year-old demographic, almost 40 percent said they would like to have a smart phone app for scheduling appointments; but among the 65 and older demographic, only 3.8 percent said that would be something they’d want.”

Similarly, 35.3 percent of patients ages 25-34 would like for their physician practice to offer secure messaging outside of office hours compared to just 11.5 percent of those ages 65 and older. Of the six digital services listed on the survey (online appointment scheduling, smartphone app for scheduling, online test results/diagnoses, online bill pay, secure messaging, and health resources/educational material), 23.5 percent of those ages 25-34 reported

they didn’t want their physician to offer any of the services, while 44.2 percent of participants 65 and older had that same response.

Graham continued, “I think it’s important for physicians to be aware of what these different demographic groups want.”

He added such information could help providers tailor their message accordingly when discussing the different ways patients could access the practice and engage with providers.

Another disconnect highlighted by the survey was provider follow-up. While 68.6 percent of respondents said it was either ‘very important’ or ‘somewhat important’ that a physician follow up with them, only 30 percent reported receiving any followup from the practice that wasn’t tied to bill pay. “They’re very good about following up related to money,” Graham pointed out, but patients want more than that. In addition to building rapport with a patient, Graham said digital communication offers an easy way to make sure instructions were understood and are being followed, check

on medication adherence, share prevention tips, and remind patients about the need to schedule routine screenings and services.

The “Trends in Patient Engagement” survey included responses from more than 400 adults across the United States regarding their digital experience at primary care practices. The survey was conducted Jan. 5-7, 2015. A download of the survey whitepaper is available at technologyadvice. com/research.

TechnologyAdvice, which is headquartered in Brentwood, Tenn., offers free, neutral research and analysis of IT products to connect businesses with technology options that best address each company’s specific needs. The company works with businesses and practices looking for the right software for just a few people up to large enterprises in need of solutions for thousands and has assisted Apple, Oracle and HP in selecting new technology. Last year, TechnologyAdvice was named to the top half of the Inc. 5000 list of America’s fastest-growing private companies.

Compiling ‘The Notebook’ A free comprehensive standards ‘cleaning product’ directory is near completion for the healthcare industry

By JULIE PARKER

tant.

It’s not sexy, but it’s certainly impor-

The Notebook, that is, a new standards “cleaning product” directory so completely new across the entire acute care spectrum that no one has touched it.

“If it was easy to do, it’d have been done,” said Stephen Sawyer, director of healthcare strategic sourcing for CBRE | Global Corporate Services in Charlotte, NC. Sawyer, who previously worked in a group purchasing organization, has voluntarily undertaken the tedious task of assembling a compendium of cleaning product information for healthcare administrators, with information ranging from the listing of chemicals used in cleaning products to the infectious diseases germs killed by antibacterial lotions.

“The healthcare industry could learn a lot from the hospitality sector,” said Sawyer, noting that hotel chains like Marriott set the standard for homogenous janitorial supplies.

“As hospitals merge and acquire physician practices, it would benefit them to follow this standardization trend. Like a hotel, hospitals can and should condense their manufacturer supply base to one brand. Standards by definition reducing waste and hard cost.”

Sawyer, who suffered from asthma and allergies as a child, was recently in a coughriddled waiting room of an urgent care clinic when he asked the administrator which germs their antibacterial lotion killed.

“Administrators and clinicians are so busy, it’s one of the last things they might think about,” said Sawyer. “Knowing the particulars of varying manufactured products is a task that gets buried with higher priority patient care and administrative processing tasks. If they do have or know information, it’s typically piecemeal because that information isn’t commonly shared with its venue of use. I consider this product directory a support mechanism – an important component of the educational toolbox – to hand out to patients and anyone in a medical office that needs or wants to know how these products will affect them.”

To complete this arduous task, Sawyer partnered with various manufacturers in five janitorial industries. “I haven’t had one manufacturer tell me they already have this information handy,” he noted.

To facilitate manufacturer responses, Sawyer provided questionnaires that made it easy for them to fit their solutions into the mold or wireframe.

“For example, can liners more commonly known as trash bags, and other products are categorized in multiple ways, such as soaps and lotions, housekeeping and floor care chemicals and related products, and paper towels, tissues and dispensers,” he said. “The Notebook will eliminate inconsistencies of products, service cleaning and pricing.”

At press time, Sawyer was near completion of the soup-to-nuts “cleaning program” compendium that CRBE will gladly share with healthcare clientele at no charge. As

products are added, deleted or changed to the skeleton directory, he’ll provide instantaneous updates.

“We’re not expecting accolades for compiling this information,” said Sawyer.

“Packaging this important type of information was simply the right thing to do. When the next epidemic comes, with healthcare providers having instant access to this specific data, we’ll be better prepared to deal with it and therefore mitigate the damage.”

Sawyer, who specializes in healthcare brand identity, said the information will also boost the patient experience, which represents one of the top three priorities of healthcare leaders over the next three years, according to new research by The Beryl Institute, a global company focusing on patient experience improvement.

“Creating consistency while capitalizing on economies of scale should be a core proponent of a system’s strategy,” he said.

“Identifying solutions that assist in delivering a uniform brand while challenging suppliers to create new visual and budgetary business models will produce a competitive advantage and best-in-class outcomes.”

Creating standards that can be replicated from location to location will deliver the outcomes that enhance the patient experience, Sawyer pointed out.

“Leveraging the expertise and knowledge available,” he said, “will eliminate waste and reduce cost while promoting the brand and allowing healthcare leaders to keep their eye on delivering superior patient care.”

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GrandRounds

We Deliver Physician Readers.

Healthgrades Names St. Luke’s Hospital One Of America’s 50 Best

If your marketing plans include impacting the medical doctors of St. Louis, you should consider an advertising program in the St. Louis Medical News.

The largest audience of medical doctors in the St. Louis area will read your advertising messages.

March of Dimes Honors Mercy Hospitals in St. Louis and Washington

We not only reach 8,400 St. Louis area physicians by mail each month, they spend quality time reading our monthly content. Our editorial content is informative, educational, ethical, and created by professional healthcare editors with years of experience. Our content is a combination of clinical and business information needed by today’s physicians. Our news content keeps physician readers aware of significant changes in our region’s healthcare community.

The March of Dimes recognized Mercy Hospitals in St. Louis and Washington, Missouri, for efforts to give more babies a healthy start in life by working to reduce the number of early elective inductions before 39 weeks of pregnancy.

Only one percent of approximately 8,500 births at Mercy Hospital St. Louis are early elective deliveries and Mercy Hospital Washington had zero early elective births.

Babies born just a few weeks early have higher rates of hospitalization and illness than full-term infants. Recent research by the March of Dimes, the National Institutes of Health and the U.S. Food and Drug Administration found that although the overall threat is small, the risk of death more than doubles for infants born at 37 weeks of pregnancy when compared to babies born at 40 weeks, for all races and ethnicities.

CONTACT ME TODAY FOR INFORMATION ABOUT REACHING OUR PHYSICIAN READERS FOR PENNIES PER MONTH:

LARRY HENRY

St. Louis Medical News 314-917-6107 lhenry@medicalnewsinc.com

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St. Luke’s Hospital has been named one of the 2015 America’s 50 Best Hospitals by Healthgrades for consistent patient care excellence. This is the ninth year in a row (2007-2015) that St. Luke’s has achieved this recognition, and St. Luke’s is the only St. Louis hospital to be named one of America’s 50 Best Hospitals since the inception of the list.

As one of America’s 50 Best Hospitals, St. Luke’s is recognized among the top one percent of hospitals in the nation for clinical excellence based on survival and complication rates. According to Healthgrades, patients admitted to America’s 50 Best Hospitals are more likely to have successful treatment without major complications.

To determine America’s 50 Best Hospitals, Healthgrades analyzed millions of Medicare patient records from 2011 through 2013 for common inpatient medical procedures and conditions. Hospitals cannot opt out of this analysis, and no hospital pays to be evaluated. In addition, the data is risk adjusted, which takes into account differing levels of severity of patient illness at different hospitals and allows for hospitals to be compared equally.

According to another 2015 Healthgrades report, St. Luke’s is among the top 10 percent of hospitals in the nation for cardiology services (2012-2015), pulmonary services (2003-2015), neurosurgery (2012-2015) and gastrointestinal medical treatment (2010-2015).

Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.

PUBLISHED BY: SouthComm, Inc. CHIEF EXECUTIVE OFFICER Chris Ferrell ASSOCIATE PUBLISHER Larry Henry lhenry@medicalnewsinc.com Ad Sales: 314.917.6107 NATIONAL EDITOR Pepper Jeter editor@medicalnewsinc.com LOCAL EDITOR Julie Parker jparker@medicalnewsinc.com CREATIVE DIRECTOR Susan Graham susan@medicalnewsinc.com GRAPHIC DESIGNERS

Katy Barrett-Alley, Amy Gomoljak James Osborne, Christie Passarello

CONTRIBUTING WRITERS Cindy Sanders, Lucy Schultze, Julie Parker CIRCULATION subscriptions@southcomm.com —— All editorial submissions and press releases should be emailed to: editor@medicalnewsinc.com —— Subscription requests or address changes should be mailed to: Medical News, Inc. 210 12th Ave S. • Suite 100 Nashville, TN 37203 615.244.7989 • (FAX) 615.244.8578 or e-mailed to: subscriptions@southcomm.com Subscriptions: One year $48 • Two years $78 SOUTHCOMM Chief Executive Officer Paul Bonaiuto President Chris Ferrell Chief Financial Officer Ed Tearman Executive Vice President Of Digital And Support Services Blair Johnson Director Of Financial Planning And Analysis Carla Simon Vice President Of Human Resources Ed Wood Vice President of Content Patrick Rains Vice President Of Production Operations Curt Pordes Group Publisher Eric Norwood Chief Revenue Officer Dave Carter Director Of Digital Sales & Marketing David Walker Controller Todd Patton Creative Director Heather Pierce

St. Louis Medical News is published monthly by Medical News, Inc., a wholly-owned subsidiary of SouthComm, Inc. ©2015 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.

stlouismedicalnews.com

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GrandRounds Ascension Unit to Purchase Michigan Insurer Michigan subsidiary of St. Louis-based Ascension is planning to buy U.S. Health and Life Insurance Co. for $50 million.

That’s according to documents filed with the Michigan Department of Financial and Insurance Services, Crain’s Detroit Business reports. Ascension would acquire the insurance company through a newly formed subsidiary, Ascension Care Management LLC, according to the publication.

U.S. Health and Life, which targets employers with fewer than 100 workers, has received approval to sell policies for small employers under the Affordable Care Act. The company is licensed in 20 states, including Illinois.

The acquisition would allow Together Health Network, a physician-led network that’s co-owned by Ascension and Michigan-based Trinity Health, to participate in Michigan’s health insurance exchange, Joseph Aoun, a health care attorney with Nuyen, Tomtishen and Aoun PC in Ann Arbor, told Crain’s.

St. Louis-based Ascension, led by President and CEO Anthony Tersigni, is the nation’s largest Catholic and nonprofit health system.

Di Cera Named Fellow of the Academy of Science SLU scientist Enrico Di Cera, MD, has been named a fellow of the Academy of Science of St. Louis, an organization that works to promote the advancement and understanding of science and technology in the region. Di Cera, who is the Alice A. Doisy professor and chair of the department of biochemistry and molecular biology at SLU, is being honored for his work with the blood-clotting protein thrombin, which shows promise for future treatments for thrombosis and stroke.

Di Cera is being given the Fellows Award, which recognizes a distinguished individual for outstanding achievement in science. The Academy notes that Dr. Di Cera has distinguished himself as a physician scientist who is biophysicist, biochemist, structural biologist and protein engineer.

Di Cera has devoted many years to the study of blood-clotting, a life-saving biological process that prevents excessive bleeding after injury, but which also has the potential to cause harm when triggered in the wrong conditions, as with deep vein thrombosis.

Throughout the course of his career, Di Cera’s contributions have made a major impact on the field. His achievements range from basic contributions to the theory of ligand binding, to defining new anticoagulant strategies with engineered thrombin variants. He has published hundreds of scholarly papers and reviews about the topic.

The awardees will be honored at the 2015 Outstanding St. Louis Scientists

stlouismedicalnews

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awards dinner on Thursday, April 9 at the Chase Park Plaza.

Maryville University Awarded Grant to Develop STEM Curriculum Women, minorities, and those from low-income areas have traditionally been underrepresented in science, technology, engineering, and math (STEM) fields.

Through a new grant partnership, Maryville University and Monsanto Fund will address this problem by sparking student interest

in the career fields from an early age.

Maryville University has been awarded a one-year, $124,995 Monsanto Fund Grant for a new program called Children using Robotics for Engineering, Science, Technology and Math (CREST-M). The funding allows Maryville educators to create an innovative math curriculum for 3rd and 4th graders using LEGO WeDo robotics.

Maryville educators will develop the CREST-M curriculum this spring. Eighty students and 18 teachers from the Fer-

guson-Florissant and Ritenour school districts will participate in the two-week program in July. Maryville educators will use test and control groups to demonstrate that children who are traditionally underrepresented in STEM fields make similar gains as other students when properly engaged in learning.

Maryville plans to make the curriculum available nationwide. Publication sales will help defray the costs of ongoing professional development for participating teachers.

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