St Louis Medical News October 2013

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PHYSICIAN SPOTLIGHT PAGE 3

David Weinstein, MD ON ROUNDS Stacking the Deck Part 1 One COMs’ winning approach to retaining medical graduates When leaders at the Florida State University College of Medicine (FSU COM) began crunching numbers, they were pleasantly surprised to learn that roughly two of three medical graduates are practicing medicine instate, even if they completed residencies elsewhere ... 8

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Characterized by a breakdown in thought processes ... 9

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The Advent of Pay-for-Value St. Louis area BHC reveals local trends in 2013 Health Care Industry Overview

BY LYNNE JETER

St. Louis hospitals are making significant progress on safety and quality issues as the Centers for Medicare and Medicaid Services (CMS) challenges healthcare providers to become more efficient in the new pay-for-value era.

“While the transition to a value-driven healthcare system continues to be more of an evolution than a revolution, change appears to be happening,” said Karen Roth, RN, MBA, director of research for the St. Louis Area Business Health Coalition (BHC), and author of the 2013 St. Louis Health Care Industry Overview, a first volume in-depth look at local hospital quality and financial trends based on fiscal year 2011 data, and limited data for FY 2012. “Thanks to pressure by CMS and the hard work of healthcare providers, data suggests that quality at hospitals nationwide and in St. Louis is improving.”

Among the highlights: • St. Louis hospitals scored slightly above the national average in the CMS Value-Based Purchasing (VBP) Program.

• Readmission rates for 2008-11 declined for 15 area hospitals, while the average readmission rate for St. Louis area hospitals also declined slightly, compared to the prior three-year period.

(CONTINUED ON PAGE 6)

Shining a Light on Physician, Industry Relationships Physician Payments Sunshine Act Now in Effect

BY CINDY SANDERS

If you’ve recently enjoyed a golf outing with your friendly pharmaceutical rep or a nice dinner with a device manufacturer, that information will soon be available for all to see.

The Physician Payments Sunshine Act went into effect Aug. 1 of this year and requires applicable manufacturers to report certain interactions with physicians and teaching hospitals that are deemed to

PHYSICIANS BUSINESS CONFERENCE

POSTPONED

have value. ‘Applicable manufacturers’ are defined as pharmaceutical, device, biologic and medical supply manufacturers whose products either require a prescription to be dispensed or for which payment under federal healthcare programs is available.

“The Sunshine Act generally applies when physicians or teaching hospitals receive transfers of value from applicable manufacturers, and the applicable manufacturers receive actual or potential value in return,” explained Tom Baker, a shareholder in the (CONTINUED ON PAGE 10)

The October Physicians Business Conference has been postponed.

Please see the November Issue of St. Louis Medical News for further details.

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OCTOBER 2013

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PhysicianSpotlight

David Weinstein, MD

By LUCY SCHULTZE

St. Louis OB/GYN David Weinstein, MD, opts not to bemoan the frustrations physicians often face in their practices.

Rather, he works to fix them.

“My focus has been on clinical care and on finding ways to improve the quality of care for patients – and to make it easier for physicians to do what they do best, which is to practice medicine,” he said.

Weinstein is acting upon those convictions both in his practice as part of Consultants in Women’s Healthcare Inc. and as chief of OB/GYN at Missouri Baptist Medical Center.

In the latter role, Weinstein has led the hospital’s OB/GYN program since January 2011.

“At a time when other hospitals work only with the physicians they employ, it’s a pleasure to work with a hospital administration that’s committed to partnering with physicians to try to improve the quality of care in the community that we serve,” he said.

Weinstein’s titles also include chair of the OB/GYN quality improvement committee, chair of the department’s ethics committee and member of the hospital’s medical executive committee. He additionally oversees the obstetrics hospitalist program.

During his tenure as department chair, a key focus for Weinstein has been finding ways to make it more convenient and easy for OB/GYNs to work at Missouri Baptist. He worked with administrators to establish a women’s outpatient center within the hospital.

“It was created in response to physician requests for a facility where women can have outpatient procedures in a warm and comfortable setting, with the efficiencies usually only seen in free-standing surgery centers,” Weinstein said. “It has a high level of patient and physician satisfaction and continues to grow.”

Meanwhile, the hospital has pushed ahead in the area of minimally invasive gynecologic surgery, offering physicians a proctoring program as they learn the new techniques.

In 2012, Missouri Baptist received designation as a Center of Excellence in Minimally Invasive Gynecology – a first in the region. The center offers minimally invasive surgical options for hysterectomies, uterine fibroids, endometriosis, ovarian cysts, prolapse and other gynecologic conditions.

In obstetrics, Weinstein has worked with hospital administrators to better accommodate both patients and physicians.

All labor-and-delivery rooms are now equipped with state-of-the-art fetal telemetry that allows women to move about the room during labor while maintaining mobile monitoring of the baby’s heartbeat.

The hospital also added new 6 a.m. and stlouismedicalnews

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8 p.m. timeslots for scheduled labor-anddelivery procedures.

“We have been responsive to physicians’ needs and have tried to make it a physician-friendly service line at the hospital,” Weinstein said.

While pursuing such a range of improvements over a short time frame has added to his schedule, Weinstein doesn’t mind.

“I am busier – but I’d say I’m a highenergy person,” he said. “I always have time and energy for things I believe are positive and meaningful.

“One of the most meaningful things in my private practice has been providing care that makes a difference in people’s lives.

“In my role as chief, that’s just been amplified as I’ve been able to partner with both physician colleagues and hospital administrators to make the OB/GYN program at Missouri Baptist the most patient-focused and physician-friendly program in town.”

Weinstein has also had the opportunity to represent physicians on the board of directors for medical malpractice insurer Missouri Professionals Mutual, to which he was appointed in April.

A native of Roslyn, N.Y., Weinstein has been part of the St. Louis medical community since the mid-1980s. He received his undergraduate degree in biology from the University of Michgan in Ann Arbor, then came to St. Louis University School of Medicine to earn his medical degree.

Initially, he was interested in family practice.

“I liked the continuity of care,” he said. “But I also loved the surgical subspecialties, and OB/GYN was the perfect combination of both.”

Weinstein completed his internship and residency in OB/GYN at Washington University School of Medicine/ Barnes Hospital, where he served a year as administrative chief resident. He has remained connected to the medical school and serves today as an associate professor of clinical obstetrics and gynecology.

In his private practice, Weinstein’s priorities include giving each patient the time that they need and ensuring that every employee in the office embraces a

go-the-extra-mile approach.

Consultants in Women’s Healthcare includes four physicians and two nurse practitioners in addition to support staff.

“The motto in our office is: Take care of patients the way you would want someone to take care of you or your family members,” Weinstein said. “Everybody in our office – from the receptionist to the nurse involved in patient care – makes a difference. This is the culture we strive to encourage in our office.”

Weinstein’s primary areas of interest include obstetrics and laparoscopic surgeries. Over the years, he has also developed a special interest in osteoporosis, and has served as principal investigator in a number of related studies as well as authored publications. He received certification in clinical densitometry in 2001.

Despite the range of his interests and involvement, Weinstein continues to find everyday rewards in the most basic joys of his field.

“I’ve been in practice 24 years, but I still love obstetrics,” he said. “It’s still a thrill every time I deliver a baby. And it’s special when, years later, you have the chance to take care of the children that you delivered.”

Outside of work, Weinstein enjoys being outdoors – playing tennis, cycling, hiking, skiing – and spending time with family and friends.

He and his wife, Elizabeth, have three daughters: Jennifer, Allison and Katherine.

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OCTOBER 2013

Making Geriatrics a Primary

National expert discusses decade of change in high demand specialty

By LYNNE JETER

TALLAHASSEE— Ken BrummelSmith, MD, almost bypassed specializing in geriatrics because of the lack of educational opportunities at medical schools during the early 1970s, when he attended, and the lack of geriatric residency slots nationwide.

Instead, it was a chance encounter that sculpted his career path and enabled him to establish the Dr. Ken nation’s first Department BrummelSmith of Geriatrics for an allopathic school.

“My first job after fellowship was teaching a family medicine residency, and my director told me about the Society of Teachers of Family Medicine having a conference on teaching geriatrics in the family medicine residency program, and said it was going to be a big deal someday.

When asked if I’d go and see what I could find out about it, my first thought was, wow! A free trip to Boston! I really didn’t have much knowledge about geriatrics then,” said Brummel-Smith, past president of the American Geriatrics Society, and founding chair of the Department of Geriatrics at the Florida State University College of Medicine (FSU-COM). “After getting enthused at the conference and involved in developing educational programs, I switched from family medicine to geriatric medicine.”

Since then, the field of geriatrics has exploded. As baby boomers have aged, the need for geriatricians grows. Currently, 38,000 geriatricians are projected to meet the country’s needs.

“We’re at 7,000 now,” said BrummelSmith. “The main problem is we don’t have enough applicants. When I started in 1980, hardly anyone believed it was worth talking about. Now, there’s interest from the general public, but not enough interest from medical students. Lack of money and prestige are two reasons why.”

To address the shortage, BrummelSmith routinely encourages high school groups pursuing medical paths to strongly consider geriatrics.

“I always give them data that says: if you look at the top income to the lowest income, geriatricians are at the bottom of the scale,” he said. “We actually make less money with a specialty in geriatrics than we would in our primary specialty of family medicine or internal medicine. But interestingly, you can line up the reverse in job satisfaction. Geriatrics has the highest; neurosurgeons, among the highest paid, have the lowest. We tell them to think about paying your bills and your loans,

but don’t think you need to sacrifice your life to do it. Choose a specialty you love rather than one that pays well. And you’ll be happy the rest of your life.”

Brummel-Smith also ensures that all FSU-COM medical students have rotations in geriatric medicine in the school’s community-based curriculum model.

“Otherwise, if you took 1,000 people in a community, 700 would have a reason for thinking about their health during that month,” he explained, referencing the well-known study, “The Ecology of Care,” which first appeared in the New England Journal of Medicine in 1961, and was recently revisited with similar results.

“About 300 would have contact with the healthcare system in some way. About 100 would be admitted to a hospital, and one would go to an academic teaching medical center. So the population of patients who are taken care of, and the doctors taking care of them in an academic medical setting, is almost completely unreal realty.

Then medical graduates after residency go into practice where the real situation is.

For family medicine physicians, 30 percent will be geriatric patients. For internists, it’s 40 to 50 percent. And they’re just not prepared for it. So during medical school and residency, students get a negative view of geriatrics because you’re not seeing that many older patients in academic medical centers, and they hardly ever see geriatricians as role models. Combined with the negative financial incentives, and the negative emotional incentives that a lot of academic doctors put on geriatrics, it doesn’t surprise me that few people choose geriatrics.”

The tide is slowly turning in favor of geriatric medicine. CMS has elevated geriatrics to primary care status, paying $38,500 per resident annually, a 10 percent payment bonus from $35,000. The shift from production- to value-based medicine will also make a difference.

South Carolina has adopted a student loan repayment program as an incentive for geriatricians, a move Brummel-Smith hopes other states will emulate.

“In general, there’ll never be enough geriatricians to take care of all people over the age of 65,” he said.

Even though baby steps are helpful, it remains problematic for geriatricians, who don’t fit the standard productivity model of many medical groups.

“Geriatric patients don’t fit into the 15-minute visit model,” he explained.

“Older patients have more medical needs and take longer for each appointment. Also, the way our healthcare system is working right now and the way of reimbursement, you’re not being paid to make a patient (CONTINUED ON PAGE 11)

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

By CINDY SANDERS

If the workforce ain’t happy … ain’t nobody happy.

This spring the Lucian Leape Institute at the National Patient Safety Foundation (NPSF) released a report, Through the Eyes of the Workforce: Creating Joy, Meaning and Safer Health Care, that underscored the fundamental importance the workplace environment plays on patient safety. The result of two roundtables on the topic, the report contends patient safety is inextricably linked to healthcare workers’ own sense of safety and well being since providers who feel disrespected or threatened are more likely to make errors and less likely to follow institutional protocols.

Julianne Morath, RN, MS, president and CEO of the Hospital Quality Institute based in Sacramento, Calif., coled the roundtables with former U.S. Treasury Secretary Paul O’Neill, Julianne now CEO of Alcoa. A Morath founding member of the Lucian Leape Institute, Morath was the inaugural recipient of the John M. Eisenberg Award for Lifetime Achievement in Patient Safety from NPSF and is a noted author and speaker on the topic of safety and workforce improvement.

Going into the roundtables, Morath said the working hypothesis was, “A workforce, no matter how committed and skilled, cannot create a culture of safety unless they themselves are free from harm and disrespect.”

This hypothesis was borne out during the discussions that included the experiences and opinions of frontline practitioners, leaders of healthcare organizations, scholars, and representatives of government agencies and healthcare professional societies. Morath said, “It became very evident through the course of the roundtables that we have a long way to go in healthcare workforce safety.”

When workers live in a constant state of risk, they become blind to that risk and resigned to their situation, Morath said.

“It’s a dangerous place to be if you think this is as good as it’s going to get no matter what you do,” she noted.

When a workforce reaches this state, Morath continued, the workers won’t speak up or speak out. Yet, the evidence clearly shows having a culture that allows for effective assertion … or a ‘stop-the-line conversation’ … is a prerequisite for patient safety.

Morath, who served as chief quality and patient safety officer at Vanderbilt University Medical Center at the time of the roundtables, said her co-leader stlouismedicalnews

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O’Neill has often made the statement that every person in a workforce should be able to answer affirmatively to three essential questions: 1. Am I treated with respect and dignity by everyone?

2. Do I have the support and training tools to do my job?

3. Am I recognized and thanked for my contributions?

Unfortunately, ‘no’ is too often the answer to those questions. “It was jarring to find not only was there a lack of respect … but even worse, there was a culture of disrespect in many of our healthcare organizations that was tolerated,” she said of the group’s findings. “We have a somewhat historic and toxic culture where the hierarchy has to do with positional titles and the number of degrees,” Morath added.

Vulnerabilities in the system include accepting emotional abuse, bullying and learning by humiliation as ‘normal,’ performing demanding tasks under severe time constraints due to the production and cost pressures that dominate today’s healthcare landscape, and having a higher rate of physical harm than such high-risk industries as mining, manufacturing and construction. This culture of fear and intimidation takes away the joy and meaning from work that most healthcare employees chose for the very purpose of helping others and making a difference.

“While this report is concerning, it’s also hopeful,” said Morath, noting there were also examples of healthcare work-

places that are getting it right … at least most of the time. New healthcare models that rely heavily on teamwork are also helping make cooperation part of the landscape. “It really requires an appreciation and respect for everyone’s contribution in a team to deliver high quality, safe care in this complex environment in which we work today,” she noted.

The report asserts joy and meaning are created when the workforce feels valued, safe from harm and part of the solutions for change. The Mayo Clinic and Virginia Mason Medical Center are two examples that Morath said stood out for their culture of respect. She also said Hospital Corporation of America (HCA) has an exemplary employee safety and security initiative.

To create safe, supportive work environments, healthcare facilities must become high-reliability organizations with a fundamental precondition that employees are their most valuable assets and that the health and well being of those employees is a non-negotiable priority. The report outlined seven strategies to move the needle toward becoming this type of an effective organization.

1. Develop and embody shared core values of mutual respect and civility; transparency and truth telling; safety of all workers and patients; and alignment and accountability from the boardroom through the front lines.

2. Adopt the explicit aim to eliminate harm to the workforce and to patients.

3. Commit to creating a high-reli-

ability organization and demonstrate the discipline to achieve highly reliable performance.

4. Create a learning and improvement system.

5. Establish data capture, database and performance metrics for accountability and improvement.

6. Recognize and celebrate the work and accomplishments of the workforce regularly and with high visibility.

7. Support industry-wide research to design and conduct studies that will explore issues and conditions in healthcare that are harming the workforce and patients.

“It sounds deceptively simple, but it’s about and individual and collective commitment to continual learning, continual improvement, and continual engagement,” said Morath. “When you start, you’re never finished. This is a commitment … a long term commitment.”

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

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The Advent of Pay-for-Value, continued from page 1

• SSM DePaul Health Center and Christian Hospital reported zero surgical site infections for patients undergoing coronary artery bypass graft in 2011, the most recent year reported.

• A dozen hospitals received an “A” from The Leapfrog Group, a national patient safety organization, as part of its Hospital Safety Score program.

“It’s too early to declare the quality problem ‘fixed,’” said Roth.

“One in five Americans still must return to the hospital within 30 days of a heart attack, too often because of a complication from care re- Karen Roth ceived.”

Existing pay-for-performance programs including CMS’ VBP are rewarding providers with bonuses for care that’s far from exceptional, Roth noted.

“For example, St. Louis area hospitals with patient satisfaction scores as low as 23 out of 100 received an incentive payment,” she said.

In the region, Medicare losses – a proxy measure of inefficiency – decreased nearly 30 percent as a slice of operating revenue, making it the largest one-year decline since BHC began reporting on this metric.

The Medicare Payment Advisory Commission (MedPAC) and other industry leaders challenged the belief that Medicare payments are inadequate to cover the cost of care, noted Roth, pointing to a 2009 report, in which MedPAC found hospitals in competitive markets were efficient enough to earn a profit on Medicare because financial pressure from the private sector forced them to constrain costs.

“MedPAC provided further evidence in its most recent report that competitive market pressure results in lower hospital costs,” she said. “In the future, as CMS maintains pressure on revenue to contain

cost and bases payment on value, hospitals must focus on continuous quality and efficiency improvements to prosper.”

In 2011, St. Louis hospitals boosted charity care, with many hospitals reporting the highest levels in report history.

SSM Health Care and Mercy reported charity care at more than 3 percent of operating revenue, a first for both hospital systems.

Strikingly, Missouri Baptist Hospital-Sullivan provided charity care at 8.6 percent of operating revenue, the highest in the region, and one of five hospitals that provided charity care at 6 percent or greater of operating revenue.

The comprehensive report also notes that St. Louis hospital profit margins decreased, yet remained strong at 4.2 percent in 2011, compared to 7 percent nationwide. Losses on investments, such as acquisitions of physician practices, were partly the reason.

“It’s clear the journey to better value has just begun,” said Roth. “CMS’ VBP program has only put 1 percent of hospitals’ payments at risk and most commercial payment reform efforts remain segregated to only a slice of care, such as bundled payment for a specific procedure.”

(CONTINUED ON PAGE 11)

To Err is Human, But …

Nearly 15 years ago, the Institute of Medicine released the groundbreaking report, To Err is Human. It brought to public light the serious safety and quality issues occurring in American healthcare and ignited a movement for transformation.

In 2004, CMS launched Hospital Compare to publicly report hospital quality.

Four years later, CMS announced it would no longer pay for complications related to certain healthcare-acquired conditions. Earlier this year, CMS’s Value-Based Purchasing program (VBP) began making incentive payments to hospitals based on quality metrics.

SOURCE: St. Louis Area Business Health Coalition, Volume 1: Hospital Quality and Financial Overview, 2013.

St. Louis Hospitals’ Quality and Patient Safety Report Medicare VBP Program Total Blended Performance Score (and Bonus/Penalty Percentage) Missouri Baptist Sullivan, 90.1 percent (.66 percent) St. Joseph Hospital Breese, 80.1 percent (.47 percent) St. Joseph Hospital-West, 79 percent (.45 percent) Saint Anthony’s Health Center, 77.7 percent (.43 percent) DePaul Health Center, 73.3 percent (.35 percent) St. Louis University Hospital, 70.55 percent (.30 percent) St. Elizabeth Hospital, 68.1 percent (.25 percent) St. Clare Health Center, 66.7 percent (.23 percent) Alton Memorial, 65.4 percent (.20 percent) St. Mary’s Health Center, 63.1 percent (.16 percent) Barnes-Jewish St. Peters, 63 percent (.16 percent) St. Joseph Health Center, 62.1 percent (.14 percent) Progress West HealthCare, 61.78 percent (.14 percent) Christian Hospital, 61.7 percent (.13 percent) Missouri Baptist Medical Center, 60.35 percent (.11 percent) Mercy Hospital St. Louis, 58.9 percent (.08 percent) Barnes Jewish West County, 54.3 percent (.0 percent) St. Luke’s Hospital, 54 percent (-.01 percent) St. Anthony’s Medical Center, 53.2 percent (-.02 percent) Memorial Hospital, 52.8 percent (-.03 percent)

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Mercy Hospital Washington, 52.3 percent (-.04 percent) Gateway Regional Medical Center, 50.1 percent (-.08 percent) Touchette Regional Medical Center, 50 percent (-.08 percent) Mercy Hospital Jefferson, 46.1 percent (-.15 percent) Barnes Jewish Hospital, 40.55 percent (-.25 percent) Des Peres Hospital, 40.45 percent (-.26 percent) Anderson Hospital, 31.7 percent (-.42 percent) St. Alexius Hospital, 18.3 percent (-.66 percent) Lincoln County Medical Center, n/a

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Note: Information is based on data gathered between July 2011 and March 2012.

SOURCE: CMS Hospital Compare.

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What You Need to Know NOW about the CHNA Deadline

By DAVID A. WILLIAMS

Within the numerous parts of the Affordable Care Act, there are still many areas of implementation and enforcement that are unclear. In the confusion, hospitals may have missed or are in danger of missing important deadlines like the Community Health Needs Assessment (CHNA). Nonprofit and dual status hospitals must submit a CHNA before the end of the fiscal 2012 year. Here’s an overview of what you need to know, along with tips on how to begin structuring your CHNA assessment to become a strategic tool you can use to better serve parts of your community that fall through the cracks, as well as to set budgeting priorities for the next few years.

1. If you are a dual status hospital (a governmental organization that is by statute not required to file a 990) and do not file a 990, you must still complete a Community Health Needs Assessment before the end of the fiscal year. The penalties for not submitting are uncertain, but it seems logical to assume that revocation of a hospital’s tax exempt status could be at stake as well as a $50,000 penalty.

2. The fact that the IRS has not yet revealed its mechanism for dual status

hospitals to submit the assessment does not exempt nonprofit and dual status hospitals from completing the CHNA. 3. The CHNA process takes several weeks from conceptualizing to staffing, information gathering to analysis, and report preparation. The report needs to include an action plan for addressing areas in your community that are underserved and have disproportionately high health issues 4. Think strategically about the CHNA. Under the Affordable Care Act, a Community Health Needs Assessment is required to be completed every three years. Taking the time to put a good process in place gives you a solid template for conducting CHNAs going forward.

But the CHNA can actually be a very helpful strategic tool to take the temperature of the community; find out where you are having successes like a decrease in diabetes, which lets you know your program is working. Or you could find out infant mortality rate has risen, so a different approach is needed to help the community in that area. By treating the CHNA as more than a compliance requirement, there is an opportunity to move more swiftly from a reactive status to a proactive status that can get ahead of serious health trends.

Providing the Peace of Mind to Practice Medicine

Addressing population health management is a vital concern for hospitals.

The reimbursement system for Medicare is shifting from a fee-for-service environment to an outcomes based delivery model. Other payors may adopt this approach moving forward, therefore, status quo is not a strategy for hospitals. The CHNA is a great tool to aid in the culture shift required to move away from the reimbursement platform that exists today.

Here are key process suggestions to get the CHNA process started at your hospital: • Develop your supervisory team. Often the hospital administration, under direction from its board, is tasked with taking point on the CHNA. The first priority is to develop a needs listing that identifies both signs of wellness and areas of concern in the community you serve.

Review existing programs with an eye for refocusing resources to meet the most critical needs.

• Develop your CHNA implementation team. Include a broad representation of residents, agencies, and medical personnel that are knowledgeable about your community and will dedicate the time and effort to make the CHNA a success.

• Design the infrastructure necessary to manage the process, and to collect and analyze data. An evidencebased approach is necessary to meet compliance.

• Establish a plan for gathering primary and secondary data. Primary data on your community provides an opportunity to identify health trends that need to be addressed. Methods used to collect primary data include postal surveys and web-based surveys, videography, observation, focus groups, and face-to-face interviews. Secondary data is information used to prepare quantifiable benchmarks.

Examples of secondary data include demographic data about the growth rate of the community population, family income trends, area employers, vital statistics about incidence rates, prevalence rates, mortality, morbidity, and outcomes. Good sources for secondary data include Centers for Disease Control, State Department of Health, and U.S. Census Bureau.

• Set up a process to analyze the data.

Prepare charts that include benchmarks that show how your community stacks up against state and national benchmarks in key areas of wellness and disease.

• Prepare a report that includes the (CONTINUED ON PAGE 8)

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Stacking the Deck Part 1

One COM’s winning approach to retaining medical graduates

By LYNNE JETER

When leaders at the Florida State University College of Medicine (FSU COM) began crunching numbers, they were pleasantly surprised to learn that roughly two of three medical graduates are practicing medicine in-state, even if they completed residencies elsewhere.

“We were concerned it was a fluke and hoped the trend kept up,” said Michael Muszynski, MD, dean of the FSU COM Orlando regional campus, and associate dean of clinical research. “Five years later, it’s holding steady between 60 and 64 percent.”

Michael State lawmakers ap- Dr. Muszynski proved the opening of the FSU COM in 2000, after the Board of Regents denied requests in the late 1990s, stating more doctors weren’t needed. The charter class graduated in 2005.

As of May, 82 of 135 FSU COM graduates who have completed residencies are practicing medicine in Florida (61 percent). Of those, 70 percent (57) are in-state primary care providers (PCPs) and 16 percent (13) are practicing in rural, medically underserved areas of the state.

“The reasons why our statistics are much better than the standard 30/60 percent split – that is, 30 percent of graduates from traditional-based medical schools typically return to the state after complet-

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ing residency and 60 percent stay where they did their residency – is because of the foundation we laid with our mission statement, which was created by us from the very start,” said Muszynski. “We wanted the foundation firmly established so that whoever inherited the program from the pioneers who started the school wouldn’t be able to vary from the mission.”

First, FSU COM stacks the deck on the front end through a holistic application approach, focusing on applicants who want to live and practice medicine in Florida. Second, the college follows a community-based medical school model during students’ clinical years, where they connect one-on-one with physicians in the community.

And third, medical school faculty makes it fun and interesting to be a community-based doctor with a mentoring system that maintains contact with students during school and afterward.

“We put a great deal of thought into how our approach might work,” said Muszynski. “We knew we had to make an impression on medical students when they were making choices about their careers. And it’s working. The only thing that surprised us was how well it’s worked.

We would’ve been happy with a 40 to 50 percent return, but 60 to 65 percent is astounding.”

Deck Stacking

Rather than reviewing only grades and scholastic ability, the FSU COM application review board selects students with attributes that mirror the school’s mission.

“We quickly discovered that students who stated upfront their agreement with our mission had experience supporting that mission alignment,” said Muszynski.

“For example, we noted that many appli-

cants from smaller towns and smaller high schools were involved in a meaningful way with their community and seemed more likely to maintain that mission. We made no apologies for those identifying descriptors.”

For several years, FSU COM only accepted in-state applicants. Now, approximately 5 percent of approved applicants cross state lines to attend. Still, the board remains very selective.

All factors considered equal between two applicants – one from a rural area and an urban applicant – the rural applicant may be get a slot above the urban applicant, said Muszynski.

“A student from a rural area is more likely to align with our mission just because of their setting,” he explained. “But the rural applicant who didn’t do much extracurricular-wise, where the urban applicant worked with the underserved, then it’s different.”

Middle Ground

To keep the in-state return mindset strong, the FSU COM uses a communitybased curriculum to place third and fourth year medical students in the field.

“Community-based curriculums have been talked down by some schools,” said Muszynski. “We contend its equal worthiness. We focus on producing physicians who can care for patients in community settings, and a community-based curriculum is central to the process.”

For example, FSU COM has a unique apprenticeship model. Students aren’t assigned to hospitals, wards or residency teams. Instead, they’re assigned to a physician practicing in the community who has been trained to be an educator.

That physician typically receives $2,000 a month on a contract basis. As a result of this model, the FSU COM has no full-

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time faculty for years 3 and 4, with the exception of the campus dean.

The approach also includes a geriatric rotation component to spark interest in caring for older patients.

FSU COM has also established a strong student advisor network. Each student is assigned to a community advisor on an 8-to-1 ratio. Students are counseled not only about their careers, but also life in general, volunteerism, and the delicate yet very important work/life balance that perplexes many physicians. Advisors are overseen by a dean or associate dean, depending on the campus, on a 20-to-1 (students-to-dean) ratio.

“That low of a ratio in the U.S. rarely exists,” emphasized Muszynski.

Stage 3

To further strengthen community ties and the job placement network, Florida Hospital recently provided a $2 million gift to establish the Florida Hospital Endowed Fund for Medical Education to help the FSU COM support its educational mission.

“Our mission aligns strongly with Florida Hospital’s except that we’re not a faith-based school; we’re public,” said Muszynski. “These students are highly sought after, and relationships end up being life-long. We have 16 graduates already practicing in Central Florida. You might think: only 16? But it’s impressive when you consider the number of graduates during our ramp-up years between 2005 and 2010, and those who are just finishing 5-year residencies. We’ve now created a number of scholarships to encourage students to return.”

What You Need to Know NOW about, continued from page 7 health priorities identified by the CHNA. Share it with the community and prepare an action plan to address any healthcare gaps.

If you treat the CHNA as a checkthe-box requirement, then you’ll have a nice statistics report you can file. But when done correctly and strategically, the CHNA truly does provide an opportunity for hospitals to proactively budget resources for a multi-year plan that meets the specific health needs of the community of residents it serves.

David A. Williams, CPA, MPH, FHFMA leads healthcare reimbursement and advisory services at HORNE LLP. For more than 25 years David has focused on the healthcare industry serving hospitals, outpatient centers, home healthcare agencies, skilled nursing facilities, assisted living centers, rural health clinics and mental rehabilitation centers. From offices across the Southeast, HORNE serves healthcare clients across the nation. Visit www.horne-llp.com for more information.

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

By CINDy SANDERS

An insidious condition, schizophrenia is estimated to occur in about 1 percent of the population worldwide. Characterized by a breakdown in thought processes, the mental illness has been described for centuries through accounts of individuals suffering from delusions, paranoia and hallucinations.

The chronic, debilitating disorder takes a heavy toll not only on affected individuals but also on their families and society as a whole. An early onset disorder, many patients are first diagnosed during the late teens or early adult years and struggle throughout their lifetime Dr. Patrick to manage symptoms.

Sullivan “It’s a horrible disorder,” stated Patrick Sullivan, MD, director of the Center for Psychiatric Genomics at the University of North Carolina School of Medicine. “It’s a huge, huge public health problem, and it’s one where the scientific discussion has been dominated on partial information.” He added, “People have done the best they can with what information they have. We’ve been debating the cause of schizophrenia for the better part of a century now.”

On Aug. 25, Sullivan and colleagues helped move that conversation forward with the online publication of a new genome-wide association study (GWAS) in the journal Nature Genetics. “This is the largest published study we’ve done in the field,” noted the lead author who also serves as a professor in the departments of Genetics and Psychiatry and UNC. Collaborators in the study include co-authors from the Karolinska Institutet in Sweden, the Stanley Center for Psychiatric Research at the Broad Institute of MIT and Harvard, and the Mount Sinai School of Medicine in New York.

“We discovered there were 22 places in the genome, 13 of which to our knowledge had never been described before, and each is a clue about the cause of schizophrenia,” Sullivan said of identifying nearly two dozen locations in the human genome that are involved in the disorder, including one that has previously been implicated in bipolar disorder.

“If finding the causes of schizophrenia is like solving a jigsaw puzzle, then these new results give us the corners and some of the pieces on the edges,” he stated, adding the number of genetic variants probably numbers in the thousands. “These 22 are the tip of the iceberg.”

The study was based on a multi-stage analysis that began with a Swedish national sample of 5,000 schizophrenia cases and 6,200 controls followed by a meta analysis of previous GWAS studies and then a repstlouismedicalnews

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lication of single nucleotide polymorphisms (SNPs) in 168 genomic regions in independent samples for a total of more than 59,000 people included in the research.

The results underscored two takeaways for Sullivan. The first, “We need to do more studies urgently. We’re actually quite encouraged and believe larger studies of this type will lead to more knowledge,” he said.

The second, “The early results we have here certainly indicate two different biological processes are involved.”

The research uncovered two distinct pathways that might be associated with the disorder — a calcium channel and micro-RNA 137. Calling the calcium channel, which includes the genes CACNA1C and CACNB2, the ‘queen of the channels,’ Sullivan explained there are a number of FDAapproved calcium channel blockers on the market today that are used for a variety of conditions ranging from hypertension and angina to migraines.

Stressing that it was much too early to draw conclusions, Sullivan said the findings at least indicate the calcium channel might be an area that deserves further attention from those studying schizophrenia. Hypothetically, he continued, calcium channel blockers might be found to have unexpected efficacy in schizophrenics. “That’s something that needs to be evaluated in a careful, rigorous way,” he said, again cautioning against jumping too far ahead.

The second pathway includes its namesake gene MIR137, which is a known regulator of neuronal development. Sullivan noted more than a dozen other genes are also known to be regulated by MIR137, as well.

Schizophrenia has long been known to have a strong genetic component. While it occurs in about 1 percent of the general population, the disorder is found in about

10 percent of people with a first-degree relative diagnosed with schizophrenia. The National Institute of Mental Health notes the highest risk for developing the illness — 40 to 65 percent — occurs in an identical twin of an individual with schizophrenia.

Yet, most scientists believe genetics is only one component in developing the disorder, which probably has environmental triggers, as well.

While Sullivan said each different approach to solving the enigma of schizophrenia is important, he noted the genetic approach offers a strong foundation for discovery. “We can measure the DNA part of people particularly well these days,” he said. “Our study is a step forward in understanding the genetic basis of the disorder.

This is really, truly nice progress.”

He added the new findings provide “a couple of good strides forward” even though an endpoint isn’t yet in sight. “But for researchers and scientists, it shows us a bunch of things we’ve never seen before … and that’s pretty cool.”

And Sullivan expects more information to be forthcoming. “What’s really exciting about this is that now we can use standard, off-the-shelf genomic technologies to help us fill in the missing pieces,” he said. “We now have a clear and obvious path to get a fairly complete understanding of the genetic part of schizophrenia. That wouldn’t have been possible five years ago.”

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Shining a Light on Physician, Industry Relationships, continued from page 1 Baker Donelson Health Law group.

Baker, who practices in the firm’s Atlanta office, pointed out the manufacturer doesn’t actually have to receive financial benefit in exchange for the ‘value transfer,’ which can take a wide variety of forms, including donated items, payment to a physician for consulting services or expenditures for entertain- Tom Baker ment. “It’s enough that it might influence a physician,” he noted.

“The Sunshine Act is about transparency in two different fundamental ways,” he continued. “First, there is the potential interference in medical judgment in clinical trials required for FDA approval of drugs or medical devices. Second, there is potential interference in medical judgment in terms of ordering an item or service for which federal reimbursement is available.”

Baker said the policy is to shine a light on interactions that could be construed to unduly influence a physician or teaching hospital and to ferret out conflicts of interest. “It’s not saying that transfers of value are, per se, illegal but that the public has a right to know when medical judgment might be influenced by the value transfer,” he continued. Relationships between physicians and industry will now be on display for patients, auditors, personal injury lawyers and others to see when the Centers for Medicare and Medicaid Services (CMS) begins publishing the reported data next fall.

The Back Story

Championed by Sen. Chuck Grassley (R-Iowa) and Sen. Herb Kohl (D-Wis.), the impetus behind the Sunshine Act came from mounting concern over potential conflicts of interest within the industry.

These conflicts were highlighted by several egregious incidents involving clinical trials and devices up for FDA approval where physicians received large payments from the manufacturers of the drugs or devices being studied.

Grassley publicly described a number of academic physicians taking money from the National Institutes of Health when

12 Key Exemptions to the Reporting Rule Certified and accredited CME. Buffet meals, snacks, coffee breaks that are provided by a manufacturer at a large-scale conference or event when the items are generally available to all attendees.

Product samples that are not intended for sale and are for patient use.

Educational materials that directly benefit patients or are intended for patient use.

The loan of a medical device for evaluation during a short-term trial period (not to exceed 90 days).

Items or services provided under a contractual warranty in the purchase or lease agreement for a device.

The transfer of any item of value to a physician when that physician is a patient and not acting in his or her professional capacity.

Discounts including rebates.

In kind items for use in providing charity care.

A dividend or other profit distribution from, or ownership or investment in, a publicly traded stock or mutual fund.

Transfer of value to a physician if the transfer is payment solely for the services of the physician with respect to a civil or criminal action or an administrative proceeding.

A transfer of anything with a value of less than $10 unless the aggregate amount transferred to, requested by, or designated on behalf of the physician exceeds $100 in the calendar year.

those physician-scientists had direct financial interests in their own research. Among the worst offenders, the former chairman of the Psychiatry Department at Stanford University received an NIH grant to study a drug when he owned $6 million in stock in the company seeking FDA approval. Similarly, the former chair of the Psychiatry Department at Emory failed to report hundreds of thousands of dollars from GlaxoSmithKline while researching the company’s drugs. Harvard also had to

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OCTOBER 2013

discipline three researchers who received almost $1 million each in outside income while heading up several NIH grants.

Outside of these flagrant examples, the concern persists that much smaller gifts might also influence medical decisions. Earlier this year, Pew Charitable Trust published Persuading the Prescribers: Pharmaceutical Industry Marketing and its Influence on Physicians and Patients, which stated the drug industry spent nearly $29 billion marketing their products in 2011 (Source: Cegedim Strategic Data). Of that amount, $25 billion was spent directly marketing to physicians.

After unsuccessfully introducing the legislation in 2007, the Sunshine Act was incorporated into the Affordable Care Act. A couple of missed rulemaking deadlines by CMS pushed the law’s effective date to Aug. 1, 2013 for the balance of this calendar year and requires annual reporting going forward.

What is a Transfer of Value?

With 12 major exceptions (see box), any direct payment or transfer of value of $10 or more (or an aggregate of $100 or more in a calendar year) to a physician or teaching hospital must be reported. Additionally, indirect transfers through an in-

termediary or third party are also subject to reporting.

There are 14 main reporting categories. These include consulting fees, compensation for services other than consulting, gifts, entertainment, food, travel, charitable contributions, education, grants, research, royalty or licensing fees, current or prospective ownership or investment interest, direct compensation for serving as faculty or a speaker for a medical education program, honoraria.

Under the new rules, Baker said a physician could accept a ballpoint pen or pad of sticky notes from a manufacturer without it being included in the annual report, but most meals, tickets, or gifts probably will fall under one of the reporting categories considering the $10 threshold.

“The days of the pharmaceutical company taking a group of physicians to the Super Bowl are over … or at least it will be disclosed and expose you to the risk of Anti-Kickback statute prosecution,” Baker said. “It’s the entertainment part of it that physicians would probably like to have exposed the least,” he added.

The law also requires applicable manufacturers and GPOs (group purchasing organizations) to report ownership interests by physicians or their immediate family members. It should be noted, however, that purchased industry stocks and mutual funds that are generally available to the public are not reportable. If Dr. Smith buys 50 shares of ABC Pharmaceutical stock, which is publicly traded, it doesn’t have to be reported. If a representative of ABC Pharmaceutical gives Dr. Smith stock, then it does.

Ultimately, a patient whose doctor recommends a specific device or drug will be able to search the CMS database to see if there is a connection between the physician and the manufacturer. “You’re going to know when your physician has a personal financial interest in your healthcare beyond the physician’s professional services,” Baker pointed out.

Disputing a Report

So what happens if your name appears on a report, and you disagree with the data? Baker said CMS is going to notify physicians of all their reported relationships. Once access is granted to the online portal housing the consolidated report, a physician should have at least 45 days to challenge the data and try to resolve the dispute with the reporting entity.

Those who cannot agree will be given an additional 15 days to come to a resolution before the information is made public. If no agreement can be reached, the data will be published but flagged as disputed. Physicians cumulatively have up to two years to dispute reports even after the data is published.

“While physicians aren’t required to track transfers of value, they are encouraged to do so,” said Baker. “How in the world are you going to be able to refute a report if you don’t have evidence to the contrary.”

(CONTINUED ON PAGE 13)

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Simplifying Systems Securing SSOs

By LyNNE JETER

For many organizations, single signon (SSO) technology is simply a tool to increase efficiency. But in the healthcare setting, it’s a difference-maker.

Expedited access to patients’ health records allows caregivers to make quicker decisions about treatment options and Dean Wiech medications.

As disparate systems continue to be pervasive, with records in multiple environments, an SSO tool easily allows users access to all systems by using just one login credential. SSO simplifies user interaction, and when done properly, may act as a catalyst to improve workflow and documentation.

“Virtually everything is digital and stored electronically,” said Dean Wiech, a national leader in IAM (identity and access management) healthcare technology.

“The real issue becomes making sure the appropriate people have access appropriate to their position or department in

The Advent of Pay-for-Value, continued from page 6

hospitals. For example, role-based access control – when a user is granted position into the network and applications – allows staff to have the ability to see information appropriate to them. You don’t want a nurse in the maternity ward to have the ability to see what’s going on the respiratory floor.”

Single sign-on security has been a grave concern of CIOs, noted Wiech.

“An employee could walk away from a monitor and leave a session open that anyone else could walk up and see,” he explained. “There are some great tools on the market to fix the issue; single sign-on is just a part of it.”

Wiech, also managing director of Tools4ever, a supplier of software and integrated consultancy services involving IAM, pointed to one solution: an enterprise-level SSO that uses badge readers and Follow Me, a tool particularly helpful for physicians making their rounds. “They log into a terminal server and the session goes up so they can go from machine to machine without waiting for any application to open,” he said. “It remains open through the terminal service environ-

ment.”

Time options for inactive screens to automatically close a session range from 30 seconds to 1 minute, configurable to the hospital’s requirements.

“Since information began converting to electronic, the ability to view it has become more widespread,” he said. “You may have 10 to 15 nurses on a floor, and you run the risk of a digital file being exposed.”

In Orlando, for example, a low-level hospital clerk misused his newly discovered access to emergency room medical charts by routinely scanning them for automobile accidents and pocketing money for every lead he gave a local attorney.

“For that reason, role-based access control is another tool that ties into single sign-on,” said Wiech. “If proper controls had been put in place during that employee’s hire, he never would’ve had access to the system. You really need an application that takes a look at different types of data elements needed, and configure and maintain that person’s access to the network, data and applications appropriately.”

Even though projections of future spending appear flat for Medicare, they reflect a steep increase in private sector healthcare costs that would lead to consumers and employers facing direct healthcare costs equal to 12 percent of the nation’s domestic product by 2020.

“So far, the private sector has been unwilling or unable to implement the same payment reforms as the government,” said Roth. “If this doesn’t change, it will likely lead to the private sector bearing an increasingly heavy cost burden.”

Finding creative ways to pool their purchasing power and differentiating those providers striving to reengineer care from those comfortable with status quo will remain the greatest challenge for employers, health plans and other providers of private sector health coverage.

“Healthcare purchasers have long asked providers to improve value,” said Roth. “Now that those calls are beginning to be heard, purchasers must be ready with a response.”

Making Geriatrics a Primary, continued from page 4 well. You’re paid to provide certain services. And many things that need to be done aren’t strictly medical. There’s coordination with long term services and supports and social issues and all sorts of things.”

For example, on a recent clinic day, Brummel-Smith spent an hour with the wife and daughter of a geriatric patient who was too demented to understand his condition.

“We wanted time to have an in-depth discussion about care planning,” he said. “I couldn’t bill for that because under Medicare rules, you can only bill for the patient’s care if the patient is there. But we were doing deep patient care planning that was very emotionally difficult, and it’s going to lead not only to a very good outcome as he nears the end of his life, but also it’ll help save CMS a lot of money for unnecessary care he wouldn’t want in the first place.

There’s no way I could bill for that.”

The PACE Elderplace Program in Oregon, which Brummel-Smith led before relocating to Florida, used a global-capitated model he calls “the ultimate model for reimbursement.”

“If the capitation is fair – and that doesn’t mean exorbitant or skimpy – then you can appropriately care for the patients, and let the geriatric team and the patient decide the right treatment rather than having insurance companies make the decisions,” he said. “We were free from all billing constraints, and we knew we had a certain amount of money to care for all our participants. We had quality measures to meet – some were patient-generated – so we were doing things they wanted, not just what we thought was good for them.

It really was the perfect way to practice stlouismedicalnews

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medicine.”

Overall, there’s an upside to the gap of supply and demand of geriatricians.

Even though geriatrics is labeled for patients over the age of 65, most seniors up to age 74 are relatively healthy and don’t need a geriatrician, Brummel-Smith said.

“The perfect patients for a geriatrician are those above age 75, and especially those with multiple chronic conditions and long-term care needs, such as dementia, and the kinds of problems that are very dif-

ficult for internists and family physicians to take care of in a standard 15-minute visit,” he said, pointing out the American Geriatric Society considers the specialty both a primary care and consultation model.

“We manage primary care for that population of complex and frail elders, and consultations to other physicians for the ‘younger’ old people,” he explained, “and for older people who are generally receiving good care from their primary care provider.”

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AAOS Updates Clinical Practice Guidelines for Osteoarthritis of the Knee

By CINDY SANDERS

The American Academy of Orthopaedic Surgeons (AAOS) recently released a revised clinical practice guideline for treatment of osteoarthritis of the knee with key changes to recommendations regarding the dosage of acetaminophen and use of intra-articular hyaluronic acid (HA).

David S. Jevsevar, MD, MBA, chair of the AAOS Evidence Based Quality & Value Committee and chair of the workgroup for OA of the knee, said the 2013 edition of the clinical practice guideline (CPG) contains 15 recommendations and replaces the first edition of the CPG, which had elicited some concern over the methodology employed in garnering some of the evidence … specifically that attached to the use of HA. Jevsevar, a board-certified orthopedic surgeon at Intermountain Zion Orthopedics & Sports Medicine in St. George, Utah, said it is the policy of the AAOS to do all CPG data analysis in-house. However, the earlier guideline utilized synthesized data from three outside sources — the

Agency for Healthcare Research and Quality, Osteoarthritis Research Society, and Cochrane Database of Systematic Reviews.

Both those who sell and manufacture HA, as well as a number of AAOS members, were specifically concerned about the issue of viscosupplementation, which garnered an ‘inconclusive’ recommendation in the first issue. Jevsevar said the committee was clear that a more vigorous internal review of the use of intra-articular hyaluronic acid could result in the same outcome, a stronger recommendation backing the use of HA … or a reversal recommending physicians not use the treatment option. “When

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we actually did the analysis, that’s what happened,” he said of the reversal, which resulted in a ‘cannot recommend’ designation for the use of HA for patients with symptomatic OA of the knee.

“When you use clinical significance as your bar for recommendation — and we took the 14 best studies out there — it really doesn’t support the use of viscosupplementation, or HA,” he said.

“Although a few individual studies found statistically significant treatment effects, when combined together in a meta-analysis, the evidence did not meet the minimum clinically important improvement thresholds.”

Jevsevar went on to explain there is a difference in statistical significance and clinical significance. He noted that on the clinical pain analysis where 0 is no pain and 10 is the worst pain, having patients move from a 9 to an 8.8 after treatment could be considered statistically significant but wouldn’t feel much different to the person with OA. “We use the higher bar of clinical significance,” he continued. ”We feel that’s the one most important to patients.”

Perhaps not surprisingly, the strong recommendation against the use of HA has created some pushback from physicians.

“They feel like we have very few treatments for osteoarthritis that work so they are always concerned when we take one away,” he said. However, Jevsevar continued, “Doing something that is expensive and hasn’t been proven isn’t the right thing either.”

He said it’s hard to gauge the true effectiveness of various treatments in the clinical setting for a couple of reasons. “Arthritis research is hard because osteoarthritis patients don’t have the same level of pain everyday,” he explained. “Many of those patients want to do anything but surgery, which is understandable,” Jevsevar continued. “They want the treatment to work, but that creates a placebo effect or bias for whatever is being used.” More research, he added, is certainly needed.

One concern for physicians using HA is that insurance companies will quit reimbursing for the treatment. “We synthesize the evidence, but we don’t make recommendations for insurance,” Jevsevar said.

However, he admitted insurance companies could misapply the guidelines for financial purposes. Still, he noted, discontinuing reimbursement for viscosupplementation might not be to a payer’s benefit since it could drive more OA patients to opt for the much more expensive knee implant.

Furthermore, Jevsevar said treatment decisions should replicate the foundation of a three-legged stool — 1) the evidence, 2) physician expertise and experience, and 3) patient preferences and values. “You have to take all three into account when treating a patient.

One doesn’t trump the other,” he said.

In addition to the controversial HA ‘no’ recommendation, the work group also 12

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reduced the recommended dosage of acetaminophen from 4,000 mg to 3,000 mg a day, which mirrors an overall change made by the Food and Drug Administration for individuals using acetaminophen for any purpose. In patients with symptomatic OA of the knee, Jevsevar said, “Actually, there’s not a lot of evidence to support the use of acetaminophen.”

Other important recommendations that remained the same in the revised guidelines included: • Patients who only display symptoms of OA and no other problems, such as loose bodies or meniscus tears, should not be treated with arthroscopic lavage.

• Patients with a body mass index (BMI) greater than 25 should lose a minimum of five percent of their body weight.

Jevsevar noted telling patients to lose weight and get active are “tough discussions” to have but important ones. Low impact exercises including swimming, walking and using an elliptical machine have been proven effective to slow the progression of OA of the knee.

The work group strongly recommended against the use of glucosamine and/or chondroitin sulfate or hydrochloride and against the use of acupuncture.

A “strong” strength of recommendation means the quality of the supporting evidence was high with an implication that practitioners should follow strong recommendations unless a clear and compelling rationale for an alternative approach exists.

Jevsevar added the ‘no’ recommendations were based on a lack of efficacy rather than a potential for harm. The group also had a moderate recommendation against custom lateral wedge insoles. A moderate recommendation also is compelling, but the quality or applicability of the existing evidence is not as strong.

Due to a lack of research, the CPG was unable to recommend for or against the use of physical agents including electrotherapeutic modalities, manual therapy, bracing, growth factor injections and/or platelet rich plasma.

In the second edition, all included studies had to have a sample size of at least 30 participants and a follow-up period of at least four weeks. More than 10,000 separate pieces of literature were reviewed during the evidence analysis phase. When completed, Jevsevar said the updated OA knee CPG was subjected to the most extensive peer review to date for any AAOS CPG. Ultimately, 16 peer reviewers representing multiple specialty societies submitted formal reviews. “Each meticulously dissected the final recommendations of the document and, based on their well-informed and insightful comments, important changes were made to the final document,” Jevsevar said in an AAOS editorial.

For more information on the second edition OA knee CPG, go online to: www. aaos.org/research/guidelines/GuidelineOAKnee. asp AUGUST 2013

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New Lines of Research

NCI Data Set Opens Access to Cancer-Related Genetic Variations

By CINDY SANDERS

How will this breast cancer drug react in patients that are HER2 positive? Will this new lung cancer therapy work in a patient with multiple genetic variations?

Finding answers to those questions just got a bit easier with the rollout of a vast data set of cancer-specific genetic variations by scientists at the National Cancer Institute (NCI).

Yves Pommier, MD, PhD, chief of the Laboratory of Molecular Pharmacology at the NCI, was one of three lead researchers on the study, published July 15 Dr. Yves in Cancer Research, that Pommier pinpointed more than six billion connections between cell lines with mutations in specific genes and the drugs that target those genetic defects. Paul Meltzer, MD, PhD, chief of the Genetics Branch at the Center for Cancer Research and James Doroshow, MD, director of the Division of Cancer Treatment and Diagnosis, were the other principal investigators.

Pommier explained the new database builds upon the NCI-60 cancer cell line collection, which is comprised of nine different tissues of origin – breast, ovary, prostate, colon, lung, kidney, brain, leukemia and melanoma. In their Cancer Research article, the authors note the NIC-60 panel is the most frequently studied human tumor cell line in cancer research and has generated the most extensive cancer pharmacology database worldwide.

“Most of the cell lines are from cancer tissues that are hard to treat and are usually resistant to therapy,” he said.

“The genomic database is unmatched and enables researchers to mine all the gene expression in relationship to a drug.”

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Pommier continued, “Each drug has a different profile in the cell line because they act on different targets.”

In this most recent study, the investigators sequenced the whole exome of the full NCI-60 cell lines to define novel cancer variants and deviant patterns of gene expression in tumor cells. “The whole genome for the cell line has never been done before,” he said. “Many, many genes had never been sequenced.”

The researchers cataloged the genetic coding variations, developing a list of possible cancer-specific gene aberrations. The group then used the Super Learner algorithm to predict the sensitivity of cells with variants to more than 200 anti-cancer drugs … those approved by the FDA and those still under investigation. By studying the correlation between the gene variants – such as TP53, BRAF, ERBBs, and ATAD5 – and anti-cancer agents including vemurafenib, nutlin and bleomycin, the researchers were able to predict outcomes, showing one of the many ways the data could be used to validate and generate novel hypotheses for future investigation.

Access to the data is freely available through multiple sources including the CellMiner and Ingenuity websites. By opening up the scalable data on the whole genome sequencing and drug connectivity,

Pommier and his colleagues hope to help other researchers connect cancer-specific gene variants with drug response to move the science forward. “It’s an evolving system,” he said, adding that profiles on drugs in clinical trials will be added to the database as information becomes available to keep the data set current.

In explaining how the system works, Pommier said a researcher interested in a specific agent could plug that drug into the database. “You’ll get the profile activity of the drug, and then you can ask if there is any match to any specific gene mutations,” he said. From there, Pommier continued, the researcher could query, “Are these cells more resistant or receptive to the drug?”

Getting those answers rapidly should help researchers move major lines of oncology drug development toward personalized medicine to achieve optimal outcomes in a safer, more efficient and effective manner. With the added knowledge provided by the data bank, Pommier said researchers might separate patients into groups based on their genetic profile and therefore be able to use specific drugs in a more rational manner.

“Between a targeted drug and a clinical application, you need a verification in the middle,” he stated. That’s just what this new database offers.

Shining a Light on Physician, continued from page 10 Baker pointed out you might not think you received an influential ‘gift’ from a device manufacturer by grabbing a bite of lunch, but even a sandwich, tea, tip and tax is often over the $10 threshold. Short of asking to see the bill, it would be difficult to gauge the cost per person at the table; and without a copy of the receipt, it would be difficult to dispute the reported item.

“As a practical rule, doctors probably aren’t going to be good at refuting the evidence,” Baker said.

However, he added, CMS has created a smartphone app with a version for industry and another for physicians to make it easier to keep track of reportable transfers. “Open Payments Mobile” is available at no charge through the Apple Store and Google Play Store.

Timeline

Data accumulation for 2013 has already begun. Below is a timeline of upcoming key dates in the process.

• Jan. 1, 2014: Anticipated launch date for CMS physician portal where doctors can register to receive notice when their individual consolidated report is ready for review. This portal also provides a means for physicians to contact manufacturers and GPOs about disputes in accuracy.

• March 31, 2014: Partial year data

(August-December 2013) must be turned into CMS. • June 2014: Anticipated access to individual consolidated reports from 2013.

Physicians have a minimum of 45 days by law to seek corrections or modifications to the information by contacting manufacturers/GPOs through the portal.

September 2014: Searchable reports are published and open to the public.

Be Prepared

“The act itself is vexing,” said Baker.

Adding to the frustrations, he continued, is that CMS is interpreting the Sunshine Act very broadly.

“The applicable manufacturers are not going to take any chances,” Baker continued. He noted, those who accidentally fail to disclose required data will face penalties of not less than $1,000 and not greater than $10,000 per incident up to a cap of $150,000 annually. Those who knowingly withhold reportable information face penalties between $10,000 and $100,000 for each value transfer with an annual cap of $1 million.

“Physicians need to know other people are going to be talking about them,” concluded Baker. “One would hope everything reported is within the legal boundaries … but if you are testing those boundaries, you better stop.”

GrandRounds Mercy Helps Companies Rein in Health Care Costs When sore throats, ear infections, allergies and other health issues linger, it can cause wreak havoc on work schedules and productivity problems with people who can’t concentrate or take time off work to see a doctor.

Now a convenient option is available for Maritz employees and their families at the company’s St. Louis headquarters.

On Aug. 1, Mercy opened Mercy Clinic at Work, a full-functioning, physicianstaffed health care clinic on the Maritz campus with access to electronic medical records at any Mercy location.

The Maritz location is open parttime with two physicians, Dr. Shane Stephenson of Mercy Clinic Family Medicine at Clayton-Clarkson and Dr. Christian Sutter of Mercy Clinic Family Medicine at Ronnie’s Plaza. They can assess patients, prescribe medication and provide all other services available in a Mercy Clinic primary care office.

Mercy can tailor the program to fit employers’ specific needs. Clinical positions can be covered by registered nurses, nurse practitioners in a collaborative agreement with nearby physicians or onsite physicians – depending on the size and needs of the employer.

In late September, Missouri Baptist University opened a Mercy Clinic at Work site to provide a convenient healthcare resource for its 1,200 student population, with 345 who live on campus and 700 student athletes. In addition, a registered nurse is also onsite to answer questions and provide screenings for front-office employees with the St. Louis Cardinals and St. Louis Rams organizations.

Christian Hospital stroke care earns prestigious Gold Plus Award!

Christian Hospital has again this year received the American Heart Association/American Stroke Association’s Get With The Guidelines®–Stroke Gold Plus Achievement Award! The award recognizes Christian Hospital’s commitment and success in implementing a higher standard of stroke care by ensuring that stroke patients receive treatment according to nationally accepted standards and recommendations. Christian Hospital was recognized at the silver level in 2011 and at the bronze level in 2010. Christian Hospital achieved a two-year Joint Commission re-certification as a Primary Stroke Center in August 2012.

To receive this recognition, Christian Hospital has achieved 85 percent or higher adherence to all Get With The Guidelines–Stroke indicators for consecutive 12-month intervals and 75 percent or higher compliance with four of nine quality measures to improve the quality of patient care and outcomes. These include aggressive use of medications like tPA, antithrombotics, anticoagulation therapy, DVT prophylaxis, cholesterolreducing drugs and smoking cessation.

The 90-day evaluation period is the first

GrandRounds SSM Medical Group adds adult primary care physician in Webster Groves Ellen Loeffler, MD, board certified family medicine, recently joined Drs. Michael Bartell, Kyra Cass, Edwin “Scott” Schmidt, and Paul Schneider at 8670 Big Bend Boulevard in Webster Groves.

Dr. Loeffler has been in private practice since 2008. She graduated summa cum laude from the University of Missouri – Columbia with her bachelor of science degree.

Dr. Ellen She earned her medical Loeffler degree and completed her residency at Saint Louis University School of Medicine.

Dr. Loeffler provides health care to adolescents and adults, ages 13 and up.

Her health care services includes, but are not limited to: women’s health, including well-women exams; preventive care and check-ups, including physicals; identification and management of acute problems and chronic diseases.

Like all SSM Medical Group physicians, Dr. Loeffler offers MyChart® to her patients. MyChart is available online or as an app on mobile devices and provides convenient, secure, access to one’s personal health record 24/7.

Washington University Orthopedics launches walk-in injury clinic Because the injuries of joggers, cyclists, high school athletes and weekend warriors often occur outside of business hours, Washington University Orthopedics is opening a walk-in clinic for those with injuries that might require an X-ray, cast or splint.

The clinic will be run by physicians and other health-care practitioners with expertise in orthopedics. Casting, splinting and radiology services will be avail-

able onsite.

The new Orthopedic Injury Clinic opened Sept. 3 and is located at the Washington University and Barnes-Jewish Orthopedic Center in Chesterfield.

Cardiac electrophysiologist joins SSM Heart Institute Ayo M. Bamimore, MD, a cardiac electrophysiologist, has joined SSM Heart Institute. He specializes in the diagnosis and treatment of abnormal heart rhythms. He performs both catheterbased interventional and device-based surgical Dr. Ayo M. Bamimore procedures to treat cardiac arrhythmia, including ablation of atrial fibrillation and other complex cardiac arrhythmias, cardiac resynchronization therapy and implantation of pacemakers and defibrillators.

Dr. Bamimore attended medical school at Obafemi Awolowo University Ile-Ife in Osun State, Nigeria. He completed a residency in internal medicine as well as cardiac and electrophysiology fellowship training at The State University of New York Downstate Medical Center in Brooklyn. He continued his training with a fellowship in clinical cardiac electrophysiology at the University of North Carolina in Chapel Hill.

Dr. Bamimore is able to follow many of his patients with implantable devices remotely. Information from the devices is downloaded from the patient’s home to Dr. Bamimore’s office for evaluation.

In many cases, this may result in adjustments to treatment prior to the next scheduled office visit, possibly reducing unnecessary hospital admissions.

Dr. Bamimore is board certified in cardiovascular diseases, nuclear cardiology, adult echocardiography and internal medicine. He is a member of the American College of Cardiology and the

Heart Rhythm Society.

He has joined the staffs of SSM St. Joseph Health Center in St. Charles, SSM DePaul Health Center in Bridgeton and SSM St. Joseph Hospital West in Lake Saint Louis.

Program at Saint Louis University Hospital, SLU Provides Sports Medicine Care for St. Louis Catholic Schools Saint Louis University and Saint Louis University Hospital have engaged in a three-year pilot program with the Archdiocese of St. Louis, St. Mary’s High School and Bishop DuBourg High School to provide on-site sports medicine care for their student athletes, offering athletic training services at games and practices.

The pilot program is provided to the schools as a community service at no cost to them.

Such partnerships are rare in area high school athletics. Should the collaboration succeed in improving the care of injured student athletes, the goal is to expand the pilot program to other areas in the St. Louis region.

To launch the program, Bridget Quirk, MAT, was hired by Saint Louis University Hospital to provide on-site training and education at the two schools. A recent graduate of Doisy College’s athletic training program at SLU, she will be working with student athletes in all the high schools’ sports ranging from boys’ football and soccer to girls’ softball and volleyball.

For more severe injuries, SLUCare orthopaedic surgeons and sports medicine physicians Scott Kaar, MD, and Adnan Cutuk, MD, will be available through the partnership to offer their expertise with accelerated access to care in their orthopaedic sports medicine clinics.

Drs. Kaar and Cutuk will also be on the sidelines for Bishop DuBourg and St. Mary’s home football games.

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