West TN Medical News Nov 2013 by FW Publishing

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PHYSICIAN SPOTLIGHT PAGE 3

Laurence Martin, MD ON ROUNDS Tennessee Hospital Association Reinventing Tomorrow’s Healthcare Every Day for 75 Years Established in 1938, the Tennessee Hospital Association has adopted the tagline “reinventing tomorrow’s healthcare every day for 75 years” as an ongoing theme for 2013 ... 4

Researchers Identify Diabetes Risk Biomarker

TMA Chief Looks at Healthcare’s Changing Landscape An advocate for doctors in a climate of uncertainty The West TN Medical News recently had the opportunity to interview Russ Miller, CEO of the Tennessee Medical Association. The following gives insight into what the TMA is championing in its role as a physician advocate in this challenging time to practice medicine.

What is the Tennessee Medical Association’s role?

When it comes down to the physician in

The TMA focuses on the big issues – those issues a his office, what is the big concern? big practice can’t handle or a hospital alone or a specialty Government intrusion into the practice of mediRuss Miller of doctors alone can’t handle. These are things like medicine. It’s all cost-driven. cal liability reform, TennCare, health insurance exchanges, the AffordI think patient care is at the forefront of every mind and “what do able Care Act and implementation, regulatory issues – things that hit I have to do to get through the day?” What’s on their mind at night? every segment of the population in Tennessee. “What’s tomorrow look like? Am I going to be told we’ve been bought? What is today’s community? Ten years ago, docs were not emAm I going to be told we’ve been kicked off the network? Can I still do ployed. Almost 40 percent of doctors are now employed by hospitals what I do every day?” Just across the board and it’s out of their hands. and physician-owned practices. It’s a different mentality. (CONTINUED ON PAGE 8)

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We have 8,000 doctors and students in training. In physicians, we have about 6,600 docs. Our market is probably about 12,000 practicing MDs in the state of Tennessee. The advocacy work, the education work and the products and services we develop are meant for docs in private practice. I like to say we have a 90 percent saturation rate in the practices. With the financial demands on practices, we may have close to one from each group.

By GINGER PORTER

HealthcareLeader

Charles Miller, MBA, FACHE

Chief Executive Officer, Regional Hospital of Jackson By SUZANNE BOyD

When a family friend, who happened to the be the administrator at a hospital in his home town, asked Charles Miller, a Certified Public Accountant to work on a project, Miller expected to complete it and return to life as a CPA. Miller now credits the experience for leading to what has resulted in a 36-year career in healthcare administration for the Virginia native. His list of assets includes 17 years with Tenet Healthcare

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Corporation and 18 years on the tax-exempt side of healthcare. In July, he left the corporate side of healthcare to return to the hospital setting to become CEO at Regional Hospital in Jackson, a Community Health Systems facility. “Fourteen years of my time with Tenet was in Rock Hill, South Carolina and then in the corporate office in Dallas, Texas. I realized I missed the hospital side of things, being active in a community, interacting with the medical staff and (CONTINUED ON PAGE 12)

Highlighting the who’s who in the West Tennessee healthcare industry. PRINTED ON RECYCLED PAPER

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No Need To Suffer From Pelvic Organ Prolapse By Dr. Don Wilson

Pelvic organ prolapse is a very common condition among women. It is estimated that half of women who have children will experience some form of prolapse; however, many women don’t seek help from a qualified doctor. Pelvic organ prolapse occurs when the pelvic floor becomes weak or damaged and can no longer support the pelvic organs. The womb (uterus) actually falls into the vagina. When the bladder and bowel slip out of place, they push up against the walls of the vagina. While prolapse is not a life threatening condition it may cause a great deal of discomfort and distress.

2. Prolapse of the posterior (back) vaginal wall • Rectocele (prolapse of the rectum or large bowel) - This occurs when the end of the large bowel (rectum) loses support and bulges into the back wall of the vagina. • Enterocele (prolapse of the small bowel) - Part of the small intestine may slip down between the rectum and the back wall of the vagina. This often occurs at the same time as a rectocele or uterine prolapse. 3. Uterine prolapse is when the womb drops down into the vagina. It is the second most common type of prolapse.

There are a number of different types of prolapse that can occur in a woman’s pelvic area and these are divided into three categories according to the part of the vagina they affect: front wall, back wall, or top of the vagina. It is not uncommon to have more than one type of prolapse.

Different factors contribute to the weakening of the pelvic floor support over time, but the most significant factors are thought to be: • Pregnancy and childbirth • Aging and menopause • Weight gain • Chronic coughing or strain • Heavy lifting • Previous pelvic surgery

1. Prolapse of the anterior (front) vaginal wall • Cystocele (bladder prolapse) - When the bladder prolapses, it falls towards the vagina and creates a large bulge in the front vaginal wall. It’s common for both the bladder and the urethra to prolapse together. This is called a cystourethrocele and is the most common type of prolapse in women.

Symptoms may include: • Feeling a lump or heavy sensation in the vagina • Lower back pain that may ease when you lie down • Pelvic pain or pressure • Pain or lack of sensation during sex When symptoms do occur, however, they tend to be related to the organ that has prolapsed. A bladder or urethra prolapse may cause incontinence (leaking urine), frequent or urgent need to urinate or difficulty urinating. A prolapse of the small or large bowel (rectum) may cause constipation or difficulty defecating. Some women may need to insert a finger in their vagina and push the bowel back into place in order to empty their bowels. Women with uterine prolapse may feel a dragging or heaviness in their pelvic area, often described as feeling ‘like my insides are falling out.’ If you have any of the symptoms of prolapse, particularly if you can see or feel something near or at the opening of your vagina, make an appointment to see your health care provider. Many women with prolapse avoid going to the doctor because they are embarrassed or afraid of what the doctor might find, but prolapse is very common and is nothing to be ashamed of. It may be difficult at first to talk about your symptoms, and some women find the examination uncomfortable, but it only takes a few minutes and, by having your symptoms checked, you are taking an active role in your health and well-being.

Questions to ask your doctor about your prolapse: • What type of prolapse do I have? • What treatment/surgery do you recommend and why? • What if I choose not to have any treatment? • What can I do to ease the symptoms? What to expect at your appointment: You will be asked about any signs or symptoms. Remember, you don’t have to be nervous; we talk about these problems every day. Also, your doctor will need to do a thorough pelvic examination. You may be asked to cough or strain during the examination. This enables the doctor to see if any urine leaks or if any of the pelvic organs prolapsed into the vaginal walls. If you have bowel symptoms the doctor may need to feel for bowel prolapse, asking you to strain or bear down. A good doctor will explain what he is doing throughout the examination, but if you have any questions, ask for an explanation. Treatment Options Most of the time, treatment will require a surgical procedure or a combination of surgical procedures to re-support the pelvic floor and surrounding structures. Often referred to as anterior (bladder), posterior (rectum) and enterocele (top of vagina), these surgeries are most often performed vaginally. Hospital stay is usually limited to one overnight stay, with many patients going home the same day! After discharge, patients can resume simple daily activities immediately. Patients can typically drive in a week and return to work in two to three weeks. However, your recovery should be individualized for your particular situation. If you feel like you suffer from any of these conditions or have any questions regarding your gynecological health, please feel free to contact Dr. Don Wilson and/or one of his partners at The Jackson Clinic, Dept of OB/GYN , 731-660-8300. Dr. Don Wilson is a board certified obstetrician/ gynecologist at The Jackson Clinic. With more than 25 years of surgical experience, having performed over a thousand vaginal repair surgeries, Dr. Wilson is one of the highest qualified, pelvic organ prolapse surgeons in the Southeastern United States.

www.jacksonclinic.com • 731-422-0330

NOVEMBER 2013

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PhysicianSpotlight

Laurence Martin, MD By SUZANNE BOYD

For more than 35 years, Laurence Martin, MD, has been treating kids both as a pediatrician and endocrinologist in his native Canada and in the United States. Although Martin initially felt his calling was in the ministry and mission work, his mission today is helping children across West Tennessee with endocrine disorders like proper growth, puberty or diabetes. Martin grew up in a small town in Alberta, Canada, and as a teen was involved with his home church and the United Church of Canada working with underprivileged children. “I did some ministry work in Northern Alberta which led me to consider being a missionary but I realized that would be too stressful,” said Martin. “But I knew I wanted to work with children so when I decided medicine was the path I would pursue, I knew pediatrics was the specialty for me.” Martin received his medical degree at the University of Alberta in Edmonton. He completed his general pediatrics residency at the Children’s Hospital of Eastern Ontario in Ottawa. It was during his residency that he discovered his interest in endocrinology. “I had no surgical skills at all. I cannot even tie a knot but if I had gone into surgery, it would have been plastics since I am drawn to the artistry of it all,” said Martin. “When friends got me interested in endocrinology, I saw it as almost artistic in a way. To be able to take a child, who is not growing, and help them grow was beautiful.” For his fellowship in endocrinology, Martin turned to one of the largest children’s hospitals in the world, the Hospital for Sick Children, also known as SickKids Hospital. In 1980, he went into practice in Edmonton, the home province of Alberta. “It was a ‘mixed’ practice because I saw both general pediatric patients as well as endocrinology patients,” said Martin. “Over the 16 years I was in practice there, I served as director of the diabetic program and worked with the Charles Best Diabetic Summer Program, which was named for the co-discoverer of insulin.” While in practice in Canada, Martin worked in the Catholic Hospital System covering five hospitals spread across a wide area. “It was tough covering that many facilities and they were so spread out it was hard not to get stuck with issues at more than one facility and having to manage those as best as I could. One of the facilities was so far north that I would joke that I could see the North Pole there,” said Martin. “My wife, Chi, even noticed that I was not happy so we decided seventeen years ago to make westtnmedicalnews

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a change. We also had a young daughter and I really wanted to see her grow up. We looked at Jackson and really liked the community. There were about 60 physicians who left around the same time. One of them was Dr. Keith Micetich who also set up practice here in Jackson.” Although the healthcare system in the United States is different from that of Canada, Martin says his practice at Jackson Pediatric Center is relatively similar to his Canadian one. Besides dealing with insurance, which was a new issue for him, the only other big difference is the number of diabetic patients he treats. “Here, the diabetic side of my practice really exploded,” said Martin. “But I also deal with growth issues and general pediatric patients.” Martin has found one other difference in the practices is the lack of available services for a diabetic patient. “In Canada, under that system, patients and doctors had access to a full compliment of support services such as dieticians, nutritionists, psychologists and psychiatrists, all of which were covered under the healthcare system,” said Martin. “Here not all those services are always covered by insurance. I would say my biggest adjustment has been learning to deal with insurance companies.” Although diabetes comprises about a fourth of his practice, the number of patients Martin sees with Type I diabetes is relatively in line with what he saw in Canada. The big difference is the number of patients with Type II diabetes and those who are pre-diabetic. “The primary cause of this is obesity, which is at epidemic proportions in this country. The best thing I can do to help these patients is to help them make lifestyle and diet modifications as well as increase the amount of exercise they get each day. Not all patients will require medication, it really depends on what their lab work says,” said Martin. “About 40-60 percent of patients I evaluate for diabetes have weight problems due to poor diet and lack of exercise.” The biggest contributor, Martin says, is high fructose corn syrup, an additive that is found in many foods. “The problem is twofold, high fructose corn syrup is not metabolized like sugar. In the liver the corn syrup is treated the same as alcohol and in the brain it does not go to the same centers as sugar,” he said. “So if you eat or drink food with high fructose corn syrup, not only do you not think you ate something sweet but your brain tells you it has not had anything to eat so it makes you hungrier.” Downtime for Martin finds he and his wife out in nature. As avid bird watchers and plant enthusiasts, the two love to hike and discover the many treasures the outdoors have to offer.

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Tennessee Hospital Association Reinventing Tomorrow’s Healthcare Every Day for 75 Years portunities unless Gov. Haslam and the Centers for Medicare and Medicaid SerEstablished in 1938, the Tennessee vices can come to an agreement about exHospital Association has adopted the tagline panding TennCare rolls, and the Tennessee “reinventing tomorrow’s healthcare every Legislature approves the plan. day for 75 years” as an ongo“We’re having a hard time ing theme for 2013. getting the Legislature to sepaOver the years, the staff rate this from Obamacare,” of the THA might have had Becker said. However, he noted many days … often stretchnegotiations with CMS are oning into many months … to going, which he said was an enhelp members prepare for couraging sign. and implement change. How“We’ve got $5.4 billion ever, in the face of industryworth of cuts over 10 years wide transformation, being under the Affordable Care nimble enough to reinvent Act,” Becker pointed out. Those the hospital’s role in healthcuts were more palatable when Craig Becker care delivery on a daily … if hospitals thought Medicaid rolls not hourly … basis has become the norm. would be expanded. When the individual Helping its membership navigate the chalmandate was upheld but not the Medicaid lenges that come with sweeping reform is expansion, anticipated coverage for large a central theme of the programming at the chunks of the population evaporated. THA Annual Meeting, held Oct. 31-Nov. 1 “I’m really concerned about my rural at Gaylord Opryland Resort and Convenhospitals. They don’t have the reserves some tion Center. of the bigger hospitals do,” Becker said. How“I’ve always said healthcare moves ever, he added no facility is immune to the glacially, but we’re getting up to lightening looming financial stressors. Addressing the speed now,” THA President Craig Becker key point of coverage for the 400,000 left out, said with a rueful laugh. “It has been a tough Becker stated, “If we don’t get it, some of our road to hoe right now for our members.” hospitals cannot make it. I guarantee that.” Yet, Becker continued, he ultimately views Three hospitals have recently shut the transformation process as ‘constructive down operations in Tennessee. While two deconstruction.’ in West Tennessee probably had more to do Going into 2014, he continued, “Our with the number of facilities in comparison number one issue is the Affordable Care Act to the population, one in East Tennessee and trying to get people enrolled … not only simply couldn’t make it in healthcare’s new the ones that are eligible through the federal financial reality. Scott County residents now exchange but to try to convince the goverhave to go elsewhere for care. “The hospital nor and Legislature to expand TennCare to was struggling. When the (ACA) cuts came, include the poorest of the poor.” it was the death nail for them,” Becker said. Becker added there are approximately The Tennessee Hospital Association is 500,000 Tennesseans who should be elialso focused on the Tennessee Payment Regible for enrollment through the federal form Initiative, which is initially slated to be exchange. However, there are another rolled out for the TennCare and state em400,000 currently left out of coverage opployee populations. Tennessee has received By CINDy SANDERS

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a CMS grant to transform the state’s healthcare payment system. While details are still being ironed out, the governor’s vision is to incentivize ‘quarterbacks’ (typically physicians) to provide the highest quality, least costly care. As part of that plan, the quarterbacks would receive a bonus for sending patients to facilities with the best quality and lowest prices. However, Becker said there are concerns arising from geographic location and from skewed price comparisons. He pointed out large academic medical centers with high-cost service lines including trauma centers and burn units and other unusual expenses such as graduate medical education cannot fairly be compared to community hospitals without those same factors. In areas with only one nearby hospital, referring patients to a facility farther away that has a better cost structure might not be feasible … or desirable … depending on the urgency of the situation. Becker noted, “Seventy-five percent of physicians admit to one hospital only so I’m not sure it makes a lot of sense. I’m not sure that this will change physician admitting patterns.” However, he continued, the general consensus is that the plan will move forward so THA staff is preparing for implementation while addressing their issues with government and provider stakeholders in an effort to design a workable plan. Despite any reservations about the plan’s mechanics, Becker applauded the general concept of shared information. “I think the more transparent and the more information you get in the hands of our physicians and hospitals, the better off we are,” he said. While the immediate future brings many challenges, Becker said the message of the annual meeting is a hopeful one. “This is the constructive destruction of the health system as we knew it. It will be very different going forward.”

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As for the THA’s role in helping hospitals shift to population management models, Becker succinctly noted, “It’s coming, and we’re here to help you do it.” He continued, “We’ve really put an increased emphasis on quality. We’ve put an increased emphasis on education and on sharing best practices and process improvement data. Our data is all geared toward giving transparent information to our members so they understand how they stack up against others.” He added the THA has also been hands-on in helping hospitals help their patients. In a move unique among hospital associations, Becker said, “We actually took $3 million out of reserves and put it aside for grants for hospitals to enroll people in the exchange.” He continued, “We touch 350,000 uninsured people every year in our emergency rooms.” Becker noted identifying those who qualify for the federal exchanges and getting them covered is a win/win for families and facilities. Hospitals have until the end of November to apply for the grants. “We’re excited to have a good opportunity to give back to our members and hopefully help our hospitals get ahead of the curve in signing people up,” he said. Despite the obvious pain points that come with transformational change, Becker and his staff are keeping an eye on the prize. “We’ll have a far better healthcare system once we get to the other side,” he concluded.

THA’s New Board Chair Before the final bell sounds on the Tennessee Hospital Association’s 2013 annual meeting, an important transition of power will take place. Dr. Reginald Joe Landsman, Coopwood president and CEO of the University of Tennessee Medical Center in Knoxville, will pass the gavel to new board chair Reginald Coopwood, MD, president and CEO of Regional Medical Center at Memphis. A graduate of Meharry Medical College, Coopwood practiced in Nashville as a general surgeon and served as chief medical officer for Nashville General Hospital. In 2005, he was named CEO of the Metropolitan Nashville Hospital Authority. In March 2010, he made the move to Memphis to take the top position at The Med. In addition to his role with THA, Coopwood also serves on the boards of several nonprofit organizations including March of Dimes, Leadership Academy, QSource and MidSouth eHealth Alliance.

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Higher Costs, Lower Compliance

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Asthma, the most common medical condition that affects Americans of all ages – about 40 million people – can usually be well controlled with drugs and patient education. The Centers for Disease Control and Prevention puts the annual cost of asthma in the United States at more than $56 billion, including millions of potentially avoidable hospital visits and more than 3,300 deaths, many involving patients who skimped on medications or did without. “The thing is that asthma is so fixable,”said Elaine Davenport, MD, of the Oakland, California, Asthma Initiative. “All people need is the medicine and patient education. While I was standing in line to pick up a prescription, I had the opportunity to talk with some people also waiting for their prescription. The first one was a 73 year-old retired teacher. She said that she used her inhaler sparingly, adding, “I minimize puffs to minimize cost.” Two 13-year-old sisters significantly decreased their amount of asthma attacks, while on medications and education, and neither has been hospitalized in the past year. Many siblings from the same household suffer from asthma. However, the mother of the two sisters said, “One of the drugs that really blew my mind was the nasal spray,” referring to her $80 co-pay for Rhincort Aqua, a prescription drug that was selling for more than $250 a month, but costs less than $7 in Europe, where it is available over the counter. As I wrote in the July issue of Memphis Medical News in a column titled, “PIPA and the Secured, Encrypted, HIPAA Compliant Physician Portal,” there are three reasons patients aren’t adherent to medications: They don’t understand the importance They are afraid of the side effects They can’t afford it Last year, $250 million was spent on lobbying for pharmaceutical and other health products. (Do the arithmetic: divide $250 million by the number of lawmakers in Washington.) Lawmakers in Washington have forbidden Medicare, the largest government healthcare purchaser, to negotiate drug prices. Gerald Anderson, who studies medical pricing at the Bloomberg School of Public Health at Johns Hopkins University said, “Americans use more generic medications than patients in any other developed countries. Prescription prices represent 10 percent of the country’s $2.7 trillion annual health bill, even though the average American takes fewer prescription

medicines than people in France and Canada.” Pharmaceutical companies also buttress high prices by choosing to sell a medicine by prescription, rather than cover a price tag that would be unacceptable to consumers paying full freight. They even pay generic drug makers not to produce cut-rate competitors in a controversial scheme called, “pay for delay.” The United States leaves prices to market competition among pharmaceutical companies, including generic drug makers. But competition is often a mirage in today’s healthcare arena – a surprising number of lifesaving drugs are made by only one manufacturer – and businesses often successfully blunt market forces. Asthma inhalers, for example, are protected by strings of patents – for pumps, delivery systems and production processes. It is hard to make generic alternatives, even when the medicines they contain are old, as most all are. The Global Economy and Competition. (Source: Health Care Cost Institute) This comparison is based on what $250 of the following two prescription drugs look like. Rhinocort Aqua (allergy spray) – two bottles in the United States, costs the same as 51 bottles in Romania. Advair (asthma inhaler) – one inhaler in the United States equals seven inhalers in France. There are no generic asthma medications available in the United States. But there are in Europe, where health regulators have been more flexible about mixing drugs and devices and where courts have been quicker to overturn drug patent protection. While, lawmakers in Washington play their fiddles, Americans are burned and burdened with the callous and uneducated policy makers who would rather act like “boy-dogs” fighting, and closing down the government for 16 days at a cost of $24 billion dollars. When lawmakers return to Washington, and come up with their farming bill, perhaps they can also look into and tell us why a net wt 7 ounce cup of a citrus salad of grapefruit and oranges costs so much. (I poured the cup in a bowl and hand counted 12 pieces of actual fruit; the rest being syrup). The average price in grocery stores that I visited: $1.29. Bill Appling, FACMPE, ACHE is founder and president of J William Appling and Associates. He serves on the Medical Group Management board of directors. He is a national speaker, presenter and a published author. He serves as an adjunct professor at the University of Memphis and Chair of Harrah’s Hope Lodge board, and serves on the board of Life Blood. For more information contact Bill at appj54@aol.com.

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National ‘Choosing Wisely Campaign’ Begins Hoping to decrease “overuse” in medicine By ED DISMUKE, MD

The Memphis Medical Society (MMS) in partnership with the Tennessee Medical Association (TMA) has received a grant to better educate physicians and their patients about the problem of “overuse” of diagnostic tests, procedures and treatments in medicine. The American Board of Internal Medicine Foundation (ABIMF) has funded 21 projects conducted by state medical societies, specialty societies and regional health collaborates to educate doctors and their patients about the national “Choosing Wisely Campaign.” Research suggests that one-third of healthcare costs ($750 B/year) are wasted and do not benefit patients. Almost all national physician organizations (56 of them) have created a “Top Five List” of tests, procedures or treatments that are frequently overused and therefore do not help patients. That would make 280 recommendations from these 56 organizations. In fact, in multiple cases, the various organizations recommended similar approaches. In order to provide an indication of these national recommendations, let me list several that seem common to many patients seeing a primary care doctor. From the American Academy of Family Physicians: • Don’t do imaging (x-rays) for lower

back pain within the first six weeks, unless red flags are present. • Don’t routinely prescribe antibiotics for acute mild to moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement. • Don’t order annual electrocardiograms (EKG’s) or any other cardiac screening for low risk patients without symptoms. • Don’t prescribe antibiotics for otitis media in children aged 2-12 years with nonsevere symptoms where the observation option is reasonable. • Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam. From the American College of Physicians (internal medicine) • Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease. • In the evaluation of simple syncope (fainting), and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI). From the Society of General Internal Medicine • Don’t perform routine general health checks for asymptomatic adults.

From the American College of Radiology • Don’t do imaging for uncomplicated headache. From the American Academy of Pediatrics • Computed tomography (CT) scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is inducted. From the American College of Emergency Physicians (ACEP) • Avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules. From the patient perspective, there are 5 questions to ask your doctor before you get any test, treatment or procedure. • Do I really need this test or procedure? • What are the risks? • Are there simpler, safer options? • What happens if I don’t do anything? • How much does it cost? The most important issue is for the doctor and patient to discuss these questions and together, decide what is best for each indi-

vidual patient. To help patients better communicate with their doctors, Consumer Reports Health now has many patient education materials to help the patient better understand and better communicate with the doctor. To find these go to www.consumerhealthchoices.org. The Memphis Business Group on Health (MBGH) has the Consumer Report’s “Choosing Wisely Toolkit” to help educate employers and employees about the campaign and how to make the best medical choices for good health. Contact Cristie Travis about the toolkit at ctravis@memphisbusinessgroup.org for more information. The MMS and TMA are trying to better educate physicians in Shelby County and the state about the Choosing Wisely Campaign. The Society can arrange lectures and discussions on the topic and can help doctor’s offices find useful educational material for patients. Those wanting more information should visit www.tnmed.org or go directly to the Choosing Wisely website: www.choosingwisely.org. Ed Dismuke, MD, MSPH, is with the University of Memphis School of Public Health.

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WTHVC.ORG 731.541.CARE NOVEMBER 2013

Alternative Dynamic Bracing for Pediatric Neurological Based Muscle Imbalances Parents of children with lower extremity hypertonic muscle imbalance face treatment of Crouch gait and long term bony deformities of the knee, ankle and foot. Traditional bracing has focused on immobilization which does not prevent the deformities in adolescent children. Ambulation for children becomes very difficult when the knee and ankle are locked. Their energy expenditure is increased and the child experiences decreased step length, Proprioception and balance. The lack of motivation to walk, run or play leads to more weakness and dysfunction along with possible deformity from absence of muscle use. More parents of physically challenged kids are embracing the concept of using night time dynamic bracing and less rigid functional daytime bracing to enhance their child’s life and activity level. Advanced technology in components of limb braces using concentric torsion adjustable tension allows us to block unwanted movement in one direction and stretch the shortened muscle in the other direction. Protocol for parents or caregivers is focusing at night long term prolonged stretch therapy for 8-10 hours. Human Technology, Inc. recently opened a pediatric specialty clinic in Germantown, Tennessee working closely with orthopedics, physical therapy and neurological clinics focusing on improving functional outcomes for better ambulation and development of physically challenged kids in the area. Pediatric patients are evaluated in a team approach including the parent, physician, Physical/Occupational Therapist and Orthotist to determine an optimal bracing plan for achieving goals. Patients with crouch gait are managed with concentric knee extension night time bracing to improve length, muscle strength and function, while at the same time using more dynamic bracing on the foot and ankle with a controlled motion system that focuses on improving balance, Proprioception and muscle function. Advocating for children to obtain the best technology for overall improvement should be high on the list for parents, caregivers and medical professionals. Advancements made in orthotics and prosthetics over the years can change the development, growth and life of physical disabilities and deformities. By Frank Caruso, CO/LO – Director of Orthotics - Human Technology, Inc. Prosthetics & Orthotics

Human Technology

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TMA Chief Looks, continued from page 1 Why does healthcare cost what it costs? Why does a seat on an airplane cost what it costs? I can sit next to you and you don’t pay what I pay. I can sit next to you and you don’t pay what I pay. It’s not the same — you have to start with the basis point, and the government has decided what that is with Medicare weights, Resource-Based Relative Value Scales. It’s a place to start, and you work countless calculations off that. You factor in everything that goes on – the quality, the standards, the reportability, the measures, the testing that covers a liability. And now government intrusion is not only in the payment but also in the portability, and they are telling you what electronic systems you have to have. It is too much for small medical practices. A mom and pop operation or a small solo practice almost can’t exist with the demands put on it by the payors, by the government. The complexities, the reimbursement levels, the margin is so small that you have to be either very specialized and have a unique niche, or you have to be part of a larger system where the margins work better.

You said primary care is in trouble. Please tell us what the TMA is doing.

good in the ACA, but the bad is so bad, it neutralizes it. One of our concerns is the dictatorial nature of how they are handling it. Our greatest gripe with the ACA is it did nothing to reduce our administrative hassles. It increased them twofold. It is taking even more time away from patients in the office. It is shifting an incredible financial burden to states. The market is already fragile. The unsustainability of the program — to go through all this is I think the fear that it all comes crashing down. There’s been very little physician input into the what — what are we providing? How do we pay for it? I call it the three-legged stool. You want low cost, high quality, access. That’s everyone’s goal. It’s a delicate balance. Just because you pass it doesn’t mean it’s going to happen. We are big advocates of the doctorpatient relationship. That relationship is sacred and crucial. Then with exchanges, they are going to tell you where to go and that endangers that relationship. You have three months now to shop, see where you are going to qualify, see if you understand it. If you have a preferred physician, start with them. Ask if they are participating. If not, you are going to be totally swayed by cost alone. It will be a very interesting year to say the least in 2014.

Yes, that bodes to lots of problems down the road. We need more providers, because we have an aging population needing more services – and we just have a growing population. Manpower issues are a big concern for us. Tennessee has to do a better job of keeping physicians. We have five medical schools. We are turning out 500 physicians a year and then you go to residency, and there are no residencies because they are Medicare funded — graduate medical funding comes back down to the states and that needs to be opened up. It is imperative Tennessee attract more doctors, because where you train you usually practice within 150 miles. The capacity is there and the willingness is there. Every hospital could use more residents. There is a great generational gap. They started the residency 80-hour-a-week cap. If you haven’t added anyone and you’ve capped how much they can work, then what do you do? The other docs have to start filling in on call more. We talk with the government about it. It is a great concern.

How have patients changed the healthcare marketplace?

Liability limits, which reduce cost of being a doctor. Your medical malpractice premiums are lower here. That’s something we did through our advocacy – dropped it 35 percent in Tennessee since 2009. That is purely a market result to fewer claims and less damages. Now, when there are legitimate cases, when they are getting to court, they are being settled faster. It has reduced cases by 50 percent, and it helps the legitimate ones get through.

What can you say that is encouraging to physicians?

When it comes to attracting doctors, why is Tennessee a good place to practice medicine?

What is the TMA’s position on the Affordable Care Act?

Again, it comes down to government intrusion in healthcare. There is a lot of

Age. Demand. Complexity of illness. The Internet has made the delivery of care more complex. WebMD is great. But when a patient comes in with printouts from three websites, saying “this is what I have,” and the doctor has to read through 45 minutes of materials to tell the patient “that has nothing to do with you,” then assess the patient — it can stall the process.

How effective have TMA’s advocacy efforts been?

I think very effective in light of the size and complexity of what we have. We have open-door relationships with all the insurers. We will work on protocols and their regulatory structures and getting them right. Obviously the best advocacy is something that does go to the legislature. Where we might be criticized is not stopping change – like not stopping managed care in the ‘80s. There are some things you can’t stop. The market changes due to consumers. You can stick your head in the sand, or you can work on those things you can influence. That’s what we have chosen to do.

We can’t get along without you, and patients really respect you. The profession as a whole has a revered spot. Our organization exists to maintain that high level of professionalism. At the heart of physicians is their patients, and as long as they don’t forget that, they’ll be OK. The uncertainty of your business is heavy on your mind, but at the end of the day, there are patients that need their physicians. And that’s not changing here. At the end, there’s patients that need surgery, kids need checkups, the healthcare service industry remains. It’s just how we pay for it. westtnmedicalnews

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began her relationship with Regions in 1996 at the suggestion of her personal accountant. She was just starting her private practice, the Miami Dermatology Center, and needed to furnish the offices. “Regions has been very helpful in allowing us to be able to start and grow the practice. They’ve also helped make it possible for us to hire the right people,” says Dr. Leal-Khouri.

“Regions is always there when I have questions. My relationship with my Regions banker is personal and I have her on my speed dial.” What started as a single location has grown to three with a full-time staff of 17 employees. These days, the Miami Dermatology Center utilizes a wide range of Regions banking tools, from Business Analyzed Checking and Treasury Management to loans and lines of credit. Dr. Leal-Khouri plans to expand parking at her Coral Gables location, and Regions is part of those plans too. To learn more about the Miami Dermatology Center and how Regions can assist your business, visit regions.com/success.

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NOVEMBER 2013

Researchers Identify Diabetes Risk Biomarker By CINDY SANDERS

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What if a simple blood test could provide information that your patient had a significantly elevated risk of developing diabetes within the next decade? What might that mean from the standpoint of early intervention and prevention? While it’s much too soon for this type of clinical application, researchers at the Vanderbilt Heart and Vascular Institute (VHVI) and Massachusetts General Hospital have identified a novel biomarker that lends itself to such intriguing questions. Led by Thomas J. Wang, MD, director of the Division of Cardiovascular Medicine at Vanderbilt and physician-in-chief for VHVI, the team recently published results of their discovery of elevated 2-aminoadipic acid (2-AAA) as a precursor to diabetes in Dr. Thomas J. Wang The Journal of Clinical Investigation. Tapping into the rich data source of the Framingham Heart Study, which is now following its third generation of participants, the Wang research team studied blood samples gathered more than a decade ago from 188 individuals who ultimately developed type 2 diabetes and 188 who did not develop diabetes. Using these blood samples, the investigators were able to compare levels of metabolites to see if there were any differences between the group that went on to develop diabetes and the group who did not. Wang noted newer technology now makes it possible to profile hundreds of metabolites at one time. “One of the things that really lit up when we looked at the people who developed diabetes was 2-aminoadipic acid,” he said. “Having elevated levels of 2-AAA predicted risk above and beyond their blood sugar at baseline, their body weight, or other characteristics that put them at risk.” Wang added there doesn’t appear to be a specific threshold of risk at this point … the higher the levels of 2-AAA, the higher the risk of developing diabetes. In fact, those in the top quartile of 2-AAA concentrations had up to a fourfold risk of developing diabetes during the 12-year follow-up period compared to those in the lowest quartile. Interestingly, the researchers found 2-AAA might not be just a passive marker. As part of the same study, the team conducted mouse model testing and discovered giving 2-AAA to the mice actually altered the way the animals metabolized glucose. “It suggests the molecules might be

playing a direct role in how the body processes glucose rather than being an innocent bystander in the process,” Wang said. He added that elevated levels of 2-AAA don’t necessarily mean the molecule is bad for the body. Instead, it could be a defense mechanism where the body is producing higher levels to fight risk from another, as yet unknown, source. Figuring out the metabolite’s exact role in the functioning of pancreatic cells is one area for future research. If, indeed, 2-AAA turns out to be a defense mechanism to stave off diabetes, the good news is that the metabolite could be given to humans in the form of nutritional supplements. On the other hand, if 2-AAA turns out to be harmful to the body’s glucose regulation system, further research could reveal methods to lower the metabolite’s presence. Wang was quick to say the next step is to conduct additional research to measure 2-AAA in other human populations outside of the Framingham study through both retrospective and prospective studies. More in depth animal model studies are also in the pipeline. “A lot of the effort will be focused on trying to understand the biologic effect of 2-AAA in developing diabetes,” he said of the work going forward. However, Wang said the current research results at least raise the possibility that somewhere in the future knowing how high a person’s circulating 2-AAA levels are could impact clinical practice by allowing providers to adopt a more aggressive intervention posture among those at highest risk, whether that be through exercise, weight loss or pharmacologic measures. It is conceivable that 2-AAA might be the type of red flag for diabetes that high cholesterol is for heart disease. “Understanding why diabetes occurs and how it might be prevented is a very intense area of investigation because of the serious consequences of having the disease,” Wang said. “Down the road, this might be one part of the armamentarium of tests that could be considered. If this were proven useful in further studies and could be used clinically, it would be an easy test to administer.” As for the impact of the findings right now, Wang added, “In 2013, it highlights a specific pathway that might be related to diabetes risk that we previously didn’t know about.” Considering the prevalence of type 2 diabetes and growing obesity epidemic in the United States, that is an important lead for researchers working to develop strategies to interrupt the disease progression and stop risk from becoming a reality.

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Where You Go For Rehabilitation Does Make A Difference RichaRd c. Senelick, M.d., editoR-in-chief, healthSouth PReSS, Medical diRectoR healthSouth RioSa

Hey Doc, I Hope You’ll Try This By TIM NICHOLSON

The most important part of your social media presence is not what your hospital or practice has to say, but what your patients have to say – especially to one another. Peer-to-peer interaction is the heart of social media. Likewise, it’s an important variable in healthcare. According to a study conducted by the Pew Research Center, more than 7 out of 10 Internet users living with a chronic illness have gone online to find other people with similar health issues. As a trusted source for healthcare information, you can use social media to reinforce that role by creating a channel for their connectivity. Your effort provides value and supports patients during their journey to wellness. Unfortunately, too much of what happens in a healthcare brand’s social media strategy is marketing and public relations centric. “We’re sponsoring a 5K.” “We have the best doctors.” And so on. What if, instead of posting content that merely announces information, you published open-ended content that creates engagement and starts conversation? Treating your social media as a sort of water cooler for conversations allows you to move in and out of it as teacher and learner. It enables conversations wherein your patients and their friends as fans and followers learn from one another. Did I just make this up? Nope. “These (social media) tools help us reach so many more people; we can bring shared interactions into our practice and that is powerful. This isn’t in addition to your job. This is part of your job. This is a conversation, and that is what we are trained to do. We can engage learners, patients and peers,” said Farris Timimi, MD, medical director for the Mayo Clinic Center. And, social media allows patients to have the conversation that you’re often reluctant to have – the one that says, “it’s going to be alright.” It starts with “I’m newly diagnosed” or “My loved one is going through a difficult treatment,” and all they’re really lookwesttnmedicalnews

.com

ing for is somebody who’s been there and can tell them what to expect. Patients and their friends are hoping to find answers, information, advice and perhaps empathy. They are hoping to find someone who truly “gets it” or who shares their experience and has made it through. They’re even hoping for an opportunity to share hope with another. You’re not a cynic. You’ve just been conditioned to focus on the serious business of medicine. But that sometimes gets in the way of the hope and promise of medicine - which is what most patients see as medicine’s role. This notion of hope and connectivity was recently affirmed by a little social experiment. My teammates built a wall, placed it on a street corner in Memphis for one day and invited people to leave a thought related to health. We called it the “I wish you well” wall. There were over 1000 post-it-notes left on the wall and dozens taken by those who happened by. We learned that patients, family members, friends and passers-by generally want the best for others. Their notes were hopeful, often funny, sometimes poignant and full of promise. The notes were personal yet widely applicable. We know that patients want to connect with you, but they also want to connect with one another. You don’t have time to build a wall for post-it-notes. So, use your social media presence to make it happen. Post a subject header like “What’s the most meaningful thing a friend has done for you during your treatment?” Your efforts will lead to connections, enable shared experiences and fuel a little hope for better health outcomes. Come on. Try it. I wish you well. Tim C. Nicholson is the President of Bigfish, LLC. His Memphis-based firm connects physicians, clinics and hospitals to patients and one another through healthcare social media solutions, branding initiatives and websites. His column, “Hey Doc”, appears here monthly. Find him on twitter @timbigfish or email tim@gobigfishgo.com

“Secondary to dying, nursing home placement for an older person who was in the community is the worst possible outcome. “ Kramer et al You or one of your family members are in the hospital and your doctor has just told you that you will need a course of rehabilitation. You may have had a stroke, fallen off your high-tech bicycle or spent time recovering from a major operation that has left you too weak to return home. Dr. Smith has been your family doctor for years, and all of your children have been born at the same hospital, but no one in your family has ever needed rehabilitation. A short time after your doctor leaves your room a case manager enters and gives you three choices. One is an inpatient rehabilitation hospital and two are skilled nursing homes that provide rehabilitation services. How do you choose? Will your choice influence your ability to improve and reach your maximum potential? Absolutely! What Is the Difference? Which will give you the greatest dose of therapy that performs functional tasks in a setting that motivates you to get better – an Inpatient Rehabilitation Hospital or at a Skilled Nursing Facility (SNF)? You have to ask some questions: Does a stroke patient do as well in a SNF as in an Inpatient Rehabilitation Hospital? Is that patient as likely to be discharged home and back to the care of their loved ones? The answer to both questions is, “definitely not!” I don’t just say this because I work in an Inpatient Rehabilitation Hospital, but because the medical literature supports this position. I know that my position will upset some very good people who work in skilled nursing facilities, but the facts support my statements. Evidence-based medicine is the gold standard for clinical decisionmaking, whether we are deciding what medicine to use or what is the best choice in rehabilitation. Just as you wouldn’t take a pill that had not undergone rigorous testing, you need to follow the evidence when making a

decision about rehabilitation. As early as 1997, a major study in the Journal of the American Medical Association compared stroke patients who received their rehabilitation at a Rehabilitation Hospital (IRF) versus a Skilled Nursing Facility (SNH). Those who received their rehabilitation at an IRF were three times more likely to be discharged home. That’s right, three times more likely to sleep in their own bed, eat with their families and kiss their grandchildren goodnight. Knowing this, where would you want to go if you had a stroke? Data has been published for joint replacements, hip fractures and medical diagnoses such as cardiopulmonary conditions. People are being sent to skilled nursing facilities to save insurance companies money, but the price in what it means in outcomes is being paid by the patient. What We Know Intensity of Rehab Drives Success: The evidence is clear that success with rehabilitation is dose-related. The intense therapy provided in a Rehabilitation Hospital is superior to the less intense setting of a skilled nursing facility. Functional Focus of Rehab is Crucial: Animal and human research demonstrates that it takes functional tasks to “rewire” the brain and restore function. Most skilled nursing facilities do not have access to the many technological advances that promote repair of the nervous system. Even Modest Functional Improvement Affects the Future of the Severely Impaired: Too often, healthcare providers assume that severely affected patients are not candidates for an Inpatient Rehabilitation Hospital. This is not true. If these people are provided proper rehabilitation, the majority of patients are returned to their homes and families. Rehab Hospitals Are Superior to Nursing Homes for Achieving Greater Gains and Going Home: The data speaks for itself. Patients who go to an Inpatient Rehabilitation Hospital achieve higher functional gains and are more likely to go home than those who go to a Skilled Nursing Facility (nursing home).

For more information on HealthSouth Cane Creek Rehabilitation, call 731 587-4231 or visit healthsouthcanecreek.com.

NOVEMBER 2013

Healthcare Leader: Charles Miller, continued from page 1 having an impact on the health status of a community I was a part of,” said Miller. “I was doing some interim work with Hospital Management Associates in Dallas prior to taking the position in Jackson.” Initially Miller started on the financial side of healthcare, working as chief financial officer for 18 years before venturing into operations. “I have always enjoyed the strategic planning, making things happen side of things more so than the keeping score side of things, so operations was a natural progression,” said Miller. “My first facility to be in charge of was the smallest one I have been in, a 100-bed facility in Fauquier, Virginia. The largest was a 550-bed Southern Baptist Hos-

pital, when I was still on the finance side.” In the last nine years of his career, Miller, who holds an Accounting degree from Virginia Commonwealth University and a Master of Business Administration from Tulane University, found himself dealing more in project development and strategic planning than with debits and credits. “I am a very collaborative type of person. I really enjoy working with people, taking thoughts and ideas and turning them into reality,” said Miller. “My finance background gives me the ability to evaluate projects and initiatives from both sides, in terms of their contribution or their added value to the organization. It also helps my

critical thinking skills to make sure that as we are evaluating projects we are looking at it from all angles to make sure we have attacked as many bases as we can before we make a decision.” Miller sees his financial background as a positive tool in dealing with the medical staff. “Doctors like data and objective information. My financial background helps me working with them to make sure they appreciate the practical side of the decisions we have to make,” he said. “Doctors are not unlike any other businessperson out there. They know that a project or initiative has to make sense for their patients and their practice. To help them understand the

I don’t just have insurance. I own the company.

Lisa Young, M.D. Sutherland Cardiology Clinic Germantown, TN Invasive Cardiology

Medical Professional Liability Insurance “These are uncertain economic times. So the way I see it, this is the time to be more diligent than ever when choosing a professional liability insurance carrier. I need a company with the proven ability to protect my livelihood for the long haul. That’s the reason I chose SVMIC. Their long commitment to physicians in our state, through their extensive physician governance system and consistently high ratings from A.M. Best, is unmatched. Only SVMIC has the track record and financial stability my career deserves. And, my career is much too important to settle for anything less.”

Mutual Interests. Mutually Insured. Contact David Willman or Susan Decareaux at mkt@svmic.com or 1-800-342-2239. SVMIC is endorsed exclusively by the Tennessee Medical Association and its component societies. Follow us on Twitter @SVMIC

NOVEMBER 2013

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ins and outs of their requests and how they impact their patients and the organization, allows us to find a solution that is workable for everyone.” As part of transitioning to the new position, Miller has been familiarizing himself with the facility, community and the staff. “CHS was a company I was attracted to. I had done my homework so there were really no surprises when I got here. I was pleased with what I found and it was in line with what I expected. Regional Hospital of Jackson is a sound facility with a strong medical staff that offers an array of services,” said Miller. “We are in the midst of expanding our emergency department and will assess some other projects in the coming year. We will address the strategic plan in the next few months. There are obviously some things we will want to give some thought to and will toss around ideas to take the facility to the next step.” Miller says he carries a large toolbox of personal experiences with him. “I have been through a number of different types of organizations, communities and situations over my career. Although this is not a turnaround, I have been through two so I have seen facilities at rock bottom and up. From product line development to practice management to organ transplantation, I have seen nearly the full gamut of things so it is just a matter of figuring out what the personality of this hospital is, what the needs of the community are and then seeing how we can enhance what is here and what opportunities are out there. The reality is we will never be everything to everyone, which is a recipe for failure.” The most important short-term goal for Miller is to get out from under all the boxes. For the long-term, his goal is getting the community to really appreciate the hospital and what it has to offer. “I think to some extent my initial impression is that we are an unknown entity,” said Miller “I also hope we can continue to grow as the community grows. Jackson is very vibrant and will continue to be the hub of West Tennessee. It’s exciting to be a part of that and I am looking forward to it.” When evaluating his career, Miller counts his efforts in the turnaround of Southern Baptist Hospital in New Orleans in the late 1980’s as one of his proudest achievements. “It had done well through the years but had fallen on hard times and I was brought in to turn it around. I took it from the verge of closing to being an extremely successful hospital that subsequently acquired the last remaining Catholic Hospital in the area. Tenet ended up buying both facilities which is how I became involved with that corporation.” For Miller, an avid golfer, he lists his two sons as his crowning achievement. Stephen and Hunter both attend The McCallie School in Chattanooga. “Stephen is a sophomore and plays lacrosse. Hunter is a senior and wants to study videography in college,” said Miller. “My wife Catherine and Stephen are the horse enthusiasts in the family and the reason we have two horses. In fact, the biggest challenge we had moving here was getting our three cats, two dogs and two horses moved. It was a 12hour trailer trip for the horses, but all seem to have settled in.”

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Hot topics in HealtH law by John Arnold

Representing Physicians, Hospitals and Healthcare Providers since 1975

Unbundling Bundled Payment Contracts As the fee-for-service model faces continued scrutiny, payors continue to explore new payment models designed to improve quality and efficiency while reducing costs. Many payors are increasingly advancing bundled payments as an alternative to fee-for-service. A bundled payment involves a single payment covering services delivered by two or more providers during a single episode of care or period of time. These new bundled payment models attempt to allocate financial risks among providers and payors more equitably while rewarding quality and outcomes. In order to achieve these lofty goals, however, bundled payments are becoming increasingly complex. Consequently, a well-drafted contract is critical to safeguarding the rights of physicians. While no two arrangements will be the same, the following offers a good starting point for physicians who are considering entering into a bundled payment contract. Defining the Bundle As payors expand bundled payment models, it should come as no surprise that new arrangements are challenging existing boundaries by making bundled payments for even more complex conditions in both inpatient and outpatient settings. Some ambitious models, for example, are making bundled payments for certain types of cancer and management of chronic conditions like asthma and diabetes. So while the specifics of the bundle will always vary, all bundled payment contracts should address the same fundamental questions:

Healthcare Law Practice Group

Angela Youngberg

William Bell, Jr.

Todd D. Siroky

John Arnold

What events trigger the bundle? When does the bundle end? What events break the bundle? What providers and services should be part of the bundle? Defining the Bundled Payment At the core of bundled payments is a pre-determined budget. At least one progressive model has elected to base budgets primarily on clinical practice guidelines, but most models continue to rely on historical data for establishing budgets. This means the contract should limit the data used to account for statistical outliers and physicians should advocate for a refined risk adjustment process that accurately mitigates health disparities in different patient populations. Also, physicians may want to consider additional contractual safeguards to protect against volatility, such as mechanisms to prevent “cherry picking” healthier patients and “lemon dropping” sicker patients or setting patient eligibility criteria as part of the standard for what triggers the bundle. Allocating the Dollars and Allocating the Risk While payments can be made prospectively (i.e., a single payment on the front end), most arrangements make payments retrospectively by paying physicians in the normal course of business (e.g., fee-for-service) and then reconciling the amount paid against the pre-determined budget at the end of the episode. Under both methods, the party bearing the risk suffers a loss when claims exceed the pre-determined budget for the bundle. This means contracts must specifically address risk allocation in addition to the method for making payments and the reconciliation process. Currently, most arrangements begin with a shared savings model to incentive physician participation and transition to a shared risk model and/or full risk model over time. In this scenario, the contract should provide adequate time for physicians to adapt before exposing physicians to financial risk. Contracts 101 Bundled payment contracts should address the same issues fundamental to most contracts. In collaborative arrangements with other providers, the contract’s governance provisions should guarantee equitable representation among the parties and define the method for approving material decisions. Such decisions include adding new providers or classes of providers, modifying compensation, establishing quality standards, and implementing and paying for new technology. Physicians should also contract for reasonable termination rights and advocate for a comprehensive dispute resolution process. Decision-making safeguards, reasonable termination rights, and comprehensive dispute resolution procedures are fundamental to most contracts and particularly important to protecting the rights of physicians in complex bundled payment agreements.

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Healthcare Law • Contracts Among Healthcare Providers • Acquisitions, Joint Ventures, and Mergers • New Practice Formations • Stark Law, Anti-Kickback Law, and False Claims Act • HIPAA and Patient Privacy Issues • RAC, ZPIC, and MAC Audits and Appeals • Billing, Coding, and Compliance • Responding to Governmental Investigations • Provider Non-Competes

www.RaineyKizer.com Memphis Jackson 1.800.677.2414 NOVEMBER 2013

GrandRounds The Jackson Clinic Announces Three New Physicians The Jackson Clinic recently added three new physicians to its staff. Dr. James J. Szabo, dermatologist, joins Dr. Holly E. Clowers, Dr. Frances K. Lawhead and Dr. Maria C. Mariencheck. The Dermatology Department is located at 87B Murray Guard Drive. Dr. Szabo received a Bachelor of Arts degree from Washington University,

St. Louis, MO. He received his Doctor of Medicine from Columbia University, College of Physicians & Surgeons, New York, NY. Dr. Szabo completed his internship at New York-Presbyterian Hospital (Columbia-Presbyterian Medical Center), New York, NY and his residency at the University of Chicago Hospitals, Chicago, IL. Dr. Szabo is Board Eligible, American Board of Dermatology. Dr. Brian J. Wheeler, hospitalist, joins

Crestview Health Care Named to U.S. News & World Report’s Best Nursing Homes List Crestview Health Care and Rehabilitation has received the highest possible overall rating of five stars from U.S. News & World Report in the publication’s fifth annual listing of Best Nursing Homes for 2013. The Best Nursing Homes 2013 ratings highlight the top nursing homes in each city and state, out of nearly 16,000 facilities nationwide. U.S. News’ goal is to help users find a home with a strong track record of good care. U.S. News and World Report calculate scores using data by the federal Centers for Medicare & Medicaid Services (CMS). It then issues an overall rating for nursing homes up to five stars, as well as ratings for detailed elements of each home, including health inspections, level of nurse staffing and quality of care. Fewer than one out of every five nursing homes got an overall rating of five stars according to Avery Comarow, U.S. News Health Rankings Editor. Crestview Health Care and Rehabilitation in Brownsville is a 115-bed skilled nursing facility providing high-quality nursing home care and services. Long-term convalescent care and short-term rehabilitative services are available, with individualized attention and treatment to help meet each resident’s need.

Dr. William Bradley Lofton, Dr. Natasha C. Mahajan, Dr. Unnatti Mehta, Dr. Osayawe N. Odeh, Dr. Aleruchi Y. Oleru, Dr. Evanna S. Proctor, Dr. Alan C. Rothrock, Dr. Bryan P. Tygart and Dr. Bradley M. Webb. The hospitalist department is located at Jackson-Madison County General Hospital. Dr. Wheeler received a Bachelor of Science Degree from University of Tennessee Martin. He received his Doctor of Medicine from University of Tennessee College of Medicine, Memphis, Tenn. Dr. Wheeler completed his internship and residency at the University of Tennessee Department of Internal Medicine, Memphis, Tenn. Dr. Wheeler is board eligible, American Board of Internal Medicine. Dr. Anita Gul, oncologist, joins Dr. Dwight C. Kaufman and Dr. Eugene P. Reese, Jr. The Hematology/Oncology Department is located at 616 West Forest Ave. Dr. Gul received her Doctor of Medicine from Dow Medical College, Karachi, Pakistan. She completed her residency at Nassau University Medical Center, East Meadow, NY. Dr. Gul is Board Certified, American Board of Internal Medicine and Board Eligible, American Board of Hematology and Oncology.

Trumbull Laboratories Receives Accreditation From College Of American Pathologists

Trumbull Laboratories, LLC has been awarded accreditation by the Accreditation Committee of the College of American Pathologists (CAP), based on the results of a recent onsite inspection. The laboratory’s director, Thomas M. Chesney, MD, was advised of this national recognition and congratulated for the excellence of the services being provided. Trumbull Labs is one of more than 7,000 CAP-accredited laboratories worldwide.

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GrandRounds New Textbook by Dr. Karl Misulis Karl Misulis MD,PhD, neurologist with West Tennessee Neurosciences, has had his most recent book published: Atlas of EEG, Seizure Semiology, and Management, published by Oxford University Press. This is his 18th textbook as sole or principal author, and second since joining West Tennessee Healthcare three years ago. This book is available in hardcover format and also available in the Kindle store. This book is used especially by neurologists and technicians as a guide to performance and interpretation of EEG and management of epilepsy.

It was the first note I ever got in crayon. “Thank you for making my daddy feel better.” I keep it on my desk, where I pore over patient records and cash flow statements. Because even if the medical field seems to be changing by the day, the reasons I practice never do.

West Cancer Center Opens New Clinical Trial The West Cancer Center has announced the opening of a prostate cancer clinical trial, which may be a potential treatment option for men with metastatic castration resistant prostate cancer (mCRPC) in patients with pain. This trial is a randomized, multicenter, double blind, placebo controlled phase 3 study of XL184 (cabozantinib) in patients with advanced symptomatic mCRPC that has progressed on multiple prior treatments. This agent will be compared with standard chemotherapy option of mitoxantrone and prednisone. Dr. Brad Somer is the principal investigator for this study. Cabozantinib is a combined VEGFR/ MET inhibitor. Early small-scale studies evaluating cabozantinib activity in various tumor types, including metastatic prostate cancer, showed resolution of bone scan abnormalities observed in some patients. Some patients also experienced improved pain control, regression of soft tissue disease, decreased circulating tumor cells and bone markers as well as PFS improvements. The main goal of this trial is to evaluate if there is pain reduction with the drug in a larger patient mCRPC population. The COMET-2 trial is a parallel ongoing trial with the COMET-1 trial. Exelixis, Inc. has an on-going trial COMET-1, which is a phase 3 randomized double blind controlled study of XL184 (Cabozantinib) vs prednisone in mCRPC, in patients who have received prior docetaxel and abiraterone or enzalutamide. The aim of the COMET-1 trial is to evaluate for a survival advantage with cabozantinib. For additional information contact Cindy Inman at cinman@westclinic.com

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