ACMS Bulletin December 2022

“You’re Not Santa Claus!” Year in Review

Thoracic malignancy expertise for

2022

Executive Committee and Board of Directors

President

Peter G. Ellis

President-elect Matthew B. Straka

Vice President

Raymond E. Pontzer

Secretary

Mark A. Goodman Treasurer Keith T. Kanel Board Chair Patricia L. Bononi

DIRECTORS 2022

William F. Coppula Micah A. Jacobs G. Alan Yeasted Alexander Yu 2023

Bruce A. MacLeod Amelia A. Pare Adele L. Towers 2024

Douglas F. Clough Kirsten D. Lin Jan W. Madison Raymond J. Pan

PAMED DISTRICT TRUSTEE

G. Alan Yeasted

COMMITTEES

Bylaws

Raymond E. Pontzer

Finance

Keith T. Kanel

Membership

Matthew B. Straka

Nominating

Raymond E. Pontzer

Bulletin

Medical Editor

Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com)

Associate Editors

Douglas F. Clough (dclough@acms.org)

Richard H. Daffner (rdaffner@acms.org)

Kristen M. Ehrenberger (kehrenberger@acms.org)

Anthony L. Kovatch (mkovatch@comcast.net)

Joseph C. Paviglianiti (jcpmd@pedstrab.com)

Andrea G. Witlin (agwmfm@gmail.com)

ADMINISTRATIVE STAFF

Executive Director Sara Hussey (shussey@acms.org)

Vice President - Member and Association Services Nadine M. Popovich (npopovich@acms.org)

Manager - Member and Association Services

Eileen Taylor (etaylor@acms.org) Co-Presidents

Patty Barnett Barbara Wible Recording Secretary

Justina Purpura

Administrative & Marketing Assistant Melanie Mayer mmayer@acms.org

Director of Publications Cindy Warren (cwarren@pamedsoc.org)

EDITORIAL/ADVERTISING

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Something to Look Forward To

Deval (Reshma) PaRanjPe, mD, mBa, FaCs

Enlightenment philosopher Immanuel Kant is famous for many things, but perhaps among his most enduring contributions are his “Rules for happiness: something to do, someone to love, something to hope for.”

I would add “something to look forward to”, which is quite different from “something to hope for.” “Something to look forward to” is a certainty, and unlike death and taxes, a pleasant one at that.

Once, during a crazy clinic day, I met an elderly woman who had undergone many eye surgeries and had still lost vision to an end-stage disease. She was no ordinary person; she held multiple Ph.D. degrees and had traveled the world multiple times in her career. At this point, she was alone in the world; blind, weak, wheelchair-bound, and terribly depressed about this state of affairs. She was tearfully despondent over rapidly losing what remained of her eyesight, and I tried my best to distract her a bit.

I asked her what her favorite place in the world was, and she replied without hesitation: “Scandinavia.”

“Why?”, I asked, expecting her to cite the Northern Lights, or the fjords, or the glaciers, or perhaps the food (Definitely not the lutefisk.)

“Because the people are actively kind to each other there. They look after each other.”

I was floored.

It struck me that despite her technical blindness, this lady had more vision than many sighted people in this world. I told her as much, and she laughed (This was a victory for both of us that day.)

The physical cause of her despair was obvious. I thought about the emotional cause of her despair. She thought she had nothing good to look forward to, only misery, isolation, and darkness.

We all have something to do; the practicing physicians among us often have so much to do that we may not always recognize the privilege while we have it. The non-practicing and retired physicians among us have something to do even though it may not be medicine; other outlets and activities appear to pass the days. It is never too late to find something useful to do what brings joy and comfort to yourself and others.

Most of us have someone to love, and if we don’t, it’s never too late to find someone to love. Love can be romantic, platonic, parental, fraternal, filial, or general. It can be dispensed with surgical accuracy or with scattershot joy. Like the Scandinavians of the woman’s

memory, it is enough to love one another; in fact, it is the only thing.

Sometimes having something to hope for is a wonderful thing---the giddy anticipation of what-if---fantasizing about life working out fantastically well. You can hope to win the lottery and retire (and then find something to do.) You can hope for someone to love. As long as you have a dream, you have something to hope for. But dreams are not guaranteed, and dreams can change. In the case of my lady in the wheelchair, dreams can seemingly die.

That’s where “something to look forward to” comes in. It’s a virtually guaranteed pleasure. For most of us, this can range from seeing a friend at a lunch date, to seeing one’s spouse and kids at dinner, to a dinner out, to a weekend getaway or a vacation. It can be looking forward to seeing your family at the holidays or looking forward to being alone for a change with your thoughts. Nothing in life is fully guaranteed but choosing an easy win to look forward to can make all the difference in trudging through the daily trials we face.

My lady in the wheelchair happened to be a psychologist and a therapist. She understood full well what was happening to her and why she felt the

From

way she did and that she needed to find a healthy method to cope. I gently offered her the prospect of low vision services to help her make the most of the vision she did have. I told her that others in her situation, after the initial shock, learn with support to adapt and live fulfilling lives. She said she understood all that intellectually, but

that emotionally she was not in a place to accept or make the most of these services. Yet. She was allowing herself the luxury of grieving her loss which, in itself, is wisdom.

From her I learned this lesson: allow yourself to grieve whatever loss you must, so that you can enter a better frame of mind and accept the “something to look forward to” that is

out there waiting for you. Relentless positivity, which is the dominant mantra in today’s world, may not be the answer. There are stages of grief that must be traversed in order to achieve and receive the bounty of Kant’s three rules of happiness.

For my part, I wish you something to do, someone to love, and something to look forward to, always.

Happy Holidays.

ACMS Year in Review

Sara C. Hussey, MBA, CAE

I’m writing this article coming right off the heels of the December 6th ACMS Board Meeting; the final board meeting of 2022. It’s hard to believe that 2022 is already coming to an end, but when I reflect back to March of this year, when I first started as the Executive Director of the ACMS, I am in awe of how much we have accomplished in just a few short months.

I’ll briefly hit the high notes of 2022. I say briefly because the team at ACMS is already preparing to hit the ground running to move forward into 2023. But in 2022, this organization has adjusted, shifted, added, removed, replaced, reorganized, and realigned in so many ways. With the hard work of the ACMS Board of Directors, and the diligence and support of the Executive Committee, ACMS is ready for a transformational 2023. We took 2022 to “get our house in order”. We are fully staffed. We have reinvigorated the work of our managed specialty groups. We have realigned with community partners. The ACMS Foundation issued over $200k in grants to local organizations. We launched new programming. And, as you will see in the election report included in this edition of the bulletin, the membership elected a diverse and energetic board for 2023. With all that reorganizing work behind us, we look forward to moving into 2023 with intention and focus.

After we reminisced about 2022, we spent the bulk of our board meeting talking about where we will go in 2023. Your board set three primary goals for the next year. They will focus on membership, including benefits, value, education, and connection. They will focus on local advocacy, with the continuation of the local physician advocacy ad-hoc committee that was launched in Q4 of 2022. And they will establish one additional ad-hoc committee that will focus on the future direction of the ACMS Bulletin.

Outside of the work that will happen at the board level, the team at ACMS looks forward to a few key initiatives. Early in 2023, we’ll launch our newly redesigned website. We’ll be working to establish a women physicians networking group. We’ll add additional CME options for those wishing to take part in local, inperson training. We will work alongside newly elected state representative, and ACMS member, Arvind Venkat, MD, on advocating for issues that matter the most to physicians. We will provide opportunities to get ACMS members in front of local and state legislators. We will combat medical misinformation by getting ACMS members in the press to talk about the medical issues facing our

Left to right is: Eileen Taylor, Melanie Mayer, Nadine Popovich, Sara Hussey, Jordan Corcoran

2022 Board of Directors

community. We will continue to tweak and update member benefits for all our membership types, including residents and retired members. And we’ll continue the important work of the ACMS Foundation.

We are excited about the opportunities that are ahead in 2023. In the next edition of the Bulletin, you will hear from the 2023 leaders of ACMS. As of January 1, we will welcome Matthew Straka, MD as the 2023 ACMS Board President. Peter Ellis, MD, immediate past president, will become the Chair of the Board of Directors for 2023. We encourage members to reach out to Dr. Straka, Dr. Ellis, or anyone on the ACMS team with feedback, questions, comments, and concerns. We want to hear from you!

I wish the best to you and your families this holiday season. Thank you for allowing me to be part of such a tremendous organization. I am inspired every day by the work of our members, and I look forward to all that we will accomplish together in 2023.

ACMS

What time is it really?

maRia j. sunseRi, mD Faasm

The American Academy of Sleep Medicine (AASM) did initially support the U.S. Senate for passing the “Sunshine Protection Act” which, by 2023, will eliminate the biannual time changes of “falling back” in November and “springing forward” in March. However, the chosen time committed to by our government of permanent Daylight-Saving Time (DST) goes against all the scientific evidence presented and a prior “pilot trial” of continual DST in the U.S. during the 1973 OPEC oil embargo. Therefore, the AASM has come out against the Sunshine Act for this reason. References for this discussion are taken from the Position Statement on DST by the AASM from 2020 and a discussion group by Erin Evans PhD at the APSS annual meeting.

It appears that our representatives state that they are told that most of their constituents want permanent DST. This is the initial reaction of many at first, including myself, until I reviewed the evidence of what we have learned about our light/dark cycle and our circadian rhythm over the years. Most of us feel better in the Spring when the days get longer, warmer and vegetation blooms. It is our job as scientists and medical doctors to not just go by what we feel but to look at the evidence and then educate and inform our patients

why DST is not the best option, and the better choice is permanent Standard Time (ST).

In the world of Sleep Medicine, it has become apparent over the last 30 years that our circadian rhythm plays a supreme role in our overall health. It not only controls when we eat and sleep but the health of organs at the cellular level, our aging, our mood and attention. Our circadian rhythm is entrained by the light/dark cycle. Standard Time is when sun time and clock time are aligned. Therefore, our circadian rhythm is entrained by the “correct” light/dark signals and has the best chance to be “in alignment”. DST changes the clock time but not the sun time, so it is like living in the wrong time zone. Your circadian rhythm is “out of alignment.” So why is this important? The evidence shows that with this switch from ST to DST there is an increase in cardiovascular morbidity, increase in strokes, mood disturbances, and motor vehicle accidents—primarily in the morning. There is more sleep deprivation from this misalignment due to increased light in the evenings causing people not to fall asleep as early, but they still have to get up at the same time. This is a situation of sleep phase delay, sometimes termed “social jet lag” that can become chronic and cause chronic

sleep deprivation. Sleep deprivation causes many health consequences, not the least of which is a 5% increased risk of all mortality. It can cause cellular derangements, altered gene expression, altered epigenetic and transcriptional clock genes, increased inflammatory markers, and increased heart rate and blood pressure due to lower vagal tone. “Social Jet lag” has been associated with an increased risk of obesity, metabolic syndrome, cardiovascular disease, and depression. This situation is exacerbated the further west you live in each time zone as the sun sets latest the further west you live. There is an increased risk of cancer for each 5 degrees (20 minute) off the meridian of each time zone. This move to permanent DST would also negate the positive effect that we have worked so hard for to get the schools to move their start times later and the benefit that that was meant to achieve.

In 1973, during the OPEC oil embargo, temporary year-round DST was instituted in the U.S. There was an increase of fatalities among school age children in the morning between January and April. This could have been due to the increased darkness in the morning, but further analysis was not done. The energy data for why we do this switch to DST was evaluated in

1975 and was “not really applicable”. Indiana found a 1% benefit from moving to straight ST.

The European Biological Rhythms Society, European Sleep Research Society, and Society for Research on Biological Rhythm published a statement declaring ST is the best option for public health. The European Parliament voted to end the mandate of DST by 2021. The AASM 2020 DST Position Statement recommending permanent ST, was endorsed by more than 20 medical, scientific, and civic organizations including the American College of Chest Physicians, American College of Occupational and Environmental Medicine, National PTA, National Safety Council, Society for Research on Biologic Rhythms and World Sleep Society.

If we get stuck with permanent DST it will be important to use artificial light in the morning to wake and keep your circadian rhythm on course as well as to allow flex work time for those whose sleep is delayed, so they can avoid sleep deprivation and its health consequences.. Let’s try to influence this decision now, to change to permanent ST, (not DST), with data and results of prior experience before we must live in the wrong time zone for life.

M. J. Sunseri, M.D. FAASM Diplomate, ABMS, Subspecialty in Sleep Medicine, American Board of Sleep Medicine (ABSM), American Board of Psychiatry and Neurology (ABPN), ABPN, Subspecialty of Clinical Neurophysiology, and American Board of Clinical Neurophysiology. mjsunseri@msn.com

Thank

membership in

Allegheny County Medical Society

Withholding Medicine From a Sick Patient

josePh C. Paviglianiti, mD

Disclaimer: I tried my best to keep this article free of any political bias. Regardless of one’s political ideology, we are all going to hopefully retire someday.

Two months ago, the United States government announced an 8.7percent cost-of-living adjustment (COLA) to Social Security benefits starting January 2023. That’s certainly great news to those retirees already receiving benefits… but NOT such great news to those of us who are further away from retirement. At some point, somebody is going to have to pay for all these extra benefits. But just who should pay and when that should start has been hotly debated over decades.

Let’s review some facts... then some proposed solutions:

• As reviewed in Part I of this article a few months ago, the Social Security Act was signed into law August 14, 1935.

• On January 1st, 1937, workers started having FICA (Federal Insurance Contributions Act) taxes deducted from their paychecks.

• Currently 6.2 percent of the first $147,000 of your salary is deducted as FICA taxes. Your employer kicks in a matching 6.2 percent. This total (12.4 percent of your salary) money

goes into the OASDI Trust Fund (The Old Age and Survivors/Disability Income Trust Fund). That’s on top of our regular income tax.

As an aside, I was very recently on a walking tour through downtown Salzburg, Austria and our guide noted that Austrians pay 25% of their income toward “pension and old age benefits” as well as about 40% of their income into income tax. Sweden’s and Denmark’s collective tax rates for “income + retirement” hovers at 45% as well.

• By January 1st, 1940, the OASDI Trust Fund (otherwise known as the Social Security Trust Fund) had built up enough cash reserves from employee / employer FICA contributions that retirees began receiving a set amount monthly “for life”. At the time, since there were only a few million retirees, only those who had contributed into the program counted vs tens of millions of American workers contributing to the trust fund. By 1955 there were over 8 gainfully employed Americans for each retired American (8.5:1 employee: retiree ratio); thus, more money was going into the OASDI/SS Trust Fund than was being paid out. Each year, the OASDI/SS Trust Fund grew; excess funds were invested in government bonds as required by law

and the interest was added back into the fund. Everything solvent. All happy.

• Currently, in December 2021, the OASDI/SS Trust Fund has its value at $2.9 Trillion dollars. Ninety percent of the OASDI/SS trust fund is financed via our FICA taxes; 6.4 percent is from interest on those funds, and 3.5 percent is from taxation of the benefits that get paid out.

• Even though the OASDI/SS Trust Fund was growing, the “employee: retiree” ratio was shifting as the baby boom was ending. By 1983 there were only approx. 3.2:1 (employee contributors: retirees). Thus in 1983, the OASDI/SS Trust Fund “paid out” more money than it took in from FICA taxes for the first time in history.

• The best analogy is the bathtub faucet and drain: The FICA tax on our salaries is the faucet and the monthly benefits paid to retirees is the bathtub drain. In the early years, the tub (the OASDI/SS Trust Fund) was overflowing. There were more workers “paying in “than retiring. But as the population demographics changed, the FICA-faucet has been turned down and the tub drain is open wider...and opening wider by the day. When the tub is empty, the tub drain will need to be slowed down to exactly match the rate of the faucet.

• As of the end of 2021, the OASDI/ SS Trust Fund/bathtub still had $2.9 Trillion dollars still in it; the faucet “in” was $1.09 Trillion, but the bathtub drain was draining faster at $1.14 Trillion “out”.

• The actuarial wonks in the late 1970s had foreseen this and so the government needed a way to increase the “money in” to the OASDI/ SS Trust Fund. After much debate, it was decided to TAX Social Security benefits (they were previously untaxed). That turned on the faucet a little more and the bathtub started to fill up, but not at nearly the rate it filled/overflowed in the early decades of the program (when there were 8 workers for each 1 beneficiary)

• Taxing Social Security benefits starting in 1984 righted the ship for a few years, but based on population demographic info, the actuarial wonks predicted that in early 2019 the math would go bad again…i.e., that the OASDI/SS Trust Fund would again start to “pay out” more money than it “took in.” The math never lies and as expected, almost to the hour, the OASDI/SS Trust Fund started paying out more in benefits than it took in via FICA taxes in March 2019.

• It should be mentioned that the OASDI/SS Trust Fund had a HUGE head start. As of right now, the trust fund still has $2.9 TRILLION dollars in it. But...since 2019, that trust fund savings goes “down” every month because it pays out more in monthly benefits than it takes in via monthly FICA taxes. It is expected that the OASDI/SS Trust Fund will be down to zero by 2035. Note that: Social

Security will NEVER go “bankrupt”, since funds from employed workers will continue to go into the fund via FICA taxes. But at that amount in approximately 2035 when the trust fund goes to zero, THEN Social Security becomes exclusively a “PAY-AS-YOU-GO Program. When it reaches “Pay-As-You-Go” status, the monthly FICA tax “in” will need to exactly equal the Social Security benefit “out.” This “post 2035” benefit amount is expected to be 20-25% less than current monthly benefit rate, adjusted for inflation. Remember, when OASDI/SS Trust Fund was doing well, it could offer benefits more than earned, COLA raises, etc. But after 2035, the OASDI/SS Trust Fund will only be able to “pay out” what it takes in that month.

• As not seen on the imaginary table that I couldn’t figure out how to copy over to this word document, there used to be 8 1/2 workers per each Social Security beneficiary back in 1955. In 2022, there are currently approximately 2.8 workers per Social Security beneficiary. The graph is only going down, it will never go back up, unless a whole lot of people start pumping out a whole lot of babies. But not just any kind of babies... they need to be babies that grow into citizens that are actually gainfully employed and who contribute FICA taxes “in”. If anyone has had any difficulties hiring medical technicians or getting a table at a “half full” restaurant or being in a hotel where there is only maid service every 4th day, the absence of “workers” in many job fields recently is obvious. And not just in entry-level jobs. How about

the difficulties in hiring a physician to join your practice or finding an anesthesiologist or nurse anesthetist to staff an operating room? The assumption that the younger generation want to work is not guaranteed. How many times have you caught yourself wondering “where are all the workers?” or “it seems that nobody wants to work”. The fact that currently “nobody seems to want to work” undercuts the entire financial foundation that Social Security is based on.

• Interestingly, it’s these very younger workers (whom us old farts feel don’t want to work at all) who fear that Social Security will “completely disappear.” A study by Nationwide Insurance in 2021 found that 71 percent of adults felt that Social Security was going to “run out” in their lifetime. More importantly, 47 percent of millennials felt “they will not get a dime of Social Security benefits they have earned”. Those are sobering numbers.

POSSIBLE SOLUTIONS

So… how to fix the proverbial Social Security faucet/drain problem?

I remember hearing that “Social Security was going broke” when I was a kid in the late 1970’s … however, other than the 1983 decision to “tax Social Security benefits,“ nothing else has been done to stop the “out” more than “in” situation. Lots of ideas have been put forth, but nobody’s had the guts to do anything about them, because reducing monthly social security benefits is political suicide.

Instead, the government just recently increased payouts with a historic 8.7 percent COLA increase. Retirees now get “full” benefits thanks to historical population and employment growth… but that comes to a screeching halt in approximately 2035 (depending on who’s math you believe) when

EVERYONE gets a 20-25 percent benefit cut. Most of us “still working” favor spreading that cut out over the upcoming 10 years to soften the blow and maybe kick the SS trust fund bankruptcy can further down the road.

But benefit cuts aren’t enough. The Committee for Responsible

Policy Ten-Year Savings

Revenue Options

75-Year

Federal Budget (CRFB) is a nonpartisan group that objectively looks at the fiscal impact of any federal spending program. In February 2020 to the CRFB suggested 10 options to secure the Social Security trust fund (see below).

Increase payroll tax rate by 1% $1.0 trillion 28% 23%

Increase taxable maximum to 90% of earnings ($350,000) $830 billion* 22% 14%

Eliminate the $147,000 taxable maximum $1.8 trillion* 68% 60%

Subject cafeteria plans to the payroll tax $470 billion 10% 6%

Cover newly-hired state and local government employees $150 billion 3% -4%

Spending Options

Grow initial benefits with prices instead of wages

$90 billion 97% 184%

Reduce initial benefits for high earners $45 billion 34% 39%

Increase earning years included for benefits from 35 to 40 $35 billion 13% 14%

Calculate Cost of Living Adjustments using chained CPI $245 billion 18% 18%

Raise retirement age to 69 and index for life expectancy $90 billion 36% 56%

Basically, it’s a mixture of increasing revenue and decreasing benefits. As one can see from the graph, the most successful revenue generator to the OASDI/SS Trust Fund would be "eliminating the $147,000 taxable limit"...in other words, don't stop FICA taxation at the first 147K of salary but

Basically, it’s a mixture of increasing revenue and decreasing benefits. As one can see from the graph, the most successful revenue generator to the OASDI/SS Trust Fund would be “eliminating the $147,000 taxable limit”...in other words, don’t stop FICA taxation at the first 147K of salary but continue the FICA taxation all year for 100% of our salaries. This would generate $1.8 trillion for the trust fund over 10 years (remember, currently as of 2022, the OASDI/SS Trust fund (the bathtub) had $2.9 Trillion dollars remaining. If the above action were taken, that would make the balance of the trust fund approximately $1.8 trillion at 2032ish...which would likely buy us 5 more additional years of “enhanced” payouts, i.e., through 2038-40ish.

Another effective revenue generator would be increasing the payroll tax (FICA) by 1 percent (the 6.2+6.2 percent=12.4 would be increased to 6.7 percent+6.7 percent=13.4 percent). Painful, but effective. This would generate $1.0 trillion over 10 years. If BOTH of these tax increases were carried out, the effect on preserving the OASDI/SS Trust Fund would be dramatic, though still borne disproportionately (i.e., totally) on those “still working” without any penalization those current retirees.

Here’s some fuzzy math: For example, assuming a $250,000 salary: Currently FICA = first 147,000 x 6.2 percent = $9114 paid in FICA taxes yearly by each of us to the SS trust fund (employer matches another 6.2%). If both of the above proposals were enacted, full $250,000 x 6.7 percent = $16,750 in annual FICA taxes paid by each of us... That’s an 85.7 percent increase in FICA taxes for a person earning $250,000; worse for those who earn more. Now, contrast this for a person earning $70,000 ($70,000 x 6.2 percent

currently= $4340/FICA annually.

Under both new proposals, $70,000 x 6.7 percent=$4690/FICA annually. That is only an 8 percent increase!! Realistically, most of the increased “pay in “ would be by high earners but would be “paid out” disproportionally to lower earners.

Alternatively, the government could also focus on decreasing payout (decreasing benefits/closing the tub drain a little), either to all or to more wealthy retirees (such that higher earners pay in more, receive proportionately less). Currently, initial payout is calculated by annual employee wage growth...changing that so that a person’s lifetime earnings would be indexed for inflation rather than wage growth would have a large impact, though a slower one (i.e., over the next 75 years or so). Raising the full retirement age to 69 and/or containing COLA adjustments (unlike the 8.7 percent that was just announced) would also have a profoundly positive effect on this OASDI/SS Trust Fund insolvency gap. Reducing benefits payouts for high wage earners and increasing benefits to those closer to the poverty line (again, disproportionately handing out the pain) could have a profoundly positive effect on the OASDI/SS Trust Fund.

Of course, there are ethical dilemmas to this Robin Hood approach. Many high wage earners spent a ton of money on their own education and have big debts and high loan repayments. High wage earners have often sacrificed their young lives and sacrificed a lot of fun because it was a commitment they chose to engage in, knowing their medical salary would make up for it in the end. We had less fun growing up, studied longer hours, missed all our kids’ soccer games and life events...and would now get penalized disproportionately for it. But

that is how the IRS tax code is set up, so it wouldn’t be a far stretch to see the OASDI/SS trust fund take this approach, either.

Clearly, these decisions are not easy and will hit some people harder than others. But the sooner some of these changes are enacted, the sooner the pain can be spread out of a much wider group of people. Social Security was NEVER intended to be an employee’s sole retirement net, and after 2035 or so, it can’t be. One wonders if the recent 8.7 percent COLA increase was a good idea. Why increase benefits a little now, if it hastens a HUGE benefit cut later? Perhaps, a small benefit cut would have been an unpopular, but more curative and gutsy solution. Whatever the answer, something needs done, and sooner rather than later. Spreading out the pain (i.e., including CURRENT retirees in some of the benefit cuts) will make the remedy less painful for all of us. Furthermore, large lobbying organizations, such as AARP, need to consider that many of their members are a long way from retirement, and will thus face a larger disproportionate share of the pain. Organizations like AARP need to lobby for quick but very thoughtful consideration of this issue and urge lawmakers to “do what needs to be done” rather than just encouraging and rejoicing when SS benefit payouts are increased. The Social Security system is ailing and any/all of the above unpopular bandaids need researched and applied. As Meryl Streep said whilst playing Margaret Thatcher in The Iron Lady: “Gentlemen, if we don’t cut spending, we will be bankrupt. Yes, the medicine is harsh, but the patient requires it in order to live. Shall we withhold the medicine? No! We are not wrong. We did not seek election and win in order to manage the demise of a great nation.”

“You’re Not Santa Claus!”

RiChaRD h. DaFFneR, mD, FaCR

“Yes, Virginia, there is a Santa Claus 1”

ast year, I published a Christmas fantasy in the December issue of the Bulletin, entitled “Letters to Santa 2”. This holiday season, let me tell \you of an encounter with a real live Santa Claus.

I was interpreting bone x-rays and CT scans in our reading room at Allegheny General Hospital one hot, steamy August day, several years ago before I retired. I was asked to do a “wet” read on the hand of an eight-year-old boy, who had fallen from his bicycle and complained of pain in his left thumb. The bones of children are not completely fused, and there are many epiphyses (growth centers) in the hands (and feet). Some radiology departments, including those in children’s hospitals, routinely obtain comparison views on all bone radiographs of their patients. As an experienced MSK radiologist, I don’t advocate routine comparisons, trusting my skills to determine whether an abnormality is present. Furthermore, to reduce the radiation exposure a child receives, I occasionally obtained selective comparison view(s) whenever I was in doubt. More commonly, when I knew the patient was still in the radiology department or the ED, I

would do something most radiologists wouldn’t do. I would physically examine the patient. And so it was that I was concerned with the epiphysis at the base of the first metacarpal on the eight-year-old’s hand. I called the technologist and asked her to bring the boy back for me to examine his hand. Jody, the tech, brought the boy and his mother back to the reading room for me to examine his hand.

“You’re not Santa Clause!” the lad exclaimed as soon as he saw me.

I looked at Jody and saw a wide grin on her face. She had told the boy they were going to meet Santa Clause.

“Why do you say that?” I asked.

“Where’s your red suit?”

“Well,” I replied, “It’s summertime. It’s too hot for my red suit.”

“And your beard is too short,” he added.

“Well, I trim my beard in the summer, so my face doesn’t get too hot. I’ll let it grow longer in time for my Christmas Eve visits.”

“Really?”

“Yes, really. Now, if you’re a good boy, I’ll visit your house on Christmas Eve and bring you gifts. But if you’re naughty, I’ll still visit, but I’ll leave you a rock.”

“Oh, I’ll be good, Santa. I’ll be good!”

“I’m sure you will be,” I said.

All the while, during our conversation I was palpating his thumb and at the same time looking at his face to see if he winced as I pressed on the area of concern. By engaging him in conversation, he was not aware I was pressing on his injured hand. He had no tenderness, and I concluded his hand was normal. Before he left, I told his mother nothing was broken, for which she thanked me. I did not need to get any comparison views.

As they were leaving the reading room, the boy turned around and said, “OK, Santa, let me hear you say it.”

I looked at him, smiled, and in my deepest voice, I said “Ho! Ho! Ho!”

So, why did my technologist tell the boy they were going to see Santa Claus? Well, at that time, I was about twenty pounds heavier, and like the prototypical Santa Claus, I had a protuberant belly (which did not shake like a bowl of jelly, as per Clement Moore’s poem3). Although I was asked many times if I had ever considered playing Santa, I never did. However, I do recite Moore’s poem (complete with nightshirt and cap) during Christmas concerts my band performs at retirement homes.

Where did Santa Claus come from? Historians agree Santa is a legendary character originating in Western Christian culture who is said to bring

gifts of toys and candy on Christmas Eve to well-behaved children and either coal or nothing to naughty children. Santa is also known as also known as Saint Nicholas, Jolly Old Saint Nick, Father Christmas, Kris Kringle, or Sinterklaas in different parts of the world. The original Saint Nicholas (270–343) was a 4th century bishop of Myra (now Demre, on the Anatolian coast of south central Turkey). Nicholas was known for generously giving gifts to the poor, particularly children. He is also the Patron Saint of children. He is usually portrayed as a bearded bishop in canonical robes, a far cry from the popular images of him.

Father Christmas is the traditional English name for the personification of Christmas. Father Christmas dates back to the reign of Henry VIII, when he was pictured as a large man in green or scarlet robes lined with fur. He typified the spirit of good cheer at Christmas, bringing peace, joy, good food, wine, and revelry.

In the Netherlands and Belgium, Santa is known as Sinterklaas, reflecting his religious origin (St. Nicholas). He is depicted as an elderly, stately and serious man with white hair and a long, full beard. He wears a long red cape over a traditional white bishop’s alb and a sometimes-red stole, a red bishop’s miter and ruby ring. In Germany, he’s known as Kris Kringle, (from Kristkindl – Christ Child) a personification of the baby Jesus who takes the place of Santa Claus in bringing gifts to people on Christmas.

The popular images of Santa derive from Clement Moore’s poem, “A Visit From St. Nicholas 3” (also known as “The Night Before Christmas”) published anonymously in 1823 in

my hometown of Troy, NY. Moore’s poem inspired political cartoonist Thomas Nast to portray Santa, as we now envision him (a jolly fat man in a red suit trimmed with white fur), in an illustration for the January 3,1863, issue of Harper’s Weekly (fig 1). The popular embellishment of the Santa story includes the sleigh, the eight reindeer by name (long before Rudolph became the ninth), the workshop at the North Pole, and the elves, who make the toys.

Figure 2. Haddon Sundblom’s portrayal of Santa Claus for Coca Cola

Santa’s popularity in the United Stated led to the forming of the Fraternal Order of Real Bearded Santas (FORBS) in 1995. This is a professional fraternity for American men who perform as Santa Claus. FORBS members must grow and maintain their own facial hair and agree to promote a positive image of Santa (unlike the drunken Santa in the popular 1983 classic holiday movie “A Christmas Story”). His popularity also resulted in many holiday-themed movies, television specials, and songs.

Figure 1. Thomas Nast’s portrayal of Santa Claus for Harper’s Weekly

The modern depictions of Santa derive from the artwork of Haddon Sundblom (1899–1976) who drew him for The Coca-Cola Company’s Christmas advertising beginning in 1931 and continuing over the next thirty years. Sundblom’s Santa firmly established the larger-than-life, grandfatherly figure as a key icon in American Christmas imagery (fig. 2).

“Miracle on 34th Street” (1947) was the first movie featuring Kris Kringle, as a man who is hired to play Santa at Macys department store. It turns out he really was Santa. The movie was remade in 1994. Santa makes cameo appearances in “A Christmas Story” (1983), “The Santa Clause” (1994), about a man who accidently causes Santa to fall from his roof and die and then must take his place, “Bad Santa” (2003), about two professional thieves who pose as Santa and his helper at a shopping mall with the intention of robbing it at night, and Tim Burton’s “The Nightmare Before Christmas” (1993), about a plot by Halloween ghouls who abduct Santa and take over Christmas. And, on the dark, but delightful side, is the one-act play by

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Carl L. Williams, “The Man Who Shot Santa Claus” (2008), wherein Santa is portrayed as a chronic trespasser and predatory home invader, whose reindeer damage rooftops, as well as an enslaver of elves, who leaves cheap wooden toys and stale hard candy, all the while getting credit for the gifts that parents and relatives buy for the children.

Popular songs include “Santa Claus is Comin’ to Town” (1934), “Rudolph the Red-nosed Reindeer” (1949), both of which became holiday TV specials, “I Saw Mommy Kissing Santa Claus” (1952), and one of my favorites, “Grandma Got Run Over by a Reindeer” (1979).

Is there a Santa Claus? Eight-yearold Virginia O’Hanlon wrote the Editor of the New York Sun in 1897: “Dear Editor, I am 8 years old. Some of my little friends say there is no Santa Claus.

Papa says, “If you see it in The Sun, it’s so.”

Please tell me the truth, is there a Santa Claus?”

Sun editorial writer Francis P. Church responded, “… Yes, Virginia, there is a Santa Claus. He exists as certainly as love and generosity and devotion exist, and you know that they abound and give to your life its highest beauty and joy. Alas! How dreary would be the world if there were no Santa Claus! It would be as dreary as if there were no Virginias. There would be no childlike faith then, no poetry, no romance to make tolerable this existence. We should have no enjoyment, except in sense and sight. The eternal light with which childhood fills the world would be extinguished …1”

So, do you believe in Santa Claus? Most children do. Most adults? Well, I know some believe in him. I certainly do. May your Holiday Season, however you celebrate it, be merry.

References:

1. Church FP. New York Sun, Sept 21, 1897.

2. Daffner RH. Letters to Santa. ACMS Bulletin, Dec 2021, pp 348 – 352.

3. Moore CC. A Visit From St. Nicholas, The Sentinel, Troy, NY 23 Dec 1823.

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Figure 3. Virginia O’Hanlon and Francis P. Church

Dr.Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine and is the author of 9 textbooks. He is also an amateur historian.

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

We are fortunate to have over 2,000 local physicians, residents, and students as part of the ACMS membership. We are grateful for the range of expertise that exists within our membership community and we want to help you share that expertise with the community!

Join the Media List here!

Featured Grant Recipient

Angels’ Place, Inc.

For 38 years single parent families have shaped a pathway to a brighter future for themselves and generations to come. The kind support of the Allegheny County Medical Society Foundation during the 2021 -2022 program year helped Showcase of Scholar families have access to life -changing programming. The Early Childhood Education and Family Support services created opportunities for children to learn and grow alongside their parents.

Support from funders like the Allegheny County Medical Society Foundation was essential to creating brighter futures for two generations. More than ever, high -quality Early Childhood Education and Family Support programming are needed in Allegheny County. Studies compiled in 2020 by Heinz Endowments and reported by WESA, indicate that “the COVID -19 pandemic has led to the loss of up to 15,600 child care spots in Allegheny County, and could push parents of young children out of the workforce if those losses become permanent. ” The U.S. Chamber of Commerce Foundation reported “71% of nonworking poor adults (nationally) with children under the age of 5 cite taking care of home/family as the reason they ’re not in the workforce. ”

Ensuring that families in the Pittsburgh community have access to high -quality child care and family support services remains a focus for Angels ’ Place and are essential to responding to the loss of child care that the region has encountered. Superior child care allows single parents meeting low -income guidelines the ability to pursue their education and career goals.

To Learn More about Angels’ Place Visit: www.angelsplacepgh.org

Donate to the ACMS Foundation to help support annual grants, like the one awarded to Angels’ Place.

In the Battle

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Carl Groth was a key person in the development of liver transplantation. Dr. Thomas Starzl wrote about Groth in his autobiography, “The Puzzle People”. He described him thus, “large by any ethnic standards … his features were strong and primitive. He towered over most adults.” Starzl then reflected on Groth’s childhood in Finland when the Russian army besieged Helsinki in the winter of 1939 and “the resolute Finnish Resistance held the vast Soviet forces at bay”. “Whether these facts are relevant”, Starzl continues “may be debatable but when describing steel, it pays to know what fires have tempered it”. There were many back in 1967 who did not believe liver transplantation was possible. But these two “men of steel” were believers. Their adversary was death. Starzl comments further on Groth, “Once the battle was joined, I wondered more than once whether anyone else saw the symbolism of his constant vigil. Sometimes, the vision was of the sentinel always alert to the circling wolves just beyond the flickering campfire. Or he was a soldier in white, interposed between the invader and his native Finland. No man’s land was the ICU on the third floor of the hospital”. Starzl was no slouch either. He had competed on a very successful football team in high school and had played basketball in high school and college. He served in the U.S. Navy. He was a hiker, a

mountain climber, skied down the Swiss Alps, and he toured across France on a bicycle averaging 100 miles per day. He was a man’s man, as was Groth. This was the stuff that medical pioneers were made of. They were directly or indirectly responsible for saving and improving thousands of lives. But today they would be viewed by some as classic examples of toxic masculinity.

Starzl’s model of the doctor as a soldier in battle with disease and death is now seen as an anachronism by at least a few academics. Some have written that the model needs to be discarded because the patient gets ignored when the focus is on the battle with death and disease. That is hardly the case in my experience and it certainly wasn’t in Starzl’s. He knew all his patients by name and remembered them for decades. Starzl and Groth were intensely focused on getting patients well again. That’s what the war on death and disease was all about and it demanded total commitment to each and every patient in the battle.

The current mantra that is being bantered about in some corners of academia is that way back in the bad old days (prior to about 1990) medicine was dominated by white males. With these white guys came this outdated model of doctors as fighter pilots in a death struggle with the bad guys

(various diseases). That’s not entirely true since they also were fighting for better access to health care. They were fighting for patient’s rights and against insurance companies, big government, and hospital conglomerates that were trying to deny necessary care and discharge patients too early. Ashley Andreou, while a medical student, wrote on this topic and is among those who see the battlefield model as just another example of toxic masculinity in medicine. Toxic masculinity includes (according to Ashley) male dominance, grueling work demands, having to wake up once or multiple times in the middle of the night, 28 hour shifts, and superiors that champion “mental and emotional toughness”. In other words, things that are just hard. Remember that Ashley is part of that generation where for the sake of fairness “everyone gets a trophy”. I wonder what former UPMC Montefiore

Lieutenant Roberto Hero’s

Surgical Chief Mark Ravitch thought about mental and emotional toughness after he operated for 36 straight hours during the Battle of the Bulge. Ashley also somehow links this toxic masculinity in medicine to the killing of George Floyd. There are others with views similar to Ashley’s who believe that real progress will only occur in medicine when such examples of toxic masculinity are put to rest. But is the model that Dr. Ravitch, Dr. Starzl, and Dr. Groth worked under really something that should be described as toxic? Would not a better term be heroic?

In looking at this, let’s first accept that the increased diversity we see in medicine these days is a good thing. But should we totally cast aside a model that has produced some of the finest physicians of the modern era just because it strikes people as being too masculine. In my own medical career, the people who had the greatest impact on modern medicine, the trend setters, were people who some would describe as embedded with toxic masculinity. I prefer to call it heroic medicine and I see these medical innovators as iconic

medical champions. What follows are just a few examples.

Henry T. Bahnson M.D., Professor and Chairman of Surgery at UPMC, seldom walked up the steps in the hospital stair wells. His entourage of medical students and surgical residents gently jogged up those steps to the 3rd, 7th, 12th or whatever floor they were going to. Elevators were off limits for Bahnson and his team. He was a hiker and mountain climber who had scaled some of the most challenging peaks in the Alps and the Himalayas. He also played 4 years of Division One Football at the then all-male Davidson College where he was an All State tackle (playing against the likes of Duke, the Citadel, N.C.State, North Carolina, V.M.I., Wake Forest, and South Carolina). He graduated suma cum laude and was “man of the year” for the class of 1941. Bahnson was a pioneer in the resection of aortic aneurysms and in the surgical correction of cyanotic congenital heart disease. He performed the first heart transplant in Pennsylvania in 1968 and initiated a full scale transplantation program in Pittsburgh with Dr. Thomas Starzl in 1981. That alliance led to UPMC becoming the leading transplant center in the world. Twice he was Pittsburgh’s Man of the Year (1968 and 1983). He was very fit and had both a demanding and an inspiring presence. He calmly

asked hard challenging questions on rounds but he also won the Golden Apple Award for excellence in teaching. Toxic masculinity? Medical School Dean Arthur S. Levine called him “The very soul of our institution”.

Allan Drash,M.D. revolutionized the care of children with diabetes, in fact he wrote a book on it. He described Dennys-Drash syndrome and was the consummate academic pediatrician. His work led to the development of Children’s Hospital and the University of Pittsburgh as the premier center for the study of Type I Diabetes. The team approach for the care of diabetes in children began with Drash. He put in long hours of work and had incredible commitment and energy. His loving wife of many years once said “his whole life was built around trying to help children with diabetes and to reassure parents.” A well-built muscular man who enjoyed weight lifting, Allan once worked as a lumberjack. He had been an Alabama All State high school running back and received a scholarship to play at Vanderbilt in a backfield that had All American, Billy Wade. He served two years in the U.S. Airforce. Drash once wrote to his daughter, “There is nothing more important than to be consumed by a sense of dedication and responsibility to a profession, a calling, that takes one out of one’s own self and into the service of others. It is not the job of medicine that is demanding, but that we are demanding of ourselves.” Toxic masculinity? A former patient of Allan’s put it this way speaking of being diagnosed as a child with diabetes: “It’s this overwhelming shadow of darkness. But we never had that, we had Dr. Drash. In the battle against diabetes, Al Drash was on our side”.

Al Drash as a fullback at Vanderbilt

Joe Maroon as halfback for Indiana University

Then there was Peter Jannetta, M.D., the Chief of Neurosurgery at UPMC and later AGH. Dr. Jannetta was a tall handsome athletic looking man who seemed tireless. He was self-assured without being cocky. He too was a “tough guy”. He had played on the football and lacrosse teams at the University of Pennsylvania. He was also on the Penn swimming team and continued to have an avocation for swimming for many years. When he discovered what is now called the Jannetta procedure for the treatment of trigeminal neuralgia, other surgeons scoffed at him. But Jannetta had the drive, determination, confidence and mental toughness to persist. The Jannetta microvascular decompression procedure is now a standard treatment for several neurovascular compression syndromes. He also served as the Secretary of Health for the Commonwealth of Pennsylvania and while at UPMC, he built what was arguably the best neurosurgery department in the country. It was also a collection of folks that Ashley Andreou and others would likely label as classic examples of toxic masculinity. If so, it may have been the most potent collection of toxic masculinity ever assembled in one department, that’s how incredibly masculine and successful it was.

There was Joseph Maroon, M.D., a pioneer in the transphenoidal approach to pituitary surgery, minimally invasive spinal surgery and sports medicine related to the head and neck. Most of the safety measures that are now used to prevent head and neck injuries in football and other sports were triggered by Dr. Maroon’s work. That’s not surprising because he was a star high school athlete who went on to start at halfback for Indiana in the Big Ten Conference.

Maroon would become the head of the neurosurgery department at West Virginia University before returning to Pittsburgh. In his sixties, he began running, biking and swimming in “Iron Man” competitions. Maroon compared some of his surgical procedures to a religious experience. The chief neurosurgical resident at that time was Dr. Leland Albright, an incredibly calm, focused and steely eyed perfectionist who became the Chief of Neurosurgery at Children’s Hospital of Pittsburgh where he orchestrated many advances in the field of pediatric neurosurgery. Albright was an All American track and field star at Louisiana State University. In 1964, he was the Southeast Conference Champion in the 880. In 1965, he was the NCAA champion in the 600. Leland Albright never complained about a busy schedule or a heavy workload. He had tremendous endurance and confidence. And then there was Dr. Roberto Heros who pioneered the surgical approach to aneuryms at the base of the brain. Heros had movie star good looks and as a young man was one of the best athletes in Cuba. He had to flee Cuba in 1959 because of his opposition to Castro and the communists. He became a lieutenant in the United States Air Force and parachuted into Cuba during the “Bay of Pigs” invasion. Heros and his squad quickly seized their objectives, but eventually ran out of ammunition and were captured. Roberto was imprisoned by the communists for two years. He returned to the USA after being basically ransomed by the Kennedy administration, went to college on a football scholarship, excelled in his studies and eventually became one of the world’s foremost neurovascular surgeons. Dr Paul Nelson was an upper-level neurosurgery resident in those days. He too was a runner and

competed in several grueling Boston Marathons. Mentally tough, always calm, and with great endurance, Paul was yet another neurosurgical trail blazer and a great teacher. He became the chairman of the neurosurgery department at the University of Indiana. Last but not least was 1st year neurosurgical resident, Laligam Sekhar , a brilliant student, came to UPMC from India where he played cricket and tennis. He put in incredibly long hours at the hospital and became one of the world’s wizards of skull base neurosurgery, a department vice-chairman, and a legendary teacher. When he finished his residency at UPMC he took his neurosurgery boards and had the highest score in the country. Basking in all that toxic masculinity obviously helped him. Toxic masculinity? You didn’t hear anything about that when Dr. Jannetta put his big arms around a patient suffering with trigeminal neuralgia and confidently told that person he could fix it or when Roberto Heros clipped an aneurysm and described the moment as “better than an orgasm”.

These men were not just good physicians, they were trail blazers. Every one of them was physically and emotionally a tough guy. Every one excelled in athletic endeavors in which one battles an opponent or the clock. They all made great sacrifices to excel in their fields. Many of them were in the military. They all put in long hours and they all got called in the middle of the night. For them the patient was of paramount importance. I don’t see examples of toxic masculinity in these men. Instead, I see heroic figures practicing heroic medicine, championship medicine. We need more doctors like these icons of the heroic medical model, not less.

Perspective

REFERENCES

Starzl, Thomas E., The Puzzle People , pp. 158-159

Andreou, Ashley, “Unpacking Toxic Masculinity in the Medical Field”, Women’s Media Center October 23, 2020.

Starzl, Thomas E., “ Henry T. Bahnson M.D. 1920-2003”, Annals of Surgery volume 237, no.4, 591-592.

Bahnson MD, Robert, “Remembering Hank”, https://bulletin.facs.org/2014,May

Stavesnick, C., “We had Dr. Drash” , Pitt Med Magazine Spring 2020, pages 18-20.

Wuycheck, Diane C., “A Revolution in Neurosurgery: The Jannetta Procedure”, A Tradition of Leadership, Innovation and Caring: A History of Medicine in Pittsburgh and Allegheny County, pp. 75-76, Legacy Publishing Co.

David M.D., FAANS, Carlos A., “Military Faces of Neurosurgery-A Hero so Named”, https://www.neurosurgeryblog. org/2016/04/18/military

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

Leland Albright as a track star at LSU

Henry Bahnson

Joe Maroon running the ball for Indiana University

Prior Authorization Reform–What is Act 146 and What Does it Mean for Physicians?

saRa hussey, mBa, Cae—aCms exeCutive DiReCtoR

On November 3, 2022, Pennsylvania Gov. Tom Wolf signed PA Senate Bill 225 into law as Act 146. This new law does not eliminate prior authorization, but it does aim to streamline the prior authorization process. It provides parameters that govern the relationships between patients, providers, and insurers for health care coverage decisions.

Pennsylvania will now join 44 states that already have external review authority. In addition, the new law also lays out standards for the review of prior authorization requests and confirms in state law that there may be no prior authorization for emergency services, consistent with the Federal No Surprises Act.

When it comes to legislation, you might feel overwhelmed as soon as you start to dig into a new bill or law. Having that legislation broken down into simpler, bite-sized pieces can be helpful in understanding the breadth of its impact. With the help of the legislative team at PAMED, I’ve created a summary of some of the main components of Act 146.

What is Act 146?

At its core, the legislation streamlines the prior authorization process, improving the sequence of events, ending with a quick and timely turnaround to move patient care forward.

Phase 1—Begins January 2023

Meet the New Provider Portal: Within 18 months of the effective date (01/2023) of this specific section of Act

146, insurers/MA/CHIP are required to have established a provider portal on their publicly accessible website that includes electronic submission of prior authorization requests, access to applicable medical policies, information regarding how to request a peerto-peer review, contact information for the insurer’s relevant clinical or administrative staff, and instructions for submission of prior authorization requests if the portal is unavailable for any reason. Within six months following the establishment of a provider portal the insurer/MA/CHIP shall make access to training available to health care providers and their staff on the use of the portal. This is Section 2153 of Act 146 and it is the first section that will go into effect. The rest of Act 146 will go into effect January 2024.

Phase 2—January 2024

Closely Related Procedures: Act 146 will allow physicians to bill insurance companies for “closely related procedures”. This means that if a patient is getting care for an already covered issue, and the doctor identifies a condition that could lead to future complications, the doctor can address the condition immediately without having to get second authorization for a service.

Emergency Services: Section 2116 of Act 146 states that insurers/ MA/CHIP can’t require a health care provider to submit a request for prior authorization for an emergency service. Step Therapy: Act 146 will create a basic framework for step therapy requirements. If an insurer/MA/

CHIP has a medical policy that includes step therapy criteria for a prescription drug it must include, as part of its prior authorization process, a request for an exception to its step therapy criteria. A request for an exception shall be evaluated based on the covered person’s individualized clinical condition and consider contraindications, clinical effectiveness of required prerequisite drugs, expected clinical outcomes of the requested drug and whether the required step therapy criteria has already been satisfied under a previous insurer.

Minimum Qualifications for Independent Review Organizations –AKA “Peer Review”:

Clinical reviewers assigned to conduct external reviews must be a physician or other appropriate health care provider who has expertise in the treatment of the covered person’s condition, is knowledgeable about the recommended health care service, is board-certified in the area of medicine appropriate to the subject of the review and has no history of disciplinary action.

Prior Authorization Review: This section – Section 2155 as it’s formally known – encompasses a good portion of Act 146. The team at PAMED was kind enough to share their overall analysis of this new law, which includes a deep dive into Section 2155.

Use the QR code below to access the full summary of Section 2155 (requires member login).

A Quick Plug for PAMED and PAMPAC

Advocacy is one of the biggest, if not THE biggest benefit, of membership in your professional association. As a member of PAMED and the ACMS, you help our organizations have strength in numbers. We need physicians helping the decision makers in Harrisburg understand what you do in your workplace and why it’s important. The larger the group, the louder the voice, and the more your contribution will be known. If you are not a member of

PAMED/ACMS, I encourage you to join and have your voice heard. If you are a current member, you might consider a contribution to Pennsylvania Medical Political Action Committee (PAMPAC), the political arm of the Pennsylvania Medical Society.

The passage of Act 146 into law is a direct result of the work of your professional association and I implore you to consider how you can get involved in what comes next.

For questions on legislation, you can contact the PAMED’s Government Relations Team at govtrelations@ pamedsoc.org

Society News

The Pittsburgh Ophthalmology Society, under the leadership of President Marshall W. Stafford, M.D. is pleased to announce the 58th Annual Meeting and the 43rd Meeting for Ophthalmic Personnel is scheduled for March 10, 2023. Both meetings will take place at the Omni William Penn Hotel in Pittsburgh, PA. We look forward to offering an engaging and robust experience for attendees and exhibitors in a welcoming environment in which to learn and gather.

Registration begins January 26, 2023 with POS members and ophthalmic personnel attendees receiving information by email and mail.

The Society is honored to welcome Leon W. Herndon, Jr., MD, as the 42nd Annual Harvey E. Thorpe Lecturer. He is a Professor of Ophthalmology, Duke University Medical Center, Durham, North Carolina. He is a member of the American Academy of Ophthalmology (AAO) and was

a member of the first class of the Leadership Development Program. He has authored over 100 peer-reviewed papers, lectured nationally and internationally, and has participated in several research projects related to glaucoma. He currently serves as Chief of the Glaucoma Division at the Duke University Eye Center where he has trained 84 clinical fellows. Dr. Herndon has been recognized for his service in the community by receiving the Senior Achievement Award from the AAO and the Dedicated Humanitarian Service Award. He is the recipient of the Distinguished Medical Alumnus Award from the UNC School of Medicine and was the Surgery Day Lecturer at the American Glaucoma Society Annual Meeting in 2019. He was named to the 2021 Newsweek America’s Best Eye Doctors list (#27). He is founder of the North Carolina Glaucoma Club, and the chair of the Glaucoma Clinical Committee of the American Society of Cataract and Refractive Surgeons as well as Vice President of the American Glaucoma Society.

Participating distinguished guest faculty include:

Philip Custer, MD, FACS— Professor, Ophthalmology and Visual Sciences, John F. Hardesty, MD, Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO.

Tom Oetting, MS, MD—Clinical Professor, Rodolfo N. Perez Jr., MD, and Margaret Perez Professor in Ophthalmology Education, Ophthalmology

Residency Program Director, Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, IA.

Michelle Pineda, MBA Risk Management Specialist, Ophthalmic Mutual Insurance Company (OMIC).

Ophthalmology Society. Dr. Sahel is Honoris Causa doctorate of University of Geneva and held the Technological Innovation Chair at the Collège de France (2015-2016). He is a member of several Editorial Scientific Advisory Boards, including Science Translational Medicine.

For more information on the Annual meeting please visit the POS website at www.pghoph.org or contact Nadine Popovich, Administrator at npopovich@acms.org or to 412.321.5030 x110.

José Alain-Sahel, MD— Distinguished Professor and Chairman; The Eye and Ear Endowed Chair Department of Ophthalmology; Director, UPMC Eye Center University of Pittsburgh School of Medicine Pittsburgh, PA. Dr. Sahel is a clinicianscientist conducting research on vision restoration focusing on cellular and molecular mechanisms underlying retinal degeneration, and development of treatments for currently untreatable retinal diseases. He co-authored over 660 peer-reviewed articles and 40 patents. Dr. Sahel is recipient of numerous awards including the Foundation Fighting Blindness (FFB) Trustee Award, Alcon Research Institute Award for Excellence in Vision Research, Grand Prix NRJNeurosciences-Institut de France, Foundation Fighting Blindness Llura Liggett Gund Award, CharpakDubousset Award, Médaille Grand Vermeil, Ville de Paris. He was elected to the: Academia Ophthalmologica Internationalis, Académie des Sciences-Institut de France, German National Academy of Sciences Leopoldina, National Academy of Technologies of France, Association of American Physicians and American

43rd Annual Meeting for Ophthalmic Personnel

The 43rd Annual Meeting for Ophthalmic Personnel, presented by the Pittsburgh Ophthalmology Society (POS), will run concurrently with the POS Annual Meeting Friday, March 10, 2023. Application to IJCAHPO has been submitted for attendees to earn a maximum of 7 credit hours.

Course directors Pamela Rath, MD; Avni Vyas, MD; Cari Lyle, MD; and Zachary Nadler, MD, PhD; have prepared an exceptional educational offering for Ophthalmic staff.

Highlights of the course include presentations on Glaucoma, Cornea, Oculoplastic, and a refractive session to include a hands-on component.

The conference provides exceptional educational opportunities for ophthalmic personnel in and around the region and continually attracts well-respected local faculty, who present relevant and quality instruction through numerous breakout sessions. Thank you to POS members who accepted the invitation to present lectures.

On-line registration begins January 26, 2023, www.pghoph.org. Contact Nadine Popovich, administrator, for details and more information at npopovich@acms.org.

31st Annual Virtual Clinical Update in Geriatric Medicine

The 31st Annual Clinical Update in Geriatric Medicine will be held virtually on March 23-24, 2023. Presented by the Pennsylvania Geriatrics Society − Western Division (PAGS-WD), UPMC/ University of Pittsburgh Aging Institute and the University of Pittsburgh School of Medicine Center for Continuing Education in Health Science, the conference provides an evidence-based approach to help clinicians take exceptional care of elderly patients. The virtual offering includes an outstanding agenda of lectures and panel discussions, including live question-and-answer sessions, vendor halls and opportunities to engage in conversations with speakers, exhibitors, and fellow attendees.

With the fastest-growing segment of the population comprised of individuals more than 85 years of age, this conference is a premier educational resource for healthcare professionals involved in the direct care of older people. As the recipient of the American Geriatrics Society State Achievement Award for Innovative Educational Programming, the Clinical Update attracts prominent national and international lecturers and nationally renowned local faculty. Continuing Medical Education credits are available to participants.

Course Directors, Shuja Hasan, MD; Neil Resnick, MD; and Lyn Weinberg, MD, along with the planning committee, are delighted to welcome distinguished guest faculty Edward R.

Marcantonio, MD, SM. Dr. Marcantonio is the Section Chief for Research in the Division of General Medicine at Beth Israel Deaconess Medical Center, and Professor of Medicine at Harvard Medical School. Dr. Marcantonio is an internationally recognized clinical investigator and thought leader in delirium research who has led more than 15 major observational and intervention studies designed to improve the diagnosis of delirium, target individuals at risk, identify modifiable risk factors, and test intervention strategies to reduce the incidence, severity, and duration of delirium. Dr. Marcantonio will present: “An Update in Delirium.”

Paula Leslie, FRCSLT, Reg HCPC, CCC-SLP will be joining us this year from the UK and is clinically licensed in the USA and UK where she is a Professional Adviser to the Royal College of Speech and Language Therapists. She is the academic author of the 2021 RCSLT National Pre-registration Competencies in Eating, Drinking, and Swallowing. Dr. Leslie will present Modern Approaches to Supporting People with Eating, Drinking, & Swallowing Impairments To view the complete conference agenda and details on registration, please visit: https://dom. pitt.edu/ugm/. Registration begins late January. Members of the PAGS-WD receive a discount when registering. To check on your membership status, please contact Eileen Taylor at etaylor@acms.org

Paula Leslie, FRCSLT, Reg HCPC, CCC-SLP

Edward R. Marcantonio, MD, SM

Efgartigimod Alfa-fcab (Vyvgart™): First in A New Class of Medications for Myasthenia Gravis

aRDen Kalsey, PhaRmD CanDiDate tuCKeR FReeDy, PhaRmD, BCPs

Myasthenia gravis is a rare autoimmune disease of the neuromuscular junction marked by painless, fatigable weakness of striated muscles. The pattern of muscle involvement varies between patients, but most commonly patients present with eyelid drooping or double vision. Other symptoms like weakness of the facial muscles, respiratory muscles, limbs, difficulty speaking, swallowing, and chewing can occur. This can lead to further complications like respiratory failure, aspiration pneumonia, falls, and muscle atrophy. Currently, the prevalence in the US is estimated at 14.2 cases per 100,000 people.1 The highest incidence of generalized myasthenia gravis (gMG) occurs in men > 50 years old, with a peak incidence at age 70. Women have a peak at ages 20-40, then another peak at age 70.1

In generalized myasthenia gravis the majority of patients (about 80-90%) will have antibodies against skeletal muscle postsynaptic acetylcholine receptors (AChRs).1,2 These antibodies alter the function of AChRs, promote degradation of the receptors, which then leads to destruction of the postsynaptic surface through complement activation. Because of this, muscle action potentials are unable to be generated because of the decreased number of functioning AChRs. It is thought that when the number of receptors is reduced to ≤ 30 percent from baseline, this is when the symptomatic effects of gMG are seen.1

Currently, there is no cure for gMG, however, the goal of therapy in gMG is to render patients minimally symptomatic or better while minimizing side effects from treatment. The initial therapy for most

patients with mild to moderate MG is an acetylcholinesterase (AChE) inhibitor, usually pyridostigmine, which can be used long term. However, acetylcholinesterase inhibitors provide only symptomatic control and are usually not sufficient alone in gMG. Importantly, no single pyridostigmine dosing schedule fits all patients. Some patients require dosing as frequently as every 3–4 hours while awake.3 When a patient has significant persistent weakness despite the use of pyridostigmine in sufficient doses, or the side effects preclude effective dosing, then immunotherapy is generally warranted. Glucocorticoids are typically the first-line immunotherapy. Many patients with gMG require addition of a nonsteroidal immunotherapeutic agent, such as azathioprine, for maintenance therapy if they are unable to tolerate or to limit long-term steroid toxicities. Alternative immunosuppressive agents like mycophenolate mofetil, methotrexate, or cyclosporine, can also be used. It is important to note that ~10 percent of patients with gMG are refractory to these immunosuppressive agents or are limited by their specific toxicities.1

In these refractory gMG patients, treatment strategies may include monoclonal antibody therapies, such as rituximab and eculizumab. The last type of treatment for gMG is intravenous immune globulin (IVIG) or plasma exchange. These therapies are generally reserved for either severe gMG or for patients experiencing a myasthenic crisis.1

However, as of December 17, 2021, a new drug, efgartigimod alfa-fcab (Vyvgart™) hit the market. This medication is the first FDA-approved neonatal Fc receptor (FcRn)

blocker - a new class of medication, for adults with gMG who test positive for the anti-AChR antibody. Efgartigimod alfa is a human IgG1 derived antibody fragment that binds to the neonatal Fc receptor, to reduce the circulating IgG and abnormal number of antibodies that attack acetylcholine receptors at the neuromuscular junction and cause weakness in skeletal muscles.3,4

The ADAPT trial5 tested the efficacy of efgartigimod alfa for the treatment gMG in adults who are AChR antibody positive in a 26-week, multicenter, randomized, double-blind, placebo-controlled trial.3 The trial enrolled 167 patients (≥18 yo) with gMG with or without AChR antibodies. Patients had Myasthenia Gravis Foundation of America (MGFA) class II to IV disease; a Myasthenia Gravis Activities of Daily Living (MG-ADL) total score of at least 5 (with > 50 percent of the score due to non-ocular symptoms) and were receiving a stable dose of at least 1 treatment for gMG (ie., AChE inhibitor, corticosteroid, nonsteroidal immunosuppressant therapy) before screening and throughout the trial. Exclusion criteria included treatment with rituximab or eculizumab within the previous 6 months; thymectomy within the previous 3 months; treatment with IVIG or plasma exchange within the previous month; hepatitis B, hepatitis C, or HIV; serum IgG level less than 6 g/L; or pregnancy. Of the 167 patients enrolled, 129 (77 percent) were AChR antibody positive.5

Patients were randomized 1:1 to treatment with efgartigimod alfa 10 mg/ kg or placebo administered once weekly for 4 weeks (1 cycle). Randomization

was stratified by AChR antibody status, nonsteroidal immunosuppressant therapy, and Japanese nationality. All patients received 1 treatment cycle; subsequent cycles were administered based on clinical response (ie., when MG-ADL score was ≥ 5 [with at least 50 percent of the score due to non-ocular symptoms]. Subsequent cycles could begin no sooner than 8 weeks from the start of the previous cycle, meaning a maximum of 3 cycles was possible during the 26-week study. At the end of the study, the number of treatment cycles received was 1 in 25 percent and 31.3 percent of the efgartigimod alfa and placebo groups, respectively; 2 in 66.7 percent and 65.1 percent, and 3 in 8.3 percent and 3.6 percent.5 In the 44 responders in the efgartigimod alfa group, onset of response occurred by week 2 in 37 (84 percent) patients; duration of response was 6 to 7 weeks in 14 (32 percent) patients, 8 to 11 weeks in 10 (23 percent) patients, and 12 weeks or longer in 15 (34 percent) patients.5

The primary efficacy end point was to compare the proportion of patients who achieved MG-ADL response (defined as at least a 2-point reduction in total MGADL score compared to treatment cycle baseline that was sustained for at least 4 consecutive weeks, with the first reduction occurring no later than 1 week after the last infusion of the cycle) in cycle 1. 68 percent (44 of 65) of patients in the efgartigimod alfa group and 30 percent (19 of 64) in the placebo group responded (odds ratio [OR], 4.95 [95 percent CI, 2.21 to 11.53]; P<0.0001). The secondary endpoint focused on the proportion of patients who achieved a clinically meaningful improvement in the Quantitative Myasthenia Gravis scale (QMG) score (defined as at least a 3-point reduction) in cycle 1. 63 percent of patients in the efgartigimod alfa group and 14 percent in the placebo

group achieved this response (OR, 10.84 [95 percent CI, 4.18 to 31.2]; P<0.0001). Additional secondary endpoints evaluated the proportion of patients who achieved early (onset by week 2) MG-ADL response in cycle 1, with 57 percent of patients in the efgartigimod alfa group and 25 percent patients in the placebo group seeing this response.5

A long-term, open-label extension study designed to evaluate the safety and tolerability of efgartigimod alfa in patients with gMG is ongoing, with an estimated study completion date of June 2023.3

Efgartigimod alfa is administered as a 1-hour IV infusion in treatment cycles. It should only be administered by a qualified healthcare professional. For adults weighing < 120 kg, administer 10 mg/ kg IV infusion once weekly for 4 weeks. For adults weighing > 120 kg, administer a maximum of 1200 mg IV infusion once weekly for 4 weeks. Administration of subsequent treatment cycles is based on clinical evaluation. Time between treatment cycles should be no sooner than 50 days. The average time between treatment cycles during clinical trials was approximately 10 weeks. If a scheduled infusion is missed, it may be administered up to 3 days after the scheduled time point. Thereafter, resume the original dosing schedule until the treatment cycle is completed. Efgartigimod alfa must be diluted prior to administration. Dilute the withdrawn efgartigimod alfa solution in an infusion bag with sodium chloride 0.9 percent injection to make a total volume of 125 mL. Patients should be monitored during administration and for 1 hour after the infusion for signs and symptoms of hypersensitivity reactions.6

Efgartigimod alfa exhibits linear pharmacokinetics. Volume of distribution is 15-20 L and terminal half-life is 80-120 hours. Efgartigimod alfa is expected to undergo metabolism by proteolytic enzymes into small peptides and amino acids. Following administration of a single IV dose

of efgartigimod alfa 10 mg/kg to healthy participants, less than 0.1 percent of the dose was recovered in urine.3,6

Pharmacokinetics of efgartigimod alfa have not been evaluated in patients with moderate to severe renal impairment. A population pharmacokinetics analysis of data from efgartigimod alfa clinical studies showed drug exposure was increased 22 percent in patients with mild renal impairment (estimated glomerular filtration rate 60 to 89 mL/min/1.73 m²) compared to patients with normal renal function. Pharmacokinetics of efgartigimod alfa have not been evaluated in patients with hepatic impairment. Hepatic impairment is not expected to affect the pharmacokinetics of efgartigimod alfa.3,6

Efgartigimod alfa’s safety and efficacy profile was established in the ADAPT trial.5 In this study, most adverse reactions were mild or moderate in severity. Severe adverse reactions occurred in 11 percent of patients who received efgartigimod alfa and 10 percent of patients who received placebo. Adverse reactions related to infection occurred in 46 percent of patients in the efgartigimod alfa group and 37 percent of patients in the placebo group. Three serious adverse events related to infection occurred, influenza and pharyngitis in the efgartigimod alfa group and upper respiratory tract infection in the placebo group. Infusion-related reactions occurred in 4 percent of the efgartigimod alfa group and 10 percent of the placebo group; all were mild in severity.5

During the ADAPT trial, 77 percent of patients who received efgartigimod alfa and 84 percent of patients who received placebo had a treatment-emergent adverse event. The most common adverse reactions in patients receiving efgartigimod alfa were respiratory tract infection, headache, urinary tract infection, paresthesia, and myalgia.5,6 Monitor for clinical signs and symptoms of infection during treatment with efgartigimod alfa.6

Materia Medica

Studies evaluating immunization with vaccines during efgartigimod alfa treatment have not been conducted. The safety of immunization with live or live-attenuated vaccines and the response to immunization with any vaccine are unknown. Because efgartigimod alfa is associated with a decrease in IgG levels, administration of live or live-attenuated vaccines is not recommended during treatment. Clinicians should evaluate the need for administration of age-appropriate vaccines according to immunization guidelines prior to starting a new treatment cycle of efgartigimod alfa.6

Hypersensitivity reactions (e.g., rash, angioedema, dyspnea) have occurred with efgartigimod alfa. Reactions were mild or moderate in severity, occurred within 1 hour to 3 weeks of administration, and did not lead to discontinuation of efgartigimod alfa treatment. Patients should be monitored for 1 hour after administration for clinical signs and symptoms of hypersensitivity reactions. If a hypersensitivity reaction occurs during administration, the efgartigimod alfa infusion should be stopped and appropriate supportive measures should be initiated.6

No formal drug interaction studies have been performed with efgartigimod alfa. It is not metabolized by CYP-450 enzymes; therefore, interactions with agents that are substrates, inducers, or inhibitors of CYP-450 enzymes are unlikely.6 Use of efgartigimod alfa with agents that bind to FcRn (e.g., immunoglobulins, monoclonal antibodies, antibody derivative containing the human Fc domain of IgG) may decrease systemic exposure of these medications and reduce effectiveness. Closely monitor for reduced effectiveness of these medications if efgartigimod alfa is used concomitantly. If concomitant long-term use of agents that bind to FcRn is unavoidable, consider discontinuing efgartigimod alfa and using alternative therapies.6

There is no data on the use of efgartigimod alfa during pregnancy in humans. However, when administering very high doses of efgartigimod alfa (100 mg/kg/day) to pregnant rabbits and rats in animal studies, no adverse outcomes were observed. Because there is limited data the risk vs benefits of use during pregnancy should be weighed. Also, efgartigimod alfa was not studied in lactating women and children while on efgartigimod alfa, but maternal IgG is known to be present in human breast milk.3,6

It is estimated that efgartigimod alfa IV solution (400 mg/20 mL) will cost around $7,140 per (400 mg/20 mL) vial.3 For an 80 kg patient, this means that for one infusion a patient would require 2 vials or approximately $14,280 per weekly infusion and $57,120 for 1 cycle.3

Conclusion

Generalized myasthenia gravis is a rare condition that is not fully understood and for which there is no cure. Current therapies should be individualized based on symptom control and other functional limitations but are often limited by unfavorable adverse effects. Efgartigimod alfa is indicated for the treatment of generalized myasthenia gravis in adults who are anti-AChR antibody positive. It has a novel mechanism of action involving selective IgG reduction through FcRn blocking and data from the phase 3 clinical trial suggest that it is an effective and well-tolerated treatment. Acetylcholinesterase inhibitors and other immunosuppressive agents will still be used as initial therapy but efgartigimod alfa can be a beneficial option for patients who do not respond adequately on these first-and second-line treatment options.

References:

1. Myasthenia Gravis. IBM Micromedex. https://www-micromedexsolutionscom. authenticate.library.duq.edu/ micromedex2/librarian/CS/763FD8/ ND_PR/evidencexpert/ ND_P/evidencexpert/ DUPLICATIONSHIELDSYNC/22C916/ ND_PG/evidencexpert/ND_B/ evidencexpert/ ND_AppProduct/evidencexpert/ ND_T/evidencexpert/PFActionId/ evidencexpert.DoIntegratedSearch? SearchTerm=Myasthenia%20 gravis&UserSearchTerm=Myasthenia%20 gravis&SearchFilter=filt erNone&navitem=searchALL#. Accessed September 5, 2022.

2. Heo, Young-A. Efgartigimod: First Approval. Drugs 2022:82:341-348.

3. Lexicomp. Efgartigimod Alfa (Lexi-Drugs). Wolters Kluwer. Updated October 27, 2022. Accessed November 30, 2022.

4. Vyvgart New Drug Fact Blast - Missouri. https:// dss.mo.gov/mhd/cs/advisory/rdac/pdf/ vyvgartblast.pdf. Accessed September 5, 2022.

5. Howard JF Jr, Bril V, Vu T, et al. Safety, efficacy, and tolerability of efgartigimod in patients with generalised myasthenia gravis (ADAPT): a multicentre, randomised, placebocontrolled, phase 3 trial [published correction appears in Lancet Neurol. 2021 Aug;20(8):e5]. Lancet Neurol. 2021;20(7):526-536. doi:10.1016/S1474-4422(21)00159-9

6. Vyvgart. Prescribing Information. Argenx; 2021. https://www.argenx.com/product/ vyvgart-prescribinginformation.pdf. Accessed September 5, 2022.

Ms. Kalsey is a Doctor of Pharmacy candidate at Duquesne University School of Pharmacy. Dr. Freedy is a Clinical Pharmacy Specialist in Medicine and Drug Information at Allegheny Health Network, Allegheny General Hospital. For any questions concerning this article, please contact Dr. Freedy at the Allegheny Health Network, Allegheny General Hospital, Center for Pharmaceutical Care, Pittsburgh, PA. (412) 359-3192 or email tucker.freedy@ahn.org

Election Report

Election Report ACMS Board of Directors and Delegates

ACMS Board of Directors and Delegates December 1, 2022

Election Report

ACMS Board of Directors and Delegates December 1, 2022

December 1, 2022

The Allegheny County Medical Society conducted its election from October 28, 2022, to November 11, 2022. The following are the official results of the election:

The Allegheny County Medical Society conducted its election from October 28, 2022, to November 11, 2022. The following are the official results of the election:

The Allegheny County Medical Society conducted its election from October 28, 2022, to November 11, 2022. The following are the official results of the election:

Chair: Peter G. Ellis, MD (Immediate Past-President)

Chair: Peter G. Ellis, MD (Immediate Past-President)

Chair: Peter G. Ellis, MD (Immediate Past-President)

President: Matthew B. Straka, MD

President: Matthew B. Straka, MD

President: Matthew B. Straka, MD

President-Elect: Raymond E. Pontzer, MD

President-Elect: Raymond E. Pontzer, MD

President-Elect: Raymond E. Pontzer, MD

Secretary: Keith T. Kanel, MD

Secretary: Keith T. Kanel, MD

Treasurer: William F. Coppula, MD

Treasurer: William F. Coppula, MD

Secretary: Keith T. Kanel, MD Treasurer: William F. Coppula, MD

Elected to Board of Directors:

Elected to Board of Directors:

Elected to Board of Directors:

Three-Year Term (Term Ends 2025) Two-Year Term (Term Ends 2024) Anuradha Anand, MD G. Alan Yeasted, MD Amber Elway, MD

Three-Year Term (Term Ends 2025) Two-Year Term (Term Ends 2024) Anuradha Anand, MD G. Alan Yeasted, MD Amber Elway, MD

Three-Year Term (Term Ends 2025) Two-Year Term (Term Ends 2024)

Anuradha Anand, MD G. Alan Yeasted, MD Amber Elway, MD

Mark Goodman, MD One-Year Term (Term Ends 2023) Elizabeth Ungerman, MD Michael Matean Aziz, MD Alexander Yu, MD Micah A. Jacobs, MD

Mark Goodman, MD One-Year Term (Term Ends 2023)

Elizabeth Ungerman, MD Michael Matean Aziz, MD Alexander Yu, MD Micah A. Jacobs, MD

Mark Goodman, MD One-Year Term (Term Ends 2023) Elizabeth Ungerman, MD Michael Matean Aziz, MD Alexander Yu, MD Micah A. Jacobs, MD

Board Members Currently Serving:

Board Members Currently Serving:

Board Members Currently Serving: Term Expires in 2023

Term Expires in 2023

Term Expires in 2024

Term Expires in 2024

Term Expires in 2023

Bruce A. MacLeod, MD

Term Expires in 2024

Douglas F. Clough, MD

Bruce A. MacLeod, MD Douglas F. Clough, MD Amelia A. Pare, MD Kirsten D. Lin, MD Adele Towers, MD Jan W. Madison, MD Raymond J. Pan, MD

Amelia A. Pare, MD Kirsten D. Lin, MD Adele Towers, MD Jan W. Madison, MD Raymond J. Pan, MD

Bruce A. MacLeod, MD Douglas F. Clough, MD Amelia A. Pare, MD Kirsten D. Lin, MD Adele Towers, MD Jan W. Madison, MD Raymond J. Pan, MD

2023 Peer Review Board – Last 3 Immediate Past Presidents*

2023 Peer Review Board – Last 3 Immediate Past Presidents

2023 Peer Review Board – Last 3 Immediate Past Presidents

Patricia L. Bononi, MD (Chair)

Peter G. Ellis, MD (Chair)

Peter G. Ellis, MD (Chair)

William K. JohnJulio, MD Robert C. Cicco, MD

Patricia L. Bononi, MD William K. JohnJulio, MD

Patricia L. Bononi, MD William K. JohnJulio, MD

*A member of the Peer Review Board cannot be an active member of the ACMS Board of Directors.

ACMS Delegates

Elected – Two-Year Term 2023-2024

Michael M. Aziz, MD

Currently Serving (Not Up for Election)

Niravkumar Barot, MBBS, MPH

Vint R. Blackburn, MD Weston F. Bettner, MD

William F. Coppula, MD Colleen A. Carignan, MD

Patricia L. Dalby, MD

Richard A. Fortunato, DO

Mark A. Goodman, MD

Richard B. Hoffmaster, MD

Amber R. Elway, DO Micah A. Jacobs, MD

Lawrence R. John, MD Keith T. Kanel, MD

Abigail A. Palmer, DO Bruce A. MacLeod, MD

Joseph C. Paviglianiti, MD

Jan W. Madison, MD

Michael M. McDowell, MD Raymond J. Pan, MD

Angela M. Stupi, MD Nadia K. Sundlass, MD Adele L. Towers, MD Matthew A. Vasil. MD

ACMS Alternate Delegates

Elected – One Year Term 2023

Douglas F. Clough, MD

Marilyn S. Daroski, MD

Anthony L. Kovatch, MD

James T. McCormick, DO

Stephen N. Fisher, MD Stacie M. McKnight, MD

Michael S. Hu, MD Devon M. Ramaker, MD

Jasbir S. Kang, MD Rajiv R. Varma, MD

Alexandra M. Johnston, DO Alexander Yu, MD

The ACMS Board of Directors congratulates all the newly elected officers, board members, and delegates. We look forward to your active participation as we continue our mission for the Society. Thank you for your dedication to our profession.

Raymond E. Pontzer, MD Chair, Nominating Committee

2022 Nominating Committee

Raymond E Pontzer, MD – Nominating Committee Chair

James W. Boyle, MD Adele L. Towers, MD

Amber L. Elway, MD Matthew A. Vasil, MD

Jan W. Madison, MD G. Alan Yeasted, MD

Legal Summary

2023 Physicians Medicare Reimbursement Cut and New Shared Service Rules

2. Malpractice expense units

3. Practice overhead units

The Centers for Medicare and Medicaid Services (CMS) issued the “final rule” https://www.cms.gov/ newsroom/fact-sheets/calendaryear-cy-2023-medicare-physicianfee-schedule-final-rule for the 2023 Medicare Physician Fee Schedule on November 1, 2022. The document is almost 3,000 pages long, and covers countless topics in exhaustive detail, but for purposes of this article we are going to focus on just two:

1. The physician pay cut imposed by the Medicare Conversion Factor reduction, and

2. The final shared/split service billing rules.

Physician Pay Cut

As most of you already know, Medicare physician payments are primarily based on the relative value units assigned to each Medicare covered service by CMS, i.e.:

1. Work relative value units (WRVUs)

The units are added together and multiplied by the Medicare conversion factor, i.e., a dollar value determined by CMS to arrive at the total payment for each service. Just as an aside, for productivity purposes, most employers and hospital systems measure productivity based on just the WRVUs, excluding the other two components.

The WRVU system was implemented by CMS in 1992, and it has always contained a mechanism for determining total Medicare payments. Since that time, there has been a constant struggle to control the total Medicare physician expenditures within a budget risk corridor, and the governing factor was the Sustainable Growth Rate (SGR) budget process, which was designed to decrease the dollar value of the conversion factor if physician volume exceeded the budget projections and increase the conversion factor if total volume was below the corridor parameters.

As might be expected, once each service was paid based totally on volume, then volume increased faster than projected, especially when hospital systems began mandating WRVU productivity thresholds and paying incentives and bonuses based upon WRVU production. The ever increasing expense is one of the reasons many systems are now continuing to quality-based payments rather than pure volume-based payments.

Some of you may recall the almost constant annual battle in which Congress postponed the impending physician fee schedule cut, because of the unacceptable reductions baked into the Sustainable Growth Rate formula. The annual decisions to postpone the required SGR reductions resulted in ballooning future pay cuts. The SGR was finally repealed in 2015, at which time the projected pay cut would have been 27.4 percent, and replaced by a new formula designed to pay productivity incentives when combined with identified quality factors.

However, the budget sequesters mandated by the 2010 Statutory PayAs-You-Go-Act (PAYGO) coupled with the impact of the passage of the $1.9 Trillion COVID-19 relief package in the American Rescue Plan has raised new problems.

For 2023, CMS is proposing a decrease in the conversion factor from $34.61 per unit to $33.06 per unit; this is a reduction of $1.55 per WRVU, which is approximately a 4.5 percent decrease, across the board for all specialties. CMS attributes the reduction to a combination of the “statutorily required CY 2023 update of 0 percent” and the expiration of last year’s “5 percent stopgap” measure.

Just as in past years, organized medicine is lobbying lawmakers to postpone these reductions. The AMA immediately issued a statement labeling across-the-board reductions as an “ominous reality”. However, as already demonstrated by past experience, simply postponing the

miChael a. CassiDy, esquiRe

Legal Summary

reductions only exacerbates the future reckoning. Repealing SGR in 2015 was touted as the “permanent fix”.

Shared or Split Service Billing

CMS first proposed to recognize split E&M visits in facility settings, when part of the service is performed by both a physician and a non-physician practitioner (NPP) who are both of the same group, in July of 2021. Although CMS delayed the implementation of this rule for 2022, the 2023 Medical Physician Fee Schedule (MPFS) proposes to implement the shared visit billing for 2023 and thereafter.

The essence of the rule is that an E&M visit in a facility is to be billed as performed by the practitioner, i.e., either MD or NPP, who provided the substantive portion of the service, and the responsible billing entity can choose to define substantive performance based upon either (1) time or (2) the practitioner that performed the medical decision making, the physical exam, or the history and physician, based upon whichever of those components selected by the billing entity as the indicator of the substantive portion.

Note that this applies only in facility settings; billing in the office setting allows 3 separate circumstances in which shared services might occur:

1. By the physician when performed by the physician,

2. By the physician and any other qualified person in the physician’s

office if performed in accordance with the incident to rules, i.e. the physician is physically present in the office to supervise and take over the care of the case if necessary, and

3. By a nurse practitioner or physician assistant at 85% of the physician fee schedule.

Physicians employed by systems which also provide NPP coverage, as most do, must be aware of the impact on their individual productivity when the system elects to be facility E&M services as if performed by the NPP. Furthermore, the shared service rules ostensibly require that physicians and NPPs practicing in facilities must be treated as being in the same group in order to provide and bill for shared services.

Index July thru December 2022

A

Cholera and Fear

ACMS Alliance News:

ACMS Foundation: ACMS Foundation Impact…….No. 11, Page 36 Angel’s Place, Inc,...…………..No, 12, Page 17

Activities & Accolades: Welcome Eileen Taylor…………No. 7, Page 15 ACMS Bulletin Photo Contest...No. 7, Page 40, No. 8, Page 36

ACMS Bulletin Photo Contest Winners..…...............................No. 11, Page 22

PAMED House of Delegates Overview…...............................No. 11, Page 26 Marcela Böhm-Vélez, M.D., FACR, FSRU, FAIUM Honored Alumni Award…...………………………No. 11, Page 38 HOD/Board Confirmations…....No. 12, Page 30 B

Bylaws…………………………...No. 7, Page 17 C D E

Editorial:

Summer’s Bounty Deval (Reshma) Paranjpe, MD, MBA, FACS……..……………...…………No.7, Page 5

Great Expectations

Anna Evans Phillips, MD………...No. 7, Page 7 Making a Book Richard H. Daffner, M.D., FACR……………......................…No. 7, Page 9

A Plague Upon Both Your Houses Deval (Reshma) Paranjpe, MD, MBA, FACS………………………..……..No. 8, Page 5

The Sweet Spot

Andrea G. Witlin, DO, PhD….…..No. 8, Page 8

The Purge

Richard H. Daffner, MD, FACR..No. 8, Page 10 Swinging for the Fences Deval (Reshma) Paranjpe, MD, MBA, FACS……………………......…….No. 9, Page 5

It’s even more complicated Andrea G. Witlin, DO, PhD……...No. 9, Page 8 Boo the Ref; Kill the Ump. Richard H. Daffner, MD, FACR..No. 9, Page 10

Fall Nourishment Deval (Reshma) Paranjpe, MD, MBA, FACS…………………………….No. 10, Page 5

Kristen Ehrenberger, MD, PhD..No. 10, Page 8 Paper Chase Richard H. Daffner, MD, FACR.......................... .................................................No. 10, Page 10

Giving Thanks

Deval (Reshma) Paranjpe, MD, MBA, FACS……..…………...…….….…No.11, Page 5 Psychological Safety in Health Care Rosemary Hanrahan, MD, MPH, PCC…........... ..............................................…..No. 11, Page 8

Thanksgiving 1976* Richard H. Daffner, MD, FACR………….….....................No. 11, Page 12

Counterpoint: Two Patients, Two Persons Christina A. Cirucci, MD, FACOG…………......................No. 11, Page 14

Something to Look Forward To Deval (Reshma) Paranjpe, MD, MBA, FACS……..…………….………....No.12, Page 5

What time is it really? Maria J. Sunseri, M.D. FAASM………..……...................No. 12, Page 8

Withholding Medicine from a Sick Patient Joseph Paviglianiti, MD……….No. 12, Page 10 “You’re Not Santa Claus!” Richard H. Daffner, M.D., FACR……...……....... .................................................No. 12, Page 14

F G H I

In Memoriam:

H. Jordan Garber, MD………….No. 7, Page 16 J

K L

Legal Summary:

Private Equity Deal Offer Both Potential Significant Return and Significant Challenges Michael A. Cassidy, Esquire………….....……............No. 7, Page 34

Post-Dobbs Fallout: Federal Guidance Abounds

Beth Anne Jackson………...…...No. 8, Page 31 Breaking Free: How to Opt Out of Medicare (and Other Payors)

William H. Maruca, Esquire…….No. 9, Page 27 After The Public Health Emergency William H. Maruca, Esquire…..No. 10, Page 22

The Basic Anatomy of a Government Investigation and How Providers Can Be Proactive

Tama Beth Kudman and Lourdes Sanchez Ridge………No. 11, Page 32 2023 Physicians Medicare Reimbursement Cut and New Shared Service Rules

Michael A. Cassidy, Esquire…..No 12. Page 32 M

Materia Medica: Treating Insulin-Induced Hypoglycemia with Confidence: Dasiglucagon (Zegalogue®)

Karen M. Fancher, PharmD,BCOP...........................No. 7, Page 30 Gemtesa® (vibegron)

Habibur Rahman, PharmD Courtney Simpkins, PharmD…………….………..……No.8, Page 20

Dietary Supplements: Widely Accessible For Better or For Worse

Anna Packis, Kendall Benjamin, Rebecca R Schoen, PharmD, BCACP……..No. 8, Page 24

Tirzepatide (Mounjaro®): The First “Twincretin” for Type 2 Diabetes

Heather N. Metro and Karen M. Fancher, PharmD, BCOP………………..No. 10, Page 24 Evinacumab-dgnb (EvkeezaTM)

Joseph Rizkalla, PharmD; Alexandria Taylor, PharmD, BCPS………………...No. 11, Page 28

Efgartigimod Alfa-fcab (Vyvgart™): First in A New Class of Medications for Myasthenia Gravis

Arden Kalsey, PharmD Candidate. Tucker Freedy, PharmD, BCPS………No. 12, Page 27 N O P

Perspective:

A Pediatrician Travels Back Home to Old San Juan

Johanna Vidal-Phelan, MD, MBA, FAAP, CHIE……….……………..No. 8, Page 13

Physicians (and others) as Collateral Damage in Today’s Political Wars

Bruce L. Wilder, MD MPH JD….No. 9, Page 15

Healthcare for Immigrants: The Visiting Nurse Service of Pittsburgh’s Irene Kaufmann Settlement

Corey Schultz…………………....No. 9, Page 18

Braving Through the Transitions

Anthony L Kovatch, M.D………..No 9., Page 20

Personalization by Design: Just Do It

Hannah Hamlin, Angela DeVanney, and Tony DiGioia, MD.…….……….No. 10, Page 13

Return to Camelot

Anthony L. Kovatch, MD………No. 11, Page 16 Top Pharmas Paradigm Shift Robert S. Whitman, MD…...….No. 11, Page 20 In the Battle

Michael G. Lamb, MD…………No 12., Page 18 Q R

Reportable Diseases...............No. 8, Page 33, No. 11, Page 7 S Society News

Pittsburgh Ophthalmology Society Announces 2022-2023 Monthly and Annual Meetings Dates……………………………..No. 7, Page 14

Pittsburgh Ophthalmology Society 2022-2023 Monthly and Annual Meetings Dates…………...........................No. 8, Page 17

ACMS Announces New Social Media Marketing & Public Relations Partnership………………..……..No. 8, Page 18

Greater Pittsburgh Diabetes Club set to host Fall Program……………………..No. 8, Page 19

Pittsburgh Ophthalmology Society 20222023 Monthly and Annual Meetings Dates…………………….........…No. 9, Page 23

Pittsburgh Ophthalmology Society Welcomes Sandra F. Sieminski, MD……....No. 9, Page 24

Greater Pittsburgh Diabetes Club Set to Host Fall Program…………..………...No. 9, Page 25

Pittsburgh Ophthalmology Society announces November and December Presenters and meeting date…………………...No. 10, Page 21

American College of Surgeons –Southwestern Pennsylvania Chapter Resident Surgical Jeopardy……………..No. 11, Page 23

The Greater Pittsburgh Diabetes Club (GPDC) Annual Fall Program…………..No. 11, Page 25

Pittsburgh Ophthalmology Society 43rd Annual Meeting for Ophthalmic Personnel Meeting……………..................No. 12, Page 24

Clinical Update on Geriatric Medicine….…...........................No.12, Page 26

Special Report:

Putting Self-care into Health care

Sara Hussey, ACMS Executive Director…...................................No. 9, Page 34

Nomination Report…...…..........No. 9, Page 31, No. 10, Page 16

Pittsburgh Magazine 40 under 40

.................................................No. 10, Page 18

ACMS Year in Review

Sara Hussey, ACMS Executive Director…....................................No 12, Page 7

Prior Authorization

Sara Hussey, ACMS Executive Director…..................................No 12, Page 22

USPS Form………………….....No 12, Page 38 T U V W X Y Z

Fenner Corporation……………........……(412) 788-8007 Charity Pittsburgh Cure Sarcoma Run……

Clinical

Allegheny Health Network ............................ (724) 933-1445 Legal Tucker Arensberg PC.................................... (412) 566-1212

Real Estate

Berkshire Hathaway: Julie Wolff Rost ...........(412) 521-5500

Berkshire Hathaway: Deb Arrisher………......(412) 367-8028

Editorial Editorial

adjacent lumbar vertebra, explaining her pain. My resident, from Georgia, upon seeing the findings said, in his deep southern drawl, “Fellahs, there’s a lesson here. Crocks daah (die), too.” Unfortunately for the patient, CT scanning and ultrasound exams had not been developed. The important lesson is that for most patients with a diagnosis of psychosomatic illness, the symptoms are real, and in fact a small number of these patients indeed have real abnormalities accounting for their symptoms.

Sigmund Freud’s view of humor was that it was a conscious expression of thoughts that society usually suppressed or was forbidden.2 As long as the humor, in this case name-

calling, is meant in a benign fashion, it is considered harmless.

However, in today’s politically divisive atmosphere, it is best to use humor only when you truly know your audience. As a good example, I remember the not so “good old days,” when it was expected that a speaker at a conference or a refresher course would tell jokes. Many of the “old timers” were very colorful characters. Today, fortunately, speakers are business-like and jokes are tacitly forbidden, since they are bound to offend someone. Finally, we should always remember that no matter how unpleasant some of our patients are to us, they are still our fellow human beings.

Dr. Daffner, associate editor of the ACMS Bulletin, is a retired radiologist who practiced at Allegheny General Hospital for more than 30 years. He is emeritus clinical professor of Radiology at Temple University School of Medicine and is the author of nine textbooks. He can be reached at bulletin@acms.org.

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

References

1. Shem S. The House of God. Richard Marek Publishers 1978.

2. Freud S, (Strachey J, Trans.). Jokes and their relation to the unconscious New York: W. W. Norton, 1960 (Original work published 1905).

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ALLEGHENY COUNTY MEDICAL SOCIETY — 2022–2023 MEETING SCHEDULE

ALL MEETINGS BEGIN AT 6:00 PM

Upcoming Events

No upcoming events

Executive Committee*

Tuesday Evenings – 2nd Tuesday at the start of each new quarter.

January 10, 2023

April 11, 2023

July 11, 2023

October 10, 2023

Finance Committee Tuesday Evenings

January 24, 2023

April 25, 2023 August 29, 2023 November 14, 2023

Committees Dates to be announced

Delegation

April, June, August, October

Nominating May, August

ACMS Foundation

PAMED BOARD

May 4

Board of Directors* Tuesday Evenings

February 21, 2023 May 9, 2023

September 12, 2023 December 5, 2023

March 14 – Planning Meeting/Special Grants

June 20 – Prep for Grant Proposals October 24 – Grant Proposal Review

PAMED HOUSE OF DELEGATES / HERSHEY

October 27-28, 2023

August 3 October 26-27, 2024

AMA HOUSE OF DELEGATES

June 10-14 Chicago, IL

AMA Interim Meeting November 11-14 National Harbor, MD AMA Annual Meeting June 2024 Chicago, IL

ACMS HOLIDAYS – OFFICE CLOSED

January 2 – New Year’s Day (Monday) September 4 – Labor Day (Monday)

January 16 – Martin Luther King (Monday) November 10 – Veteran’s Day (Friday)

February 20 – President’s Day (Monday) November 23 – Thanksgiving Day (Thursday)

May 29 – Memorial Day (Monday) November 24 – Thanksgiving Friday (Friday)

June 19 – Juneteenth Day (Monday) December 25 – Christmas (Monday)

July 4 – Independence Day (Tuesday)