ACMS Bulletin June 2023

ACMS Board of Directors Update Treating the

OB-GYN expertise for your patients.

When your patients need the best possible specialty care, AHN has physicians with the right expertise — like our new OB-GYN.

Dr. Simons offers personalized, high-quality gynecological and obstetrical care to meet each patient’s individual needs.

To refer your patient, call (412) DOCTORS.

Kathryn M. Simons, MD

OB-GYN

Locations:

AHN North Fayette Health + Wellness Pavilion

Western Pennsylvania

OB/GYN Associates — Brentwood

Western Pennsylvania

OB/GYN Associates — Green Tree

Specialties : Skilled at surgical management of pelvic organ prolapse and minimally invasive surgery

Focuses on menopause, menstrual disorders, incontinence, contraception, and obstetrics

Allegheny County MediCAl SoCiety

Opinion Departments

ACMS Board of Directors

Update.......................................5

• Peter Ellis, MD

Chair—ACMS Board of Directors

Editorial....................................6

• Festival Time

Deval (Reshma) Paranjpe, MD, MBA, FACS

Associate Editorial ................10

• Treating the Myopia Pandemic—

Part II

Joseph Paviglianiti, MD

Editorial ..................................14

• Our Partners in the Healing Arts

Richard H. Daffner, MD, FACR

Perspective ............................16

• Helping Your Patients Navigate Seasonal Skin Care Needs

Amidst the Growing Natural Skin Care Industry

Charles E. Mount III, MD, FAAD

Special Report..........................9

• CHIP Turns 30: Children’s Health Insurance Program Shows What Health Companies, Communities Can Accomplish Together

Alexis Miller

Foundation..............................22

• Ronald McDonald House

ACMS News ...........................24

• Call for Nominations

ACMS News ...........................26

• The ACMS Announces the Launch of the Women in Healthcare Committee

Sara C. Hussey, ACMS Executive Director

Articles

Materia Medica ......................18

• U.S. Food and Drug Administration (FDA) approved weight loss medications and the management of obesity in adults

Sydney Sadkin, PharmD

Legal Summary.......................20

• Telemedicine Audits: OIG Toolkit

Informs Payers and Physicians

Beth Anne Jackson

ACMS Meeting Schedule ......28

On

Singing Canyon

John Hyland, MD

John Hyland, MD specializes in Radiation Oncology.

2023

Executive Committee and Board of Directors

President

Matthew B. Straka, MD

President-elect

Raymond E. Pontzer, MD

Secretary

Keith T. Kanel, MD

Treasurer

William Coppula, MD

Board Chair

Peter G. Ellis, MD

DIRECTORS

Term Expires 2023

Michael M. Aziz, MD

Micah A. Jacobs, MD

Bruce A. MacLeod, MD

Amelia A. Paré, MD

Adele L. Towers, MD

Term Expires 2024

Douglas F. Clough, MD

Kirsten D. Lin, MD

Jan B. Madison, MD

Raymond J. Pan, MD

G. Alan Yeasted, MD

Term Expires 2025

Anuradha Anand, MD

Amber Elway, DO

Mark Goodman, MD

Elizabeth Ungerman, MD

Alexander Yu, MD

PAMED DISTRICT TRUSTEE

G. Alan Yeasted

COMMITTEES

Bylaws

Raymond E. Pontzer

Finance

William Coppula, MD

Nominating

Raymond E. Pontzer, MD

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

Associate Editors

Douglas F. Clough

Richard H. Daffner (rhdaffner@netscape.net)

Kristen M. Ehrenberger (kricket_04@yahoo.com)

Anthony L. Kovatch (kovatcha42@gmail.com)

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)

Part-Time Controller

Elizabeth Yurkovich (eyurkovich@acms.org)

ACMS ALLIANCE

Corresponding Secretary

Doris Delserone Treasurer

Sandra Da Costa

EDITORIAL/ADVERTISING

OFFICES: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212; (412) 321-5030; fax (412) 321-5323.

USPS #072920. PUBLISHER: Allegheny County Medical Society at above address.

The Bulletin of the Allegheny County Medical Society is presented as a report in accordance with ACMS Bylaws.

The Bulletin of the Allegheny County Medical Society welcomes contributions from readers, physicians, medical students, members of allied professions, spouses, etc. Items may be letters, informal clinical reports, editorials, or articles. Contributions are received with the understanding that they are not under simultaneous consideration by another publication. Issued the third Saturday of each month. Deadline for submission of copy is the SECOND Monday preceding publication date. Periodical postage paid at Pittsburgh, PA.

Bulletin of the Allegheny County Medical Society reserves the right to edit all reader contributions for brevity, clarity and length as well as to reject any subject material submitted. The opinions expressed in the Editorials and other opinion pieces are those of the writer and do not necessarily reflect the official policy of the Allegheny County Medical Society, the institution with which the author is affiliated, or the opinion of the Editorial Board. Advertisements do not imply sponsorship by or endorsement of the ACMS, except where noted.

Publisher reserves the right to exclude any advertisement which in its opinion does not conform to the standards of the publication. The acceptance of advertising in this publication in no way constitutes approval or endorsement of products or services by the Allegheny County Medical Society of any company or its products.

Annual subscriptions: $60

Advertising rates and information available by calling (412) 321-5030 or online at www.acms.org.

Assistant Treasurer

Liz Blume

COPYRIGHT 2023: ALLEGHENY COUNTY

MEDICAL SOCIETY

POSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212.

Board of Director’s Update

Peter G. ellis, MD Chair - aCMs BoarD of DireCtors

Hello Colleagues,

The executive committee of ACMS would like to update all our fellow members on happenings at our ACMS. As you know from prior updates, the office is now fully staffed, led by our very capable Executive Director Sara Hussey. There is much more to relate, I will be brief but feel free to reach out to Sara or any of us on the Executive Committee if you have questions or thoughts.

• Regionalization—As healthcare continues to evolve in the state, the Pennsylvania Medical Society is interested in member counties exploring the pros and cons of joining forces in a given region. Regionalization would allow physicians in counties without an active society to have a voice and receive services that otherwise may not be available to them. We have applied for a $10,000 grant, through PAMED, to begin exploring this possibility. We have also reached out to our neighboring counties to start these conversations. There will be more on this as we gather information.

• Membership—Membership has been a challenge for all professional organizations across the country. At your ACMS, we are putting strong emphasis on providing support and services that will expand and maintain our roles here in Western PA. We currently boast 2300 members (both physician and non-physician) with 2000 being physicians. We thank you for your support and ask that you consider ways to become active in the society as we move forward, including encouraging your colleagues to join ACMS.

• ACMS Board—We have a strong board made up of a diverse representation of our physician community. We are always looking for new faces and encourage any of you to put your name in the hat for a board position or to join a committee to make a difference. The nominating committee will meet on June 7th to begin the Nomination process.

• Financials—Our financials remain strong, thanks to the work of Sara and your board. We recently passed our audits of the ACMS as well as the ACMS Foundation. The 990 for 2022 has been completed and is available if you have an interest.

• Actions—This is where it gets busy! On a social note, we have sold out our Pirate game tickets for the Saturday, July 15th game against the San Francisco Giants (125 ticketes sold). That is Fireworks Night and there will be a pregame tailgate at the Babb building to include a food and beverage truck. An ACMS Bulletin Committee is meeting to discuss ways

to further enhance what is already a quality product. It is also looking at ways that we might be able to use the Bulletin to better get the word out to non-members about the good work we are doing on their behalf. On an advocacy level, we continue to work with PAMED on State initiatives of interest to all of us as physicians, as well as reaching out locally physician employers to have better lines of communication for the benefit of our members. We are actively raising our profile on both social and traditional media. We have redesigned our website to make it an asset for our physician community. I urge you to give it a review at www.acms.org.

• Foundation—We had a fun and successful night at the Heinz History Center on April 27th for the ACMS Honors event. The event had an excellent turnout and great reviews, and raised money for worthy causes. The ACMS Foundation Board will meet this summer to begin the process of collecting RFPs for grants for the 2024 year. We anticipate funding of over $250,000 this year.

There is much more to tell, but (for good reasons) I am told to limit this article. Please connect with your ACMS either online, through social media, email or a direct call to the office! We look forward to your thoughts and involvement.

Festival Time

Deval (reshMa) ParanjPe, MD, MBa, faCs

Wondering what to do this weekend? Want to get away but have kids and pets to manage? Don’t feel like braving cancelled or delayed flights and long lines at the airport?

Stay local and explore the joys of regional summer festivals---it is sometimes a journey into Americana, it is sometimes an exploration of cultural delights, it is always full of simple pleasures.

Here are some of this summer’s highlights— mark your calendars!

Greek Food Festivals:

Always a hit with delicious food and entertainment, check out these festivals to compare baklava and leave happy:

6/13-6/16 Holy Cross Greek Orthodox Church, Mount Lebanon

6/15-6/17 Aliquippa Greek Food Festival, Kimisis Greek Orthodox Church, Aliquippa

6/23-6/25 Oakmont Greek Food Festival, Dormition Greek Orthodox Church, Oakmont

7/18-7/22 Ambridge Greek Food Festival, Holy Trinity Church, Ambridge

7/21 Monessen Greek Food Festival St. Spyridon Greek Orthodox Church, Monessen

8/319/3 Holy Trinity Greek Food Festival, Holy Trinity GOC, Pittsburgh

Food, Wine and Beer Festivals:

Check out these delicious events celebrating summer’s bounty and beer.

6/24 Freedom Farms Berry Festival and Craft Show—Valencia

7/8 Pittsburgh Vegan Expo and Arts Festival—Monroeville

7/15 Pittsburgh Summer Beerfest Pittsburgh

7/15-7/16 Freedom Farms Wildflower Festival—Valencia

7/21-7/23 Picklesburgh—Pittsburgh 7/21-7/23 Butler Bikes and BBQ— Butler 8/5 Pittsburgh VegFest—Pittsburgh 8/25-8/27 Corks and Kegs—

Community Festivals: Explore the local charm and flavor of your own and other local communities.

6/24 Bridgewater Summer Festival— Bridgewater

7/4 Pittsburgh’s Independence Day at Point State Park—Pittsburgh

Community

(formerly

8/5 Reggae at Riverview—Pittsburgh

8/12 Barrel and Flow—A celebration of Black Arts on Tap—Strip District, Pittsburgh

8/12 Outlaw Music Festival—(Willie Nelson, Avett Bros, Alison Krauss, Robert Plant)

8/12 The Music For MS Roots Music Festival—Allison Park

8/19 Rock Reggae and Relief Market Square, Pittsburgh

8/26 Squirrel Hill Night Market II— Pittsburgh 8/26-8/27 Pittsburgh Renaissance Festival I—West Newton

8/26-8/27 Shadyside: The Art Festival on Walnut Street—Pittsburgh

Continued on Page 8

From Page 12

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.

was that it was a conscious expression of thoughts that society usually suppressed or was forbidden. long as the humor, in this case name-

calling, is meant in a benign fashion, it Dr. Daffner, associate editor of the

• Physician Billing Services for All Specialties

We would use OUR billing system or YOUR billing system based on YOUR preference.

• Credentialing Services for All Specialties

• Accounts Receivable Follow-Up for Practice Support

We would work your accounts on your system to maximize cash flow.

NEW Billing Client Example: A new client (a 6-physician family medicine group) liked their EHR, so the group asked us to bill using their billing system. Besides the benefit of keeping their EHR, the group is now experiencing greater efficiency and stability in their office by eliminating problems caused by biller turnover, vacations, diversion, and other time off.

Contact

CHIP Turns 30: Children’s Health Insurance Program Shows What Health Companies, Communities Can Accomplish Together

By Alexis Miller, Segment President for Government Business, Highmark Inc.

Thirty years ago, Highmark enrolled the first child in Pennsylvania in CHIP (Children’s Health Insurance Program)—a comprehensive, low-or-no-cost health insurance program that ensures our kids are protected. CHIP is a cornerstone of American health care today, providing an affordable coverage option for more than seven million kids in the U.S. and peace of mind for families.

While CHIP is all grown up—it’s a millennial!—it’s worth revisiting how this thriving program came to be. In the wake of economic hardship, stakeholders from across Pennsylvania rallied to make sure our kids’ health needs were met—and in the process, created a national model for children’s health care and cross-sector partnerships.

The collapse of the steel industry in the 1980s devastated Pittsburgh’s economy. Many workers lost health insurance coverage not just for themselves, but also for their spouses and children. Families were under immense pressure and faced heart-wrenching decisions. Food, rent and health care—some could only pick two. That’s not a choice that any family should have to make.

What we at Highmark heard above all else is, “please do something for our kids.” Health issues that could have been resolved or better managed with regular access to care worsened. The region’s economic crisis was leading to a health crisis.

Highmark partnered with more than 15,000 individuals, churches, unions, schools and other community organizations to raise funds and identify uninsured children. We brought together those groups and health care providers to offer services and design a first-of-its-kind offering: The Caring Program for Children.

The Caring Program for Children was a needs-based insurance program that provided the same level of care and access offered to other Blue Cross Blue Shield members. No child was excluded due to a pre-existing condition. Communities stepped up by raising funds for uninsured children in their own neighborhoods. And we stepped up by matching those funds dollar-for-dollar, and by covering the administrative costs of the program. It was the first health insurance program in the nation to cover at-risk kids.

We also got creative. Fred Rogers, of “Mister Rogers’ Neighborhood” fame, graciously supported the effort. He lent credibility to our effort to help families in distress. This program really was about helping your neighbors. The Pittsburgh Steelers, a beacon of hope for the region through difficult times, partnered with us to promote the programs and raise funds.

Other Blue Cross Blue Shield health plans from across the country took note of our region’s success. They understood that their local communities had some of the same unmet health needs and that The Caring Program offered a proven model. We were able to show that opening the doors to the health care system decreased unmet medical care, improved health outcomes, and ultimately enhanced both the economy and quality of life in the region.

The Caring Program evolved into a coalition of more than 20 other Blues plans serving kids across the country. But we knew that we could make an even greater impact on the lives of children and families

in Pennsylvania. So, we partnered with legislators and community organizations to create a sustainable model for a statewide children’s health insurance program. We worked together to design benefits and create public-private partnerships. We took the learnings and successful model of The Caring Program and scaled it. And in 1993, Highmark enrolled the first child into CHIP in Pennsylvania. Pennsylvania led the way in caring for at-risk children, and the rest of the nation followed.

Healthy kids make healthy adults. When children have strong health insurance coverage, it sets them on a course for lifelong wellness and success. It frees them to be their best, and allows them to grow and develop physically, socially and emotionally. For families, there’s relief in knowing that their children are protected.

The leaders involved in The Caring Program for Children had to do something that had never been done before. The Caring Program served as inspiration for providing high-quality, affordable health care to children across Pennsylvania and, later, across the country. It provided a pathway for the national CHIP program.

The Caring Program demonstrated that when you listen to the concerns of the community, and involve them in creating the solution, systemic change is possible. And it showed how the public and private sectors can work together to create solutions to major problems.

We are proud to have played a leading role in The Caring Program, and in building CHIP into what it is today. CHIP has been strengthened over the years, offering additional supports to children with complex health conditions, and most kids are eligible. CHIP is a source of pride for Highmark—which insures more than 15,000 kids across 62 counties in Pennsylvania through our Highmark Healthy Kids program—and for all Pennsylvanians. It’s an example of putting kids and families first.

As Pennsylvania’s CHIP program blows out the candles, its creation and staying power show that when we partner with the communities that we proudly serve, anything is possible. And, with Medicaid redetermination resuming after the end of the COVID-19 public health emergency, CHIP remains a vital program. CHIP will be a safety net for some children in families who may no longer qualify for Medicaid coverage and do not receive insurance from another employer-based or government program. CHIP was there for kids and families 30 years ago in a time of need, and it’s there for them today.

Alexis Miller Allen Kukovich Dan Onorato Tom Doran

Treating the Myopia Pandemic Part II

josePh PaviGlianiti, MD

Last month we reviewed how the incidence of myopia was increasing at an alarming rate, both here at home in the USA and globally. Rather than this being just a “nuisance,” the axial lengthening of the eye that causes myopia can cause significant visual and career-ending problems, in the form of retina detachments, which are much more common in longer eyes. Therefore, slowing down myopia in childhood can theoretically lower the rate of myopia-associated retina issues as our patients and our own children/ grandchildren get older. Slowing down the axial lengthening of eyeballs must be done in childhood…once an eye is “too” long, we can’t shrink it. Refractive procedures/LASIK can change the cornea shape to eliminate glasses, but they have no effect on the underlying long eye that caused the glasses in the first place. Therefore, the post-LASIK patient is forever at risk for myopicrelated retina issues later. Clearly, axial lengthening is the enemy, and the goal is to control it/minimize it during childhood.

Sooo…how do we slow down the axial lengthening of pediatric eyeballs? If your parents had long eyes, you are likely going to have long eyes. Therefore, the biggest thing one can

do is choose non-myopic parents. But if you messed that one up, The World Society of Paediatric Ophthalmology and Strabismus recently updated their consensus statement on slowing down the progression of myopia. Some things work, some things don’t. Some things are myths. Some beliefs we had during ophthalmology residency training have been challenged and maybe disproven.

THINGS THAT DON’T WORK to slow down myopia:

1. Under correcting myopes/keeping myopes out of glasses. As recently as 25 years ago, when I was in training, myopic “under correction” was widely accepted as a way to slow down myopia. Recent studies have proven otherwise, and it may actually accelerate myopia. This method is no longer advocated.

2. Pin hole glasses. Yes, these are for sale on Amazon. No Effect on slowing myopia.

3. Blue light glasses. No effect on myopia control.

4. Putting kids in progressive bifocals “for myopia control”. Minimal to no effect. NOTE that bifocals for

the control of “accommodative esotropia” are greatly effective and most kids are wearing bifocals for that purpose. Bifocals do NOT have any significant effect on myopia control. Bifocals in kids are for treating eye crossing, not myopia.

5. Regular soft contact lenses/RGPs/ glasses have no effect on slowing down myopia, nor do they aggravate it. They should be worn so you can see, but they don’t offer any “myopia control.”

THINGS THAT APPEAR TO WORK to slow down myopia

1. Increased time spent outdoors. Sunlight causes retinal dopamine release, which reduces ocular axial elongation. The current recommendation is that children should spend two hours outside every day. If your child or grandchild is addicted to reading, or their iPad or smartphone, send them outside to do it. Debatable whether this “outdoor” time is helpful once kids are myopic but deemed helpful in preventing the initial onset of myopia.

2. Reduced time on smart phones/near digital devices/near tasks. Yup, you knew it. Get them off their devices and send them outside to play. A working distance of less than 20 cm has been shown to be a risk factor for myopia progression. Doing their tasks in dim light has also been shown to be a possible risk factor for myopia progression (again, another 180 degree turn from how I was trained 25 years ago when dim lighting was studied at length and was NOT considered a risk factor at all). Unfortunately, near work tasks are part of daily education in today’s world, so taking breaks from near tasks/IPAD/IPHONE/laptop is possibly helpful. This is the 20/20/20 rule, which states that for every 20 minutes a person looks at a screen, they should look at something 20 feet away for 20 seconds. Not sure if that has been proven, but definitely not harmful. Furthermore, the size of the monitor used at work/school seems to correlate with myopia. Near work done on smart phones and iPads had a greater risk of myopic progression during the pandemic versus kids who were using television monitors and projectors at home with larger screens for the near work. Having a viewing distance of greater than 20 cm also appears protective. Maybe I can parlay this idea into a “90 inch” TV once my spouse reads this article?

3. Defocus Incorporated Multisegment Spectacle lenses (DIMS glasses). These are not yet approved by the FDA in America, but are available in Canada, Asia and Europe. These glasses consist to be central distance optical zone of 9 mm surrounded by an annular mid peripheral zone of multiple (approx. 400) small round segments, each segment being 1.1 mm diameter with +3.50 diopters of add power. This allows clear central vision and allows myopic defocus of the peripheral retina.

In a Chinese study, these spectacles reduced myopic progression in half… It didn’t stop it, but it slowed it down. Kids DID complain of mid peripheral blurry vision wearing these glasses. These glasses are too new to know whether they are “catching on” and whether they are tolerated well. Managing expectations will be a big issue. Kids want to see clearly out of their glasses and their periphery will be blurred with these glasses. Time will tell, but kids in general don’t like putting on glasses that blur their vision, as their amblyopic friends have proven. Furthermore, these glasses will likely be costly and ugly, furthering the economic disparity of healthcare.

(Regular glasses on left / DIMS glasses right)

4. Highly Asherical Lenslet Spectacles (HALS). These are another type of glasses not yet available in the United States and are a variation on the above DIMS-glasses theme.

5. Soft Multifocal Contact Lenses. Not all bifocal contact lenses slow down myopia; these are different than the traditional multifocal contact lens prescribed for presbyopia because they have concentric zones of relative plus power through the lens periphery. These are sold under the brand name: MiSight contact lenses from CooperVision and have been shown to have a 59% reduction in myopia progression over a threeyear period in children ages 8 to 12.

Unfortunately, these have been priced in the USA as a package “similar to how orthodontia is priced” and the price is relatively steep, further adding to the economic disparity of eyecare. Plus, many kids can insert contact lenses and many kids can’t, especially in the younger age groups. Hopefully, the prices of this contact lens myopia control system will decrease much like the price of dilute atropine has decreased.

6. Orthokeratology. These are “overnight,” reverse geometry, rigid gas permeable contact lenses, which “reshape” in the cornea at night such that no glasses are needed during the day. These lenses are more effective with “lower” amount of myopia. Orthokeratology has been around since the 1940’s, but never is really

caught on because of the waning efficacy in later parts of the day. Much like a corset, when the RGP lens is removed in the morning, the cornea slowly starts to go back to its natural shape during the day, meaning that many people find they need to put their glasses back on after lunch. However, as a form of myopia control, orthokeratology has shown some promise similar to those seen with MiSight lenses and/or with dilute atropine. Its use for this in America, though, has been hampered by the fact that the ophthalmology profession has long eschewed children sleeping in contact lenses, and gas permeable lenses in general tend to be less comfortable than their soft counterparts. However, it’s all in managing expectations and this is an area of myopia control that should be further investigated. Again, very pricey; multiple trips to the eye doctor. Wearing uncomfortable contacts overnight. Probably the same success rate as getting your kids to wear their retainers at night over many years.

7. Dilute Atropine to slow down myopia progression. It has long been known that certain dilating drops that block muscarinic receptors can slow down myopia. It’s believed that atropine acts directly on the retina/sclera, inhibiting stretching of the sclera and thereby slowing down axial lengthening. But who wants to walk around dilated all the time? Then, in 2012, the ATOM Study (Atropine for the Treatment of Myopia) showed that DILUTED atropine (regular strength is 1%, diluted is 0.01%) can slow down child of myopia

progression without the annoying dilation/blur. And the drop doesn’t sting like most other pediatric dilating drops. Later studies have shown that .02% and .05% dilute atropine may be more effective. However, as this percentage gets closer to full strength atropine, there’s definitely an increased complaint of dilated visual blur from children. Using dilute atropine is becoming much more popular on a daily basis. Even though this eyedrop is NOT FDA approved for the indication of “myopia control,” many parents come into the office requesting it, particularly parents who are themselves highly myopic. Furthermore, the cost of dilute atropine, which must be made at a compounding pharmacy, has really come down to now be approximately $30-$40 per month. Insurances are slowly thinking about covering this, but unfortunately through the typical time-intensive prior authorization process. Also, dilute atropine, particularly at the higher strengths, has a well-known rebound effect when the eyedrops are stopped, such that there is some catchup in myopia. This can likely be avoided by continuing atropine (maybe at lower doses) to later in the teen years, so that when it is stopped, the kids are near the end of their growth curve. Dilute atropine is a great choice for myopia control!

8. Combinations of the above.

9. Most importantly: choosing your parents wisely. Children of hyperopic parents who are themselves hyperopic, can likely play on their IPADS in dim lighting at close range til their hearts content. Kids of myopic parents: not so lucky.

In the ophthalmology world, pediatric eye problems have long been given short shrift. Kids don’t vote, don’t belong to AARP, and don’t have any clout on their medical issues; therefore, their ophthalmic issues often don’t receive as much attention (or research funding) that adult eye issues do. Their Medicaid reimbursement is way below what Medicare reimbursement for adults is, so many healthcare professionals don’t want to see pediatric patients anymore. The scarcity of pediatric

ophthalmologists, and pediatricians in general, is becoming frightening, locally and nationally. However, childhood myopia eventually turns into adult myopia and later predisposes to a host of retina problems that can be visually catastrophic. Clearly, there is a need to slow down axial elongation in children, particularly in children of highly myopic parents who are at the greatest risk. By incorporating behavioral measures, such as increased time spent outside, less time spent on near devices, particularly small ones, increasing distance from eyeball to monitor, using dilute atropine (perhaps combined with orthokeratology and/or peripheral defocus contact lenses/spectacles (some of which are not approved for use in the United States… yet) may help to slow down the pandemic of childhood myopia and the subsequent catastrophic effect on adult vision 40 to 50 years from now.

Sources:

He, M, et al. Refractive Error and Visual Impairment in Urban Children in Southern China. Invest Ophth Vis Sci. 2004: 45(3)793-9.

Hsu, CC, et al. Prevalence and Risk Factors for Myopia in Second Grade Primary School Children in Taipei: a Population-Based Study. J Chin Med Assoc. 2016: 79(11): 625-32.

Matsumura, S, et al. Global Epidemiology of Myopia. 2020. In Ang, M and Wong, T (editors): Updates on Myopia. Springer.

Theophanous, C, et al. Myopia Prevalence and Risk Factors in Children. Clin Ophthal. 2018: (12):1581-1587.

Sun J, et al. High Prevalence of Myopia and High Myopia in 5060 Chinese University Students in Shanghai. Invest. Ophth Vis Sci. 2012: 53(12):7504-9.

World Society of Paediatric Ophthalmology and Strabismus: Myopia consensus Statement 2023.

Our Partners in the Healing Arts

riCharD h. Daffner, MD, faCr

Irecently picked up a prescription for the anti-viral drug Paxlovid® at my local CVS pharmacy. The pharmacist reminded me that since I was also taking an anticoagulant, I had a higher risk of bleeding. Neither my internist who prescribed the Paxlovid® nor my cardiologist, who prescribed the anticoagulant had mentioned that risk. That experience reminded me of the important role pharmacists play as our partners in the healing arts. It also emphasized how the practice of pharmacy has changed in the sixty years since I graduated from Albany College of Pharmacy, where I earned my undergraduate degree.

So, what was the world of pharmacy like in 1963? Ninety percent of graduates at that time entered retail pharmacy; 6% worked in a hospital pharmacy. The remaining graduates pursued degrees in medicine, dentistry, or other health-related fields. A few did pharmaceutical research, working for “Big Pharma”. Most pharmacies in 1963 were operated by independent owners. Yes, there were chains at the time. Walgreens, the nation’s second largest chain, began in Chicago in 1901. (CVS, founded in 1963 is now the largest)) Several small chains included Fay’s Drugs, Brooks, and Eckerd Drugs, all of whom eventually merged into Rite Aid, founded in 1962. Today they’re the third largest.

But changes were coming. New laws were enacted by state legislatures that allowed prescription drugs to be sold in supermarkets and ultimately in “big box” stores such as Walmart, Target, and Costco. These retail giants had the advantage over the small independent pharmacist entrepreneur in that they could buy huge lots of merchandise and take advantage of volume price discounts. In the mid-tolate 60s smaller drugstores began to either sell out to one of the large chains or to fail outright. I remember when Rite Aid approached my father and my uncle with a generous buy-out offer that included guaranteed employment for all of their staff. Currently most of the chain stores are basically merchandising emporia that also happen to sell prescription drugs.

One of the biggest changes in pharmacy was the availability of generic drugs. In the 1960s the high cost of brand name medication prompted the FDA to begin licensing generics as the patents for prescription drugs expired. Although by law, generics must contain the same amount of active ingredient as its brand name counterpart, some generic formulations didn’t allow the active ingredient to be absorbed into the patient’s body and the medication passed out of the patient intact. That initial concern for physicians and

patients has been largely overcome, particularly by the more reputable generic manufacturers. However, problems still exist, particularly for medication manufactured outside of the United States.

There have also been changes in the day-to-day duties of the pharmacist. In 1963 approximately 15 to 20% of prescriptions in a busy pharmacy required compounding. Dispensing Pharmacy, a major course in all colleges of pharmacy at the time began taking on a less important role and for most schools has disappeared entirely. I remember when I was in the Air Force in 1969, writing a prescription for a dermatologic cream that had to be compounded. The hospital pharmacist called me to tell me that he, as a recent graduate, had never done any compounding in pharmacy school. I went to the hospital pharmacy and showed him, and his pharmacy techs how it was done.

Computers are now an integral part of the practice of pharmacy. They have made the job of checking for drug interactions easier - provided patients use the same store or chain for obtaining their prescriptions. It matters not if I had a prescription filled at my CVS in Pittsburgh and need a refill while travelling. The information will be in the system if I go to another CVS. The challenge, however, is for

the individual who fills one prescription at Rite Aid, another at CVS, and a third in the supermarket because their computer systems don’t link. My hope is that in the future, all the computers will be able to talk to each other, perhaps through a national data bank, to assure drug safety and avoid potentially lethal complications from drug interactions.

Changes were also occurring in the training of future pharmacists. I was in the last four-year class. (Ironically, my father was in the last three-year class when he graduated in 1932 and my uncle was in the first four-year class, graduating in 1934.) In 1960, the curriculum expanded to five years; in 1990 it was extended to six years, with the graduates receiving a Doctor of Pharmacy (Pharm D) degree.

The opportunities for pharmacy graduates continue to expand. I first became aware of this while working as part of the Trauma Team at our hospital. I made daily x-ray rounds with the trauma surgeons. I noticed that one member of the team was a Pharm.D. I asked her what her role on the team was, and she told me that she was there to help the surgeons with medication issues, including dosages and drug interactions. I later spoke to the Director of Pharmacy who told me that pharmacists work with each of the other medical and surgical teams throughout the hospital. I now understand why Hospital Pharmacy requires a one-year internship.

Traditionally, the main duties of pharmacists are to fill prescriptions. In most cases this entails counting pills. In larger chain pharmacies this task is usually assigned to Pharmacy Technologists, who are supervised

by the registered pharmacists. Today, the role of the pharmacist has also changed. New state laws now permit pharmacists to give vaccinations, something that was in view of the public during the recent Covid-19 pandemic. The main role of pharmacists today is to not only oversee prescription preparation, but also to counsel patients regarding any medication issues, such as drug interactions, of which physicians are often ignorant. They also will question patients if two of the same kind of drug have been prescribed. I became aware of this when one of my pharmacists asked if I was aware I was taking two beta blockers at the same time after the second one had been prescribed. I told her that the first one (long-acting) was to treat my paroxysmal atrial fibrillation, and the second (shortacting) was for occasional bouts of tachycardia. I was happy to know that my pharmacists were overseeing my medications. This is particularly important when medications are prescribed by different physicians. In addition, some pharmacy chains offer “Mini Clinics” for their customers.

The shortage of pharmacists in the country in the 1990s led to an explosion of new schools of pharmacy being established. Between 1960 and 1995 there were 90 pharmacy colleges in the US. In 2014 the number was 152; today it is 1411. All the new schools were at established universities. The sudden increase in the number of pharmacy colleges erased the shortage of pharmacists, but also forced the three remaining free-standing pharmacy schools (Albany, Massachusetts, and Philadelphia) to add schools in the other health sciences, such as Public

Health as they lost potential students to the increased competition. Last year, Philadelphia College of Pharmacy and Health Sciences merged with St. Joseph’s University to remain solvent. Mergers may be in the future for the remaining two.

Much as the practice of pharmacy has changed over the past decades, so have the opportunities for graduate pharmacists. I am a member of the Board of Trustees of my alma mater, Albany College of Pharmacy and Health Sciences (ACPHS). The Board is made up of alumni and non-alumni members. When I look at the resumés of my fellow alumni members I see quite a diversity in what they are doing with their pharmacy degrees. Two are directors of pharmacy services in medical centers; three work in development of new drugs for pharmaceutical manufacturers; one is an executive of a drug manufacturer; two earned medical degrees; and two operate their own independent pharmacies. This diversity of our pharmacy partners has led me to coin a new slogan for our recruiting at ACPHS: “Pharmacy. It’s so much more than counting pills.” Times have indeed changed for our partners in the healing arts.

Reference

1.Grabenstein JD. Trends in the number of US colleges of pharmacy and their graduates, 1900 to 2014. Am J Pharm Ed 2016;80: 25 – 35.

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. He was a practicing pharmacist before and during medical school.

Helping Your Patients Navigate Seasonal Skin Care Needs Amidst the Growing Natural Skin Care Industry

While many conditions such as infections and types of injuries shift with the seasons, so do types of rashes and skin conditions. While dry skin and eczematous rashes often worsen with drier winter weather, others worsen with summer heat, sun, outdoor exposure to plants, and products being used more frequently with the better weather such as sunscreens and bug repellents. It can no doubt be challenging for physicians to determine if these changing skin conditions are truly due to summer sun exposure in the case of connective tissue diseases or skin care products being used more frequently during the same season. In both private practice and the Autoimmune Institute at West Penn Hospital, I often see patients convinced they have autoimmune disorders whereas their skin ailment often lies in either irritation or contact allergy to their of skin and hair care products. Most skin allergy presents as an eczematous dermatitis (allergic contact dermatitis) which is a type IV, or delayed-type cell-mediated hypersensitivity typically due to chronically exposed substances; whereas most chronic urticaria are not allergy related. It is critical to remember almost any foreign chemical,

natural or artificial, can elicit a chronic hypersensitivity over time and with enough exposure. For example, Lanolin, a sheep-derived group of chemicals which have skin healing properties and are often found in medicinal and cosmetic skin products, is the current contact allergen of the year listed by the American Contact Dermatitis Society. Because neomycin causes a significant number of reactions in patients(upwards of 10% in various reports (1)) it is generally not advised for basic cuts and scrapes or post-operatively by most dermatologists.

Over the last few decades, the “clean” and “natural” skin care market has grown exponentially as companies hoped to improve skin care utilizing natural, plantbased ingredients. On the business end of this movement, conservative estimates place the natural skin care market around at least $6 billion with some sources stating much higher values. However, this rising trend of products has coincided with changing trends in skin conditions, specifically those involving both irritant and allergic contact dermatitis. Contact dermatitis affects close to 1 in 5 individuals and is twice as common in females (2). Preservatives, metals, emulsifiers, and fragrances top the list in sources of contact dermatitis due to skin/ hair care products with fragrances.. In their efforts to replace ingredients such as parabens and sulfates with botanical ingredient alternatives the cosmetics industry has created some potentially

more irritating and allergenic products in susceptible individuals. It should be noted that some companies replace artificial versions with plant sourced versions of the same chemical, however, the allergenicity potential remains the same.

In my patients with contact dermatitis undergoing evaluation for new onset diffuse or treatment resistant eczematous dermatitis, my general rule is the fancier, better smelling, more organic, “so good you could eat it” product the more likely it is to contain high risk contact allergens and is suspect until proven otherwise. For example, a product that describes itself as a “Vanilla Lavender Honey Almond Scrub” likely contains ingredients that benefit and stimulate our olfactory cortex and limbic system more than directly benefit our skin.

While natural skincare ingredients should not simply be viewed as bad, butas potentially both therapeutic and problematic just as we view most traditional ingredients including our medicines and rather used safely in moderation. There is data to support lavender may help with anxiety and sleep. Tea tree possesses both mild antimicrobial and anti-inflammatory properties. Researchers have discovered eucalyptus may help deter malaria-laden mosquitos and this summer your patients may choose natural bug repellants that utilize eucalyptus, citronella, cloves, or peppermint rather than traditional DEET. However, their benefit doesn’t exclude

Charles e. Mount iii, MD, faaD

PittsBurGh skin DerMatoloGy & Mohs surGery

the possibility of allergy and side effects. Most patients understand the concept of allergies to the pollens from flowers in the air but fail to understand allergic response is possible if you crush up the flowers and place it into a topical product. Most of us can agree penicillin (taken intermittently over a few days) can be beneficial in the appropriate clinical setting while taking it indefinitely or in excessive doses could pose risk and consequences. It can be helpful to explain to patients if you can be allergic to penicillin, which is derived from mold, then you can become allergic to chemicals derived from any flower or plant.

An important recent trend in medicine to consider is the growth of medical marijuana and/or CBD. Providers prescribing them for their patients should recognize that these therapeutics are derived from flowering plants and contain natural terpenes specifically linalool and limonene. These chemicals are also found in numerous shampoos and soaps and are also produced by other plants such as lavender, eucalyptus, chamomile, and tea tree. Again, while potentially therapeutic medical

marijuana and CBD, both have inherent hypersensitivity risks due to their naturally derived chemicals.

With sunburns, poison-ivy dermatitis, bug bites, and sports injuries on the rise in summer months your patients will surely have questions regarding skin care advice. It is crucial to consider that all topical therapeutic products, whether artificial or natural, can provide both potential harm and benefit. When evaluating your patients with warmer weather rashes consider if the rash is truly isolated to sun exposed areas or areas at high risk for contact allergy such as the eyelids, face, neck, and hands. Remember there is no FDA-standard for “hypoallergenic” or “sensitive” labeling and often many products with such labeling are quite the opposite. Lastly, for your patients with suspected chronic skin care product allergy refer them to the following web resources (https://www. skinsafeproducts.com/ and https://www. fda.gov/cosmetics/cosmetic-ingredients/ allergens-cosmetics) and refer them to a dermatologist and/or allergist who specializes in contact allergy and comprehensive allergy patch testing.

References:

1. Warshaw EM, Belsito DV, Taylor JS, et al. North American Contact Dermatitis Group patch test results: 2009 to 2010. Dermatitis. 2013;24(2):50-59.

2. Peiser M, Tralau T, Heidler J, Api AM, Arts JH, Basketter DA, English J, Diepgen TL, Fuhlbrigge RC, Gaspari AA, Johansen JD, Karlberg AT, Kimber I, Lepoittevin JP, Liebsch M, Maibach HI, Martin SF, Merk HF, Platzek T, Rustemeyer T, Schnuch A, Vandebriel RJ, White IR, Luch A. Allergic contact dermatitis: epidemiology, molecular mechanisms, in vitro methods and regulatory aspects. Current knowledge assembled at an international workshop at BfR, Germany. Cell Mol Life Sci. 2012 Mar;69(5):763-81.

doi: 10.1007/s00018-011-0846-8.

Epub 2011 Oct 14. PMID: 21997384; PMCID: PMC3276771.

The author wishes to thank Dr. Ned Ketyer for his editorial expertise when the article was originally published in the Pediablog. Permission was granted by the young physician, whose story was recounted above, to include it in this narrative in the Bulletin.

U.S. Food and Drug Administration (FDA) Approved Weight Loss Medications and the Management of Obesity in Adults

syDney saDkin, PharMD, PGy-1 aCute Care— aMBulatory Care foCuseD PharMaCy resiDent

alleGheny health network, alleGheny General hosPital, PittsBurGh, Pa

Background

Obesity is a chronic disease that affects more than 4 in 10 adults in the United States.2 This disease state is characterized by a multitude of factors including an elevated BMI, elevated waist circumference and comorbidity risk. The threshold for BMI is > 25 kg/m2 or > 23 kg/ m2 for certain ethnicities. Waist circumference thresholds for abdominal obesity vary based on the population and the organization; however, for the American Heart Association (AHA) an elevated waist circumference in men is > 40 inches and > 35 inches in women.1 Weightrelated diseases or complications include, but are not limited to, prediabetes, metabolic syndrome, type 2 diabetes, dyslipidemia, hypertension, cardiovascular disease, obstructive sleep apnea, asthma, osteoarthritis, urinary stress incontinence and depression. The interpretation of these components contributes to the classification of obesity into different classes, ultimately guiding the overall management approach.1

Treatment Approaches

There are various treatment approaches including non-pharmacologic and pharmacologic to aid in weight loss management; however, for those that are indicated, research has found clear benefit in utilizing a combination of these approaches in long-term management and success. Non-pharmacologic recommendations are also commonly referred to lifestyle and behavioral therapy. Effectively designed

programs consist of a healthy meal plan, physical activity and behavioral interventions.1 These interventions are effectively executed by a multidisciplinary team consisting of dieticians, nurses, educators, physical activity trainers and clinical psychologists. Within Allegheny Health Network, pharmacists are a crucial part of the multidisciplinary team in the ambulatory setting. Grade A recommendations include a reduced-calorie meal plan that is high in macronutrients which supports the evidence that reducing total energy intake should be the main component of any weight-loss intervention. Focusing on increasing the macronutrient composition has been found to optimize adherence, eating patterns, weight loss, metabolic profiles, risk factor reduction and clinical outcomes.1 Grade A recommendations for physical activity include > 150 min/week of moderate exercise performed during 3 to 5 daily sessions per week.1 Resistance training should be advised; however, physical activity should be individualized to the patient based on capabilities and preferences.1 For the behavioral component this can be effectively executed by integrating goal-setting, education, stress reduction and counseling. There are five FDA approved medications for weight management. Short term treatment of 3 to 6 months has not demonstrated long term health benefits with the current evidence (Grade B)1; therefore, the pharmacologic agents recommended should be individualized for the patient based on efficacy, side effects, cautions and warnings. The effectiveness of weight loss medications is

defined as > 5% weight loss after 3 months use as this is the threshold for experiencing metabolic benefits. If the response is insufficient, discontinuation of the medication is considered, and alternative medications and approaches are evaluated.3

Pharmacologic Options

Wegovy (semaglutide) and Saxenda (liraglutide) are glucagon-like peptide-1 (GLP-1) receptor agonists. They mimic the GLP-1 hormone that is a physiological regulator of appetite and caloric intake. This receptor is present in several areas of the brain involved in appetite regulation.4 Through the stimulation of insulin secretion, reduction of glucagon secretion and decreasing of the appetite, these medications have shown benefit in weight reduction. These are injectable medications that are dosed either once weekly for Wegovy or once daily for Saxenda. Common adverse reactions of these medications can include nausea, vomiting, diarrhea, constipation, dyspepsia and abdominal pain. GLP-1 agonists are contraindicated in patients with a personal or family history of medullary thyroid carcinoma or in patients with Multiple Endocrine Neoplasia syndrome type 2.1, 4 They should also be avoided in patients with a history of pancreatitis, in females and males of reproductive potential and in pregnancy.4

Contrave (naltrexone HCl/bupropion HCl) is an oral combination medication that is also FDA approved for weight loss. Naltrexone HCl is an

Materia Medica

opiate antagonist and bupropion HCl is a weak inhibitor of the neuronal reuptake of dopamine and norepinephrine. The exact neurochemical effects of Contrave leading to weight loss is not fully understood; however, nonclinical studies have found that naltrexone and bupropion have effects on the hypothalamus and the mesolimbic dopamine circuit which are involved in the regulation of food intake.5 Common adverse reactions include nausea, constipation, headache, vomiting, dizziness, insomnia, dry mouth and diarrhea. This medication is contraindicated in uncontrolled hypertension, seizure disorders, anorexia nervosa or bulimia or undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates and antiepileptic drugs. It is also contraindicated in patients with chronic opioid use or during or within 14 days of taking a monoamine oxidase inhibitor (MAOI).1, 6 This medication also carries warnings and precautions for patients with a history of suicidal behavior and ideation, hepatoxicity and angle-closure glaucoma. Contrave is also not recommended for use during pregnancy.5, 6

Qsymia (phentermine/topiramate ER) is also an FDA approved medication for weight management. This medication is taken orally. Phentermine is a sympathomimetic amine. Its role in weight management is likely mediated by release of catecholamines in the hypothalamus which result in reduced appetite and decrease food consumption, although the exact mechanism is unknown.7 Topiramate’s mechanism is also unknown, but is thought to be due to its effects on both appetite suppression and satiety enhancement through its enhancement of gamma-aminobutyric acid (GABA) activity.7 Common adverse reactions include paresthesia, dizziness, dysgeusia, insomnia, constipation and dry mouth. This medication is contraindicated in pregnancy, glaucoma, hyperthyroidism and when taking or within 14 days of stopping MAOIs. Qsymia also carries warnings and precautions in embryo-fetal toxicity, increase in heart rate, suicidal behavior and ideations, risks of acute myopia and secondary angle closure glaucoma and mood and sleep disorders.1, 7

Xenical (orlistat) is a reversible gastrointestinal lipase inhibitor. It exerts its therapeutic activity in the lumen of the stomach and small intestine by forming a covalent bond with the active serine residue site of gastric and pancreatic lipases and inhibits the absorption of dietary fats. As undigested triglycerides are not absorbed, the resulting caloric deficit may have a positive effect on weight control.8 This oral medication is also available over the counter as Alli. Common adverse reactions include oily spotting, flatus with discharge, fecal urgency, fatty/oily stool, increased defecation and fecal incontinence.1,8 Xenical is contraindicated in pregnancy, chronic malabsorption syndrome and cholestasis. There are warnings and precautions to use in patients with renal insufficiency and severe liver injury. Gastrointestinal events may also increase with a high fat diet (>30% total daily calories from fat).8

Patient-centered Approach

Management of weight loss should be patient-centered and individualized based on the patient’s comorbid conditions, goals, lifestyle and affordability. It is pertinent to consider all aspects of each of the medications when making treatment decisions, as there are many limitations for use for each of the pharmacologic treatment options. Multidisciplinary approaches to weight management have been proven to be highly efficacious in the long-term management of weight loss and thus should be utilized in practice to support the best outcomes for our patients.

References:

1. Garvey WT, Mechanick JL, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients With Obesity. Endocr Pract. 2016;22(suppl 3);1-205.

2. Prescription Medications to Treat Overweight & Obesity. Available at: https://www.niddk. nih.gov/health-information/weight-management/prescription-medications-treat-overweight-obesity. Accessed March 20, 2023.

3. American Diabetes Association; 8. Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes—2021. Diabetes Care 1 January 2021; 44 (Supplement_1): S100–S110.

4. WEGOVY. Package insert. Novo Nordisk, 2017.

5. CONTRAVE. Package insert. Currax, 2014.

6. Gohil K. Pharmaceutical approval update. P T. 2014;39(11):746-772.

7. QSYMIA. Package insert. Vivus, 2012.

8. XENICAL. Package insert. Cheplapharm, 1999.

Dr. Sadkin is a PGY-1 Acute Care – Ambulatory Focused Pharmacy Practice resident at Allegheny General Hospital. For any questions concerning this article, please contact Dr. Sadkin at the Allegheny Health Network, Allegheny General Hospital, Center for Pharmaceutical Care, Pittsburgh Pa., (412) 359-3706 or email Sydney.sadkin@ahn.org.

Telemedicine Audits: OIG Toolkit Informs Payers and Physicians

By Beth anne jaCkson

Having pursued and prosecuted significant fraud that took place in telehealth during the COVID-19 public health emergency (“PHE”), which ended May 11, the Office of Inspector General (“OIG”) is now poised to identify fraud related to telemedicine on an ongoing basis. In April 2023, the OIG published “Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risk” (the “Toolkit”). While the OIG specifically intended the Toolkit to assist Medicare Advantage plans, state Medicaid programs, and private health plans in analyzing their own telehealth claims data to identify key risk areas, the Toolkit also serves as a compliance blueprint for telemedicine providers. By knowing what the OIG and other payers are looking for, physicians can take affirmative steps to avoid coming under scrutiny or to become prepared to mount a strong response to allegations of improper billing or practice patterns.

Risk Number One. Providers who bill telemedicine visits to a large number of unique beneficiaries (rather than repeated services to a smaller number of patients) are considered to be high risk. For Medicare, the OIG considered providers who billed telehealth for more than 2,000 Medicare beneficiaries in a year to be high risk. The median was 21. As most other plans are significantly smaller than Medicare, expect their thresholds to be much lower. If you are billing for a high number of unique patients via

telemedicine, be prepared to answer questions and justify any arrangements that you have. Further, ensure that you can demonstrate that the nature of your practice justifies how many different patients that you are seeing.

Risk Number Two. As with in-person services, billing for telemedicine services at the highest, most remunerative level for a high proportion of services – “upcoding” – demonstrates substantial risk of improper billing and is likely to prompt pre- or post-payment review or an audit. If you code at the highest level for all or most visits, make sure that your coding is justified and supported by the patient’s health care needs and rigorous documentation. The same is true if billing for prolonged services.

Risk Number Three. Billing a high average number of hours of telehealth services per visit is considered to be high risk. For purposes of this analysis, the OIG considered a “visit” to include all telehealth services a provider billed for a single beneficiary for one date. The Centers for Medicare & Medicaid Services (CMS) publishes a list of the median number of minutes for each CPT code that can be downloaded from its website. The median length of telehealth services per visit for all providers who billed Medicare for telehealth was 21 minutes. If you average significantly more than that amount of time for your telemedicine visits (the OIG threshold was an

average of two hours, but other payers may have lower thresholds), that will likely be targeted for further scrutiny. To mitigate risk, it is important to establish a system for documenting time in a consistent manner. In addition, understand the data that your telemedicine platform can record and how that data can be extracted to support coding if needed. Finally, routinely monitor your billing so that you are never billing for an “impossible day” (that is, billing for 25 hours of services in a day).

Risk Number Four. Providers who bill for telehealth for a high number of days in a year will draw scrutiny because, to payers, doing so may indicate that the provider is billing for services not provided. The OIG threshold for this risk factor was 300 unique dates in a one-year timeframe for which the provider billed a telehealth service. The median was 26 days in a year. Once again, documentation will be key to defending claims billed, including not only medical record documentation, but also supporting documentation such as calendars, scheduling programs and data from your telemedicine platform.

Risk Number Five. Not surprisingly, the OIG identified providers who bill primarily (or solely) for telehealth visits with patients with whom they did not have an established relationship as a being a high fraud risk, as it may indicate that the patient information

Legal Summary

was stolen or compromised. Consult a knowledgeable health care attorney before entering into any arrangement involving patients with whom you are not establishing a treatment relationship.

Risk Number Six. Providers who bill multiple plans or programs for the same telehealth services were considered a high risk for fraud and abuse. Billing Medicare fee-for-service and a Medicare Advantage plan for the same service on the same day was the example given. This is never appropriate.

Risk Number Seven. Billing for a telehealth service and then ordering medical equipment for a high percentage of patients indicates risk as well. The OIG threshold for this analysis was ordering equipment for 50 percent of patients seen via telehealth. The median is 3 percent. The OIG has prosecuted multiple physicians for fraud for arrangements in which the physician is hired to do telehealth visits for the purpose of assessing patients’ eligibility for items and services like durable medical equipment and genetic testing, often as part of a kickback scheme.

Risk Number Eight. Billing for both a telehealth service and a facility fee for most visits was the final risk factor that the OIG identified. For the Medicare program, this is never allowed. State Medicaid programs and private payer policies may vary, but as a general rule, do not bill for both a telehealth visit and facility fee.

In addition to the risks enumerated above, the OIG also advised payers to analyze billing trends of group practices as well as identifying providers who “appear to be associated with telehealth companies” that contract with physicians to provide on-demand telehealth services to patients (a/k/a direct-to-consumer telehealth vendors). If providers who pose program integrity risk are associated with such companies, the OIG reasoned, the telehealth companies may need to be monitored more closely. The OIG conceded, however, that there is currently no systematic way to identify such associations as claims are billed with the provider’s individual number.

Audits, pre- and post-payment reviews, and repayment demands can interfere significantly with a practice’s cash flow. The toolkit’s identification of high-risk billing and practice patterns allows providers to either modify their behavior to avoid audits and other actions or to implement protective measures to allow a robust response to such actions. Physicians can start with a self-audit to identify risk factors if ongoing monitoring is not already in place. In addition, physicians should pay attention to any Comparative Billing Reports (“CBRs”) they may receive from CMS. These reports

reflect a physician’s specific billing and/ or prescribing patterns as compared to peers on both a state and national level and are intended to educate physicians on Medicare billing rules and payment policy. CMS develops CBR study topics based on the level of risk for improper payments or over-utilization. In 2021, a CBR on the impact of the PHE on telehealth was issued. Subjects can be, and have been, repeated, so physicians who routinely bill for telemedicine services should remain alert for another CBR on telehealth. To ensure that you receive any such reports, make sure that your email address in PECOS is updated.

DISCLAIMER: This article is for information purposes only and does not constitute legal advice. You should contact your attorney to obtain advice with respect to your specific issue or problem.

Ms. Jackson is a shareholder in the Health Care Practice Group of Brown & Fortunato, P.C., which is headquartered in Amarillo, Texas, and serves healthcare providers nationally. She is licensed in both Pennsylvania and Texas and maintains an office in the greater Pittsburgh area. She may be reached locally at (724) 413-5414 or bjackson@bf-law.com. Her firm’s website is www.bf-law.com.

MISSION

Founded in 1960, the Allegheny County Medical Society Foundation has extended the reach of physicians into the community through grant giving to local organizations.

The mission of the Foundation is: A Advancing Wellness by confronting Social Determinants and Health Disparities. This mission works to fulfill an overall vision of a healthy and safe Allegheny County.

Throughout the ups and downs of the past few years, the Foundation’s work has become even more important in supporting local non-profits.

The desire to give back to the community is an inherent trait of those who become physicians. Please consider how you can personally help support the Foundation and, in turn, continue to support a healthy region.

Contact the ACMS team to learn more about how your organization can help support the ACMS Foundation.

As physicians, you know that it takes a village to keep the community healthy and safe. Please consider a donation to the Allegheny County Medical Society Foundation.

Your donation will help the Foundation fund local non-profits in future grant cycles, and will help further the mission of the ACMS Foundation.

Donations can be mailed to: ACMS Foundation

850 Ridge Avenue Pittsburgh, PA 15212

Scan this QR Code to Donate via Qgiv:

Call for Nominations – 2024 Leadership Positions

BoarD of DireCtors anD aCMs house of DeleGates noMinations are Due By auGust 15, 2023

The ACMS Nominating Committee is accepting nominations for six open positions on the 2024 Board of Directors, including (5) three-year term board seats, and (1) 1-year term board seat that has become vacant. The ACMS Election will take place during the first week of November and the new board members will be announced following certification at the December 5, 2023, Board of Directors meeting. The terms of the new Board members will begin on January 1, 2024.

Serving on the ACMS Board of Directors requires participation in four meetings per year (held quarterly), with in-person attendance preferred at all meetings. There may, from time to time, be special meetings of the Board of Directors should the need for a meeting arise. Board positions are open to all ACMS physician members.

The ACMS Delegation will also elect several members to serve as Delegates or Alternate Delegates for the PAMED House of Delegates. The 2024 dates for the House of Delegates are October 25-26, 2024. ACMS Delegates are elected for a term of two-years (and may not serve more than 3 consecutive terms). Alternate Delegates are elected for a oneyear term and there is no limit to consecutive terms for Alternate Delegates. Applicants for a Delegate or Alternate Delegate position should be considerate that the ability and willingness to attend the House of Delegates in-person will be considered during the vetting process. In-person attendance will be encouraged.

Joining the Allegheny County Medical Society board of directors and/or Delegation

can provide a multitude of benefits, including professional development, networking opportunities, the ability to influence and impact the medical profession, and personal fulfillment. It can be an excellent platform to contribute to the medical community and advance one’s career in healthcare. We hope you will consider nominating yourself or a colleague for these important roles.

To nominate yourself or a colleague please use the online submission portal by visiting https://www.acms.org/2023-acms-leadership/ nominations. If you have any questions, please reach out to ACMS Executive Director, Sara Hussey (shussey@acms.org) or Dr. Raymond Pontzer, ACMS Nominating Committee Chair.

2023 ACMS Board of Directors

Ryan James - Commercial Litigation

Rebecca Moran - Mergers & Acquisitions and Physician Contracts

Jerry Russo - Criminal Defense and Investigations

Paul Welk - Mergers & Acquisitions

The ACMS Announces the Launch of the Women in Healthcare Committee

By: sara C. hussey, aCMs exeCutive DireCtor

At the May 9th ACMS Board of Directors meeting, the ACMS Board unanimously approved the creation of the ACMS Women in Healthcare Committee. The ACMS Women in Healthcare Committee has been created to provide a space dedicated to inspiring all ACMS members to support and mentor women physicians; to encourage their interest and active participation in organized medicine; to advance their role in political and legislative advocacy; and to promote women physicians as leaders.

The objectives of this committee will be:

• To increase the number of ACMS women members.

• To increase the number of women involved in top medical leadership positions, including governance roles at ACMS and the Pennsylvania Medical Society.

• To promote women in medicine.

• To increase opportunities for mentorship for young physicians.

• To become the leading primary resource for women physicians.

Glenhaven - Fox Chapel

Wilmar - Fox Chapel $1,100,000

Fox Chapel Rd - Fox Chapel $3,995,000

ALLEGHENY COUNTY MEDICAL SOCIETY — 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.

July 11, 2023

October 10, 2023

Committees

Delegation

Nominating

ACMS Night -Pittsburgh Pirates Game

ACMS Foundation

Finance Committee

Tuesday Evenings

August 29, 2023

November 14, 2023

Board of Directors*

Tuesday Evenings

September 12, 2023

December 5, 2023

Dates to be announced

April, June, August, October

May, August

July 15, 2023

June 20 – Prep for Grant Proposals

October 24 Grant Proposal Review

PAMED BOARD

May 4

August 3

AMA Interim Meeting

AMA Annual Meeting

PAMED HOUSE OF DELEGATES / HERSHEY

October 27-28, 2023

October 26-27, 2024

AMA HOUSE OF DELEGATES

November 11-14 National Harbor, MD

June 2024 Chicago, IL

ACMS HOLIDAYS – OFFICE CLOSED

June 19—Juneteenth Day

July 4—Independence Day