West TN Medical News June 2014 by FW Publishing

FOCUS TOPICS RURAL HEALTH PRACTICE MANAGEMENT MEN’S HEALTH

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PHYSICIAN SPOTLIGHT PAGE 3

Timothy Davenport, MD ON ROUNDS

Rural Hospitals Face Threat of Closing Without Medicaid expansion, more shutdowns likely By EMILy KEPLINGER

Telemedicine: An Idea Whose Time Has (Finally) Come? Technology can help underserved rural areas receive healthcare Healthcare experts have suggested the time has come to electronically link the skills and knowledge of West Tennessee’s experienced medical specialists to underserved rural communities that are in desperate need of greater access to such care ... 4

Drowning in a Sea of Change MGMA Tackles Tough Issues to Help Practices Stay Afloat Value-based reimbursements, ICD-10 reboot, meaningful use, clinical integration physician alignment, transparency, PQRS, 5010 implementation, e-prescribing, stafﬁng and training, compliance, audits … oh yes … and caring for patients ... 7

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Just six months ago, the Tennessee Hospital Association warned that rural hospitals would begin to close if Tennessee did not expand its Medicaid program. Now those prophetic words are ringing true as the hospital in Brownsville is scheduled to close this summer. Effective July 31, Community Health Systems is ending both inpatient and emergency services at Haywood Park Community Hospital because it cannot afford to keep operating them. Craig Becker, president of the Tennessee Hospital Association, sees this closing of rural hospitals as an example of what is to follow. “Closing a rural hospital is likely to trigger the departure of physicians, as well as pharmacists,” Becker said. “Patients will experience increased costs as they have to travel for their care. Acute care will likely necessitate the use of an ambulance. Even routine care will be impacted, especially if a patient needs to see a specialist. “Underserved areas will increase, which is likely to be the beginning of the unraveling of an area’s social fabric. (CONTINUED ON PAGE 6)

HealthcareLeader

Neal Rager Administrator, Physicians Surgery Center By SUZANNE BOyD

After graduating with a degree in history, Neal Rager remained at Union University to work and pursue his Master of Business Administration degree. It was during this time that he realized that academia was not the path for him. Today Rager is lending his business acumen as the administrator for Physicians Surgery Center and is serving as Presi-

dent of the West Tennessee Medical Group Management Association (MGMA) Chapter. “While working on my MBA, I realized I was wired for business and that I wanted to use my talent where it was most needed,” said Rager. “Healthcare was a viable option because physicians are often times not geared toward the business portion of a practice. There was an opportunity with a local cardi(CONTINUED ON PAGE 8)

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PhysicianSpotlight

Timothy Davenport, MD By SUZANNE BOyD

Poised to take over the family business, Timothy Davenport, deviated from the construction business to pursue a career in urology. Today at the Jackson Clinic, PC, Davenport is using a different skill set and tools, including DaVinci Robotics to care for his patients. In 2012 he was awarded Doctor of the Year by the Tennessee Men’s Health network for his work toward the advancement of prostate cancer awareness and treatment. A Memphis native and Briarcrest graduate, Davenport was in line to follow in his father and grandfather’s footsteps and enter the family’s construction business. When he found he was more interested in how the scientific world worked, he made the decision to buck tradition and pursue medicine. “I had two younger brothers so I figured one of them would step in to run it,” said Davenport. “Turns out they both ended up pursuing medicine as well but our parents were happy and the business has survived.” While studying biology and chemistry as an undergraduate at Samford University in Birmingham, Davenport spent two summers as a Howard Hughes Fellow working in the biochemistry department at St. Jude Children’s Research Hospital where he researched the mechanisms of leukemia. After graduation, he returned to Memphis to attend medical school at UTHSC. In his third year of medical school, Davenport knew he wanted to pursue surgery, he just was unsure what field. While working in reconstructive gynecology, he found pelvic floor reconstruction to be interesting due to its intricate nature. “Some urology residents asked me to come hang out with them to see what they did,” said Davenport. “I was fascinated by the cancer side of the specialty. Since I knew intricate surgery was what I wanted to do, urology was a perfect fit.” During the fourth year of his fiveyear urology residency at the University of Mississippi Medical Center in Jackson, Davenport found that his growing up in the construction business was paying off. “Due to my business training I was pretty good at reading contracts. I would help the older guys with the contracts for their permanent positions after residency,” said Davenport. “The chief resident in front of me was about to take a position with the Jackson Clinic, but his fiancé wanted to be on the coast. Since I had reviewed the contract I knew what the job entailed and decided to pursue it myself. Jackson was the perfect sized medical market for me since I knew it would allow me to get to know my patients.” In 2009 Davenport joined the Jackson Clinic, PC. Today the group has three urologists on staff. Davenport’s practice centers around his interests: urologic cancers, female stress incontinence westtnmedicalnews

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and pelvic organ prolapse. As Davenport’s cancer patient population grew, he realized that in order to better serve this population he needed to dedicate one day for his cancer patients and started a unique urologic cancer clinic. “The types of cancers I treat require lifelong surveillance. If a patient is going to be seeing me for 30 years having a clinic dedicated to them made sense because it allows us to provide more efficient care while affording patients the opportunity to get to know one another and build a network of support,” said Davenport. “I have a nurse that is dedicated to just these patients which streamlines the follow-up process. I review the patient’s data with the nurse and where we need to go from there. We both see the patient in the office. With this coordination, we have a very efficient model of how to implement treatment that has been very successful.” Davenport is also very active in cancer awareness and education in the community, two elements he attributes to his being named the 2012 Doctor of the Year for the state. “Each year I do a community wide prostate cancer awareness seminar,” he said. “It brings in patients, wives, and children of prostate cancer patients. We discuss treatments, innovations and where we are headed.” One outstanding innovation that Davenport says is allowing physicians to push the limits of surgery that cannot be done with the human hand is the use of the Da Vinci Robotic Surgical System. “The entire field of surgery is working toward more minimally invasive procedures, and this has allowed urologists to perform more difficult operations more ef-

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ficiently. Nearly all of my prostate cancer surgery is performed with the DaVinci, and overall, we have had excellent outcomes,” said Davenport. “I recently submitted an article regarding the integration of the DaVinci system into the treatment of pelvic organ prolapse. With transvaginal mesh falling out of favor in the surgical community, the robotic approach has risen in prevalence with the evolution of the DaVinci sacrocolpopexy and other prolapse procedures.” Away from the office, Davenport is a busy father who is active in his church and the local chapters of Young Life and Fellowship of Christian Athletes. Each summer, he takes his wife Jennifer and their three children to spend one week at a Young Life camp, where he serves as the camp physician. He also serves as a Board member and Financial Chairman for Young Life in Jackson. Davenport, who is a Board member for the local chapter of Fellowship of Christian Athletes, organizes the group’s annual high school golf tournament. Education is another passion and Davenport recently was a guest lecturer for the Anatomy and Physiology Class at the University School of Jackson’s Upper School.

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Telemedicine: An Idea Whose Time Has (Finally) Come? Technology can help underserved rural areas receive healthcare By JUDy OTTO

Healthcare experts have suggested the time has come to electronically link the skills and knowledge of West Tennessee’s experienced medical specialists to underserved rural communities that are in desperate need of greater access to such care. The idea is actually not new. The first interactive telemedicine system, was launched in 1989 over standard telephone lines. It was designed to remotely diagnose and treat cardiac patients at 12 hospitals in the United States. Since 1998, Memphisbased Interactive Solutions, Inc. (ISI), a leader in the field, has designed, installed and supported more than 1,500 telemedicine units across the country for a wide range of medical specialties and subspecialties, from neurology, emergency medicine and high-risk OB consults to stroke networks, surgery collaboration and more. Brock Slabach, senior vice president of the National Rural Health Association (NRHA), says the need is definitely there and notes that 20 percent of Americans live in rural communities and only 9 percent of the nation’s doctors practice there. The need is exceptionally keen in the Mid-South. Mississippi has the highest

JUNE 2014

stroke prevalence rate in the nation, and Arkansas, Tennessee, Alabama and Louisiana are among those sharing the top six highest rates; Mississippi likewise has the highest infant mortality rate, with Louisiana, Alabama, Tennessee and Arkansas close behind. Telemedicine has proven it can work – impressively and produc-

tively: The University of Arkansas for Medical Sciences (UAMS) has spent $20 million to set up a model telemedicine program and, working in partnership with ISI since 2006, has deployed more than 500 remote/rural sites across the state. It continues to grow and evolve, offering every flavor of telemedicine and subspecialty, and serving those who might otherwise go without healthcare service in any form. The American Telemedicine Association Conference’s credentials as the fastest-growing trade show in the U.S. also demonstrate the increasing fascination with the field. Yet, according to Jason Moore, ISI’s account manager, fewer than 10 percent of Memphis-area specialists are being utilized for telemedicine. Slabach agrees that “although there are some specific niche programs that telemedicine has been used for and continues to be very effective in terms of utilization, the spread of it has not gone as fast and as far as possibly we would have hoped.” While the technology may be marvelous in its design and execution, the concept and operation are relatively simple. Jeremy Johnson, vice president of sales for ISI, described a hub-and-spoke structured network, with typically a convenient desktop terminal at the doctor’s end and a mobile cart that administrators or nurses at each of the participating rural clinics or hospitals can move from room to room, utilizing specialized technology that ranges from basic video conferencing to add-ons such as a digital stethoscope, an ultrasound machine or an ear, nose and throat scope, for example. “With some of the clinical assessment tools, we can integrate into these consults; it really is the closest thing to being there,” Johnson said. Additionally, as new needs are discovered, e.g. for telestroke or telecardiology, the ISI technology can easily be expanded with additional scopes, pieces, even a computer — to make it as flexible and cost-effective as possible. The video conferencing equipment is versatile

enough to do double duty in also offering on-site access to CME credits for the physicians, Moore pointed out. As in so many other contemporary healthcare frustrations, cost seems to be the culprit, Moore said. “A lot of the challenges with telemedicine — and something that’s really starting to change — is the reimbursement for it.” An in-person consultation with a physician is reimbursed at a different rate than a telemedicine visit — which reimburses at “much less,” Moore said. “That’s been the big hesitation, I think, for a lot of people: how can they make enough money doing this to sustain the program?” ISI helps to identify available grant sources to fund the equipment and get the program going, but, Moore said, once the grant money is gone they haven’t been able to sustain, due to limited reimbursements. Individual states are now starting to reimburse for many more procedures, he points out — Mississippi is leading the charge as one of 16 states that have open reimbursement for different levels of telemedicine. The House Energy and Commerce Subcommittee on Health is also seeking input on how 21st-century technology can improve healthcare and help patients — through government support of technology adoption and identification of ways the government is currently inhibiting the use of such technologies — good news, indeed, for telemedicine’s future. Slabach agrees that Medicare has already done some work on its telehealth reimbursement policy. “The real issue for Medicare is not that they don’t want to pay for it, necessarily, but that there’s a scarcity of data that shows the effectiveness of telehealth services,” he said. “A lot of research is being done now, however, so we should start seeing some peer-reviewed science coming out that could, with time, change Medicare’s mind on some of their payment policies.” Prices of the technology itself also seem to be improving. “The equipment and the software to run it have really become much more affordable,” Moore said. “A few years ago folks would spend typically $30,000 on a high-definition site; today, sub-$5,000.” Costs will vary, depending on the different subspecialties and the tools required, but outreach through telemedicine may be becoming a venture increasingly worth investigating. “People are looking at this as much more than just a technology decision,” Johnson said. “It’s now an access to care decision. We need to make sure that the hospital logistically is ready to serve potential patients in the most effective way possible.” Go online to: Americantelemed.org or isitn.com.

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Limited Access Rural Communities Risk Losing Hometown Healthcare By CINDY SANDERS

At 11:59 p.m. on July 31, Haywood Park Community Hospital will cease inpatient admissions and emergency services. At the stroke of midnight, the Brownsville, Tenn. hospital will become an urgent care clinic, leaving the county’s rural residents to drive close to 30 minutes to hospitals in Covington, Ripley or Jackson. According to a release from the hospital, operated by Community Health Systems, inpatient admissions had dropped from 1,300 in 2009 to less than 250 in 2013. Additionally, the Emergency Room had also seen a sharp decline with 15 or fewer patients per day over the past several months. The release went on to cite changes in guidelines for inpatient admissions and federal reimbursement cuts under the Affordable Care Act that have not been offset by Medicaid expansion in Tennessee as contributing factors to the hospital’s demise. In light of the new reality, Haywood Park CEO Joel Southern said maintaining a full-service hospital was simply not sustainable. Although the latest to make a news splash, Haywood Park isn’t the only hospital that has closed in Tennessee or been reassigned as an outpatient clinic in recent months. Craig Becker, president of the Tennessee Hospital Association, noted Scott County in East Tennessee has only recently reopened (and without obstetric care) after being shuttered for several months and two others have closed in West Tennessee. Both Humboldt General Hos- Craig Becker pital and Gibson General Hospital both closed earlier this year, and yet another hospital in Upper East Tennessee is currently on life support. A common theme among the recently departed inpatient facilities and the more than 50 others that have been deemed ‘in danger of closing’ is their rural location. “These rural areas are the most vulnerable,” Becker said, adding it was hard to envision how to adequately service these communities without hospitals. Joellen Edwards, PhD, RN, FAAN, president of the Rural Health Association of Tennessee (RHAT), concurred, noting hospital closures have a ripple effect. “You lose your prenatal care. You lose your primary care because they just can’t make it when the hospital closes.” Edwards, whose research focuses on rural populations, is a professor and associate dean at East Tennessee State University’s College of Nursing. Looking at a number of the threatened hospitals in the state, she said, “Some of these are critical access hospitals, which means there is not another hospital for a minimum of 30 miles – or it could be even further away ... westtnmedicalnews

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and probably is.” She continued, “In East Tennessee, if you live in our mountains, 30 miles is not an easy drive. Not having a hospital available in minutes … rather than an Joellen Edwards hour or more away … makes a difference literally to life and death.” In addition to losing access to care, Becker said the economic impact of losing a hospital is a topic that has been glossed over. “These are often some of the best paying jobs in these communities,” he said. Edwards pointed out hospitals are frequently the economic driver in rural towns and are sometimes one of the few jobs in the county that come with health benefits. Losing those jobs only exacerbates the problem of uninsured and under-insured rural populations. “I can guarantee you Brownsville is hurting right now because of losing those jobs,” Becker said. He added CHS couldn’t be blamed for their decision to cease emergency and inpatient services … it’s simply an economic reality. “It certainly isn’t that the community doesn’t deserve to have a hospital. The reality is now you can’t afford to have one.” Even in communities that don’t close hospitals, Becker said he anticipated seeing service lines that are not typically profitable … such as oncology and obstetrics … dropped. “Cutting services isn’t much of a strategy, but we’re going to see a lot of that,” he surmised. He added lawmakers have, at times, accused the THA of ‘crying wolf’ as the association leaders have discussed the imminent danger to numerous hospitals in the state. “This is the kind of thing we’ve been predicting,” Becker said of the recent closures, adding he wasn’t happy to be proven right. The current closures, however, are feared to be the tip of the iceberg. Fueling the concern is that the federal funding cuts, such as DSH payments, are back loaded. Becker said Tennessee hospitals face $1 billion in cuts in the year 2019 alone. “Even with (Medicaid) expansion, it’s going to be difficult,” he said of the financial stressors hospitals face. “But without expansion, we’ll lose even more hospitals and definitely see more services cut.” He added, “One-third of the hospitals in the state are losing money. I see other hospitals on the border … on the brink.” The Tennessee Plan proposed by Gov. Bill Haslam as an alternative to the Medicaid expansion program rolled out by the federal government, which has been accepted by 26 states plus the District of Columbia so far, is still stalled …

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(CONTINUED ON PAGE 12)

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Rural Hospitals, continued from page 1 For example, businesses looking to locate to a particular area will consider available medical care, just as they consider school systems, in their decisions. Truly, it will have a wide-spread ripple effect.” But these closings are not merely the result of what has happened in the last six months. For years, rural providers have been warning that failure to expand the public health program would put them in jeopardy. Becker explained, “The choice was left

to each state, and Tennessee is one of the states that is not participating in the Obamacare provision of Medicaid expansion. In fact, most of the states that are not participating are in the South, and have large segments of their population in rural areas.” Many rural hospitals operate at a loss because they serve a high number of poor and uninsured patients who can’t always pay for their care. These hospitals, referred to as Disproportionate Share Hospitals (DSH), received reimbursements from the

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federal government. Because the Affordable Care Act intended for every state to expand Medicaid, thereby reducing the number of uninsured people who can’t pay their bills, the reimbursements for those DSH hospitals have been reduced. According to Kathleen Sebelius, former secretary of the Department of Health and Human Services, Tennessee began losing out on more than $6 million a day on January 1 when the federal government began picking up all the cost for covering people who newly qualified for Medicaid under expanded guidelines -- an offer that goes away at the end of 2016. It then phases down the federal match to a permanent 90 percent in 2020. W. Larry Cash, chief financial officer for the community health group that operates the hospital in Brownsville, says Tennessee’s refusal to expand Medicaid was a “contributing factor” in the move to close the hospital. The 62-bed facility will become an urgent care clinic, treating minor illnesses and non-life-threatening injuries. A document prepared by the Rural Policy Research Institute Health Panel reports that states can opt to expand Medicaid at any time and receive the 100 percent federal match for newly eligible recipients. Arkansas is one of two states (the other is Iowa) that have been granted waivers from the Centers for Medicare and Medicaid Services (CMS) allowing Medicaid recipients with incomes between 100 percent and 138 percent of FPL to purchase health plans through the new marketplaces, using Medicaid payments to cover the costs of premiums. Paul Cunningham, executive vice president of the Arkansas Hospital Association, said, “We have chosen to implement a state-tailored version of the expansion. We are losing financially on the Medicare side, but we hope to balance things out with our private option insurance option. Yet, even in states that opted for Medicaid expansion, such as Arkansas, rural hospitals are still facing difficulties. Case in point, Crittenden Regional Hospital in West

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Memphis. With or without its Medicaid expansion, the hospital serves a high number of people who cannot pay for their care. Crittenden Regional is trying to address its financial problems by asking local residents to vote for an increase in the local sales tax to help save the hospital. The vote is scheduled for June 24. “Basically, what we’re seeing is just the beginning,” Becker said. “There will be more and more areas without acute care services. Similar situations have already occurred elsewhere in Tennessee, in Jellico and in Scott County. In the latter case, the hospital reopened, but without OB services. The big question is, ‘How do we keep a medical presence in these communities?’ If not a hospital, then what?”

Limited Access, continued from page 5

although not yet dead. During the 108th General Assembly, however, state lawmakers added another hurdle to getting funding to Tennessee hospitals by passing a bill requiring Haslam to obtain legislative approval before accepting any expansion dollars. Becker, who called himself an eternal optimist, said he still believes the Tennessee Plan could pass. Unfortunately, he said it might take having more hospitals close to drive the message home. “Maybe there is going to be some pressure on some of these rural legislators when they realize they are losing part of the social fabric of their communities,” he said. From RHAT’s standpoint, Edwards said, “We have a stance that uninsured people in Tennessee should have an opportunity to be covered just like in Maryland where they chose to expand Medicaid.” Although she said the association doesn’t take a political stance as to which expansion plan is implemented, Edwards concluded, “We in the Rural Health Association do want to see a reasonable expansion of services to people in this state … it’s what they deserve.”

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Rural hospitals such as Haywood Park are particularly impacted by new cuts in federal program reimbursement as part of the Affordable Care Act. These cuts were based on more people having insurance, whether through Medicaid expansion or the insurance exchanges. Tennessee has forgone the option to cover more individuals with Medicaid, leaving many of the state’s most vulnerable citizens without access to health insurance, and with no means to address the unsustainable burden of uncompensated care.

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Drowning in a Sea of Change MGMA Tackles Tough Issues to Help Practices Stay Afloat By CINDY SANDERS

Value-based reimbursements, ICD-10 reboot, meaningful use, clinical integration physician alignment, transparency, PQRS, 5010 implementation, e-prescribing, staffing and training, compliance, audits … oh yes … and caring for patients There’s no question the American healthcare system is in the midst of a sea of change as foundational rules are rewritten and a new infrastructure for care delivery is being put in place. While providers, practice managers and administrators are supportive of many of the concepts, it doesn’t make the transition any easier. With wave after wave of change washing over practices, it’s certainly ‘sink or swim’ time. For those trying to navigate the rough waters, the Medical Group Management Association’s extensive resources, advocacy and insights on critical issues help shore up practice managers as they fight to keep afloat. Laura Palmer, FAC- Laura Palmer MPE, a senior industry analyst and subject matter expert for MGMA, said practices across the country are facing unprecedented change. While much of it is tied to the Affordable Care Act, a move to restructure the delivery and payment system was underway even before the landmark legislation was set in motion but has since been greatly accelerated. Today’s practice managers are being asked to alter ‘business as usual’ on most every front. Benefits & Eligibility Referencing the ACA impact, Palmer said it’s about much more than just expanding coverage. “It’s really a change in how insurance plans work,” she noted. Keeping up with who covers what, where, with whom and at what point has become increasingly complex as staff members drill down through eligibility requirements and benefits to figure out the bottom line for patients. While access might be expanding as more people join the insurance rolls, Palmer noted there has actually been a trend of narrowing networks. Not every physician or service provider is on every plan level under a payer. Adding to the confusion, not every family member is on the same plan. “We’re starting to see more differentiation, and it’s more difficult for the patient and provider, who needs to know where to send someone for referrals,” she noted. westtnmedicalnews

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Whereas traditionally a lab company would have been on every plan under a payer, that’s not necessarily true today. A platinum plan might have more options than a gold or silver plan. “It’s a lot more complicated,” Palmer said. “You can’t depend on what you knew in the past to be true.” Therefore, she continued, it’s critical to regularly check coverage parameters and limits. Verifying benefits annually used to be pretty common. However, Palmer said that no longer works. “Best practices say we really need to check eligibility and benefits every single visit for every single patient,” she said. Although patient benefits tied to large employers or government entities still aren’t likely to change more than once a year, the same isn’t necessarily true for smaller employers. And, Palmer pointed out, people change jobs much more frequently now so even if a company’s plan hasn’t changed, the patient’s job status might have. Appropriate Staffing True access to care doesn’t mean simply having the coverage in place to allow a patient see a provider. The second part of the equation is having providers available to meet appointment demands within a reasonable time frame. “The days of a doctor’s office being closed for two hours over lunch are long gone,” Palmer said. In fact, she noted, many practices are looking at evening and/or weekend hours, group care settings and adding non-physician extenders to meet demand. From a reimbursement standpoint, practices must see enough patients to keep the doors open. From a quality standpoint, which now ties to reimbursements, it’s critical to meet best practice parameters. Palmer noted evidence-based standards might call for a patient with a specific complaint to be seen within 48 hours. Practices have to figure out how to do that or risk the consequences … both of missing quality benchmarks and of lowered patient satisfaction scores, which also will soon tie into reimbursement rates. “You don’t want patients to go to the Emergency Room because they couldn’t get an appointment,” Palmer said. She added, “Practices need to make sure they have adequate staff coverage and a triaging system in place to ensure patients are getting the right care in the right environment in the right time frame.”

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Making New Friends “Practices that in the past might have (CONTINUED ON PAGE 9)

JUNE 2014

Neal Rager, continued from page 1 ologist looking to start a solo practice. After developing a business plan for him, it led to helping him find a location for his practice, and ultimately to serving in his new clinic.” Over the course of the four years Rager worked for the cardiology clinic, he met what he calls his mentors, Angela Youngberg, Donna Klutts and Raymond Kee. It was Klutts who approached him with the opportunity to run the Surgery Center. “I joined the center two and a half years ago and it has been a great experience. I see the physician owners about once a week when they cycle through the center,” said Rager. “Raymond and Donna also encouraged me

to get involved with MGMA, which I did about a year and a half ago. It is a wonderful networking tool, fantastic educational experience and also helps me market our business.” Since the surgical center is structured much like a surgical floor of a hospital, the staff includes a clinical manager and approximately 34 employees. “We run a pretty tight ship,” said Rager. “The key is knowing what I do well and bringing what I can on the financial and business side. I have a lot of confidence in the surgical staff here and rely on them a great deal. Our clinical manager worked her way up from

the bottom, so I rely on her for knowledge on clinical aspects. It is this teamwork that is essential to our success.” Rager says the challenge facing every clinic is staying relevant and learning what is required to keep the doors open. He feels the accessibility of MGMA is a great solution. “I see membership in this group as key to being successful as a manager or administrator,” he said. “It gives you access to information needed to do your daily business. It will put you in front of people who can facilitate conversations on whatever you are facing as well as keep you abreast of changes coming in the future.”

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JUNE 2014

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As president of West Tennessee MGMA, Rager is charged with seeing that the organization is facilitating conversations that are relevant and providing networking opportunities. One of the goals he hopes to implement while in office is a mentoring program. “I want to facilitate those relationships through MGMA,” said Rager. “In this group there is a great deal of experience across specialties and practices and it is important that we share that wealth of knowledge with younger members to help them as they develop their careers.” With the changes coming in healthcare, Rager notes there are big decisions facing clinics, especially small ones. “The salient question is not how you will comply with meaningful use, but if you will comply at all,” he said. “Meaningful use carries a great cost in terms of compliance. We may see clinics in the next few years that decide not to comply in some areas. ICD-10 is one that you are not going to be able to avoid since it is going to be implemented for all insurance carriers. The cost to comply though is significant. The retraining is exceptional but it is non-negotiable because coders must be bilingual. Other things you see are little pockets of civil disobedience where fiscal prudence precludes clinics from keeping pace with ever-growing regulation. Some clinics just do not have the deep pockets needed to implement them and the small clinics will simply have to say no.” At the recent state MGMA meeting, this issue was discussed. “One requirement is that clinics have a certain percentage of patients using a patient portal, but as a clinic how can you compel a patient to do that? I think it will be especially challenging for clinics that deal with an older population that may not be as comfortable with computers and technology,” said Rager. “I see the benefit of it but to have a threshold that must be met is too far of a stretch. I can’t see holding a clinic responsible for someone’s actions that far exceed their ability to control.” Growth is a constant goal for Physicians Surgery Center. “We are always looking to add new surgeons and MGMA has helped us identify surgeons who are looking for an alternative to the hospital setting,” said Rager. “Freestanding surgery centers are a cost effective option because we typically feature lower per case costs and are reimbursed roughly 40 percent less than our hospital and hospital-owned counterparts creating tremendous savings for our patients. Nationally the trend is that we have better infection and recovery rates.” Balance is something that is at the top of Rager’s list. “There is nothing more important than faith and family to me and that was a decision my wife and I made early on, even before our daughter was born three years ago,” he said. “Fortunately, this guiding principle also is one that is part of the culture at the Surgery Center. Everyone who works here is doing so to help meet the needs of their families. Meeting our patients’ needs is of the utmost importance to us and we have been able to find a way to take good care of patients while honoring family commitments.” westtnmedicalnews

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Drowning in a Sea of Change, continued from page 7 been competitors in a particular community are now having to play nice with each other,” Palmer pointed out of new coverage rules and clinical integration models. Tied to the narrowing network trend, providers are finding payers and plans increasingly dictate referral patterns. Palmer said new payment models, such as the formation of accountable care organizations, also are forcing more collaborations encouraged by both the financial setup and patient need. She added that while this kind of collaboration across care settings is generally viewed as a good move for quality patient care, it is different than traditional practice silos and will take time for providers to adjust to creating more community-based care than has been available in the past.

again put ICD-10 on the back burner only to panic again next year instead of using this time to really prepare. Practice Setup “Integration and alignment issues are still a big topic of conversation,” Palmer said. What is the most effective practice model? Should practices merge? Sell to a hospital? Specialize or become multidiscipline? The ‘correct’ answer, she said, truly varies depending on circumstances and location. “Healthcare is local,” Palmer pointed out. “What would work in Maine won’t necessarily work in Arizona.”

The MGMA Lifeline MGMA’s resources can serve as a lifeline to practice managers who are treading water as fast as they can. Palmer stressed the organization’s role is not to make decisions for practice managers but to put them in a position to proactively make thoughtful choices based on their own unique set of circumstances. The goal, she said, is to “bring people vetted information – good information from reliable sources – so practice managers can make informed decisions.” She continued, “There isn’t one right answer. The joke around here is if you’ve seen one practice … you’ve seen one practice.” Although new delivery models are building local alliances, there is certainly

still a competitive relationship among practices in a given geographic area. Palmer said a key benefit of MGMA is that it provides a safe environment for peer networking to allow the exchange of information across regions. Where a practice manager might not ask the competing cardiology practice down the street how they are handling benchmarking or succession planning, MGMA membership provides a forum where that manager could talk to cardiology practices outside the market catchment area to find out how they are addressing those issues. Finally, she noted, MGMA offers the tools to allow managers to excel in their careers. “We provide professional development so we grow the next generation of practice managers,” Palmer stated.

Adjusting to New Payment Models Although the vast majority of reimbursements remain in the fee-for-service world, the switch to a value-based system is already underway. “The practical aspect of how we deliver care is already changing,” Palmer said. Practices have begun investing in changing technology and staffing models before reimbursements have caught up to the new way of doing business. Case managers, nutritionists and non-physician providers are being added … even when those services aren’t clearly reimbursable across most payers … because of the value they add to patient care. Currently, Palmer noted, only about 3-5 percent of a practice’s reimbursements are tied to quality metrics. While those numbers have remained pretty steady for the past few years as reported to MGMA, Palmer said she was eager to see if there is a change indicated in this year’s data. Anecdotally, she said MGMA staff members have heard from more practices that contracts are being negotiated with quality metrics in mind. Despite payments lagging a bit behind, Palmer said practices have really embraced the concept of value-based care. “It’s the right thing to do,” she stated. “I think physicians and practices know to really manage care, the best way is to look at total patient care.” ICD-10 Recognizing that not every provider in every setting is on the same page about the latest ICD-10 delay (with a new implementation date of Oct. 1, 2015 as confirmed by CMS in May), Palmer said it cropped up as the number one concern for 2014 in MGMA’s annual Medical Practice Today survey. Chief among worries are cash flow concerns, vendor issues, testing, and adequate staff training. Palmer noted, “The delay in implementation is going to allow for more testing, and that’s got to be good for everyone.” She added, she thinks it will give vendors the needed extra time to resolve software issues and practices time to get the technology and training in place. However, Palmer acknowledged there would be some practices that once westtnmedicalnews

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To learn more, visit healthcare.goarmy.com/y941 or call 1-888-550-ARMY.

JUNE 2014

MedicalEconomics BY BILL APPLING

Pour Over Ice and Shake Well

I enjoy looking at food magazines. One of the magazines I was reading recently was a summer edition that had some nice drink recipes, including Jimmy Buffett’s original Margarita. That interested me because I bartended all through college – and was a good one, if I do say so. I also noticed that almost every drink recipe included instructions to “pour over ice and shake well.” At this point, you may be asking, what does a margarita recipe have to do with healthcare? Hopefully by the time you finish this article you may see some analogy, and possibly even have an “aha moment.” I am blessed that my mom and dad, both in their early 80s, still live in the house they have lived in for years. From my house, I can be there between 15 to 30 minutes depending on traffic and how fast I drive. As their caregiver, it is important for me to be close. Mom has been a patient of Frederick Pelz, MD, for a number of years. She looks forward to her appointment with Dr. Pelz and his nurse, Sandra. Dr. Pelz is board certified in Geriatrics and Internal Medicine and is a physician in Baptist Medical Group. Mom was diagnosed with Alzheimer’s in May, 2013. Like most cases, Alzheimer’s usually comes on gradually and you start

noticing little things – not thinking too much of it at first. But then you start noticing more. During one of the times I accompanied my mom to Dr. Pelz’s office, both he and his nurse Sandra, told mom and me about Baptist Onecare, MyChart. Of course, like many older Americans, my folks don’t have the internet (nor do they want it). However, this application enables my sister and me access to mom’s health records. Both of us downloaded MyChart to our iPhones, and we now have her information right at hand. MyChart was easy for me to access. Its support line was very helpful when I called. They were able to tell me what I was doing wrong and help me fix it. (Of course, most technical issues like this can be traced to a problem being somewhere between the chair and the keyboard.) There are a lot of things this system can do and I am discovering more useful things as I access it – labs, diagnostic results, consults etc. One thing that got my immediate attention was the segment regarding medications. My parents are just like anyone else’s – they have medicines in their medicine cabinet that have been there a long time. They never throw any of their pills away. One area, safety concerns me the

most. I will periodically look at their medications; the dates, dosages etc. I am able to email Dr. Pelz and he returns my email by the next day. At the beginning of mom’s office exams, we reviewed her medications and were able to address any concerns. (I used the word “we” to include Dr. Pelz, his nurse, and me, son and caregiver.) It really doesn’t matter if you refer to it as Accountable Healthcare or Affordable Healthcare, it can’t be done without information, education and action. As with all caregivers, you worry, you stress, and often you neglect your own health. But keeping up with my mom’s health has helped me be more informed about my own health issues as well. In my opinion, the majority of patients are not purposely non-compliant. They just need the help of a competent bartender who can pour over ice and shake well. And, as I mentioned in the first part of this article, I’m a good bartender and mom enjoys a good margarita. Bill Appling, FACMPE, ACHE, is founder and president of J William Appling, LLC. He is a national speaker, presenter and a published author. He serves as an adjunct professor at the University of Memphis and is on the boards of Hope House and Life Blood. For more information contact Bill at j.william.appling@ outlook.com.

Kirkland Cancer Center Welcomes Two Local Physicians

Healthcare is Changing.

ADMINISTRATORS How can you stay on top of the issues?

Join MGMA in 2014! Monthly luncheons with Executive Level Education! For more information, contact J. Neal Rager at 731-661-6340 or nrager@pscjackson.com.

WEST TN MGMA 10

JUNE 2014

Two local oncologists have relocated their practices to the Kirkland Cancer Center. The new physicians, Archie Wright, D.O. and Brian Walker, D.O., specialize in hematology and oncology. Other physicians who recently have relocated to the clinic include Radiation Dr. Archie Oncologists Anastasios L. Wright Georgiou, M.D. and Jeffrey J. Kovalic, M.D., Clyde E. Smith, M.D., Hematology/ Oncology and nurse practitioner Worthy Walker, MSN, FNP-BC; Jackson Clinic Hematology and OncolDr. Brian Walker ogy Department, including Eugene P. Reese, Jr., M.D., Dwight Kaufman, M.D., Ph.D., and Anita Gul, M.D., and nurse practitioners Nekayeh P. Carothers, MSN, APRN, FNP-BC and Mary McMillin, APRN, FNP-C, OCN. Located on the Jackson-Madison County General Hospital campus, the Kirkland Cancer Center’s third floor Medical Clinic provides dedicated space for physicians and office staff. Having physicians and other providers on site at the Cancer Center encourages collaboration and offers patients the added convenience of being able to access all major cancer treatment services in a single location. Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.

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GrandRounds WTH Implements My Health Records West Tennessee Healthcare is implementing a new information system that will allow patients to view their personal medical information securely online. Patients will be able to access their medical information through a patient portal on the West Tennessee Healthcare website called “My Health Records.” Patients are being registered for the portal when visiting one of the West Tennessee Healthcare hospital facilities for treatment. Anyone not currently being treated at one of the WTH hospitals can sign a Release of Information authorization form and present a valid photo ID to be registered for the portal. If requesting access on behalf of someone else, then the requestor must provide documentation and proof of role as the legal representative. Patients will initially have to complete an online registration process to access their hospital information. However, once the registration is complete, they will be able to access their medical information from any computer at any time they wish. The patient portal allows West Tennessee Healthcare to offer its hospital patients a convenient, easily accessible information source so that they may become more involved in their care and better informed about their health. The system includes safeguards for patients to protect their health information. The site is encrypted so that unauthorized persons will be unable to access patient information. A password is required to log into the site. Patients will have to authorize others who can see their records. The patient portal went live on the West Tennessee Healthcare website earlier this month. Enrollment instructions are available at the Patient Portal located on the West Tennessee Healthcare website, www. wth.org.

Trenton Urgent Care Welcomes Two New Family Nurse Practitioners Two new family nurse practitioners, Amy Little, MSN, APRN, FNP-BC and Stephanie Sells, MSN, APRN,FNPBC have joined the staff at Trenton Urgent Care at the Trenton Medical Center. Both family nurse practitioners graduated from Union University with honors. Amy Little Little had been working in Family Practice at the Regional Medical Associates in Jackson managing acute and chronic illnesses in pediatric, adult and geriatric patients. Sells formerly worked as an RN at Jackson-Madi- Stephanie Sells son County General Hospital. She is a native of Trenton. They join Family Nurse Practitioner Kristi Hazelwood, BSN, MSN, FNP. Hazelwood works one day a week at Trenton Urgent Care, as well as practicing at the Milan School Clinic.

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JUNE 2014

The Rest of the Story... (SUI and Transvaginal Mesh)

by Timothy C. Davenport, M.D. 2012 Doctor of the Year, Tennessee Men’s Health Network.

Increasingly, I find myself consulting with women who are pushing themselves harder physically in fitness programs. As a result, the topic of stress urinary incontinence (SUI) arises frequently, and then often progresses to a discussion of litigation regarding the use of transvaginal mesh and slings. My patients ask if mid-urethral slings (MUS) are safe, and whether they remain the standard of care for surgical treatment of SUI. The answer is yes, and the following explanation aims to clear up some of the confusion. Mid-urethral synthetic polypropylene mesh sling placement is the most common surgery currently performed for SUI, and is the recognized worldwide standard of care for the surgical treatment of stress urinary incontinence. To date, there are greater than 2,000 publications in literature describing the MUS. Among historical SUI procedures, the MUS has been studied as long in follow-up after implantation as any other procedure and has demonstrated superior safety and efficacy. No other surgical treatment for SUI before or since has been subject to such extensive investigation. It is very important to distinguish between vaginal mesh used for the correction of pelvic organ prolapse (POP) and mesh slings used for treatment of incontinence. Due to the advancement of the robotic sacrocolpopexy and uterosacral ligament suspension, I rarely use transvaginal mesh for the treatment of prolapse. However, I remain an advocate of the mid-urethral sling for SUI, and I continue to have outstanding results with this technique. Developed in the early 1990’s, this technique treats SUI in a minimally invasive, generally outpatient procedure. The technique typically involves placement of a small strip of monofilament polypropylene through a twocentimeter transvaginal incision just below the urethra.

some potential although rare complications. I hold the belief that these complications are due to a combination of surgical technique, the materials utilized and patient anatomy. It is also important to recognize that many of these complications are not unique to mesh surgeries, and occur with non-mesh incontinence procedures as well In 2008, the FDA issued a Public Health Notice regarding potential complications associated with transvaginal placement of mesh to treat POP and SUI. In 2011, the FDA issued an update to this notice, and then convened a panel to examine the use of this mesh to treat both POP and SUI. The panel recommended that the FDA consider increasing the regulatory requirements for transvaginal surgical mesh products used for pelvic organ prolapse. However, the panel recommended that slings used for the treatment of SUI are properly classified by the FDA with respect to risks and benefits offered. No further studies were required on standard sling products. The panel recommended that current regulatory requirements remain unchanged. In 2013, in response to the 2011 FDA Notice, the American Urogynecologic Society (AUGS) performed a survey that included over 500 experienced surgeons who use vaginal mesh on a regular basis. It found that there was an overall decrease in the use of mesh for pelvic organ prolapse, but no decrease in the use of mesh for stress incontinence. 99% of the reporting surgeons continued their usage of the mid-urethral sling despite the FDA Notice.

Polypropylene material has been used in most surgical specialties (including general surgery, cardiovascular surgery, transplant surgery, ophthalmology, and otolaryngology) for over five decades, in millions of patients in the United States and the world.

I, along with the American Urological Association (AUA), agree with the FDA that a thorough informed consent should be conducted prior to incontinence procedures using synthetic mesh. Surgeons who wish to perform synthetic mesh implantation should: • Undergo rigorous training in the principles of pelvic anatomy and pelvic surgery. • Be properly trained in specific techniques. • Be able to recognize and manage complications associated with synthetic mesh sling placement.

As with any implantation of synthetic material in the body, mesh placement is associated with

In conclusion, the mid-urethral sling procedure is likely the most important

Download our incontinence brochure at jacksonclinic.com/incontinence or call 731.422.0330 for more information.

advancement in the treatment of SUI in the last 50 years. It has my full support, along with the support of most relevant professional organizations. Used prudently, and in the hands of experienced surgeons, this option is an exceptional one for the treatment of female stress incontinence. The Jackson Clinic Department of Urology would appreciate the opportunity to serve the needs of you and your patients, and are gladly accepting referrals. Call us if we can help.

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