West TN Medical News November 2014 by FW Publishing

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PHYSICIAN SPOTLIGHT PAGE 5

Jennifer DiCocco, MD

ON ROUNDS Use of Scribes to Give Doctors Relief Is Currently on Upswing How are front-line doctors going to continue to maintain good medical practice, avoid burnout, increase revenue and maximize patient-doctor interaction in the new era of dwindling reimbursement, primary care physician shortages, increased numbers ... 6

Short of Breath COPD Foundation Sheds Light on State’s High Rate of Progressive Lung Disease With 8.7 percent of residents suffering from chronic obstructive pulmonary disease, Tennessee has one of the highest rates of COPD in the country. During November, National COPD Awareness Month, it seemed appropriate to share data and insights into the third leading cause of death in the United States and in Tennessee ... 7

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Doctors, Patients Feel Sting of BCBS Cuts

Contract amendment imposes difﬁcult decision on physicians By EMILy ADAMS KEPLINGER

Health insurance is costing everyone more these days, and physicians are no exception. In fact, the pinch for many West Tennessee-area doctors has been quite painful indeed. Physicians received notice from Blue Cross Blue Shield of Tennessee (BCBSTN) last November that the insurance company was making a unilateral amendment to its contract with physicians. The amendment stated that physicians would receive a 48 percent reduction in the reimbursement cost, set by 2013 Medicare payments standards, for all services deemed “in-office physician lab services” by BCBSTN. The amendment went into effect on Jan. 1 of this year. At the time of the notice, physicians were given until Dec. 20, 2013, to decide whether they would accept the amendment ... or not. And if not, they would no longer be in the BCBS system. The threatened termination from the network was for all services, not just for lab services. Approaching the one-year anniversary of this contractual change, the impact of this amendment is clear. For most physicians, the choice was not a choice at all. Blue Cross Blue Shield is the largest insurance carrier in Tennessee. The average patient load for physicians’ (CONTINUED ON PAGE 8)

Regional Hospital of Jackson Awarded Gold Seal performance. Regional Hospital established an orthopedic unit in Going for gold has resulted in a first for a hospital 2010 after physicians, John Masterson, MD, and Kelly in Jackson, Tennessee. Regional Hospital of Jackson has Pucek, MD, requested a dedicated area for total joint earned The Joint Commission’s Gold Seal of Approval replacement surgery. Soon after the program launch, for both its Joint – Knee Replacement and Joint – Hip Regional Hospital decided to pursue the Gold Seal ApReplacement programs. The award is the culmination proval certification for the programs. The process started of an intense three-year process that reflects Regional’s in 2011 with reviewing the Commission’s Disease Spededication to meeting The Joint Commission’s national cific Care requirements and consulting with other Comstandards for health care quality and safety in these two munity Health System facilities that had received the Dr. John Masterson areas of care. The “Gold Seal of Approval” is an interaward. nationally recognized symbol of quality that indicates an organiza“There are numerous standards you have to meet that can be tion’s commitment to high quality patient care and its willingness interpreted in different ways. It really came down to interpretation (CONTINUED ON PAGE 10) to be measured against the highest and most rigorous standards of By SUZANNE BOyD

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The Case for Covering Low-Dose CT Lung Cancer Screening By CINDY SANDERS

Perhaps it is only appropriate the Centers for Medicare & Medicaid Services is scheduled to announce its highly anticipated coverage decision for low-dose computed tomography (LDCT) lung cancer screening in November. After all, this is officially ‘National Lung Cancer Awareness’ month. For proponents of using the diagnostic imaging study for early detection, the cost/ benefit analysis is simple … LDCT saves lives in a cost efficient manner among a targeted, high-risk population. Medicare already covers broad-based screenings for colon, breast and prostate cancers. According to the American Cancer Society Cancer Facts & Figures 2014, the combined estimated annual deaths from those three types of cancer is still significantly less than deaths from lung cancer (120,220 vs. 159,260). One of the most vocal supporters for extending coverage to Medicare beneficiaries is Ella A. Kazerooni, MD, MS, FACR, associate chair for Clinical Affairs and division director for Cardiothoracic Radiology at the University of Michigan. “I firmly believe that screening for lung cancer with CT saves lives,” she stated. An expert in the field, Kazerooni’s long list of credentials includes serving as a trustee on the American Board of Radiology, chair of thoracic imaging for the American College of Radiology’s Commission on Body Imaging, chair of ACR’s Committee on Lung Cancer Screening, vice chair of the National Comprehensive Cancer Network’s Lung Cancer Screening Panel, and past president of the American Roentgen Ray Society. “Medicare received two formal requests for a national coverage decision,” she explained of actions taken earlier this year precipitating the CMS determination. “They statutorily have until Nov. 10 to post their draft coverage decision,” Kazerooni continued, noting a final decision was expected in February 2015 following a comment period.

The Science

While CMS will complete the coverage decision process in a 12-month period, proponents say the science supporting CT scans for diagnosing lung cancer goes back several decades. Considering the current poor survival rates, this delay in integrating the scientific research into routine practice has been particularly frustrating for providers. Kazerooni said more than three-quarters of lung cancers are found in a late stage when the disease has spread, making surgical intervention ineffective or impossible. Patients are typically asymptomatic until the disease has progressed, which contributes to dismal survival rates. Currently, more than 90 percent of those diagnosed annually with lung cancer will die from the disease. Research from the International Early Lung Cancer Acton Program (I-ELCAP), which was formed in 1992, has shown annual CT screening to be an effective tool. westtnmedicalnews

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In the original study, more than 1,000 highrisk, asymptomatic patients were screened. Of those who received a lung cancer diagnosis, more than 80 percent were at a clinical Stage 1. Subsequently, findings from a much larger international pool were published in several publications in 2006 after long-term follow-up of more than 31,000 asymptomatic study participants. While less than 2 percent of those screened received a lung cancer diagnosis, 86 percent were found in Stage 1 with an overall cure rate of 80 percent. Similarly, the National Lung Screening Trial (NLST), one of the largest and most expensive clinical trials ever undertaken in the United States, evaluated the impact of screening methods on survivability. The trial, which ran from 2002-2010 and included more than 53,000 participants, compared outcomes when screening with standard chest x-ray vs. LDCT. The results published in 2011 in the New England Journal of Medicine demonstrated a 20 percent reduction in lung cancer mortality for those screened by LDCT. In both arms of the trial, more than 94 percent of positive screening results turned out to be false positives upon further testing, which is one of the arguments against annual screening. It should be noted, however, that the false positive difference between LDCT and conventional x-ray was less than 2 percent, yet decreased mortality with LDCT was 20 percent. The available science led the United States Preventive Services Task Force (USPSTF) to assign a grade of B to lung cancer screening among high-risk patients —current or former heavy smokers, ages 55-80, with a smoking history of at least 30 pack-years. The USPSTF website defines the evidence behind a grade of B as being strong enough to recommend the service be provided. The task force isn’t the only organization to support LDCT screening for highrisk patients. In fact, Kazerooni said most every major clinical healthcare professional society, including the American Medical Association, has stepped up to voice support for CMS adopting coverage. “There’s overwhelming professional support,” Kazerooni said. “We also have a lot of support from the House and Senate,” she added, noting congressional support is bipartisan.

The Decision

The irony, Kazerooni continued, is the USPSTF recommendation led to a screening inclusion in the federally mandated Affordable Care Act requiring third party payers cover LDCT for those at high risk of developing lung cancer. “It’s not a ‘recommended;’ it’s not a ‘they should;’ it’s a ‘must,’” Kazerooni said of the screening becoming a covered benefit beginning Jan. 1, 2015. If CMS doesn’t reverse current policy, then those who have received annual

screenings for as much as a decade will abruptly lose the benefit when they hit 65 and qualify for Medicare coverage. “The average age of lung cancer diagnosis is 70 so to not offer lung cancer screening as they enter their peak years of risk would be a tragedy,” Kazerooni stated. Among the issues being weighed by CMS are patient safety, frequency of testing, impact of false positive results, consistent quality across screening facilities, evidencebased data to identify eligible patients and inform follow-up and treatment, and cost of screening in relation to improved outcomes. Kazerooni noted CMS is undertaking the normal due diligence that goes into releasing a national coverage analysis decision. She and colleagues across a number of medical specialties have provided information and parameters for the screening. For example, she noted, the American Association of Physicists in Medicine has created specific exam protocols. The ACR, which is one of three bodies that accredits CT facilities, has developed a practice standard for the screening. Proponents, she stressed, are specifically calling for low-dose, rather than standard dose, scans to improve the safety profile. Providers also agree smoking cessation counseling should be part of the overall professional intervention for all

high-risk individuals who qualify for screening. As for cost, Kazerooni said, “Low-dose CT screening is at least as cost effective, if not more so, than breast cancer screening. When you’re talking about breast cancer screening, you’re talking about every woman of a certain age. Even though CT scans are more expensive, we’re targeting resources to a smaller, high-risk group.” Bolstering that assertion, a study published in August in American Health and Drug Benefits found LDCT to be cost effective in the Medicare population. The researchers found implementing the screening cost less than $20,000 per life-year saved, which is less than the costs associated with cervical and breast cancer screening. Kazerooni is favorably encouraged CMS will follow suit with private payers and cover LDCT screenings for those with the necessary inclusion criteria who are not suffering from another medical condition that would significantly limit life expectancy. However, she added, she is interested to see what conditions CMS attaches to approval. “It’s hard to believe they would do anything else but cover it,” she concluded of CMS. “There is a huge need for this, and we want to see it brought forward to benefit individual patients and the public at large.”

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MedicalEconomics BY BILL APPLING

Let’s look at the different benefits to the different stakeholders in the healthcare business. Remember, healthcare is a business, and in business you always follow the dollar. In a letter to the New York Times, Jeremy Lazarus, MD, former president of the American Medical Association said, “We agree that Congress must pass a permanent solution to the broken physician payment problem that plagues Medicare with frequent scheduled cuts, but eliminating this problem by putting in place other physician cuts rather than true payment reforms will only continue to threaten patients’ access to care. Medicare physician payments have already been nearly frozen for a decade, while the cost of caring for patients has increased by more than 20 percent. More cuts are not the answer. They would compromise physicians’ ability to participate in new models of care delivery.” The escalating cost of healthcare puts tremendous pressure on an already teetering system in which the threat of reduced Medicare reimbursement to address over-spending against the Sustainable Growth Rate continues to loom large. The SGR was established by

NOVEMBER 2014

Navigating Payment Reform Centers for Medicare and Medicaid (CMS) to set a budget trajectory for Medicare expenditures each year. That spending trajectory has been surpassed every year since 2002, without Congressional action. An American Medical Association letter to Congress in September, 2011, summed up the situation this way, “Continued delay in replacing the SGR has escalated the cost of permanent payment reform from $48 billion in 2005 to nearly $300 billion today. We estimate additional short-term interventions will double the cost to approximately $600 billion by 2016.” (An additional failure by Congress) Oh, and by the way, according to Congressional Research Services, out of a total of 435 U.S. Representatives and 100 Senators (535 total in Congress,) 170 members of the House and 60 Senators are lawyers. So lawyers compromise the biggest voting block of one type, making up 43 percent of Congress. This ratio is much too large.

ICD-10 and Reimbursement Cuts The ICD-10 code sets are not a simple update of the ICD-9 code set. The ICD-10 code sets have fundamental changes in structure and concepts that

make them very different from ICD-9. When examining the differences in the code sets, one thing is clear: there will be a need for detailed training to prepare for the transition because of the complexities of converting to the ICD-10 codes. Justification of the need to make this transition is the concern with the lack of specificity of the information conveyed in the ICD-9 codes. Another issue with ICD-9 is that some chapters are full and impede the ability to add new codes. In some cases, new codes have been assigned to different chapters making it difficult to locate all available codes. ICD-10 codes have increased character length, which greatly expand the number of codes that are available for use. With more available codes, it is less likely that chapters will run out of codes in the future. Other issues that are addressed in ICD-10 include the use of full code titles and appropriately reflecting advances in medical knowledge and technology. (ICD-9 = 13,000 codes ICD-10 = 69,000 codes) The move to ICD-10 will not be easy. It will include greater detail, changes in terminology, and expanded concepts for injuries, laterally, as well as other related factors. The complexity of ICD10 provides many benefits because the increased level of detail conveyed in the codes. Again, the complexity also underscores the need to be adequately trained on ICD-10 in order to fully understand reporting changes that will come with the new code sets. ICD-10 codes have been in the works for years. Work on the codes began in 1983 and was completed in 1992. Other countries have already adopted the new codes. They include: • Canada – 2000 • China – 2002 • Korea – 2008 • Dubai – 2012 • U.S. -2015? Considering the costs involved for American physicians to make the transition in 2015, Dr. Lazarus’s words become even truer, “More cuts are not the answer. They would compromise physicians’ ability to participate in new models of care delivery…” To identify, develop, support, and evaluate additional models of payment and care delivery, the government instituted the CMS Innovation Center. (Opposite of innovation is stagnation.) I prefer to call it the “Sinner of Innovation.” Some of the payment reform provisions developed by the Sinner that will that will have an impact on providers over the next few years are: • Medicare bonus payments to physicians who participate in quality reporting • Reduced Medicare payments to hospitals with high readmission

rates • Bundled payment pilot program with four models of payment • Hospital value-based purchasing program, with payments • Higher federal Medicaid matching payments for states that pay for care coordination services (ends December 31, 2014) “Value index” based on quality and costs added to Medicare physician payment methodology; reduced Medicare payments for physicians not participating in Physician Quality Reporting Incentive program; and reduced Medicare Payment rates for hospitals with high rates of hospitalacquired conditions In 2016, Medicare will launch a payfor-performance pilot program Private payers are highly motivated to cut healthcare costs, since they are responsible for treatment costs not covered by government programs or paid directly by patients. Private payers are trying a variety of payment reforms – none of which are likely to emerge as the dominant model but serve, nevertheless, as steps along the way to the ultimate shape of payment reform. As an example, more than 25 health plans now incorporate PatientCentered Medical Home recognition into their own programs, and many will offer financial incentives to practices that adopt the model. “In a scathing study published in JAMA, RAND researchers compared 32 (National Committee for Quality Assurance, NCQA) recognized practices in southeast Pennsylvania with 29 that were not. During a three-year period, a significant difference was found in only one of the 11 quality measures and there was no robust association with utilization of costs. The NCQA recognizes more than 6,800 physician practices as medical homes.” (J.William Appling, “CMS Hasn’t Got a Clue! Memphis Medical News, April, 2014) It may take a decade or more for healthcare to shift entirely away from fee-for-service, but, with a debt crisis, we have reached the point where payment reform is inevitable. No one knows how payment reform will evolve over time, which programs will succeed and which will fail, but there are a number of common threads. While reimbursement remains cloudy, some trends stand out: Markets are aligning around value-based healthcare; major initiatives are focused on changing provider and patient behavior; and quality measures are taking hold. 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.

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PhysicianSpotlight

Jennifer DiCocco, MD By SUZANNE BOyD

As a 26-year-old general surgical resident, Jennifer DiCocco, MD, had been well trained on the surgical options used to treat breast cancer. As a woman, she felt she could also bring a female perspective to the disease. What she was not prepared for was to be the patient herself. Today, DiCocco is bringing her experience as a patient and her surgical skills to patients where she is spearheading an effort to establish a Breast Cancer Center of Excellence at Baptist Hospital Union City. At the ripe old age of 10, Dicocco, who hails from Dayton, Ohio, broke her arm in gymnastics. When she woke from surgery she started telling folks she was going to be a surgeon. A sentiment that was reinforced several more times thanks to accidents endured from gymnastics that caused her to have more surgeries. “I loved that idea of going in, fixing the problem and making the person better,” said DiCocco. “I think that is especially true in surgery versus other medical specialties where you are dealing with more chronic illnesses.” After graduating in molecular genetics from Ohio State, DiCocco chose the University of Cincinnati for medical school. Her residency in general surgery was completed through the University of Tennessee Center for Health Sciences in Memphis where she rotated through multiple hospitals including The MED (now Regional One Health), LeBonheur, Methodist, Baptist, St. Francis and the

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VA facility. DiCocco chose a seven-year residency that included five years of surgery and two of research. In 2008, while in the third year of her residency, DiCocco felt a mass in her breast. Initially she chalked it up to being nothing because she was only 26 years old and thought she would just watch it for awhile. When the mass did not go away, her medical side prevailed and she sought the advice of one of the doctors she worked under. “She was a female surgeon who did mostly breast surgery. I told her I was concerned and she examined me. Within 48 hours I had a mammogram, an ultrasound then a biopsy. Twenty-four hours later the results were back and I was told I had breast cancer. Ironically, I was diagnosed on October first, which is the first day of Breast Cancer Awareness Month,” said DiCocco. “Based on the size of the

cancer my options were a lumpectomy and radiation or mastectomy. I opted for a bilateral mastectomy with reconstruction.” Since she was in the research portion of her residency at the time of her diagnosis, DiCocco had the flexibility in her schedule needed to accommodate surgery and chemotherapy without having to put her residency on hold. “I had my initial surgery in October. Started chemotherapy in November and finished in April,” said DiCocco. “My reconstruction surgery was immediately after I completed chemo because I had already had expanders put in at the time of my mastectomy. A couple of years later I had them redone by Dr. Laura Cooper, a plastic surgeon from Memphis.” DiCocco met her husband right after completing chemotherapy. “I had practically no hair, just peach fuzz,” she said. “Eleven months later we were married and I was a mom to my step daughter. While I was still in residency in October 2012, we had another daughter. Our next one came in 2014 right after moving to Union City.” “Initially I thought I would do trauma surgery and did an additional two years of research in trauma as a part of my residency,” said DiCocco. “While I was doing my rural surgery rotation in Union City, I worked with Dr. Thomas Jernigan, III. I saw him having the time to not only be a devoted surgeon but a father as well. Balancing my career and a family was important to me so I chose to stay with general surgery. When I finished my residency in June 2013, I joined the Jernigan Surgery Clinic in Union City which was a very welcome change from life in the big city.” Managing a practice with a family is important to the mom of three girls,

who range in age from eight years to nine months old. “Being in a smaller town means things are just not as crazy for me. I take call every third night and it is a lot easier to be at home with the girls and be at their activities,” said DiCocco. “My husband is also a huge help and is a great father. When I was in residency and had our daughter who is now two, he stayed home with her for practically the whole first year. Now he is the office manager at the clinic which gives him a great deal of flexibility in his schedule.” Being a cancer survivor and cancer free for the past six years has brought a new perspective to DiCocco’s practice. “There are things you never realize until you have been through it yourself,” she said. “Had I not gone through it I would not know the challenges breast cancer patients face, many of which affect how you go through your daily activities. I went through chemotherapy as a young woman, which is a very unique experience. I can relate to patients better since I truly know what they are going to go through.” DiCocco takes the treatment of breast cancer not only personally but wants to make sure that patients in Union City receive the highest quality of care. To this end, she has made it a goal to have the Breast Cancer program at Baptist Memorial Hospital – Union City designated as a Center of Excellence. “It is a process that will take several years but we are submitting data and have all the components needed to receive this prestigious designation,” said DiCocco. “We have to have two years of data that has been reported in six month increments. It will be at least a full year before we can have the designation but we are definitely working toward that goal.”

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Use of Scribes to Give Doctors Relief Is on Upswing By GINGER H. PORTER How are front-line doctors going to continue to maintain good medical practice, avoid burnout, increase revenue and maximize patient-doctor interaction in the new era of dwindling reimbursement, primary care physician shortages, increased numbers of patients and electronic medical records? Some experts propose the use of medical scribes. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) defines a scribe as “an unlicensed individual hired to enter information into the EHR or chart at the direction of a physician or licensed independent practitioner (physicians, advanced practice registered nurses, physician assistants).” “Previously, scribes were being used in emergency departments to allow the maximum involvement of the physicians with the patients,” said Soumitra Bhuyan,

PhD(C), MBBS, MPH, professor of health administration at the University of Memphis. “Now we are witnessing an increased use of scribes in other areas like hospitals and physi- Dr. Soumitra cian offices. This is an inBhuyan teresting trend. It is partly due to federal government’s push for adoption of EHRs.” Alan Flippin, MBA, CMDS, has been a medical practice consultant for 21 years. He serves medical offices and forecasts that the use of scribes within his clientele will increase from 15 to 50 percent in the next one to two years. “For revenue generation in a doc’s office at this time, it’s one of the best things they can do and not change their practice,” he said. “Before, they would see 25 patients a day; now they really need to see 35 to make

the same amount of money since reimbursements have gone down. Anytime doctors are typing, they are not seeing patients.” He also said there is the benefit of not facing dictation at the end of the day. The time saved can be used to study the latest treatments, drugs and technology emerging. He added that studying the 50,000plus additional ICD-10 codes to be enacted Oct. 1, 2015 is not a good use of doctors’ time. Flippin said some of his clients are adding exam rooms to meet the demand of extra patients seen as a result of the efficiencies of using scribes. The Feb. 12, 2014 issue of Information Week: Health Care reported that the numbers don’t always work in the positive for doctors. Citing an internist who maintained his own EHRs, the story said he could not justify scribes for primary care due to lower income. It is too early to tell whether scribes can boost physician productivity outside emergency departments where they are

Prescribing Exercise as Medicine – How to Talk to Your Patients About Exercise By MIKI MARTIN

Fifty percent of the US population has at least one chronic medical condition. According to the Centers for Disease Control, chronic diseases and conditions such as heart disease, stroke, cancer, diabetes, obesity, and arthritis are among the most common and costly health problems facing Americans and the healthcare system today. Because 80 percent of disease, illness, and injury is due to poor decisions and lifestyle behaviors, most of these chronic conditions are preventable. The top two health risk behaviors leading to illness, suffering, and early death related to chronic disease are lack of exercise and poor nutrition. In 2011, more than 50 percent of US adults did not meet the recommendations for aerobic physical activity and 76 percent did not meet recommendations for strengthening physical activity. Physical activity is the solution to preventing or treating many of our most common chronic diseases. The Exercise is Medicine (EIM) initiative was launched in 2007 by the American College of Sports Medicine (ACSM) and the American Medical Association (AMA) to encourage primary care physicians to include exercise when designing treatment plans for patients. Encouragement from a patient’s trusted physician is often the greatest influence on a patient’s decision to make a lifestyle change. According to the CDC, 6

NOVEMBER 2014

overweight patients are nearly five times more likely to exercise if their doctors counseled them to do so. Some suggestions for introducing exercise into the physician/patient conversation: Actively listen to the patient. A patient who feels their physician is attentive to their concerns will be more receptive to their suggestions. Capitalize on teachable moments. When a patient has had a potentially lifechanging event, he or she may be motivated to make a behavior change. Assess the patient’s knowledge level. Many people think that it is too late in life or they are too far gone to make changes. A lack of knowledge may have contributed to past failures. Determine what is important to the patient. Some patients may not be motivated to change for themselves, but they may be motivated to remain independent so as not to burden others or so they can play with their grandchildren. Help the patient understand that it is not necessary, nor realistic, to completely overhaul all of their poor habits at once. Changing one unhealthy habit at a time is the key. As demands on providers’ time increase, even with their best efforts, they will have even less time available to effectively counsel their patients on exercise. LIFT Wellness Center, located downtown in the Jackson Walk development, has a mission to improve the health of the community by promoting healthier life-

styles through education, physical activity, and nutrition. The Exercise is Medicine medical fitness programs at LIFT allow physicians and other healthcare providers a simple and easy way to prescribe exercise as a way to address and manage chronic disease and risk factors such as cancer, heart disease, arthritis, osteoporosis, sleep apnea, obesity, high blood pressure and high cholesterol. The Exercise is Medicine medical fitness programs offer an affordable option for patients to work with degreed and certified exercise specialists to ensure their program is safe, effective, medically appropriate and goal-oriented. They also have access to registered dietitians, physical therapists, healthy cooking classes, health education, and group exercise on land or in water. Patients who are referred to the Exercise is Medicine program do not have to be members of the LIFT Wellness Center. The physician simply fills out a referral form available by calling 427-7048 and faxes the form to the Exercise is Medicine Program Coordinator at 731-425-6878. The EIM coordinator will contact the patient to set up their first appointment. For information about the Exercise is Medicine programs at Lift Wellness Center, email Miki Martin, PT, MBA, COMT, Lift Wellness Center Director at miki.martin@wth.org or Hilary Keen, MS, HFS, Exercise is Medicine Program Coordinator at hilary.keen@wth.org.

more commonly used, said an Aug. 24, 2013 article in Modern Healthcare. Use of medical scribes also brings up other issues, according to Bhuyan. “As this profession is not fully grown, there are still concerns about patient confidentiality among other legal issues,” he said. “Some patients might not like the idea of the presence of a third person in the exam room, which may negatively impact their communication and sharing relevant information with their physicians.” He also said scribes might not have a clear understanding of terminologies and disease management, which could result in documentation errors. Lastly, he said that scribes are still an unlicensed profession, so the physician clinic or hospital employing them must ensure that scribes follow the patient care documentation guidelines. A quick survey of scribe usage in larger Memphis hospital emergency departments showed St. Francis with no comment, Regional One not using scribes, Baptist using a scribes agency and Methodist self-hiring them. “We grow our own and teach them ourselves,” said Ray Walther, MD, medical director, emergency department, Methodist University Hospital. “We employ about 25 here, a few full-time ones and most parttime. They are pre-med or pre-physician’s assistant.” Walther said they find the use of scribes cost-effective because it makes physicians more efficient and provides reminders of when test results are back. He said it also gives them extra time with patients. He said he had tried EHRs with voice recognition technology and all the advances in software, and he was still not satisfied and preferred scribes. Walther sees the use of scribes enduring with the fast pace of the ED. One hospital spokesperson said he thought scribes were temporary, or a stopgap measure until older physicians retire and younger, more technology-proficient physicians enter the workforce. Bhuyan agreed it might be true that younger and more tech-savvy physicians will find it easier to use EHRs. But, he pointed out, with the Affordable Care Act, more Americans have access to health insurance, many for the first time, and the transition to ICD-10 codes will be challenging. Use of EHRs can add to this stress, he said, with time-consuming data entry and interference with face-to-face patient care. He cited a study published in Journal of the American Medical Association in October 2012 that said nearly 46 percent of physicians in the study had at least one symptom of burnout. The study reported that burnout is more common among physicians than other U.S. workers, and the highest rates were found in internal medicine, family medicine and emergency departments – where scribes are more likely to be used. “If medical scribes can contribute to reduce the physician’s stress associated with EHR use, I think it will continue to grow in the future,” he said. westtnmedicalnews

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Short of Breath COPD Foundation Sheds Light on State’s High Rate of Progressive Lung Disease By CINDY SANDERS

With 8.7 percent of residents suffering from chronic obstructive pulmonary disease, Tennessee has one of the highest rates of COPD in the country. During November, National COPD Awareness Month, it seemed appropriate to share data and insights into the third leading cause of death in the United States and in Tennessee. Unlike most major illnesses, chronic lower respiratory diseases have actually increased in frequency over the past three decades, and the numbers rise even higher when factoring in those who are misdiagnosed or underdiagnosed. Currently, close to 15 million Americans are living with known COPD. However, Jamie Sullivan, senior director of Public Policy and Outcomes for the COPD Foundation, noted, “The NIH estimates there are Jamie Sullivan about 12 million nationally who have COPD symptoms but haven’t received a diagnosis.” Sullivan continued, “There tend to be more women who are misdiagnosed than men.” Compounding the issue, COPD tends to affect women disproportionately with a national average of 6.7 percent having COPD compared to 5.2 percent of men. “That disparity between men and women is actually worse in Tennessee than in the nation.” Sullivan said data from the Behavioral Risk Factor Surveillance System shows the COPD rate for women in Tennessee is 11.7 percent compared to 6.7 percent for men. The Volunteer State, she added, has the third highest rate of COPD overall in the country at 8.7 percent compared to the national average of 6.3 percent. Tennessee trails only Kentucky and Alabama in prevalence.

Deb McGowan, senior director of Health Outcomes for the COPD Foundation, noted the reasons behind Tennessee’s higher rates are multifactorial including environmental issues and smoking rates in the South. Although Tennessee has made significant strides in sharing smoking cessation strategies, nearly a quarter of the state’s adult men (24.7 percent) and onefifth of the state’s adult women (19.7 percent) still smoke. While there can be a genetic component to COPD, McGowan said smoking leads the way as a key contributor to the chronic illness. A quarter of those with COPD have never smoked with the condition likely linked to genetics, occupational and environmental pollutants, leaving the other 75 percent related to smoking. Sullivan added, “Definitely exposure to tobacco is the main risk factor, but it’s not just curDeb rent smokers who are at McGowan risk, it’s people who had a history of smoking.” She noted these are individuals who followed the recommendations and quit smoking but 10-15 years later begin to have trouble with their breathing. The COPD Foundation embarked on a listening tour this past summer and spent time in East Tennessee to learn more about the incidence rates for COPD. Sullivan said one thing they heard over and over again was the air quality in the valley exacerbated asthma and the ability to breathe easily. The problem isn’t limited to the eastern part of the state, however. The Asthma and Allergy Foundation of America routinely includes Tennessee’s largest cities in its annual list of “Most Challenging Places to Live with Asthma.” In 2014, Memphis ranked second, Chattanooga sixth, Nash-

ville 38th and Knoxville 41st. In addition to smoking history and environment, Sullivan said other risk factors include a history of asthma, early nutrition and prenatal events, early childhood infections, age, and socio-demographic status. She noted nearly one in five adults with annual incomes under $15,000 (19 percent) have COPD. As with most chronic diseases and conditions, early detection, intervention and education improve quality of life and reduce healthcare costs and economic burden. McGowan said providers could help by being more aware of COPD when taking a patient’s personal history. Instead of asking if someone smokes, McGowan urges physicians and nurses to ask if an individual has ever smoked. “Around 100 cigarettes lifetime is where you start thinking differently,” she said of risk factors for COPD. Additionally, McGowan said providers should be attuned to any respiratory symptoms that seem to be ongoing. “We don’t have to have a patient hit the hospital before we test them,” she noted of diagnosing COPD. “You do that through spirometry testing. It’s a simple breathing measure and can be done in a primary care office.” Although billable, McGowan said most outpatient clinics and practices are not aggressively utilizing the test to screen appropriate patients with symptoms. Many practices don’t have spirometers … or if they do, too often the equipment is sitting on a shelf collecting dust. Yet, she noted, getting that early diagnosis is critical to properly educating and treating patients. She added a number of studies have shown “patients who are uneducated and not activated in their care are twice as likely to be admitted to the hospital.” Unfortunately, she continued, “We find a lot of patients don’t even know how

to use their inhalers correctly. Not all inhalers work the same.” She added patients should call their doctor if they aren’t getting relief from their inhaler, have a fever, stronger cough, more productive cough, or noticeable discoloration in mucus. “All those signs and symptoms indicate you’re heading down the wrong path.” McGowan said a common, easy way for patients to think about COPD is to use the ‘green, yellow, red light’ approach. The green light, she explained, is no change in what a patient is able to do. A yellow light means a patient is showing some symptoms and signs and should call a doctor. The red light means nothing is working, and the patient should proceed directly to the ER. “It’s more about taking care of yourself and being aware of your body every day,” she said of managing COPD. Sullivan added, “We do have resources that are designed for healthcare providers. We also have resources they can use with their patients.” The Pocket Consultant Guide (PCG) even has an app attached to it for information on the go. Physicians could also join a moderated online community with discussion about particularly difficult cases and various treatment options. Additionally, there is a quarterly digital magazine tailored to providers. To sign up for the magazine or access other resources, go online to copdfoundation.org.

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Doctors, Patients Feel Sting of BCBS Cuts, continued from page 1 practices includes 30 to 50 percent BCBSTN patients. Not acquiescing to the unilateral amendment change meant that doctors’ patient loads were going to be significantly reduced. That was a gamble that most physicians were not in a position to make. Yarnell Beatty Yarnell Beatty, inhouse counsel for the Tennessee Medical Association (TMA), explains, “There were some medical practices and clinics that were big enough in their markets that they could say no — but they were few and far between. Both in rural and urban settings, only those practices that BCBSTN deemed ‘essential to the network’ — area IPAs (Independent Practice Associations) and large specialty practices – had enough clout to not accept the new terms. The largest groups of physicians who were negatively impacted were primary care providers, pediatricians and family practice groups.” The TMA responded to BCBSTN, urging the insurance carrier to rescind the cuts or reduce the sting of a mid-contract, dramatic decrease in rates. In a letter to BCBSTN, the TMA relayed concerns expressed by its members: • Having to outsource lab services, even driving revenue to out-of-state lab providers and laying off their own staff, because the cuts are untenable for their practices • Inconveniencing patients and their employers by having to send patients to other facilities to obtain lab services • Delay in care and liability issues • Reducing access to care by possible closures of satellite clinics in rural areas • Reducing patient compliance with their treatment because of added burdens of being diverted to other facilities for their labs

• Confusion as to scope and applicability of the amendment • The drastic nature of the cuts compared to other payers. So in January of this year, physicians continued to carry the same overhead expenses for their practices, ordered the same lab work, yet began receiving 48 percent less of their previous lab reimbursement from BCBSTN. It is the feeling of some physicians that Blue Cross is intentionally forcing some of the liability back on the medical practitioners to either provide the service at a loss, or bear the liability of the delay in treatment. In cases where the patient might be compromised by a delay, physicians believe that Blue Cross knows that doctors will provide the necessary service, including inhouse lab work, and eat the financial loss. Another negative impact being faced by smaller practices involves supplies. The cost of the lab reagent necessary to run lab tests actually is more than the reimbursement given by Blue Cross, so physicians are continually operating at a loss. Regardless of the practices’ size, in most cases clinics had their 2014 budget in place well before they received notice of this reimbursement change. The managing partners had reviewed their budgetary line items such as staff salaries, health benefits, anticipated expansion and modernizing equipment, but now they were faced with meeting their budgets with less than half of the expected income from lab reimbursements. And the impact didn’t stop with the physicians; the changes also affected patients. In some cases, primary care physicians were forced out of business. Without access to their doctors, patients had to choose between going to an emergency room for care or going without care and running the risk of getting sicker. The latter choice carried the added risk of being hospitalized for extended care. Either option incurred higher expenses for the patients — and was counterproductive in terms of patient care.

Tom Reed, former executive director of West Tennessee Physicians Alliance and West Tennessee Primary Care IPA, said, “In rural Tennessee, outside of Shelby County, doctors in independent clinics have banded together under the umbrella of an IPA as a means of being protected from antitrust scrutiny. These physicians use a Messenger Model to facilitate contracts. As BCBSTN contracts with employers to be their insurance provider, a list of participating doctors is provided. For those who opted not to accept the amendment, they were forced out of the BCBSTN network. This translated to employers no longer being able to provide access to some of the physicians that employees signed up for when they selected their healthcare plans.” Beatty adds, “For some patients, it came down to seeing their doctor out of network and therefore paying more out of pocket, or being forced to select a new physician who was within network.” Beatty continues, “A medical practice is a business. You can’t keep your doors open if you can’t pay your rent and retain your staff. The situation is disheartening to a lot of physicians who just want to take care of patients but are constrained by these types of decisions that are being made by those holding the purse strings. “For example, a pediatrician sees a child and needs lab work to make a diagnosis. With in-office service, labs can be handled right then and there, allowing the doctor to make a diagnosis and a treatment plan and if necessary order a prescription. After the cuts to lab reimbursements went into effect, doctors had to decide if they were going to do as before and lose money, or take the option to send the lab work off campus, to Quest Diagnostics or somebody out of state, where the cost is cheaper due to volume. But the latter option means the patient walks out of the office and will have to come back or get a call from the doctor to learn the lab results. For the patient, it is a hassle

that translates to additional time off of work for parents and more time missed at school for children. There’s a clinical downside, as well as an economic downside, for Tennesseans.” Mary Danielson, director of corporate communications for Blue Cross Blue Shield in Chattanooga, said, “BCBSTN’s stated reason for the decrease was to put BCBSTN costs at market rate. Approximately 9 out of 10 of our total provider population accepted the lab Mary amendments. Those who Danielson did not accept were removed from our provider network or have had (or will have) their lab reimbursement addressed during scheduled negotiations in order to allow our members access to these services at more market competitive rates.” In a letter sent to BCBSTN in response to the amendment, the TMA stated, “Unilateral changes to rates affect a business’s bottom line, which determines jobs, supply purchases and the volume of medical services that can be delivered to patients — your company’s covered lives. TMA sees this as stymieing the growth of medicine and limiting access to healthcare in Tennessee. … The message we have inferred from senior BCBSTN officials is that the curtailment of in-office lab services is acceptable because it will result in lower costs to BCBSTN.” Insurance providers’ contracts routinely incorporate wording that effectively says they can change rates, payment methodologies and policies anytime they want … and if providers don’t want to accept the changes, they risk being out of the network. There have been “nickel and dime” changes from TennCare MCOs and other commercial insurance plans that have resulted in cuts. However, some clinics say they are facing unrivaled challenges from this BCBSTN amendment.

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Ebola Preparedness Update Expert Brieﬁngs & More By KELLy PRICE & CINDy SANDERS

Ebola Drug Therapies Vanderbilt University researchers have partnered with Mapp Biopharmaceutical Inc. to develop their new human antibody therapies to provide short-term protection for people exposed to the deadly Ebola and Marburg viruses. These hemorrhagic filoviruses kill, in part, by causing massive bleeding. The San Diego-based company has developed an experimental treatment, called ZMapp, which contains antibodies manufactured in plants. ZMapp has prevented lethal disease in rhesus monkeys but has not yet been tested for safety and efficacy in humans. At Vanderbilt, researchers are using a high-efficiency method to isolate and generate large quantities of human antibodies from the blood of people who have survived Ebola and Marburg infections and are now healthy. No live virus is used in the research. “We’re the only lab in the world that has a high-efficiency human hybridoma technique for isolating human monoclonal antibodies,” explained James Crow, Jr., MD. He said Vanderbilt has been isolating antibodies to major human pathogens to better understand the basic science of immunity. “However, with the current urgent medical need for treatments for Ebola infection, we are thrilled to be working with Mapp Biopharmaceutical to produce the antibodies we have discovered as antiviral drugs that may benefit patients and healthcare workers facing this terrible epidemic,” Crowe said. Notes from the TDH Last month, Tennessee Department of Health Commissioner John Dreyzehner, MD, MPH, FACOEM, led a media briefing regarding the state’s level of preparedness and response to Ebola. While stressing there had been no confirmed Dr. John or suspected cases of Dreyzehner the deadly virus in Tennessee, Dreyzehner said should the need arise, “We’re confident we can provide patient care and mitigate transmission to others.” He added the TDH had been providing guidance to hospitals and facilities for several months … not only on Ebola but on MRSA and other contagions, as well. “In addition, we’ve been encouraging hospitals to conduct response exercises.” Dreyzehner noted, “Fear, mistrust and stigma are really thriving with this epidemic.” For that reason, he said it was critically important that healthcare providers and media outlets help the public understand the facts about Ebola including that it can’t be spread through the air, westtnmedicalnews

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by mosquitos, in the water and typically not through food. Instead, it is spread through bodily fluids or on items grossly contaminated by bodily fluids, such as a needle. “Ebola cannot live long outside the human body and is easily killed by common disinfectants,” he said. Asymptomatic patients and those who have recovered from the disease are not a public health threat. However, once someone shows symptoms, Dreyzehner said the viral load increases as the person becomes sicker. While the incubation period is generally three weeks, days 8-10 are often the time when symptom onset occurs. Some individuals have taken longer than 21 days to test positive for the virus, and Dreyzehner said it appears people are capable of transmitting Ebola for about 90 days through semen. Since bodily fluids can transmit through open wounds or through the eyes, nose, mouth and skin, it is critically important for healthcare providers to protect themselves. “The most basic thing we can do is washing our hands,” Dreyzehner said. “We touch our faces about 16 times and hour,” he added to emphasize the importance of killing germs through proper hand-washing protocols. Equally, he said, healthcare providers need to be sure to follow the specific order of putting on and taking off personal protective equipment (PPE). “I know as a healthcare provider myself, we don’t always put as much attention as we should on putting on and taking off personal protective equipment,” Dreyzehner said. “Let he who has never snapped their glove in the trashcan cast the first aspersion,” he added wryly. Recently, the CDC (cdc.gov) updated PPE guidelines to more closely match protocols in place by Doctors Without

Borders, which has a successful history of fighting Ebola and other contagious diseases around the world. On home soil, Dreyzehner lauded the depth and breadth of public health experience in the state. “I have great confidence in Tennessee’s ability to respond to this or any other threat,” he concluded. HCA’s Gift In late September, HCA made a $1 million cash donation to the CDC Foundation’s Global Disaster Response Fund to help support international Ebola response efforts involving the CDC and their work with partners on the ground in West Africa. HCA has a long history of supporting relief efforts including those following the earthquake in Haiti, the Indonesian tsunami, Hurricane Katrina and Typhoon Haiyan in the Philippines. The donated funds will be used to provide much-needed supplies and equipment to aid workers including personal protective equipment, infection control tools, ready-toeat meals, generators, exit screening tools and supplies at airports such as thermal scanners to detect fever. “Ebola continues to R. Milton spread rapidly in West Johnson Africa, and CDC and others have made it clear that the window of opportunity to contain the virus is closing quickly,” said R. Milton Johnson, president and CEO of HCA. “The time to act is now, and we strongly encourage other companies, particularly those in the healthcare industry, to join us in this important effort to save lives.”

Waller Launches Ebola Legal Resource Site In late October, Waller Lansden Dortch & Davis, LLP announced the launch of a comprehensive online resource to help healthcare leaders and other organizations impacted by the Ebola virus navigate diverse issues pertaining to the arrival of the virus in the United States. The website can be accessed at EbolaLegalResource.com. “The immediate and long-term legal implications of the Ebola virus on all facets of hospital, clinic and practice management must be seriously considered,” said Mark Peters, a partner in Waller’s Labor and Employment practice who works extensively with healthcare employers. “Waller’s Ebola legal resource website comes in response to the many questions we’ve received from clients. Preparation in this situation is important, whether an Ebola patient walks through your doors or if you are simply dealing with the climate it has created.” The site launched with a compilation of media articles, links to outside resources, and original articles from Waller attorneys including: • The Role of Healthcare Employers during the Ebola Crisis, • Patient Privacy Concerns, • FAQs on Employee Discipline, Discrimination & Harassment, • Workers’ Compensation for those Contracting Ebola, and more. The site, which will be updated as new information becomes available and is analyzed, is tailored to healthcare executives, board members, risk managers, human resources professionals and others who are asking what Ebola means, from a legal perspective, for their organization, employees and patients.

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Regional Hospital of Jackson Awarded Gold Seal, continued from page 1 of the standards,” said Lisa Wall, RN, Clinical Director of Orthopedic and Total Joint Center. “Anytime The Joint Commission comes in you are nervous because you want everything to be like it is supposed to be and they look at so many processes. Although we felt we were on the right path, you are never really Lisa Wall sure you are until the examiners get here.” Wall felt good about the process and its outcome but knew that there would be some things that would come to light that needed improvement. “That is what is great about pursuing this certification,” she said. “You really get to look for things you can improve on, which means better care for patients. It also starts a focused pattern of continuous evaluation of the programs and striving to always improve.” The process started in 2011 when Regional began collecting data on patients who underwent total hip replacement surgery or total knee replacement. “We collected 24 months’ worth of data in preparation for the certification process,” said Wall. “We looked at that data from all aspects of the program and identified four areas we felt we could improve. We then collected data focusing on these four areas of improvement. Not only were the measures we selected important but also the process of formulating and implementing a plan for improvement was equally important. “One area that we reviewed was blood transfusions rates which can impact infection rates. By November 2013 we had decreased the transfusion rate by 60 percent. We then had to make sure we knew how to sustain that improvement, so we continue to track this measure.” Physicians were also a big part of the entire process both throughout the preparation stage and the survey. Masterson was a strong advocate for pursuing Gold Seal of Approval accreditation. “We know what it means to have a program go through this level of scrutiny. It is an arduous process but one that really causes us all to be better at what we do and how we do it which results in providing a higher level of quality care to patients,” said Masterson, an orthopedic surgeon with Sports Orthopedic and Spine Clinic in Jackson. “The whole process is multi-disciplinary and it takes all parts being on board to make things better and safer for the patient.” Once the hospital felt it was ready, it submitted its application to The Joint Commission in January 2014. The survey took six months to get scheduled and on July 18, 2014, Regional Hospital of Jackson underwent its rigorous on-site review. A representative from the Joint Commission evaluated the hospital for compliance with standards of care specific to the needs of patients and families, including infection prevention and control, leadership and medication management. The Joint Commission’s Disease-Specific Care Cer10

NOVEMBER 2014

tification Program is designed to evaluate clinical programs across the continuum of care. Certifications requirements address three core areas: compliance with consensus-based national standards; effective use of evidence-based clinical practice guidelines to manage and optimize care; and an organized approach to performance measurement and improvement activities. “The surveyor spent a day looking at the programs from the moment when a patient comes in the door to the time they are discharged to outpatient therapy, a skilled nursing facility or rehabilitation facility or to home with home health. They looked at closed and open records, interviewed physicians and talked to a patient on the unit – all to assess our compliance with the standard” said Wall. “All processes were reviewed and evaluated from the pre-operative process, intraoperative standardization, post-operative care and discharge plans. They looked at Human Resource files on employees, physician credentials and the continuing education we offered our employees on total joints.” At the end of the process, Regional Hospital of Jackson’s hard work and commitment to excellence had paid off. “The surveyor said we had best practices in several areas which meant they found nothing we needed to change in those areas. Pre-admission practices and pain control were two of the areas highlighted and there were no negative findings on our total hip program regarding the way we care for these patients,” said Wall. “He only had one suggestion on equipment use for total knee replacement patients. From everything we are hearing from other hospitals it is unusual to only have one suggestion for improvement for an initial survey. Our surveyor commented that this was one of the most mature programs he had visited. ” While the hospital got a glowing report and has achieved the Gold Seal of Approval from The Joint Commission for its Joint Replacement- Knee and Joint Replacement- Hip programs, it does not mean they will be resting on their laurels. The Gold Seal of Approval credentialing is an on-going process that requires recertification every two years. “It is a constant process of identifying areas to improve in and working to implement those improvements,” said Wall. “Of the original four measures we started evaluating initially, we will drop two and replace them with two new ones while we continue to monitor the two original measures. It is basically a process of constant improvement in all areas and is a great way to make sure we are staying on top of things and giving our patients the highest quality of care possible.”

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GrandRounds West Tennessee Bone & Joint’s Physicians Surgery Center Performs Knee Replacement

West Tennessee Bone & Joint Clinic is now performing outpatient knee replacements at Physicians Surgery Center, which is more convenient, less expensive and results in a faster recovery. Dr. Michael Cobb, who is board certified in orthopedic surgery, recently performed the first outpatient kneere p l a c e m e n t procedure in Jackson. The patient, Kathy Pannell, was able to stand just hours after surgery and went home that afternoon. Outpatient joint replacement is similar to traditional joint replacement. However, patients go home the same day of the procedure. The patient receives Exparel, a longer-acting anesthetic during surgery. Besides Dr. Cobb, physicians at West Tennessee Bone & Joint Clinic are Drs. Lowell Stonecipher, David Johnson, Kelly Pucek, Harold Antwine III, David Pearce, Jason Hutchison, Adam Smith, Doug Haltom, Michael Dolan, Eric Homberg, Blake Chandler and John Everett. For more information, visit wtbjc. com.

West Tennessee Heart & Vascular Center Earns Highest Award from American College of Cardiology

The West Tennessee Heart & Vascular Center at Jackson-Madison County General Hospital has achieved the highest award offered by the American College of Cardiology for high-risk heart attack patient treatment. The ACTION Registry-GWTG Platinum Performance Achievement Award was bestowed only to those hospitals that maintained a performance measure score of 90 percent or better in the treatment of acute myocardial infarction (heart attack) patients for eight consecutive quarters, ending in the last quarter of 2013. West Tennessee Heart & Vascular Center’s compliance with standards outlined by the American College of Cardiology and the American Heart Association as well as strategies for streamlined processes of transferring patients from nearby facilities were factors that boosted the platinum score the hospital received. West Tennessee Heart & Vascular Center partners with Medical Center EMS and Air Evac Lifeteam to host a STEMI conference and drills to teach best practices in heart attack treatment at participating hospitals in West Tennessee. At a surprise STEMI drill earlier this year, the total transfer time from Milan General Hospital to a team ready to start treatment at the JMCGH Chest Pain Center with PCI was 98 minutes, well under the American Heart Association standard of 120 minutes.

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GrandRounds Jackson Assisted Living Facility Misspent Thousands in State Grant Money

The administrator of the Jackson Street Faith Home in Jackson, TN properly used just $85 of the $54,650 in state grant funds the home received to assist with the care and services of low income residents. A new investigative report from the Tennessee Comptroller’s Office reveals that much of the grant money was misspent or used for questionable expenses. The Jackson Street Faith Home is a residential assisted living facility housing approximately eight full-time residents. The home received $54,650 in Quality Enabling Program (QED) funds from the Tennessee Department of Health, Division of Health Care Facilities over a three year period. The Comptroller’s Office was asked to investigate after the Department of Health notified the Tennessee Bureau of Investigation about the alleged misappropriation of state grant funds. Investigators discovered a cash shortage of at least $38,235.43 as a result of misspending, falsified or no documentation, and documentation submitted outside the grant period. Investigators also identified $16,329.57 in questionable expenses. The home’s administrator admitted using bad judgment and creating phony invoices that were submitted to the state as documentation. The Comptroller’s findings have been sent to the District Attorney General for the 26th Judicial District for consideration. Comptroller investigators are recommending the Department of Health take steps to recover the QEP grant funds. The Department should also properly monitor grantee expenditures to provide proper accountability. Funding appropriations for the Residential Homes for the Aged Quality Enabling Program were eliminated by the Tennessee General Assembly in 2012. The Jackson Street Faith Home’s license was closed as of January 21, 2014. To view the investigation online, go to: http://www.comptroller.tn.gov/ia/.

West Tennessee Healthcare Foundation Announces Relationship With Craig Morgan

The West Tennessee Healthcare Foundation worked out an agreement to work with country music performer and philanthropist, Craig Morgan. Craig Morgan has several charitable interests that include the Special Operations Warrior Foundation and the USO. His current main area of interest is for the construction and operation of a shortterm home for foster kids called, “Billy’s Place.” The Craig Morgan Charitable Fund is the initial effort to build “Billy’s Place” that will be able to house 16 children under the Craig Morgan Foundation located in Dickson, TN. On July 20, the annual Craig Morgan Charity Ride and Concert took place in Downtown Dickson. All proceeds from this effort will go towards the construction and operation of “Billy’s Place.” With four children, Craig Morgan has a special place for children lacking a loving home and place to be loved while go-

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ing through difficult family times. At the site of a house fire, Craig Morgan rescued the children from the burning home then proceeded to assist the fire fighters put out the fire. His heart is touched, as many are, when children suffer. As Craig travels around the country, he will be sharing this dream of building this home for children in rural Dickson County. All charitable contributions will be directed and managed through the Foundation. Born in Kingston Springs, TN, Craig became an Emergency Medical Technician at 18. He served for ten years in the

U. S. Army as a member of the 101st and 82nd Airborne Division and remained in the reserves for another nine years. Prior to his successful musical career he worked as a security guard and for Wal-Mart. His music career began as a demo singer for song writers and publishing companies. In 2000 he came out with his first album with Atlantic Records called, “Craig Morgan.” Since that time he has written and performed numerous hits including “That’s What I Love About Sunday,” “Redneck Yacht Club,” “International Harvester” and many others.

For the past 30 years, the Foundation has been supporting various community needs. The Foundation has more than 500 funds and manages more than $28 million in endowments for community causes. Charitable donations for “Billy’s Place” can still be sent to the Foundation at 620 Skyline Drive, Jackson, TN 38301. Checks can be made out to the “Foundation.” Each donor will receive a receipt for their records. For more information, contact the Foundation at Frank.McMeen@wth.org

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