Birmingham Medical News March 2015

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The Brave

UAB, Lakeshore Foundation and DOD Join Forces to Aid Veterans

Young Physician’s Interests Bridge Genres, Cultures The phrase “he has a wide range of interests” appears frequently in biographical material, but Micah A.S. Howard, MD, gives the reference a new meaning.

When he’s not working as a family practitioner, hospitalist, certified hypnotherapist, or in hospice care, ... page 2

Surviving Sudden Death Therapeutic Hypothermia Becoming Standard of Care in Cardiac Arrest For fans of TV medical dramas, reality can come as a shock. Week after week, they are accustomed to seeing defibrillators restoring flat lined heartbeats to happy ever afters ... page 7

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One of the great ironies of war is that from the suffering of armed conflicts have come some of the greatest advances in medical history.

Antibiotics in World War II, new trauma surgery techniques and air ambulances in Korea, and the modern paramedic and emergency medical procedures that grew out of Vietnam and more recent conflicts are all saving civilian lives today. Wars in the Persian Gulf are writing new chapters in treatment of injuries to the point that a higher percentage of soldiers are surviving serious wounds than ever before.

Helping more survivors also brings the challenge of finding better ways to overcome the after-effects of traumatic brain injuries which have become more prevalent due to an increase in blast injuries.

In The Brave Initiative, funded by a $2.7 million grant from the Department of Defense, UAB and The Lakeshore Foundation are working in parallel to study and compare the effectiveness (CONTINUED ON PAGE 4)

Edward Taub, PhD (right) looks on while a patient performs a task with his weakened hand, the other hand in a mitt.

Small Practices Don’t Need to Sell Out

By Jane Ehrhardt

These days, small practices face a daunting trend. “They’re getting less money for what they’re doing and the administrative burden is costing more than it ever has,” says Jerry Callahan, a partner at the CPA firm of Kassouf & Co. in Birmingham.

Behind the clinical side of every practice, physicians run a business that Jerry Callahan, CPA includes coding, billing, collections, tech support, hiring, leases, equipment care, and contracting with payers, like Blue Cross Blue Shield. “They didn’t go to school for all that,” says Gerry Kassouf, partner at Kassouf & Co. Throw on top of that all the new electronic health record equipment, software and data handling demands, and

Kassouf says, “The economic benefit no longer outweighs that burden.”

So practices, especially smaller ones, are selling out to hospitals or joining up with other practices. A 2013 survey by Jackson Healthcare on practice acquisition trends found nearly half of 118 hospitals surveyed were buying practices. And most of the acquisitions were initiated by the practice.

Gerry Kassouf, CPA Kassouf says small practices do have another choice. Instead of selling or merging, they can hire an all-in-one practice management firm. This allows the physicians to retain all of the control they relish “without having to ride quarterback on all the administrative (CONTINUED ON PAGE 18)

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HEALTHCARE SPOTLIGHT

Young Physician’s Interests Bridge Genres, Cultures By daLe short

The phrase “he has a wide range of interests” appears frequently in biographical material, but Micah A.S. Howard, MD, gives the reference a new meaning.

When he’s not working as a family practitioner, hospitalist, certified hypnotherapist, or in hospice care, Howard’s off-time pursuits include poetry, fiction writing, visual arts, publishing, and music. And his learning adventures have taken him from India to Haiti to the Czech Republic.

“My mother told me ‘You can be anything you want to be,’” he says with a smile, “but I think I mis-heard my mother as saying ‘You can be everything you want to be.’”

Howard’s first educational trip was six months in India, where he studied Ayurvedic medicine, a set of ancient Hindu healing practices. “Because of my undergraduate work, I figured I wasn’t a shoo-in to get into medical school,” he says, “so it was on the India trip that I fell in love with traveling and different cultures, learning their music and their approach to life and healing. When a practice is 6,000 years old, it has a lot of information to share.

Medical mission work in Haiti and a residency in the Czech Republic with the Prague Selective for future physicians

Healing is the cure.

Micah Howard, MD

added further to his cultural awareness, Howard says: “I think along the way I picked up some cultural savvy that allows me to meet a patient where they’re at, rather than just bringing my concept of them to the table.”

Though he gravitated toward primary care during his training at UAB, Howard was also attracted to hypnother-

apy, whose uses include weight loss, smoking cessation, and more.

The mechanism that makes hypnotherapy effective, Howard says, “is to uncover the unconscious processes that are driving people’s behaviors. The example I use is learning how to drive a car. It’s an incredibly complex machine, but it doesn’t take you six months of driving before you start doing all kinds of tasks simultaneously. You’ve incorporated them into your behavior in an unconscious way.

“Similarly, hypnotherapy puts you into an introspective state that allows you

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to uncover your core values and beliefs.

You may discover that the reason you believed you were doing a particular behavior is not the real reason. Then you can decide, ‘Do I really want that choice?’

To stop smoking, for example, it’s a case of tipping the balance between the desire and the risk--’Is it something I want to stop doing more than I want to do?’”

Howard says a related professional skill--Neuro-Linguistic Programming, or NLP--has proven to be invaluable in relating to patients. Wiki describes NLP as a system through which “a connection between neurological processes, language, and behavioral patterns learned through experience can be changed to achieve specific goals in life.”

“For me, I use NLP as an instant rapport-building strategy,” says Howard.

“I can come into a room with a patient and within 15 minutes instantly bond and uncover some huge things. It’s a kind of therapeutic mirror for doing change work and doing it incredibly quickly.”

As for Howard’s non-medical pursuits in the arts, “People sometimes say, ‘How do you find the time?’” he says, “but these activities allow me to get a reprieve at night after a hard day of work. Plus, they’re a way to have positive encounters with different types of people and better understand a wide variety of human beings.

“I’ve also learned something about burning candles at both ends. Which is that energy breeds more energy. A candle has more ends than you knew existed. And a picture is worth a lot more than a thousand words.”

The small press Hayloft Publishing, for instance, recently released his shortstory collection. “The Lily and the Crow” which he describes as a romance between the character Merlin and the Lady of the Lake. “I’ve always been a fan of Arthurian legend, and there were always these unanswered questions,” he says. “So I’ve tried to fit those characters into the legends of others--and with a little science fiction (CONTINUED ON PAGE 20)

REHABILITATION FOCUS

Which Rehab Option?

Matching the Referral to the Patient

By Laura Freeman

When the condition is less serious and the patient is well enough to go to and from outpatient appointments, the choice may be obvious. You simply look for a facility that has the expertise on staff, is well equipped and has a track recording for achieving good outcomes.

However, when the patient’s condition is more challenging, especially when it’s layered with other health issues, when more intensive rehab is required for optimal recovery, or when travelling to an outpatient facility is difficult, the physician’s task in matching rehab approach to patient becomes more complex.

In such cases, there are essentially three options. If the primary concern is that the patient can’t come to rehab, visiting therapists can bring rehab to the patient. The limitations in this approach are time and technology for patients who might recover faster and more fully with more hours of targeted therapy or the benefits of new technologies that aren’t necessarily portable. However, when financial limitations or coverage benefits are a concern, or when patients are being cared for at home by family and other caregivers, visiting therapists can bring the advantages of professional rehabilitation services, instruction and encouragement to the patient at home.

The other two choices are either an inpatient rehabilitation hospital where the primary focus is recovery or a skilled nursing facility that offers rehabilitation services as part of its care. Considerations in choosing between these approaches include 1) the optimal outcome desired, 2) the patient’s overall condition and prognosis, and 3) medical issues that might require closer physician monitoring.

For Michael Rosemore, DO, Medical Director at HealthSouth Lakeshore Hospital, physician monitoring is a particularly important component.

“Many rehabilitation patients are dealing with multiple health issues that may need to be closely monitored by Michael a physician. They aren’t Rosemore, DO likely to be able to go to their doctor’s office every day. However, we have a minimum of two physicians assigned to each case. We not only assess each patient promptly on admission—we make daily rounds. Based on how patients are doing, we can make adjustments in their therapy and consult with their physicians if an issue arises,” Rosemore said.

Physician monitoring in a skilled nursing facility may vary, but it typically reflects Medicare rules and reimbursement restrictions. It may be a matter of several days after admission before patients are seen by a physician, and physi-

cian visits may be limited to once a month and can require a change in the patient’s status for reimbursement to be approved.

The second consideration in deciding which approach to rehab is likely to be the best choice—the patient’s overall condition and prognosis—also factors into the first and perhaps most important consideration—the optimal outcome desired.

If a patient is in decline, nearing the end of life or is likely to need more and more supportive care for a condition with a poor long-term prognosis, rehabilitation services available at a skilled nursing facility may help to improve quality of life.

However, if the outcome desired is returning patients to the fullest possible function as quickly as possible, in-patient rehabilitation hospitals have a great deal to offer.

“The entire focus is on recovery and helping patients achieve the best possible outcome. Our goal is to help them regain function and return to their lives as soon as possible,” Vickie Demers, CEO of HealthSouth Lakeshore, said. With 107 facilities across the country, Birminghambased HealthSouth is the largest provider of Vickie Demers in-patient rehabilitation hospital services in the United States.

“One of the key differences in how we help patients regain maximum function so quickly is intensity. Instead of an hour a few times a week at home, or perhaps less in a facility where rehabilitation isn’t the primary purpose, our patients receive at least three hours of therapy a day, at least five days a week,” Demers said.

Medical director Rosemore also points out that the targeted focus on rehabilitation also adds the collaborative advantages of having a multidisciplinary team highly trained in the specialized aspects of rehabilitation.

“We have leading edge rehabilitation expertise in exceptionally well trained physical therapists, rehabilitation nurses, speech therapists, respiratory therapists and occupational therapists who help patients regain independence in the everyday functions of daily living so they can live safely and well, even if they live alone,” Rosemore said.

“We may also call in our nutrition and dietary team to address specific issues. For example, in our initial assessment when patients come through the door, we sometimes find difficulty in swallowing, particularly in patients with neurological problems. Our dietary team can help them work around the problem to get adequate nutrition to regain their strength and avoid complications from reflux and aspiration.”

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The Brave, continued from page 1 of UAB’s Constraint-induced Movement Therapy (CI therapy) and Lakeshore’s Enriched Fitness Training (LEFT) in improving function along with physical and psychological conditions in veterans with motor impairment from traumatic brain injuries.

“We hope to gather data on what each type of therapy does best so we can merge and refine what we learn to create a new, more effective standard of care,” principal investigator and UAB psychology professor Edward Taub, PhD, said. “80 patients will be randomly assigned to either CI therapy or LEFT. Judging from past experience, we anticipate that CI therapy will be strong in improving function, while LEFT should be very effective in improving physical and psychological condition.

Developed by Taub at UAB over the past 30 years, CI therapy has proven exceptionally effective in helping patients overcome motor impairment from stroke, brain injuries and deficits from neurological conditions such as MS. It has been shown to increase white matter in the brains of children with cerebral palsy and has been used in an adapted form to help patients overcome aphasia.

Co-investigator UAB psychology professor Gitendra Uswatte, PhD, pointed out another key finding that came to light through CT therapy.

“Contrary to the long-held belief that therapy must begin within a limited time frame after the injury to be effective, with CI therapy we have seen improvement in motor deficits years after strokes and brain injuries,” Uswatte said. “The concept grew out of Dr. Taub’s early work with primates.

Neuroplasticity allows the motor training techniques used in CI therapy to teach the brain to rewire itself.”

“When people have motor impairment from a stroke or brain injury, they may find one arm and hand to be more difficult to use,” Taud said. “It can be frustrating. To avoid the frustration, they begin to teach themselves to rely more on the other hand, using the impaired hand less.

“To improve motor function in the more seriously affected hand and arm, we use a mitt to constrain the use of the hand

patients normally depend on. We benchmark their best time doing tasks with the affected hand, and then we help them use a set of training techniques so they see their speed and agility improve as their brains begin to rewire the control of movement to other areas that haven’t been damaged.”

CI therapy is used extensively in other countries, and the paper Taub and his associates wrote introducing the concept, “Technique To Improve Motor Deficit After Stroke,” is the most cited paper in rehabilitation journals over the past 30 years. During the Dalai Lama’s visit to Birmingham, using CI therapy to harness the neuroplasticity of the brain was a topic of conversation between Taub, his associates and the leader of Tibetan Buddhism, who has an interest in the brain’s ability to heal itself.

Another irony is that although the effectiveness of CI therapy in clinical use internationally has been confirmed in what could well be the most papers in this area of rehabilitation, CI therapy is not accessible to most residents in the state where it was developed except through self funding because it is not covered by the predominant insurer in Alabama.

However, it will be provided at no charge to study participants in the CI therapy group. This study is a rigorous randomized clinical trial (RCT), and will begin and end with an MRI to assess progress in both groups. Participants will receive treatment for three and a half hours daily for ten days, which will be preceded and followed by two days of testing for a total of 14 weekdays. There will be follow-up by phone and at the end of a year to see how the intensive course of therapy translates into improving arm function in everyday tasks and in quality of life.

For non-local participants, the grant will cover transportation and housing for the participant and a companion. To qualify, potential participants should be active-duty or veteran military personnel at least 19 years of age and be at least three months post TBI with movement problems or weakness in one or both hands.

To learn more about how to participate, call (205) 934-9768 or visit www.tbirehabtherapy.net.

Which Rehab Option?, continued from page 1 rehabilitation services for patients with a wide range of conditions ranging from stroke, post-op neurosurgery and other neurological conditions to recovery from cardiac events and surgery, multiple trauma and joint replacement.

Two other advantages rehabilitation hospitals are well positioned to offer are new technologies and new therapies.

Among the technologies used in rehabilitation at HealthSouth Lakeshore are the Autoambulator™, which robotically assists patients in walking and adjusts the amount of weight bearing as the patient progresses, and LiteGait™, which assists weight bearing and balance. Bioness™ is used to improve hand movement and grasping. There are also technologies to

help with arm and shoulder movement, to improve swallowing, and help wheelchair patients improve strength and flexibility.

The SmartStep™ is an insole that collects information on how a patient is walking and provides visual and auditory feedback. Wii ™makes the repetitive movements of therapy a game so it is more engaging and fun. The X-Sensor™ detects how much pressure patients are putting on which areas of their bodies to help prevent complications from pressure points.

“One of our newest therapies is also one of the simplest,” Demers said. “Our music therapy gets our patients singing.

They enjoy it, and it’s great for helping them with respiratory therapy and speech therapy, too.”

GASTROENTEROLOGY FOCUS

Are You a Baby Boomer?

Get Screened for Hepatitis C C has greatly improved thanks to the development of new medicines Almost 4 million people that are easier to use and in the United States are livtolerate. “Past therapies ing with Hepatitis C and for Hepatitis C were toxic don’t know they are infected. and had a lot of side efAs a result, they have not refects. Interferon was the ceived care and treatment main drug used then, for this virus which is a leadand it had to be injected ing cause of complications into the skin weekly. The from chronic liver disease. treatment made patients The Centers for Disease sick and could lower Control estimates that the blood counts to dangermajority of infected persons ous levels,” he says. “As a were born during 1945 to result, each patient had to 1965 and has recommended be closely monitored and testing for this group of the cure rate was not imadults in an effort to prevent and control this blood-borne Christopher Shaver, MD of Birmingham Gastroenterology Associates talks with a patient in his pressive. There were no guarantees that a patient virus. Common risk factors Homewood office. would be cured.” for contracting Hepatitis C Over the past six include past or current injecwas,” says Christopher Shaver, MD of months, Shaver says, a new class of medition drug use – the most common factor, Birmingham Gastroenterology Associates. cations to treat Hepatitis C have been receiving a blood transfusion before 1992, “We also didn’t have a way to screen the approved by the Food and Drug Adminisgetting an unregulated tattoo, and other blood supply then, so Baby Boomers were tration. “The age of interferon is basically incidences of blood-to-blood contact. at high risk. That led to the recommendaover. These new medications are what we “During the time period in question, tion to screen everybody born during that call ‘direct-acting antivirals.’ The pills are Hepatitis C was poorly understood. In time.” taken orally, and duration of treatment fact, it was called Non A Non B hepatiShaver says the cure rate for Hepatitis has decreased from 24-48 weeks down to tis because we weren’t sure what the virus

By Ann B. DeBellis

eight to 24 weeks,” he says. “We’ve seen a major improvement in medical therapy for this virus in terms of safety and the end result. We are seeing these breakthrough drugs give patients a much greater chance at a cure, usually in excess of 90 percent.”

The only way to know if people have Hepatitis C is to test them. A simple antibody marker blood test makes it easy to mass screen the population so that those with the virus can be identified and treated quickly. “Testing and any necessary treatment can eliminate the virus safely and prevent long-term complications like cirrhosis or liver cancer,” Shaver says.

“When you have simple, safe, and strong drugs, it makes a lot of sense to screen atrisk patients for the virus.”

Because this resting recommendation is new, Shaver encourages both physicians and patients to work together to identify those who may be infected. “Gastroenterologists typically will recommend screening in eligible patients. The virus may also be recognized during a routine physical or blood work that shows elevated liver enzymes, which may be an indication of liver inflammation related to Hepatitis C,” he says. “It needs to be a team approach.

(CONTINUED ON PAGE 18)

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GASTROENTEROLOGY FOCUS

The Mighty Blessing of Service room). “One patient came in with a spear in his head, and another came in with a markFor a number of years, edly distended abdomen which Gregory Champion, MD, appeared to be a bowel obstrucof Gastroenterology Assotion,” he recalls. “He was taken ciates in Birmingham has to surgery where surgeons filled taken his family and his a large bucket with worms from medical knowledge overhis intestines that were causing seas on mission trips with the blockage.”

World Medical Missions.

The hospital does have a World Medical Missions varied medical staff with suris the medical arm of SaX-ray of patient. Film shows a spear through his geons, internists, obstetricians, maritan’s Purse, a nondehead. pediatricians and even ophthalnominational evangelical mologists. Despite that, situaChristian organization that well as parasitical illnesses, later tions often would occur where a certain provides spiritual and physstage HIV and tuberculosis,” he specialist would be needed. “Many times, ical aid to hurting people says. “On my first night on call, it seems, that during a critical moment the around the world.

I saw someone who had TB appropriate specialist would ‘just happen’ Champion has used peritonitis, another person with to be visiting and available to deal with the his knowledge and mediTB pericarditis, and another need at hand,” Champion says. “It seems cal skills to care for patients with TB pleuritis. We don’t see that God was orchestrating the different and to teach doctors about these conditions at home.” specialty physicians to be there at the right advances in gastroenterolTreating patients with extime to take care of a patient, whether it ogy treatments. On his last otic diseases, coupled with a was the neurosurgeon, the ENT or the ortrip to Bomet, Kenya, he lack of resources, often required thopedic specialist. When we looked back spent a month working with Champion to make significant on those times, we said, “Wow. That was the staff at Tenwek Hospi- Champion, right, and one of the endoscopy nurses present a Bible to an elderly patient decisions that he would not providential.” tal, along with the Pan Af- with end-stage esophageal cancer. have faced at home. “We had Champion says that the goals for rican Academy of Christian only one functioning ventilathese mission trips are to care for not Surgeons, to teach surgical at the hospital, they also have a training tor in the ICU, so when we had several only the people’s physical needs, but also residents endoscopic procedures in addiprogram for medical residents, so I was patients who needed it, we had to decide their spiritual needs. Tenwek Hospital is a tion to providing care to hospitalized paable to train a medical resident while I which person we thought would do the Christian mission hospital that has existed tients. was there. It’s like the fishing adage: I can best and have the greatest chance of sursince the early 1900s.

The 300-bed hospital, located in teach someone what I do, so they can do vival. Then we gave the ventilator to that “At the hospital, we prayed with every western Kenya, is a large regional referral it after I’m gone.” person,” he says. “In the states, we have patient before we performed a procedure. center serving five million people. “There In addition to using his endoscopy incredible resources, but in Africa the reThis was a way to remember that we trust are one million people in the immediate skills at Tenwek, Champion used his insources are limited. Often they don’t have God for His direction and thank Him for area and five million in the larger area, ternal medicine knowledge as well. “I covthe diagnostic tests we need, nor equipthe skills and wisdom He has given us and but it is the referral center for all of them,” ered the internal medicine ward service ment or supplies, so we just had to make a which allows us to care for our patients,” Champion says. “Tenwek Hospital has which is usually quite busy. There were decision and be creative to make do with Champion says. “I remember Franklin endoscopic services, which was one of the as many as two or three patients per bed, what we had. Then we prayed and asked Graham saying that Tenwek is one of the reasons I chose that location. I can use my many of whom had unusual illnesses. The God to provide.” great Christian outreach hospitals in the endoscopic skills not only to treat patients, African people have a variety of infections Champion saw some memorable world today, and it does a great job of but also to train the next generation of enthat we don’t see in the United State, as cases in the trauma center (emergency caring for needy people and also meeting doscopists. In addition to having surgeons their deeper spiritual needs.”

Champion’s family has been accompanying him on these trips for years, since his children have been old enough to participate. “When I became a Christian in 1980, I had a desire to help and serve others. When we started our family, one of my goals was to teach our kids to serve The new MRI technology incorporates magnetic others. I remember a quote about there resonance imaging (MRI) with ultrasound resulting being two types of people – givers and takers. I wanted my children to be willing to in a more accurate diagnosis. For prostate cancer help others and not be focused only on patients, that accuracy means earlier, more reliable themselves,” he says. detection and helps to avoid unnecessary biopsies.

The Champion family has traveled to a number of different places, including the overseas trips their father has taken. The children have seen how others around the world live and have learned that they can live a lifestyle without conveniences and still be happy. They also have seen how one life can impact another. “Any time we go on a mission trip, our family thinks we are going to give, serve and bless others,” Champion says. “What always happens is (205) 930-0920 | 800-452-1464 that we end up receiving the bigger bless27 skilled physicians | practicing in 14 locations ing. We always are blessed more than we 3485 Independence Drive | Homewood, AL 35209 ever give.”

By Ann B. DeBellis

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6 • MARCH 2015

Birmingham Medical News

Birmingham Medical News

MARCH 2015 • 7

GASTROENTEROLOGY FOCUS

Eosinophilic Esophagitis Diagnosis on the Rise

By Rajat N. Parikh, MD

In recent years, we have found that we are diagnosing Eosinophilic esophagitis (EoE) more and more frequently in young adults at our practice with Birmingham Gastroenterology Associates.

EoE is defined as a chronic immune/ antigen-mediated esophageal disease, characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation.

EoE was a diagnosis discovered in the early 1990’s, initially on patients who did not respond to standard anti-secretory therapy for GERD. The prevalence in the United States is estimated to be approximately 55 cases per 100,000 people. The recent incidence rates of EoE in children exceed those of Inflammatory Bowel Disease.

Clinical manifestations of EoE in adults include dysphagia, food impaction, central chest pain, GERD-like symptoms/refractory heartburn, and upper abdominal pain.

Younger children most commonly present with abdominal pain and difficulty feeding.

There is a strong association of EoE with allergic conditions such as asthma, food allergies, environmental allergies, and atopic dermatitis.

Multiple studies have also found an association between EoE and celiac disease.

Diagnosis for EoE is made based on symptoms, endoscopy findings and histology of esophageal biopsies. Characteristically, more than 15 eosinophils are seen per high power field on histology of esophageal

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biopsies. This finding should persist after at least two months of daily PPI therapy. Endoscopic appearance is classically a feline esophagus or ringed esophagus. However, endoscopy can be relatively normal, appearing with mild narrowing or linear furrows and small whitish micro-abscesses. The disease can be patchy so clinicians take biopsies from the lower, mid, and upper esophagus.

Imaging and labs do not play a major role in diagnosis.

Typical treatment for EoE includes elimination and elemental diets to decrease allergen exposure, acid suppression for reflux symptoms, topical glucocorticoids, and esophageal dilation for strictures. Clinicians and researchers are studying a number of other therapies for EoE which include systemic steroids, antihistamines, immunosuppressants and immunomodulators.

Empiric elimination diets are quite effective but often difficult for patients to adhere to. Generally, the diet eliminates the most common foods that cause hypersensitivity in the U.S. including milk, egg, soy, wheat, peanuts/tree nuts, and fish/shellfish.

This is also known as the six-food elimination diet (SFED). A patient with EoE will eliminate all of these food groups simultaneously and then reintroduce one at a time over a planned period to see which food group causes symptoms and should therefore be avoided.

While effective, most patients have difficulty being compliant with elimination diets.

Therefore, we commonly have assistance from allergists creating a testing-directed elimination diet based on skin prick testing (SPT) or atopy patch testing (APT).

Pharmacological therapy in addition to acid suppression and esophageal dilation where indicated revolves around use of topical steroids to coat the esophagus and decrease inflammation without causing significant systemic side effects. Options for adults include fluticasone by metered dose inhaler sprayed into the patient’s mouth and then swallowed, not inhaled. Typical adult dosing is 220 mcg x 2 sprays twice daily.

We use lower dosing in younger children.

Patients who do not respond to fluticasone are normally switched to an oral viscous budesonide which is usually prescribed at a compounding pharmacy. Adult dosing is normally two mg daily and lower dosing for children. This is normally made by mixing pulmicort respules with sucralose.

As I mentioned earlier, EoE is being diagnosed more commonly and the incidence is on the rise. Current therapy is quite effective with more research into newer therapies on the horizon. As a result, treatment for this disease should continue to improve outcomes.

Patients seeking more resources and information on EoE can consult the American Partnership for Eosinophilic Disorders (www.apfed.org), which is an advocacy group for patients with eosinophilic gastrointestinal disorders.

Rajat N. Parikh, MD practices gastroenterology with Birmingham Gastroenterology Associates.

The Federal False Claims Act

Violations of Conditions of Payment or Conditions of Participation?

By Jim Hoover

With the increase of Qui Tam lawsuits alleging violations of the federal False Claims Act (“FCA”), it is important to understand that FCA liability maybe predicated on whether the alleged wrongful act violated a condition of payment or a condition of participation. False claims can generally be categorized into two broad types of actionable false claims, those that are factually false and those that are legally false. Factually false claims are those that are false for any number of reasons including the provider submitted an incorrect description of the services, the claim was billed using the wrong provider or the services were never provided at all. Legally false claims are not false on their face. Instead, the claim is false because the provider falsely certified that it is in compliance with certain statutory or regulatory provisions at the time it submitted the claim. Legally false claims are sometimes referred to as “false certification” claims. Increasingly, FCA suits in the health care context involve false certification claims.

The success or failure of a FCA suit based on false certification claims will depend on whether the underlying violations are violations of conditions of payment or conditions of participation. The distinction between a condition of payment and

a condition of participation is particularly important because of the damages available under the FCA. These damages include treble damages, so once the trier of fact determines the amount of damages, the judge must then triple the amount. In addition to treble damages, a provider may be subject to civil monetary penalties ranging from $5,500 to $11,000 per claim. Finally, the relator’s lawyer is also entitled to a recovery of reasonable attorney’s fees.

Because of the possibility of large recoveries under the FCA, relators attempt to expand the FCA to enforce violations of rules and regulations that are only remotely related to the payment of claims.

The amount at stake in these cases often hinge on the distinction between conditions of payment and conditions of participation.

As all healthcare providers understand, they are regulated by a myriad of complicated laws and regulations. Many of these rules relate to the quality of care rendered to patients or are rules that providers must meet in order to participate in the Medicare and Medicaid programs. These types of rules are generally considered conditions of participation. If the condition or requirement that has not been satisfied relates to a condition of participation in a federal health care program a claim may still be eligible for payment even if a pro-

vider is out of compliance with one or more conditions of participation. If conditions of participation are not met, various administrative sanctions are generally available to the government, including imposing a corrective action plan, monetary sanctions, increased reporting requirements, and even exclusion from the federal health care program. Because exclusion is relatively rare, a number of courts have recognized that it would be both inappropriate and premature for the government to refuse to pay otherwise appropriate claims on the basis that the provider failed to fulfill all conditions of participation.

In contrast, conditions of payment are requirements that must be satisfied before the government will pay a claim. Failure to comply with a condition of payment can result in the denial of the claim. If payment has already been made then the amount paid maybe considered an overpayment which must be refunded or recouped.

Failure to comply with a condition of payment properly forms the basis for a FCA suit under the theory that payment would not have been made on the claim absent compliance with the condition of payment.

Therefore, if the false certification clearly relates to a condition of payment, the courts generally have found that the claim satisfies the “falsity” element of the FCA and all of the FCA damages are available.

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Determining whether a condition is one of participation or payment is not always easy. Generally, the closer the regulation is connected to the government’s payment to the provider, the more likely a court will consider the regulation a condition of payment. On the other hand, if the condition relates more to the quality of care or enrollment in the federal healthcare benefit program the more likely the court will consider the regulation a condition of participation.

Because so much is at risk in FCA litigation, the distinction between conditions of participation and conditions of payment is a critical issue. For example, a recent case was settled for $1 million when many valued the damages in excess of $200 million because the judge determined the underlying violations were violations of a condition of participation, not a condition of payment. Thus, if the FCA lawsuit involves allegations of false certification Healthcare providers and their counsel should carefully analyze the alleged violations to determine whether they are violations of conditions of participation or conditions of payment.

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What’s Happening to our Safety Net? Changes, challenges of free clinics and covering the uninsured

By JULIE PARKER

America’s free and charity clinics are undergoing a transformation, and not necessarily in a good way.

According to a 2014 report by the National Association of Free and Charitable Clinics (NAFCC), patient demand has spiked 40 percent while donations have dropped 20 percent.

“As soon as there was the perception of universal healthcare, the likelihood of receiving donations goes down,” Colin McRae, JD, told the Wall Street Journal in December.

For the last two fiscal reports ending June 30, OrlandoDr. Kathryn Crampton performs free back-to-school phycical. based Shepherd’s Hope, one of the nation’s most successful free clinic networks, experienced a 22 percent siana, Mississippi, Missouri, North and increase in patient volume, seeing 16,973 South Carolina, Tennessee, Texas, and patients in 2012-13, and nearly 21,000 Virginia are among 18 states that haven’t patients in 2013-14. Based on trends, the expanded Medicaid and aren’t likely to, free clinic expects patient volume to climb with the exception of Tennessee, one of to 24,000 for the 2014-15 fiscal year. four states anticipated to possibly expand “It’s a concoction of the most toxic in 2016. kind without the resources to resolve it,” David W. Strong, who will leave said Marni Stahlman, CEO of Shepherd’s the University of North Carolina (UNC) Hope, noting a May 2013 report by the Health Care system next month to take Congressional Budget Office showed that over as CEO of the expansive Orlando even though the healthcare law is exHealth network in Florida, pointed out an pected to reduce the number of uninsured aspect of Medicaid expansion that doesn’t by 25 million in 2023, 31 million Ameriget much press. cans will remain uninsured. “The role of “It’s important to note the bulk of the free clinic is more critical than ever.” every state’s Medicaid program is already Medicaid expansion, or the lack of it, funded by the federal government,” said lies at the heart of the problem.

Strong. “All states are relying on signifiIn Medical News’ coverage area, Arcant federal funds now. Unfortunately, kansas and Kentucky are among 28 states by not expanding Medicaid, Florida and that have expanded Medicaid.

North Carolina are among the biggest losAlabama, Florida, Georgia, Louiers in the country because of the popula-

tion base. Ultimately, we all bear the burden for the lack of expansion because people will continue to seek care in our emergency departments and facilities.”

Much national attention has been placed on Florida, the nation’s fourth most populated state with 18 million residents and the highest percentage of 65 and older adults.

The sunshine state ranks 41st on the list of highest volume of uninsured residents nationwide.

“What you have is a really bad sandwich. Without resources, insurance, or access to healthcare, many Floridians who’ve been captured in the healthcare coverage (Medicaid) expansion gap find themselves without anything,” said Stahlman. “There’s also a gap on the high end.”

According to a 2014 Modern Healthcare report, the nation’s busiest emergency room is Florida Hospital, with 206,800 visits to emergency departments at Florida Hospitals in Altamonte, Apopka, Celebration Health, East Orlando, and Kissimmee – and Winter Park Memorial Hospital.

Orlando Health’s Orlando Regional Medical Center accounted for the nation’s fifth busiest ER, including emergency departments at the Arnold Palmer Hospital for Children, University of Florida (UF) Health Cancer Center, Dr. P. Phillips Hospital, Lucerne Hospital, South Seminole Hospital and the Winnie Palmer Hospital for Women & Babies.

“Florida is at a particular disadvantage because we have one of the highest uninsured rates in the nation, and a comparatively smaller percentage of residents on employer healthcare plans to absorb

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the cost,” said Florida Hospital CEO Lars Houmann. “Federal, state and local funding sources cover some but not all costs.

And so the burden is passed on to insured patients and their employers in what’s commonly called the cost shift … a hidden tax applied to premiums, co-pays and deductibles.”

University of Florida economists predict $4.7 billion in Medicaid dollars will be sent to other states in 2016, including nearly $400 million to Ohio, where Republican Gov. John Kasich has reduced the state’s budget by $404 million over two years by expanding coverage.

Despite previous opposition to the idea, recently reelected Florida Gov. Rick Scott announced more than two years ago that he supports a legislature-approved, three-year Medicaid expansion. However, Scott, a Republican, hasn’t marked it priority.

Even with gubernatorial support, Tampa General CEO Jim Burkhart said Medicaid expansion won’t be an easy sell to state lawmakers.

“It’s going to be a pretty heavy lift because there are lots of people who think they know a different way, or don’t think we should do it at all, or only believe we should do it for people that don’t match up with what the federal government says you have to have in your criteria for the money to be made available,” he said. “At least discussion is ongoing. We’re hopeful it’ll continue and lead to something concrete.”

Mississippi Gov. Phil Bryant, a Republican, has firmly said no, thanks. “For us to enter into an expansion program would be a fool’s errand,” in case Obamacare is repealed or altered in a way that forces states to foot the bill,” he told the Associated Press. “We’d have no way to continue the coverage.”

While states continue to determine the best solution, ER visits are piling up.

The average admission cost of an ER visit is roughly $4,600 versus the average cost of a visit to the free clinic valued at $77, said Stahlman, referring to 21,000 visits anticipated this fiscal year.

“Do the math on 21,000 visits last year, each valued at $77 ($1.6 million) versus $4,600 ($96.6 million),” she said.

“The role of the free clinic is more critical than ever.”

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Shepherding a Flock How Shepherd’s Hope bucked trend with innovative healthcare model and thriving network of free clinics

By JULIE PARKER

During a critical time when free and charitable clinics for the uninsured in the United States are under increased economic pressure and in some cases closing, one nonprofit healthcare provider has adopted an unduplicated, recognized national model so highly regarded that its principal leaders were invited in 2012 to the White House as part of a delegation to discuss national intervention strategies for the uninsured.

Founded in 1997 by Rev. William S. Barnes, PhD, Shepherd’s Hope has grown into a network of five free clinics in Central Florida that’s remained not only viable, but is flourishing.

“We’re unaware of any free clinic in the country that takes the elaborate array of multi-faith, community, hospitals, and clinical and lay volunteers and weaves them all together with no one group’s agenda superseding the mission,” said Marni Stahlman, CEO of Shepherd’s Hope. At least in Florida, the nation’s fourth most populous state with 18 million residents and the highest percentage of adults 65 and older, “no other model has the intricate system of primary and secondary disciplines in place to provide the delivery of high-quality, compassionate patient-centered care to this medically underserved and uninsured segment of the population.”

Responding to Community Needs

Even though the original mission of Shepherd’s Hope was to serve the urgent health needs of the uninsured who were living at 200 percent or below the federal poverty guidelines, Shepherd’s Hope has morphed into the role of secondary/specialty care clinical provider.

“Over the last few years, we’ve seen a new mix of individuals who find themselves entering the safety net community for healthcare services for the first time in their lives,” said Stahlman. “Some were even previous donors! Now they’re standing in line, telling us, ‘I’ve never not had a doctor, I have no idea what to do.’ We’ve become the alternative to the emergency department, hoping to mitigate the financial impact to our community.”

For the last two fiscal reports ending June 30, Shepherd’s Hope has experienced a 22 percent increase in patient volume, providing 16,973 patient visits and medical services in 2012-13, and nearly 21,000 patient visits and medical services in 2013-14. Based on trends, the free clinic expects patient volume to climb to 24,000 for the 2014-15 fiscal year.

Roughly one-third of Shepherd’s Hope urgent care patients return for secondary specialty care services.

“For example, we might have a female patient with upper respiratory problems who hasn’t had a mammogram in eight years,” said Stahlman. “We’ll refer them for a screening with our partners. Then if a breast cancer diagnosis is made, they’re referred to our other specialty partners.”

A Very Busy Landscape

Central Florida is already one of the nation’s busiest metropolitan areas for urgent and emergency care. According to a 2014 Modern Healthcare report, the nation’s busiest emergency room is Florida Hospital, with 206,800 visits to emergency departments at Florida Hospitals in Altamonte, Apopka, Celebration Health, East Orlando, and Kissimmee – and Winter Park Memorial Hospital.

Orlando Regional Medical Center accounted for the nation’s fifth busiest ER, covering emergency departments at the Arnold Palmer Hospital for Children, University of Florida (UF) Health Cancer Center, Dr. P. Phillips Hospital, Lucerne Hospital, South Seminole Hospital and the Winnie Palmer Hospital for Women & Babies.

Both hospital systems, along with Central Florida Regional Hospital, are Shepherd’s Hope’s primary partners. Last year, the trio of healthcare networks provided the free clinics with nearly $22 million of inkind contributions and services. Many of the more than 500 volunteer doctors, physician assistants, nurse practitioners and nurses at a Shepherd’s Hope clinic nightly are coming from work as an employee at one of these hospitals.

“The average admission cost of an ER visit is roughly $4,600,” Stahlman pointed out.

“We reported roughly 21,000 patient visits and medical services last year, where we didn’t charge patients anything. Those visits are valued at $77. Do the math on that ($1.6 million), versus $4,600 times 21,000 ($96.6 million), you can easily see why it’s a good investment for Shepherd’s Hope to be here.

Our hospital partners get it right away.”

Momentum has prompted other healthcare providers to jump on board. In 2014, Shepherd’s Hope initiated a pilot project to attract more pediatric providers.

“Only about 8 percent of our population is 18 and under,” Stahlman explained.

“It’s not because they don’t come; it’s because we don’t have enough pediatric clinical volunteers. We approached Nemours in late July to streamline a process for uninsured children to get required school physicals at Shepherd’s Hope. With no primary medical home of their own, over two days, our two teams saw 108 children at two locations. That’s remarkable.”

Last October, Shepherd’s Hope and Sand Lake Imaging aligned for a Pink October initiative, which garnered 219 free mammograms.

And while other free and charity clinics across the country are floundering because of funding shortfalls and what some experts view as the misperception of universal healthcare, Shepherd’s Hope augments its operating budget with three successful, community-rooted annual fundraising events – Call to Hope Breakfast in April, Celebrity Golf Classic in July, and Famous Faces Masquerade Ball in October.

“We’re very grateful for the support of the local physician and practitioner community,” she said. “Their support makes us very distinctive.”

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Birmingham Medical News

MARCH 2015 • 11

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By the Numbers: The Latest Stats on Cancer Death rates down, more work awaits

By CINDY SANDERS

As the ‘official sponsor of birthdays,’ the American Cancer Society (ACS) found a reason to rejoice in their latest report – Cancer Facts & Figures 2015. Since hitting a peak in 1991, cancer deaths have fallen 22 percent over two decades in the United States, which means more than 1.5 million deaths have been avoided … and more birthdays celebrated.

An ACS infographic showed 3.3 million cancer survivors in the United States in 1973. Today, there are more than 14.5 million cancer survivors, and that number is projected to jump to 18.9 million by 2024.

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tistics and the Centers for Disease Control and Prevention. The most recent five-year data (2007-2011) showed the overall cancer incidence rate held steady in women and declined by 1.8 percent per year in men. The decrease in men was attributed to rapid declines in colorectal cancer (3.6 percent per year), lung cancer (3 percent per year) and prostate cancer (2.1 percent per year).

During the same time period, the average annual decline in cancer death rates was 1.8 percent in men and 1.4 percent in women. Lung cancer, while still the deadliest form of the disease, has declined 36 percent between 1990 and 2011 among men. Women have also seen double digit declines attributable to reduced tobacco use. On another happy note, breast cancer death rates for women are down more 35 percent from peak rates, and prostate (CONTINUED ON PAGE 14)

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President Obama’s Precision Medicine Initiative

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After first introducing the topic during the State of the Union Address, President Barack Obama held an event at the White House at the end of January to unveil details about the Precision Medicine Initiative, a major research push to pinpoint the best, most precise treatment options for individual patients considering genetic profile, environment and lifestyle.

In a fact sheet created for the program, White House officials stated, “The Precision Medicine Initiative will pioneer a new model of patient-powered research that promises to accelerate biomedical discoveries and provide clinicians with new tools, knowledge and therapies to select which treatments will work best for which patients.”

While the move away from ‘one-size-fits-all’ medicine is not limited to cancer research, oncology is at the centerpiece of the initiative and a recipient of significant funding. If passed, President Obama’s 2016 budget includes a $215 million investment in the program including $130 million to the National Institutes of Health to develop a voluntary national research cohort of a million or more volunteers to propel the science forward and to create a model for responsible data sharing. Additionally, $70 million is specifically earmarked for the National Cancer Institute to scale up efforts to identify genomic drivers to various cancers, and a major objective of the initiative is to create ‘more and better treatments for cancer.’

In response to the Jan. 30 announcement, American Association for Cancer Research CEO Margaret Foti, PD, MD (hc), said, “We live in an extraordinary time when the scientific opportunities and our ability to translate this new knowledge into ways to both save and improve the quality of life of patients are simply astounding. This is why we are so excited about today’s event at the White House and specifically about President Obama’s major investment in the enormous potential of precision medicine, which is in the very early stages of transforming healthcare.”

Similarly, the Pancreatic Cancer Action Network voiced their appreciation and support for the initiative. “The Pancreatic Cancer Action Network applauds President Obama for his new Precision Medicine Initiative and for making an important investment to advance cancer research and arm the scientific and medical community with the cutting edge tools and resources needed to fight cancer,” said Julie Fleshman, president and CEO of PanCAN. “This is especially welcome news for patients fighting pancreatic cancer who face a five-year survival rate of just 7 percent.”

With personalized medicine for pancreatic cancer still in the early stages, she added, “We recognize, as President Obama highlighted, that the “one-sizefits-all” approach does not work for pancreatic cancer and recently launched Know Your Tumor, a personalized medicine service available through our patient services program. In addition to providing molecular profiling that may help a patient’s oncologist determine the best treatment options, we will collect tumor information from thousands of pancreatic cancer patients to assist with future research and development of new therapies and diagnostics for pancreatic cancer.”

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Use of InterStim Therapy Continues to Expand Oxford physician leads region in InterStim procedures for OAB and FI sufferers

By JuLie Parker

When InterStim® therapy was FDAapproved in March 2011 for treating patients with fecal incontinence (FI) – 14 years after the federal agency approved it for use on overactive bladders (OAB) – only a scant number of specialty-trained urologists around the country began offering the innovative sacral neuromodulation therapy for bladder and bowel control.

Even though it’s easy to assume the lion’s share of discovery and testing on the Medtronic device emanated from major metropolitan areas, much of the early work actually took place in the tiny city of Oxford, Miss., via urologist Doyle “Land” Renfroe, MD. Renfroe, founding partner of Oxford Urology Associates, has quickly become the “go to” doctor for InterStim, a reversible treatment that uses electrical pulses to stimulate sacral nerves just above the tailbone. He has arguably performed more InterStim procedures than any urologist in the southeastern United States.

Problem Solving

“I first began studying severe cases of overactive bladder in the late 1990s.” said Renfroe, 52, who earned undergraduate and medical school degrees from the University of Mississippi, where he also ran track during college. “At that time, very few doctors in the United States were doing the procedure.”

Chuck Secrest, MD, at Mississippi Urology in Jackson, Miss., introduced Renfroe to InterStim therapy.

Medtronic’s bladder control therapy, delivered by the InterStim system, has been FDA-approved since 1997 for urinary incontinence (UI) and since 1999 for urinary retention and significant symptoms of urgency-frequency.

Here’s how it works: The sacral nerves – generally S2, S3 and S4 – activate or inhibit the bladder, sphincter and pelvic floor muscles that contribute to urinary control. More specifically, S3 influences pelvic floor behavior.

Electrical stimulation artificially excites nerve pathways that may activate or inhibit muscle action, depending on their normal function. Electrical pulses may stimulate somatic nerve fibers without prompting simultaneous contractions of the bladder. This may decrease the UI

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Dr. Land Renfroe has arguably performed more InterStim procedures than any urologist in the southeastern US.

symptoms of urgency, frequency, urinary retention and urge incontinence.

Implanting the InterStim neuromodulation system requires outpatient surgery with local and/or sedation anesthesia.

The sacral neurostimulator is inserted under the skin via a small incision in the upper buttock. The long-term lead is implanted under the skin, with one end of the lead connecting to the neurostimulator and the other lead end placed in the sacral foramen adjacent to the third sacral nerve (S3). Generated by the neurostimulator and delivered by the lead, the electrical stimulation modulates nerve activity

to improve bladder and bowel function in many patients who were often out of treatment options.

Each patient undergoes a test phase prior to final implantation to ensure a positive response prior to implanting the permanent neurostimulator. This therapy is not an option for patients with a mechanical obstruction of the urethra or prostate.

Taking Off

Renfroe completed his first InterStim procedure in 2002. A simple screening test to verify candidacy for the therapy has

driven patients to Renfroe, whose volume of Medtronic’s bladder control therapy cases continues to increase.

As a result of his success, Renfroe has spoken at the corporate offices of Medtronic in Minneapolis, Minn., discussing case studies and the benefits of InterStim, and to other groups regionally.

“This procedure can absolutely restore a patient’s quality of life,” Renfroe emphasized. “Patients with overactive bladders and fecal incontinence will frequently refuse to leave their homes for fear of not being able to quickly find a bathroom. It can become psychologically debilitating.”

InterStim therapy is a treatment for patients with chronic, debilitating symptoms of voiding dysfunction who have been unsuccessful finding relief via medication or diet alteration. Because this type of bladder dysfunction can have a crippling impact on a patient’s social and personal life, effective therapy provides great potential for life-changing benefits.

“For patients who have reached that point, this can be a life-changer,” Renfroe said, pointing out that success rates for InterStim therapy top 90 percent.

Other specialists have noticed the impressive results.

“Dr. Renfroe knows more about this procedure than just about anybody because he’s done more of them than anybody else in this part of the country,” said urologist Jeffrey G. Clark, MD. “Doctors seek advice from other doctors who have done certain procedures. Land is the guy to see about InterStim; there’s no question about it.”

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MARCH 2015 • 13

By the Numbers: The Latest Stats on Cancer, continued from page 10 and colorectal cancer deaths are down by nearly half (47 percent).

Despite the good news, though, ACS officials also noted there is much more work to be done. “The continuing drops we’re seeing in cancer mortality are reason to celebrate, but not stop,” stated John R. Seffrin, PhD, chief executive officer for ACS, when the report was released in Dr. John Seffrin January. He added can-

cer was still responsible for nearly one in four deaths in the United States in 2011.

Furthermore, Seffrin noted the country’s second leading cause of death overall is actually the top cause of death among adults ages 40 to 79.

Looking to this year, the ACS has projected 1.658 million new cancer cases will be diagnosed in 2015, and 589,430 Americans will lose their battle with the disease. Of the new cases, the estimate is that men will account for about 848,000 diagnoses across all sites and women 810,000. Prostate, lung and colorectal

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cancers will account for about half of all cases in men with prostate cancer accounting for around 25 percent of all new diagnoses. Among women, it is anticipated the three most common diagnoses in 2015 will be breast, lung and colorectal cancers.

Of those, breast cancer is expected to account for 29 percent of all new cancers for women this year.

Of the 589,430 estimated deaths in 2015, the gender breakdown is 312,150 men and 277,280 women. The most common causes of cancer death are lung, prostate, colorectal and breast cancer with

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these four accounting for almost half of all cancer deaths. More than a quarter of all cancer deaths (27 percent) will be attributable to lung cancer.

While death rates have declined, the report noted mortality improvements aren’t equal from coast-to-coast. In fact, cancer death rates vary by state and region with the Southeast being on the lower end of improvement scale (15 percent decline in overall cancer mortality) and the Northeast on the higher end (between 25-30 percent decline). The variation has been attributed to a number of reasons including risk factor patterns (such as the number of smokers), distribution of poverty, and access to healthcare.

Risk Awareness

A recent survey by the American Institute for Cancer Research found there is an ‘alarmingly low’ awareness of key cancer risk factors, and many Americans put fear before facts. The Cancer Risk Awareness Survey, released on Feb. 4 in conjunction with World Cancer Day, found Americans worry about factors over which they have little or no control … such as genetic risks or food additives … with less than half recognizing the correlation between an increased risk of cancer and alcohol, obesity, lack of physical activity and poor diet.

The findings of the biennial survey give providers and other health experts an idea of whether or not cancer messaging is being heard by the American public. This year’s results were decidedly mixed.

Only 42 percent surveyed were aware a diet low in vegetables and fruit increases cancer risk. This number has trended downward since 2009, when it stood at 52 percent.

Only 43 percent knew alcohol increases cancer risk, an increase of five percentage points since the 2013 survey.

And only about 1 in 3 Americans (35 percent) realized diets high in red meat have been convincingly linked to colon cancer. This figure has not changed since the survey was last conducted in 2013.

Awareness that carrying excess body fat is a cancer risk factor is rising. In this latest survey, 52 percent realized obesity and overweight impact cancer risk, a rise of 4 percentage points.

Awareness that being inactive increases cancer risk jumped 6 percentage points, from 36 percent in 2013 to 42 percent in 2015.

There was a high recognition of several known risk factors for cancer including 94 percent of those surveyed correctly identifying tobacco use and 84 percent citing excessive sun exposure as risks.

However, a significant number of those surveyed also worried about risks for which research has yet to provide a definitive answer. Pesticide residue on produce (74 percent), food additives (62 percent), genetically modified foods (56 percent), stress (55 percent), and hormones in beef (55 percent) were all cited as concerns.

Birmingham Medical News

MARCH 2015 • 15

The Literary Examiner

BY TERRI SCHLICHENMEYER

Touch: The Science of Hand, Heart, and Mind

by David J. Linden; c.2015, Viking; $28.95 / $33.00; Canada; 261 pages denied its pleasure, “the consequences are dramatic.” Children who are touch-deprived in infancy show higher incidences of obesity, heart disease, and type 2 diabetes later in life.

But social glue isn’t the only reason scientists are touching upon this sense.

Chances are right now, for instance, that you’re touching something – the Birmingahm Medical News you hold as you read this - and you’re doing it almost automatically, with very little mental effort.

You can thank touch sensors and nerve fibers for that. Glabrous skin (that without hair, such as what’s on your lips, palms, and the bottoms of your feet) has a dense amount of sensors at its surface while hairy skin contains fewer sensors. The various sensors allow you to perform a multitude of actions, such as grabbing, retrieving, determining, and grasping, and they collect information that goes to your brain at different speeds, taking with it experiences, emotions, and context so you can act (or don’t overreact) to what your skin feels.

Something’s wrong, and you can’t quite put your finger on it.

Everything feels so drab, so negative.

It’s Murphy’s Law on overdrive, nothing in your day is going right, and your mood just took another nosedive.

Looks like someone needs a hug, and in the new book Touch: The Science of Hand, Heart, and Mind by David J. Linden, you’ll see why that could truly help.

Shaking hands, patting someone on the shoulder, caressing a cheek, or grabbing a wrist; There is no mistaking the meaning behind any of those actions but David J. Linden why do we understand them, even if they happened wordlessly?

Skin, says Linden. It’s a social medium. We humans (as well as most mammals) are born needing to be nurtured and touched: researchers believe it’s the first sense we developed as fetuses, and if we’re

These sensors also help make a “touch map” inside the brain, which connects information being collected and identifies the source of the touch. While there’s still much to learn, scientists know that your personal touch map can be affected by aging and disease – and if you’re feeling touchy about that, take heart: they also say that maps can change through practiced sensory habits. Doesn’t that make you feel better?

If you could only have one sense, which would it be? Read Touch: The Science of Hand, Heart, and Mind and your answer will be clear.

I only wish the book was, too.

In between illustrative stories that can completely capture interest, author David

J. Linden immerses his readers in deep neurology, complete with scientific terms that could boggle a layman’s mind. We’re handed a lot here, including alphabet-soup language, and while that’s certainly not bad, it does mean that this book is best consumed slowly and in small bites with rapt attention.

Still, if you’re interested in the mechanics of your mind or you want to know why you itch and what you have in common with koalas, read this and you won’t be disappointed. Touch: The Science of Hand, Heart, and Mind is a book to get your fingers on.

Terri Schlichenmeyer. Terri is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.

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Personalized Messaging A Marketing Manifesto

By CINDY SANDERS

With better understanding of the human genome, physicians and researchers have opened up exciting new lines of personalized medicine to fit a patient’s unique needs. While a highly scientific, very targeted approach is often used to promote improved outcomes, it is rarely employed when it comes time to promote a facility or provider expertise to improve income.

If precision medicine works, why not precision marketing?

A Call to Arms

In his 2011 manifesto for transforming healthcare marketing, “Joe Public Doesn’t Care About Your Hospital,” author Chris Bevolo explored why the digital world had made it possible … and desirable … to change not only the message but also the manner in which it is delivered. His September 2014 follow-up, “Joe Public II: Embracing the New Paradigm,” offered practical strategies for making the move from mass marketing campaigns to much more precise digital and content marketing options.

The norm, Bevolo pointed out, has been to take a shotgun approach via mass marketing. “It really was a call out to the industry to say, ‘This isn’t working … we need to stop this,’” he said of his first book.

Change doesn’t come easily, pointed out Bevolo, executive vice president for healthcare marketing communications firm ReviveHealth. And just as the industry was beginning to get the hang of Facebook and Twitter, the digital landscape shifted again.

“Social media is still important, although we’re beginning to see the limits of what it can do from a marketing standpoint,” said Bevolo. “Instead of a few big players, you’re seeing more and more players emerge,” he continued of the segmentation of social media. “It’s an important supportive tool, but I think there was a time when people thought it would totally revolutionize marketing.”

Instead, it is one device in the bigger picture of digital marketing, which is revolutionizing the way the industry reaches its target audience. Bevolo said ‘search’ should be a primary driver of how customers … also known as patients … find you and your message. Whether by purchasing prime real estate in popular search engines or effectively using tags, it’s clearly a competitive advantage to be among the first few sites that pop up when someone looks for “urologist, Nashville,” or “safest hospitals, Tennessee.”

Additionally, emerging technologies allow practices and health systems to really drill down and target specific messages to specific populations in a way that is timely and useful. “It has to be relevant, and it has to be relevant to what they need in the moment,” Bevolo stressed.

Content is King

Bevolo said there is no question that people are facing information overload, and he noted research has shown individuals are hit by thousands of marketing messages daily but can only process about 100 of them.

“How do you become one of the 100 out of 3,000 or 6,000?” he asked. “The key is relevancy.” Bevolo continued, “That’s the challenge for any marketer, but it’s particularly challenging for hospitals. What they have to offer is not relevant to the vast majority of people at any given time.”

Expecting consumers to hone in on messages that don’t apply to them isn’t realistic, he said. “If you’re not in need of a doctor at this moment, you don’t care about awards, service lines or how great

a hospital’s doctors are,” he pointed out.

“Yet, we try to do broad marketing. Not only is it silly, it’s a waste of money and time … and you don’t have time to waste, and you don’t have money to waste.”

When patient volume is down, Bevolo said the gut reaction is to believe it’s because not enough people know about you and your wonderful services. The prevailing sentiment is that if you just get a message out there about how good you are, then people will a) hear it, b) care about it, and c) will take action on it. “All three are false, by and large,” he said.

Bevolo continued, “That’s the fundamental breakdown in logic … that telling people how great you are will get people through your doors. I don’t care how good

the billboard is, it’s not going to make me run in and have my gall bladder taken out if I don’t need it removed.”

With limited resources, why pay to broadcast to a million people when only 30,000 need your message, he questioned.

However, he added, targeting the 30,000 doesn’t mean you are giving up on the other 970,000. Instead, Bevolo continued, you just have to rethink the messages.

“You’re missing a lot if you don’t focus on people who do not need services today,” he said. “There’s an opportunity to connect with those people around something that is relevant to them.”

Bevolo suggested using digital options such as blogs, channels, websites and (CONTINUED ON PAGE 18)

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Small Practices Don’t Need to Sell Out, continued from page 1 pieces or coordinate with all the vendors,” Callahan says.

“They don’t have to sign checks, approve vendor invoices, or know how much money is in the bank to meet payroll service,” continues Callahan. No more overseeing an office bookkeeper or a separate billing office for collections either. These comprehensive management companies even handle leasing and maintenance of the office space, hiring personnel, and all the IT needs.

The all-in-one approach can make

Baby Boomer? continued from page 5 Doctors need to be vigilant about screening patients who might benefit from treatment, and patients need to ask questions if they are at risk.”

It is important, Shaver says, that patients in a high-risk group be proactive about being screened. “Whether you’re seeing your primary care physician or your gastroenterologist, you should ask if screening is appropriate,” he says. “Don’t avoid screening because you feel okay or don’t have any symptoms. Many of the people diagnosed with Hepatitis C have no idea where they got the virus and often are asymptomatic. So if you were born between 1945 and 1965, have elevated liver enzymes or other risk factors, I absolutely recommend that you be screened.”

18 • MARCH 2015

Birmingham Medical News

a remarkable difference. Last year, Kassouf’s group saved a local practice around $300,000. “That’s more the exception than the rule, but depending on how large your practice is, the potential for really large savings is out there,” Callahan says.

One area Kassouf’s group has found to be rife with overlooked revenue is credentialing. “The bills are being sent to the payer, but the practice receives no payment because they’ve not signed up with the payer. So the practice writes that money off,” Kassouf says.

For each physician, a practice may need to get credentialed with 20 to 25 payers. “It’s not just filling out paperwork for Blue Cross or Medicare,” Callahan says.

“There’s an arm’s length-long payer list inside each of the major payers. Medicare has plans inside its plan.”

An area for savings under the comprehensive practice management model that makes mergers so appealing lies in combined purchasing power. Currently Kassouf’s healthcare team manages 21 practices. “Because we’re serving as the inventory managers for many practices, we can see how the pricing for supplies to practices compares to one another. If we see one out of line, we can come back to that vendor to get those prices back in line with what others are paying,” Callahan says.

The collective power of getting more for your money applies to staffing as well.

With the management of many practices under one roof, a comprehensive practice

management firm can hire more qualified expertise than a small practice could afford. “So you get a much higher level of management while only paying for a fraction of it,” Callahan says.

Workflow also never wavers in any administrative area. Practices may have one or two coders on staff. That means a sick coding specialist can directly impact a practice’s revenue cycle. Not so when under the care of an all-in-one management firm. “There’s enough staff that if someone goes down with something unexpected, there’s no loss of flow of billing or work,” Kassouf says.

One practice Kassouf now manages said they had to replace their billing manager three times in one year. “You don’t really know the competence of your employees in those functions until you’ve hired them,” Callahan says. “But we’ve already vetted our staff and have processes and controls in place, so if performance is not being met, we know it.” And practices never feel the bump of staff turnover.

With HIPAA violations setting off audits by the Office for Civil Rights, and Medicare contractors scrutinizing coding and billing with new intensity, practices are undertaking more and more detailed administrative duties. “These are things that physicians did not have to deal with historically and have no infrastructure for dealing with if they occur. Likewise, there is no arrangement in place to prevent them from occurring,” Callahan says.

But the solution does not have to mean selling out. “With our model, physicians maintain the ownership in their practice,” Kassouf says. Also unlike selling to a hospital or joining with another practice, the decision to hire a comprehensive management firm can be reversed. “And since we know they can change their management company any time they want, we know we have to do the job at the peak of perfection.”

Personalized, continued from page 17

apps to share messages about prevention, healthier living and other topical content.

A young mother might not care that you are the top joint replacement hospital in the area, but she might really want to learn how to make quick, healthy lunches for her children. A retiree who isn’t interested in how many babies you delivered last year could be eager to learn about fall prevention measures.

“That’s how you resonate with Joe Public … because you are the arbiter of health,” Bevolo shared.

Instead of trying to target potential patients right before they need services, he said the idea is to reach out to them much earlier. “Those people will need care one day; and if you are the resource they turn to when they are healthy, you’ll be the one they turn to when they do need services.”

Recent Antitrust Decision May Slow Down Physician Practice Acquisitions

By Colin Luke

Last month, a federal appellate court issued a decision that may have widereaching implications for acquisitions and mergers of physician practices. The 9th Circuit Court of Appeals upheld a challenge by the Federal Trade Commission (FTC) and competing hospitals to the December 2012 acquisition of a 40-physician group practice in Canyon County, Idaho,

by St. Luke’s Healthcare System in Boise, Idaho. The 9th Circuit upheld a district court’s determination that the acquisition violated state and federal antitrust laws and had to be unwound.

The deal at issue involved the largest independent physician practice in Idaho, Saltzer Medical Group, and the largest hospital system in Idaho at the time, St. Luke’s Health System, a non-profit system with nine hospitals in Southern Idaho.

The acquisition gave St. Luke’s ownership of 80 percent of the primary care practices in Namba, Idaho, a city located about 25 miles from Boise. St. Luke’s had paid approximately $28 million for the practice and the physicians get to keep almost $9 million if the transaction is actually unwound.

In its decision issued in January of 2014, the district court had specifically found that the transaction would increase healthcare costs for both consumers and payors. The lower court judge determined that the transaction would allow St. Luke’s to dominate the health care market in Canyon County and use this dominance to pass rate increases onto payors and consumers. He also found that St. Luke’s would impose higher hospital-based rates for ancillary services such as lab work and x-rays.

St. Luke’s argued that the acquisition was necessary to maintain and improve patient care. The health system contended that the deal was necessary to implement an innovative payment system whereby providers would be paid for quality. St. Luke’s also argued that the deal would help stabilize insurance rates in Idaho and permit greater numbers of indigent patients to get medical care.

Lawyers for the FTC introduced internal emails and accounts of conversations to demonstrate that executives wanted to acquire the Saltzer practice for economic reasons and to avoid competition with the Saltzer doctors and other hospitals for market share in Canton County. They also provided evidence that other acquisitions of physician practices had raised costs and stifled competition.

Idaho’s Attorney General had supported the challenge to the transaction and argued that the transaction also violated state prohibitions on monopolistic behavior. In August of last year, the at-

torneys general of 16 states filed a brief supporting the district court’s decision and the position of the Idaho Attorney General. Although they recognized the benefits of healthcare integration, they argued that these benefits could be obtained without the actual large-scale consolidation of hospital and physician care.

Because this decision follows a string of FTC successes in challenges to physician practices, a number of national experts believe that this case will have a chilling effect on mergers and acquisitions involving large physician practices, unless the acquiring party has some sort of sustainable exception from antitrust review such as a state law protection. Problematically for mergers and similar transactions, it appears as though the FTC is able to assert successfully that healthcare markets are local as opposed to regional or statewide for assessing the resulting consolidated market share. Moreover, it appears as though the consolidation of primary care practices may be subject to heightened scrutiny because of their role as “gatekeepers” to specialists and health care systems.

This case arguably undermines efforts to achieve greater integration of healthcare delivery through common ownership and legal acquisitions. There is no question that hospitals and their counsel will become more conservative in pursuing the acquisition of larger physician practices.

Our

As pointed out in the two decisions in this case, however, similar levels of clinical integration and efficiencies may be achieved through more innovative methods such as co-management agreements, the sharing of health information systems or accountable care organizations. These mechanisms may become even more commonplace.

It will be interesting to see what impact, if any, the St. Luke’s case and other physician practice challenges will have on the cases pending against various Blue Cross/Blue Shield plans with respect to their market power and consolidation. It would seem unlikely that federal courts

will only rule against physicians and hospitals for anticompetitive behavior if federal courts remain so focused on the ultimate costs to employers and consumers.

It is also important to note that the St. Luke’s case may end up at the United States Supreme Court and that a more definitive national set of standards may emerge for the review of physician practice mergers and acquisitions.

Colin Luke is the former chair of the Alabama Bar’s Health Law Section and is a partner with Waller where he specializes in healthcare law.

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Young Physician’s

Interests, continued from page 2 thrown in as well.”

Howard first made his mark in visual arts with a first-prize win in the University of Alabama School of Medicine’s student art show. The piece was a nature photo collage which he framed with board from an old window of a house he’d lived in most of his life. Nowadays he finds most of his creative outlet for visual expression through designing publications; the most recent title is “Panacea: Healing is the Cure.”

As for his musical pursuits, Howard sang and played guitar in bands ranging from original blues to classic reggae between 1997 and 2013, and was co-owner and operator of a Hoover-based studio and label known as Barn Records. He’s not currently playing in a band, but says he’s recently taken a liking to the piano.

In the professional realm, Howard is in the process of transitioning from a residency to a private practice with the Decatur group River Oak Family Medicine. Its facilities should offer “a lot of freedoms,” he says.

But no discussion of professional credentials is complete, Howard says, without mention of his alma mater: “I’ll always appreciate UAB and what they do. The university stands as a kind of tower of excellence that I carry with me whatever I do. Being a graduate means something, in this state.”

REPRINTS: If you would like to order a reprint of a Medical News article in a PDF format or request an additional copy of an issue, please email: subscribe@medicalnewsinc. com for information.

Fighting Sepsis in the Emergency Department

By JeFFrey F. Jones, md, FaCeP

Sepsis is an infection and subsequent immune response that causes whole-body inflammation. Sepsis is usually caused by a bacterial infection, and the resulting mortality can be 30 to 50 percent. Severe sepsis has an even poorer prognosis, and is defined as sepsis along with poor organ function as a result of insufficient blood flow to tissues. Signs of organ dysfunction with severe sepsis include altered mental status, tachypnea, tachycardia, decreased urine output, and delayed capillary refill.

A technical diagnosis of sepsis requires presumed infection and at least two of the following systemic inflammatory response syndrome (SIRS) criteria: • Temperature < 96.8° F or > 100.4° F • Heart rate > 90 beats per minute • Respiratory rate > 20 breaths per minute • White blood cell count < 4000/ mm3, > 12,000/mm3, or >10% bands (immature forms)

In a 2001 study, Dr. Manny Rivers reported a reduction in the mortality of septic patients with an treatment approach called early goal-directed therapy. Starting in the emergency department, Rivers attempted to keep a patient’s central venous pressure, mean arterial pressure, urine output, venous oxygen saturation, and hematocrit above certain levels. This often involved aggressive use of mechanical ventilation, fluid resuscitation, vasopressors, and transfusions.

This work led to the Surviving Sepsis Campaign. This group of experts issues guidelines for the treatment of sepsis. They favor “bundles”, or groups of evidencebased interventions that result in better outcomes when implemented together.

The campaign has a six-hour bundle that applies for inpatient care, and the following elements of a three-hour bundle that are intended to be completed within three hours of patient presentation: • Measure lactate level • Obtain blood cultures before giving

BIRMINGHAM MEDICAL NEWS

antibiotics • Administer broad spectrum antibiotics • Administer 30 mL/kg of crystalloid solution for hypotension or for a lactate > 4 mmol/L Many hospitals are adopting protocols for the early identification and treatments of sepsis. At Trinity Medical Center, every patient presenting to the emergency department is screened for signs of sepsis (questioned regarding possible infection or altered mental status; measurements taken for hypotension, hypoxia, and the above SIRS criteria).

If a patient is positive for the screening criteria items, the ED provider is notified. He then has access to computerized order sets to efficiently order all tests and interventions that are part of the sepsis bundles. Additional protocols are in place for inpatient use. These efforts will hopefully achieve the 25 percent reduction in sepsis mortality that is the goal of the Surviving Sepsis Campaign.

Jeffrey F. Jones, MD is the Medical Director of the Trinity Medical Center Department of Emergency Medicine.

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A Meaningful Use Post-payment Audit?

Say it Ain’t So, Joe!

By Susan Pretnar

Oh, what I mean is “Say it ain’t so, Mr. Figliozzi, CFA, CFF, FCPA.” Who knows if Shoeless Joe really threw the 1919 World Series, but in our world, if you attested to Meaningful Use, you know for sure that CMS could come calling to see if what you attested to is indeed what happened back in the day. And that ‘day’ could be the very first year you attested to Meaningful Use. In 2014, CMS audited just five percent of the providers who had attested to Meaningful Use for any year. How could they possibly find you? Well, five percent was still over 20,000 providers. The rub: the government paid out more than $20 billion and CMS was blasted for not auditing enough to assure the money was properly spent. Is there fraud in the Medicare and Medicaid programs? Just sayin… might that also be the case with Meaningful Use? I thought I’d offer a first-hand account of what might happen if you receive an email (yes, it comes as an email of High Importance) notifying you that one of your physicians has been selected for a HITECH EHR Meaningful Use audit.

It is important to remember the contact

email address that was given when you attested to Meaningful Use, because that is the person who will receive the email from meaningfuluse@figliozzi.com . Is that person still with your practice? There are all kinds of un-pleasantries if the selection email bounces back to figliozzi.com.

• Make a note - recheck the contact information on your attestations By the way, at the end of their notification email, it advises you to add this email address to your safe sender list, otherwise their correspondence might be blocked as spam. You cannot respond back to this address mind you, but you had best let them contact you.

• 2nd note – ask the tech people to let the figliozzi email address come flying through the firewall • 3rd note – ask the tech people to check everybody’s spam folder better safe than sorry Then what? The person who has been assigned as your very own personal auditor is named in the email and his/ her contact information is included. You email and talk to that person, not meaningfuluse@figliozzi.com . They are probably not coming on site. After all, over 20,000 of these emails were sent out last year. They prefer a desk audit, with your

personal auditor sitting comfortably at his desk waiting for your stuff, while you probably have not been allowed to sit down since the selection email arrived.

The email gives directions of how to send in a list of requested documents and how to identify each file. My small sample of just two examples indicates the selection email will give you a month to reply.

Though not a statistically valid sample, I’d go out on a limb and say that is the norm.

So, what happens in a practice in order to respond to a selection email?

While every practice will be a unique scenario, the following is a brief synopsis of some generously shared notes from one practice about the time dedicated to complete their response (retrieving documents, correctly labeling and emailing files, rebuttal opportunities, etc.), the number of people who participated in the response, and what they wish they had and hadn’t done ‘back in the day.’ In retrospect, this practice did not feel that the total cost of the audit was significant enough to try to compute.

The practice was given three opportunities to submit documentation for specific core measures because their first submission was not completely satisfactory. Since so many practices lack a comprehensive

risk assessment, it was a primary document Figliozzi focused on and one that the practice had to clarify further, necessitating a request to their outsourced IT managed service provider for additional documentation.

Another stumbling block was the fact that the practice’s attestation in question was based on a certified EMR that had subsequently been sold, and sold again.

The original product certification was no longer on CMS’s system, so there was much ado about whether their EMR was truly a certified system. The practice’s current EMR vendor was able to research and substantiate the original vendor certification. In addition, their EMR had been upgraded several times. Recreating reports from prior periods was problematic because of configuration changes and enhancements to the reporting tool. Therefore, research and correcting of records for unmatched statistics was required.

The final hurdle was the inability to electronically submit syndromic surveillance data to a state public health department. The practice was given a waiver since their EMR was incapable of electronically creating syndrome-based public health surveillance information in the (CONTINUED ON PAGE 22)

Pediatric Rehabilitation Medicine

moving forward at the speed of life

Our Team Drew Davis, MD Associate Professor Medical Director, Pediatric Rehabilitation Medicine

Paola "Lala" Mendoza, MD Assistant Professor

Erin Swanson, MD Assistant Professor Starting August 2015

Pediatric Rehabilitation Medicine Rehabilitation Medicine at Children's of Alabama provides the ONLY acute pediatric inpatient rehabilitation service in the state.

Our interdisciplinary team addresses the prevention, diagnosis, treatment and management of congenital and childhood onset physical impairments. These can include related or secondary medical, physical, functional, psychosocial, cognitive and vocational limitations or conditions --- and our approach takes into account the life course of disability.

Common treated conditions and services include: l Spinal cord injury l Cerebral Palsy l Brain tumors l Spina Bifida l Strokes l Muscular Dystrophy l Botulinum toxin and phenol injection l Brachial plexus injury and baclofen pump management l Acquired brain injury

For a clinic appointment, call: 205.638.9790 Inpatient Referrals: 205.638.6997 Fax for sending referral info: 205.638.9793 Lowder Building, Suite 510 1600 7th Avenue South Birmingham, AL 35233

PEDIATRIC REHABILITATION MEDICINE

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Birmingham Medical News

MARCH 2015 • 21

The Long Range Plan in Medical Real Estate

By Richard A. Campbell III, CCIM

When was the last time you assessed the long range plan for your clinic space?

Do you have enough space? Do you have too much space? Are you looking to hire another MD, PA or NP in the next five to ten years? Where do you want to be in 10 to 15 years? Are you a small practice, large practice or solo practice? Do you need to be near a hospital campus? Are you located conveniently to your patients? Is your clinic easily accessible? Do you have growth options? All of these questions affect your occupancy costs, and ultimately your bottom line. Therefore, they should be evaluated on a regular basis.

While pondering your clinic space, you should start by asking yourself where are you in the life cycle of your practice.

Are you in the early years with decades ahead of you? Or perhaps you are the veteran who wants to retire in the near future.

Most likely, however, you are somewhere in between. As a result, you will need a regular assessment of your space needs.

Controlling fixed costs has never been more important than now, as we face a new healthcare environment driven by recent Federal changes. Whether you are a dermatologist with a three doctor practice, or a solo family practice doctor, you are likely concerned about the bottom line. After the cost of your employees, real estate is likely your next largest expense.

Controlling that expense should be near the top of your list to keep a healthy bottom line. So, do you see major changes in partnerships or practice employment?

Are you a solo doctor who plans to re-

main that way throughout your career or are you on a path to build a multi-doctor practice with potential for new satellite locations? Either way, you should regularly go through a comprehensive space planning and forecasting process.

The key to effective planning and decision-making today involves thinking about where you want to be in 15 years.

Medical real estate decisions are almost certainly tied to longer commitments, oftentimes 10-year terms. Building owners will dangle enticing carrots in front of you in return for a long-term deal, but it may not always be in your best interest.

In particular, that commitment could be problematic if it confines you to a direction that is not part of your long-range plan. You must know and understand all of your options. If your decision is based

on a well thought out, long-range plan, it will work out even if you have to make some shorter-term sacrifices.

Here are some key points to help you assess your current practice state: 1) Do not get caught up in the false belief that owning your own building is always the best thing. Sometimes it may be a reasonable option, but often it is not financially feasible.

2) Think in terms of total occupancy costs as opposed to per square foot rates.

For example, it’s possible to negotiate an excellent rental rate but lease 2,000 sf of space that you don’t need and your resulting total occupancy costs ends up too high.

3) Term is gold to property owners.

Make sure you get the weight worth the gold you pay for longer term commitments.

4) Always be familiar with your next best alternative. Whether you are leasing or buying, knowing your options is fundamental.

5) Seek the advice of a specialist in medical real estate.

Richard A. Campbell III, CCIM is an advisor with Veritas Medical Real Estate Advisors.

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A Meaningful, continued from page 21

required format. At one time, there was a requirement to attempt a transmission, regardless of the ability of your State Department of Health to accept it, because ONC supplied test data and the criteria for testing this capability. There was confusion about whether a ‘failed’ test was sufficient, and whether it could even be attempted in Alabama during the first year of attestations. Apparently, there was enough confusion that Figliozzi granted the waiver.

In summary, this practice was complementary of their treatment by their auditor, who was generous with extensions due to the holidays overlapping their audit period. Because of the way they had stored their backup information, the practice had to recreate or separate results for just one doctor, even though some of the data applied to all of them. However, this practice was able to rely almost entirely on one manager to formulate their responses, who was also instrumental in their attestation process. The audit did not cause a major disruption in their day-to-day operations, nor much concern by the management team.

By the way, there was also a happy ending. Just wanted you to know.

Susan Pretnar is the President KeySys Health, a company that helps medical practices implement policies and plans that satisfy HIPAA and HITECH requirements.

Grand Rounds Birmingham MGMA New Board of Directors The Birmingham chapter of the Medical Group Management Association has elected the Board of Directors for the upcoming year.

Lenora Jones, who is the administrator for Henderson & Walton Women’s Center, is the Lenora Jones incoming President, and Thalia Baker with UAB has been elected Vice President.

The Immediate Past President is Debbie West Thalia Baker and the Past President is Jason Biddy.

Connie McDonald of Cardiovascular Associates is the Chapter Historian and Philip Langston of Lemak Sports Medicine is the Treasurer. Richard Stroud of UAB Eye Care and Joseph Bolen of ART Fertility Program of Alabama are the Members at Large.

EDITOR & PUBLISHER Steve Spencer VICE PRESDIENT OF OPERATIONS Jason Irvin CREATIVE DIRECTOR Susan Graham

Kovacik Joins Norwood Clinic Mark S. Kovacik, MD has joined the Norwood Clinic Neurology practice.

Kovacik attended the University of Illinois College of Medicine. He completed his residency and fellowship at the University of Wisconsin Hospital and Mark S. Clinics. He is Board Cer- Kovacik, MD tified in Adult Neurology and has been an active staff of Brookwood Medical Center since July 1993.

Larremore Named Partner at Waller Kristen Larremore has been named a partner with Waller where she practices in the health law division, counseling hospitals, health systems, outpatient service providers, and medical practices on Stark law compliance, federal Kristen and state anti-kickback regLarremore ulations, HIPAA, patient privacy and state healthcare regulations.

Larremore earned her BSBA in Economics and Accounting from the University of Southern Mississippi in 2001 before earning her Masters in Theological Studies and Juris Doctorate, Law from Vanderbilt University.

She gained experience with Balch & Bingham and Bradley Arant before joining Waller in November 2013.

Birmingham Heart Clinic Opens Vein Center

The Sanders Trusts Builds and Acquires New Properties

Birmingham Heart Clinic (BHC) has opened a BHC Vein Center to diagnose and treat venous disease with minimallyinvasive procedures. The BHC Vein Center offers many services in detecting and treating venous disease including duplex ultrasound, ablation therapy, laser therapy and more.

About 15 percent of Americans have venous disease, which is caused by diseased or abnormal veins. When vein vessels become damaged, blood flows backward causing the veins to stretch, swell and twist. One of the most common signs of venous disease is spider veins, which appear as small, purplish clusters of veins on the leg. Varicose veins are larger, bluish veins.

Venous disease may not present itself until leg pain or skin problems emerge.

Venous disease symptoms may include the following: • Swelling in legs • Leg pain or cramping • Varicose or spider veins • Discoloration of skin • Dry or weeping eczema • Leg ulcers • Restless legs Venous disease can worsen over time due to the pressure created by the backflow of blood in the legs. This may lead to additional spider and varicose veins, and in some cases can lead to swelling and venous ulcers.

The Sanders Trust (TST), a Birmingham-based medical real estate investment firm, has undertaken several new projects recently.

In late February, TST began construction on Reliant Norwood Rehabilitation Hospital near Cincinnati, Ohio.

Construction of the 40-bed, $17 million inpatient rehabilitation hospital will take 11 months to complete and is expected to open in February of 2016.

Earlier in the month, TST acquired four healthcare clinics representing a total of $11.9 million and 45,932 square feet.

The clinics are located in key suburbs in Indiana, Georgia, and Pennsylvania.

The acquisitions include the 15,000-square-foot Collegeville Park Medical Center, located in Collegeville, Pennsylvania. The facility is anchored by Jefferson Outpatient Imaging, an affiliate of Thomas Jefferson University Hospitals.

TST also acquired two multi-specialty clinics located in the Atlanta suburbs of Peachtree City and McDonough, Georgia. The stand-alone clinics have a combined total of 18,205 square feet and are leased by Emory Specialty Associates and Emory Hospital-Midtown.

Similarly, TST acquired Orthopaedic Associates and Deaconess MOB located near Evansville, Indiana. The 13,000-square-foot facility is leased to Orthopaedic Associates, an independently owned and operated orthopaedic clinic, as well as Deaconess Health System.

STAFF PHOTOGRAPHER Jimmy McGillis CONTRIBUTING WRITERS Ann DeBellis, Nancy Dorman-Hickson, Jane Ehrhardt, Sharon Fitzgerald Laura Freeman, Kathy Hagood Dale Short, Cindy Sanders Birmingham Medical News 270 Doug Baker Boulevard, Suite 700-400, 35242 205.215.7110 • FAX 205.437.1193 Ad Sales: 205.978.5127 All editorial submissions should be mailed to: Birmingham Medical News 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242 or e-mailed to: editor@birminghammedicalnews.com —————————————————— All Subscription requests or address changes should be mailed to: Birmingham Medical News Attn: Subscription Department 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242 or e-mailed to: steve@birminghammedicalnews.com Birmingham Medical News is published monthly by Steve Spencer ©2015 Birmingham Medical News, all rights reserved. Reproduction in whole or in part without written permission is prohibited. Birmingham Medial News will assume no reponsibilities for unsolicited materials.

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