Birmingham Medical News June 2022

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JUNE 2022 / $5

Carter Wants to Help People of Color Enter the Medical Field Through Scholarship By ansley Franco

Hernando Carter, MD has achieved his lifelong dream of becoming a physician, and in the spirit of giving back, he wants to help extend that opportunity to other people of color who are pursuing a career in medicine. Born premature at just 28-weeks, Carter spent the first six months of his life in the newborn intensive care unit and suffered from upper respiratory health is-

sues, including asthma and bronchitis, as a child which meant he spent a lot of time in the pediatrician’s office. “I always looked up to my pediatrician and viewed her as a role model,” Carter said. “When I was four years old, I told my family I wanted to be a doctor. I knew from that young age what my goal was, but I didn't have a clue about how to get there.” When touring Morehouse College, he met Thomas Blocker, PhD, (CONTINUED ON PAGE 4)

Amore Dixie receives the Prescription for Better Life Scholarship with Hernando Carter, MD.

St. Vincent’s Implants Birmingham’s First Cordella Heart Failure Monitor By laUra Freeman

Barry Rayburn, MD (third from left) and Alain Bouchard, MD (third from right) with the heart cath team.

Heart failure is the number one cause of hospital admissions for Medicare-age patients in the United States. It directly accounts for 8.5 percent of heart disease deaths, contributes to up to 36 percent of all heart disease deaths, and it is mentioned in one out of eight death certificates. The global economic burden is $108 billion per year and the human costs are immeasurable. More than half-million Americans will get the bad news this year that their

(CONTINUED ON PAGE 5) Increase Collections T H E M E D I C A L B I L L I N G C O M PA N Y

heart is beginning to fail. The course of their disease is likely to be progressive, robbing them of the vitality to do many of the things they enjoy. Medications have been developed to treat the disease, but for maximum effectiveness, there is still the challenge of getting the right drug to the right patient at the right time. “Patients with heart failure tend to already be on several medications,” cardiologist Barry Rayburn, MD said. “The difficulty has been our ability to recognize when those medications need to be


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Costly Reimbursement Pitfalls By Jane Ehrhardt

“Medical billing is unique. It’s different from any other service,” says Tammie Lunceford with Warren Averett. “There are so many layers to getting paid.” From aging claims to an overbalance of credits or from pre-surgery patient payments, clinics can be continually trickling away their revenue or endangering their financial stability from simple lack of oversight. Handling insurance claims can be particularly complex. “There isn’t just one person responsible for those collections. Everyone at the clinic or hospital has a part to play,” Lunceford says. The problem can begin with the clinician. She knew one physician who held patient encounters for 60 days, leaving little room for claims to be reviewed and corrected before passing the dangerous 90-day mark. “You want all payments in before 90 days because after 90 days, nothing good happens,” Lunceford says. Statistics show 35 percent of reimbursement claims and patient bills do not get paid after those crucial three months. Only 10 percent get paid after a year. If after 30 days, a reimbursement

has not been paid, statistics have found that the error mostly fell to misinformation on the claim, such as the patient providing the wrong information or a coding error. But without a process for following up and correcting these claims, revenue needlessly slows and becomes jeopardized. The amounts owed can become staggering. One cardiology practice lost $500,000 in reimbursements because a certain procedure required notes or responses to the insurer that were never submitted. “So the claims aged out past the insurance company timeline, and they lost that revenue,” Lunceford says. Most payers give a claim 12 months to be successfully processed. With the nationwide staff shortage, many practices have had a hard time finding people to handle reimbursement, further exacerbating the unpaid claim problem. Some clinics have chosen to outsource only their aging claims to billing companies. “That’s the right thing to do if you can’t focus on it internally,” Lunceford says. “Because the clock is ticking.” The 90-day bucket of unpaid claims and patient bills should hold less than five to 15 percent of the practice’s accounts receivable.

Tammie Lunceford, CMPE CPC

Cal LaGroue, CHBME

“The practices that collect from patients best are performing at the highest level,” says Cal LaGroue with the Valletta Group. Having the patient’s credit card on file can be the answer. If the patient pays $20 at the time of the service, but ends up owing $50, no action is needed. Instead, the practice’s credit card vendor automatically charges that $30 outstanding balance at end of day. “The merchant vendor would batch out just like if you were running that card in the office that day,” he says. “This is how to keep your patient balances as low as possible.” This is a newer option in the healthcare industry and clinics may be hesitant to use it. But through a credit

card agreement, the patient determines the parameters alongside the practice. They can decide the maximum to deduct and the payment schedule, such as $100 per month. This option also overcomes the challenge of larger balances due post-procedure. “Sit down with the patient and set up a payment plan after the procedure,” LaGroue says. “Every time is a new agreement for each of those balances. You could try to collect cash up front, but then you get into credit balances.” Credit balances present a new accounting headache in healthcare. When high deductibles came on the scene in (CONTINUED ON PAGE 4)

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Carter Wants to Help People of Color Enter the Medical Field, continued from page 1

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who was a member of the Morehouse Office Health Professions for over 30 years. His meeting with Blocker sold him on enrolling in Morehouse and beginning his journey toward a medical career. Growing up black in Birmingham was a challenge Carter had to overcome. “I felt there were a lot of visible and invisible barriers and limitations,” he said. He believes that the faculty and administrators at Morehouse spent a lot of time helping the students remove those selfimposed barriers and encouraging them to realize their potential. Blocker had a personal mission to help students who were interested in the medical field achieve their goals. He called Carter’s mom when he got a C in biology class, took him on trips to tour medical schools and wrote for grants to help students pay for preparation courses for the Medical College of Admissions Tests. After graduating and becoming a physician, Carter wanted to come home and give back to his community. “I knew that there was a space I could fit into that would blend mentoring and community service as far as health, education and promotion of health equity,” he said. He had this in mind when he formed the Prescription for Better Life scholarship program. Prescription for Better Life aims to increase the number of Birminghamnative black and brown youths pursuing healthcare careers. Carter focuses on students from Birmingham specifically because health care is one of the main industries of the city and there are many opportunities. “I think that if we

can expose young people and they can see what is out there, we can help them make a better life for themselves and their families for generations to come. And we can retain a lot of the talent that we have here in Birmingham that otherwise tends to leave,” Carter said. This is the second year of operation for Prescription for Better Life and the program was able to give two students a scholarship of $1,000 each. The application process can be found online and asks students what inspired their career choice, their grade point average and standardized test scores, among other things. Amore Dixie is one of this year’s scholarship recipients. She is graduating from Springwell High School and was involved in Beta Club, Student Council and dance team. As she continues her education at Tennessee State College, she plans on becoming a nurse anesthetist. After applying for the scholarship, she was asked back for an interview. “I was nervous at first but I think I did pretty good,” Dixie said. The interview is the first step in the mentoring process where the students can get pointers and advice about college from Carter. The scholarship is given directly to the student to use for books, supplies or whatever they see fit. Dixie plans to use her scholarship money to pay the remaining balance on her tuition and books. “We don’t have a lot of opportunities in higher positions so I think that Dr. Carter has helped a lot of people with this scholarship and it will help me out,” she said.

Costly Reimbursement Pitfalls, continued from page 3

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the last few years, clinics found themselves needing to collect those large amounts for the first time. As a solution, they started requiring any unpaid deductible up front and putting it in a holding bucket on the account. “Everybody focuses on collections for services; no one is running a credit account report. They have blinders on,” Lunceford says. But if the deductible is incurred by another provider, such as the surgery center, the practice is left with a credit balance that is not earned profit. If not paid back, those credits can add up and cause trouble. Credits do not always derive from collecting deductibles. One plastic surgeon built credits over years of more than $750,000 from selling cosmetic procedure packages, such as chemical peels, that were never redeemed. “They had no services to overset that revenue, so it was all credits,” Lunceford says.

“If you have credits not resolved on account, your profit is inflated.” Artificial profits can lead to a painful outcome. When a surgeon with a $250,000 credit on his account had a debilitating accident, he was forced to sell his practice. “The purchaser was willing to buy his accounts receivable, but not his credits,” Lunceford says, biting into what the surgeon had expected as profit. That same situation arises when a physician wants to retire. The partners should make sure any credits are taken from his profits before he leaves so they are not holding liability for that provider. “You have to have processes in effect to keep the entire revenue and credit resolution optimal and continually reviewed,” Lunceford says. “It’s a huge administrative burden to have claims or credits build and have to go back and clean that up.”

St. Vincent’s Implants Birmingham’s First Cordella Heart Failure Monitor,

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continued from page 1

adjusted in time to avoid more damage and the need for hospitalization. “Unfortunately, until recently, changes in pulmonary artery pressure could only be detected during a heart cath procedure. But now, we’re testing a new device that allows pulmonary artery pressure to be checked, recorded and transmitted every day. When we see a trend that suggests a fluid overload is building up, we can take action immediately.” Rayburn, who specializes in advanced heart failure, recently implanted Birmingham’s first Cordella Heart Failure sensor that monitors pulmonary artery pressure and transmits readings in real time. “Ascension St. Vincent’s was selected to test the Cordella Heart Failure System as part of a large international research study, the Proactive-HF Clinical Trial,” Rayburn said. “Dr. Christopher DeGroat and I are the implanting physicians, and Dr. Alain Bouchard is the principal investigator in our Birmingham office. “When we see pressure changes that suggest a problem, we can act immediately to prevent further damage. Medications or dosages can be changed and combined with other interventions. We hope that by giving us the ability to respond quickly, the heart failure monitor will help us avoid the need for hospitalization and help to slow or prevent progression of the disease.” “In addition to that, because we can see daily changes in pressure, we will get an early indication of which patients are likely to respond well to a particular medication and when we may need to move on to try another option.” This allows doctors can make those change sooner, which means the patient won’t have to wait until his/her next office visit for improvements in medications.

In this catheter-based procedure, the sensor is implanted using venous access through the leg or neck and positioned just to the right of the sternum. “The procedure is usually well tolerated, even by patients with more advanced heart failure,” Rayburn said. “Another major advantage is that the sensor doesn’t require a battery or internal power. The system includes a hand-held unit about the size of a phone. Patients simply place the unit against the skin to the right of the breast bone. The unit connects with the sensor, records the reading and transmits it directly to the cardiologist’s office.” Developed by Endotronix, the Cordella Heart Failure System is undergoing what is expected to be final clinical testing before data is submitted for approval. Local investigators are hoping to complete recruitment of participants by the end of the year. “We are primarily looking for participants who might be at risk of hospitalization to treat heart failure. One of the best predictors of that risk is a previous hospital admission for the condition,” Rayburn said. If you have a patient who might be a good candidate for the trial and you are interested in learning more about it, you can talk with any of the three investigators at the Cardiology Specialists of Birmingham office on the campus of Ascension St. Vincent’s in Birmingham at 205 939-7100. Following submission of final data and FDA approval, keeping heart failure patients healthier longer should soon becomes simpler for physicians and their patients everywhere.


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Birmingham Medical News

JUNE 2022 • 5


Transparency and Communication Are Critical in Volatile Materials Market By JJ Kamholtz and Nancy Ferren

These are unprecedented times in the construction industry and even more-so in healthcare construction. The early days of the pandemic saw construction material costs soar as a record-setting building and remodeling boom hit the residential side of construction, fuJJ Kamholtz eled in part by so many people spending more time at home. The instability of those early weeks and months caused almost all commercial and healthcare projects to be put on indefinite hold while everyone waited to see how real estate and construction would shake out. Of course, the pandemic also had a great impact on healthcare itself with offices closed, elective procedures halted, social distancing in full swing, and in turn, many not seeking healthcare services whether needed or not. This constraint on physician offices and hospitals

multiple pre-pandemic healthcare projects and renovations that had been on hold, the skilled labor market recognized a near breaking point strain. In healthcare construction, the demand for materials and labor practically doubled. According to Cushman & Wakefield, the national average fit-out costs for a first-generation space are now $122 per square foot. Locally, however, we are seeing a minimum of $150 per square foot for new construction.

Nancy Ferren

caused healthcare professionals to put off decisions on making physical changes to existing facilities due to the unknown of what the “new normal” would be for healthcare. As clinics began to reopen and commercial projects started back up, the industry faced challenges of demand for materials, supply chain disruptions, skilled labor shortages, manufacturing delays, and natural disasters such as timber forest wildfires, all of which contributed to driving costs to unprecedented levels. Adding the aforementioned to

TIME, COST, AND QUALITY Prior to the pandemic, these three cornerstones of construction generally held similar weights. In 2022, it is more likely that healthcare clients will need to prioritize one over the others. For a project to be completed on time, for example, cost and quality may require extra value engineering. Scenario planning with a fully integrated team that communicates early and often is now more valuable than ever. Engineers, architects, client stakeholders, project managers, and trade

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contractors working in unison to achieve a shared purpose is of the highest importance. Transparency and communication from the earliest days of planning and design aids in setting a tone for continuous value engineering throughout the project. As issues arise, all members of this team must take responsibility to look for alternative ways to reach the end goal. Frequent sharing of creative options and what-if ideas offer greatest protection of the project’s goals and budget, becoming a strong defense against supply and/or cost issues. Sharing of recent project ideas and obstacles is of great importance to offer insight on possible delays in order to keep present projects on track and within budget. By working synergistically, identifying multiple alternatives and thinking outside of the box, a collaborative advantage emerges to tackle the challenges of a volatile marketplace opening up creative options and new possibilities. JJ Kamholtz and Nancy Ferren are with Veritas Medical Real Estate Advisors.

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Brookwood Baptist Health Primary and Specialty Care Network is proud to welcome home Dr. Joseph Sherrill. Dr. Sherrill is a practicing orthopedic and hand surgeon and is joining Dr. Robert Agee and Dr. John Young at Precision Sports Medicine & Orthopedics in Vestavia Hills, AL. He is affiliated with Brookwood Baptist Medical Center in Homewood. Dr. Sherrill is a fourth generation Alabama physician and is a third generation Alabama orthopedic surgeon. He has been in practice in Birmingham, AL since 1980, is double board certified in both orthopedic and hand surgery and is a lifetime member of the American Society for Surgery of the Hand (ASSH). He was an Associate Professor at the University of Alabama at Birmingham (UAB) and continues to serve as the Director of the Hand Surgery Fellowship program. Dr. Sherrill specializes in the surgical and nonsurgical treatment of disorders involving the elbow, forearm, wrist and hand. Dr. Sherrill utilizes comprehensive rehabilitation protocols to maximize recovery from both surgical and nonsurgical conditions.

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Birmingham Medical News

JUNE 2022 • 7

New Federal Healthcare Cybersecurity Bill Introduced, CISA Offers Cybersecurity Guidance and Tools By Beth Pitman and Tayler Chambless

Prompted by growing concerns of Russian cyberthreats on key U.S. infrastructure, the bipartisan Healthcare Cybersecurity Act of 2022 (S.3904) was introduced by U.S. Senators Jacky Rosen (D-NV) and Bill Cassidy, M.D., (R-LA) on March 23, 2022. The Act would direct the Cybersecurity and Infrastructure Security Agency (CISA) to collaborate with the Department of Health and Human Services (HHS) to improve cyber security in the healthcare and public health sector. The establishment of CISA was required by the Cybersecurity Information Sharing Act of 2015 (CISA 2015), and the proposed law does not amend CISA 2015. Instead it appears to strengthen and expand the previously mandated cybersecurity obligations of both agencies, CISA and HHS, to healthcare businesses. The increasingly malicious cyberattacks experienced by healthcare organizations in recent years have led to data breaches which have increased healthcare delivery costs and, in some instances, affected patient health outcomes. According to the proposed legislation, data reported to HHS shows that

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in “almost every month in 2020, more than 1,000,000 people were affected by data breaches at healthcare organizations.” The bill also states that cyberattacks on healthcare facilities rose by more than half in 2020 and resulted in a 16 percent increase in the average cost of recovering patient records over 2019. Similarly, data from the HHS Office of Civil Rights indicates that “health information breaches have increased since 2016, and in 2020 alone, the Department reported 663 breaches on covered entities . . . affecting more than 500 people, with over 33,000,000 total people affected by health information breaches.” The Healthcare Cybersecurity Act of 2022 would:

• Require CISA and HHS to collaborate, including by entering into an agreement to improve cybersecurity in the healthcare and public health sector, as defined by CISA. • Authorize training to healthcare providers on cybersecurity risks and ways to mitigate them. • Require CISA to conduct a detailed study on specific cybersecurity risks facing the healthcare and public health sector, including an analysis of how cybersecurity risks specifically impact healthcare organizations, an evaluation of the challenges healthcare providers face in securing updated information systems, addressing vulnerabilities in medical devices and

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• Require CISA to assess relevant cybersecurity workforce shortages and provide recommendations for how to address such shortages and issues. In early March, CISA issued a rare “Shields Up” warning regarding cybersecurity attacks, stating that “every organization – large and small – must be prepared to respond to disruptive cyber activity.” To provide quick access to resources for urgent security improvements, CISA has compiled guidance, updates, and free cybersecurity services and tools from government and industry partners on its website. CISA also maintains a Known Exploited Vulnerabilities Catalog, which identifies vendors and products with known exploited cybersecurity vulnerabilities and indicates what actions to take if an organization utilizes such vendors or products (e.g., if you use Adobe Acrobat and Reader be sure to apply pending updates per vendor instructions). As mandated by CISA 2015, HHS has implemented measures educating and incentivizing healthcare companies to implement cybersecurity practices. HHS established the 405(d) Program and Task Group which, in late 2018, issued Health Industry Cybersecurity Practices (HICP), the Office of the Chief Information Officer and the Health Sector Cybersecurity Coordination Center (HC3). Initially a voluntary guidance document, HICP was redefined as “recognized security practices” in 2021 by the Health Information Technology for Economic and Clinical Health (HITECH) Act. As a result, healthcare providers that have implemented HICP for no less than 12 months prior to the point of an OCR investigation may be entitled to a shortened period of investigation and/or reduced penalties for violations of HITECH and HIPAA. OCR now regularly requests this data as part of post-breach investigations. HHS and CISA currently provide resources specific to healthcare providers and related businesses. These resources can be found at the agency Health Sector Cybersecurity Coordination Center (HC3) and CISA, and we encourage security officers, compliance officers and directors of IT to subscribe to listserv alerts from HC3 and CISA. Subscription to receive emails is available on the homepage of each agency website. Beth Pitman is a partner with Waller where she advises healthcare systems and providers as well as healthcare IT businesses. Tayler Chambless, an associate with Waller, assists clients with healthcare operations and regulatory matters.

UAB Breaks Ground on New Inpatient Rehabilitation Facility The University of Alabama at Birmingham broke ground on its replacement inpatient rehabilitation facility on May 6th. The new building will be located on Seventh Avenue South and is slated to open in 2025. The $156.7 million, 350,000-squarefoot project will replace the existing Spain Rehabilitation Center. The building will be 11 stories tall and will hold 78 rehabilitation beds, 28 acute care beds, and state-of-the-art technology specifically designed to provide comprehensive rehabilitation care for patients from across Alabama and beyond. The new facility will include a focus on neurorehabilitation for patients following stroke, traumatic brain injury and spinal cord injury. It will also include a seizure monitoring unit that offers clinical, research and education services to patients with epilepsy. “Our current facility is about 60 years old, and although multiple renovations have been made throughout the years, this new building will allow us to maximize UAB Medicine’s com-

mitment to providing patient-centered care,” said Vu Nguyen, MD, chair of the Department of Physical Medicine and Rehabilitation in the UAB Marnix E. Heersink School of Medicine. Each floor is designed to treat specific patient populations, allowing for patients, families and care team members to remain on the same floor. This provides a seamless provision of care and maintains the proper support for physical, mental and emotional recovery. “The facility is designed with our patients in mind, so we can continue to meet the needs of our patient population as they continue to evolve,” said Selwyn Vickers, MD, dean of the UAB Heersink School of Medicine, CEO of the UAB Health System and CEO of the UAB/ Ascension St. Vincent’s Alliance. The new area is flooded with natural light and is designed to foster activities of daily living within each of its indoor and outdoor environments. There will be a garden on the top floor where patients can work on goals around mobility, cognition and range

of motion. The bottom floor will have a terrain park for patients to practice navigating different terrains, including gravel, mulch, turf, sand, wood decking, crushed stone and paving stones. There will also be a city street simulation with cross walks, curbs, sidewalk ramps and traffic lights, and an auto simulation that allows patients to learn and practice car transfer skills in the comfort and safety of a clinical setting. Patients and their families will also be able to enjoy a putting green and basketball court. Inside the space, there will be overhead lifts in each room, an open therapy gym, private therapy suites and speech therapy suites. The facility will also include family rooms on each patient

floor, a respite room featuring a patient art gallery and two outdoor terraces that offer beautiful views of Birmingham. Spain Rehabilitation Center has been named one of the U.S. News & World Report’s best hospitals for rehabilitation. The physicians in the Department of Physical Medicine and Rehabilitation lead an interdisciplinary team that includes specialists in rehabilitation nursing, rehabilitation case management, therapeutic recreation, psychology services, physical therapy, occupational therapy and speech therapy, providing comprehensive rehabilitation for patients with medically complicated conditions in need for multiple therapy interventions to improve their functional abilities.




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JUNE 2022 • 9

Eleventh Circuit Affirms Convictions Against Florida Physician, Pharmacist for Violating Anti-Kickback Statute By Jim Hoover and Jessie Bekker

Prosecutions related to the submission of claims to Tricare for compounded pain creams continue. The Eleventh Circuit Court of Appeals affirmed convictions against a Florida pharmacist, physician, and Navy veteran for their involvement in a federal kickback scheme related to prescribing compounded pain creams. Larry Howard, a pharmacist, Nicole Bramwell, MD, a physician, and Raymond Stone, a retired Navy veteran turned cream-salesman were all found guilty in a jury trial on a seven-count indictment. The three were charged with Anti-kickback Statute violations stemming from reimbursements paid by TRICARE, the federal health benefits program for military service members. Howard was also indicted on two counts of money laundering in connection to the kickback funds. While Howard and Stone were sentenced to over thirteen years and two years in

prison, respectively, a lower court sentenced Bramwell to three years of probation, including one year on house arrest. Howard, Bramwell, and Stone all appealed their convictions claiming insufficient evidence beyond a reasonable doubt that each participated in the kickback scheme. Howard also appealed the money laundering convictions by the same standard. According to the Eleventh Circuit opinion, delivered by Circuit Judge Ed Carnes, during a 14-month period be-

tween April 2014 and May 2015, Howard paid Bramwell $138,500 to write cream prescriptions to patients referred to Howard’s pharmacy by Stone. Howard paid Stone about $20,000 for his referrals. Howard’s pharmacy—Fertility Pharmacy in Winter Springs, Florida—garnered nearly $4.4 million in revenues tied almost entirely to pain cream prescriptions. TRICARE reimbursed $9,400 on average per prescription during that period—amounts so astronomical, they drove Howard to shift his aptly named Fertility Pharmacy from selling fertility drugs, to selling almost 90 percent compounded creams, according to the opinion. Howard attracted patients to his pharmacy through direct mail marketing, sending flyers to patients advertising free evaluations conducted by “Tricare Wellness,” a call center Howard created which was unaffiliated with TRICARE, but which asked questions about patients’ health and military status to determine potential interest in or need for his compounded creams. Information

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for patients who call center employees determined were TRICARE beneficiaries was recorded and delivered to Bramwell, who called patients and delivered to them cream prescriptions to be filled only at Fertility Pharmacy. She also ran a no-cost weight loss program under the “Tricare Wellness” brand, prescribing those patients the costly creams. In at least one instance, Bramwell even filled cream prescriptions for a patient’s wife, whom she had never evaluated, garnering over $131,500 in TRICARE reimbursements for three months’ worth of one couple’s cream prescriptions. In exchange, Howard paid Bramwell in fluctuating amounts that correlated with the reimbursement amounts paid by TRICARE. Over 14 months, Bramwell wrote 394 prescriptions, totaling over $3.5 million. Seven other physicians wrote the remaining compounded prescriptions during that time period. Patients also came through Fertility Pharmacy via Stone, who falsely advertised himself as a submarine veteran who (CONTINUED ON PAGE 12)

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When it comes to your health


By lynne Jeter

The task: to support neurological patients by focusing on improving their quality of life through symptom control, both physical and psychological, instead of the diagnosis and treatment of their underlying diseases. Neurologists can find updated guidance in a new Lynne Taylor, MD Kate Brizzi, MD position paper, “Clinical Guidance in Palliative Care,” which grees of acute survival, functional recovwas developed by a joint committee of ery, or chance of recurrence, according the American Academy of Neurology to the paper: (AAN), American Neurological Associa“Neurologists often cite prognostic tion and Child Neurology Society, and uncertainty as the reason they feel uncompublished March 8th in Neurology. It’s a fortable discussing decision-making with long-awaited revision to the AAN 1996 patients and families, but the literature position statement. supports that patients desire prognostic in“The revised position statement is formation even when prognosis is uncerwell-timed,” said Kate Brizzi, MD, a tain and appreciate when their physicians neurologist at Massachusetts General disclose the presence of that uncertainty. Hospital with hospice and palliative care Discussions of prognosis are critical to expertise. “In the last several years, I’ve facilitating disease understanding and emwitnessed a significant increase in trainee powering patients and surrogates in the interest in the field, and there is growing decision-making process to achieve care recognition of how a palliative care apconsistent with established goals of care.” proach can improve patient care.” When clinicians have a longstandThe position paper states that, given ing relationship with a patient, or when the high prevalence of life-altering neuwithdrawal bias is present, they run the rologic conditions, neurologists need risk of overestimating or underestimattraining in serious illness communicaing prognoses and “must remember to tion. And in this regard, 42 percent of use evidence-based estimates and explore respondents in 49 neurology residency personal biases when offering prognostic programs say they are dissatisfied with assessments,” according to the paper. their palliative care education. “The statistical language clinicians use The report states: “Necessary comis easily misinterpreted by patients and munication skills include delivering bad their families, particularly among lowernews, assessment, explaining prognosis, educated patient families.” assisting patients and families in the proEstablished strategies for decisioncess of decision-making, and setting limits making in the setting of prognostic unwhen certain types of care are objectively certainty include the best/worst case futile. The familiarity that neurologists scenarios and most likely functional outhave with these tough conversations supcomes for a particular illness. To improve ports the argument that all neurologists accuracy and flexibility, the paper sugshould attend to their patients’ palliative gests framing predictions of longevity in needs and be able to recognize when the vague time intervals rather than specific demands of the situation require assistime frames, adding that routinely adtance from palliative care specialists.” dressing goals of care “may de-stigmatize Lynne Taylor, MD, a professor at conversations around the potential for the University of Washington School of worsening illness and help patients and Medicine in Seattle and an AAN fellow, families be more prepared to make decisaid “neurologists provide palliative care sions when clinical deterioration occurs.” to people living with life-altering neuroChallenges surface when the prognologic illnesses, not just at the end of life but sis is uncertain. In that case, time-limited throughout the course of a disease, imtrials may be suggested to allow maxiproving their lives with symptom control.” mum recovery before further decisions Many neurologic illnesses such as are made. “A prolonged period of aggresstroke, postanoxic coma, traumatic brain sive life-prolonging care should not be injury, encephalitis, and demyelinating disease inherently involve unknown de(CONTINUED ON PAGE 12)





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JUNE 2022 • 11

Eleventh Circuit Affirms Convictions Against Florida Physician, Pharmacist, continued from page 10

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Birmingham Medical News

had been a Lieutenant Commander in the Navy. Stone—a Navy veteran who, at the time of his discharge, was at the second-lowest pay grade—also worked as an alkaline water machine vendor and captured the attention of TRICARE beneficiaries with the promise of a free water machine. Once hooked, Stone referred the patients to Bramwell and other physicians, who would write compounded cream prescriptions. In some instances, Stone told patients that a doctor’s prescription was required for a water system. While Stone and Howard paid for those water systems themselves, Stone received a $1,000 to $1,400 commission for every machine “gifted” to a patient. Both direct payments to Stone for patient referrals, and payments for the alkaline water machines, amounted to kickbacks found the Court. TRICARE issued a new policy in March 2015 that took effect in April 2015, limiting the reimbursements for compounded cream subscriptions. As a result of the new policy, reimbursements for compounded creams fell by 98 percent, from $480 million to $10 million. Bramwell stopped writing prescriptions for compounded creams in June 2015 and Howard stopped paying Stone. In his opinion, Judge Carnes, affirming all convictions, pointed to the above detailed facts as evidence sufficient to support convictions against Howard, Bramwell, and Stone. Judge Carnes called Bramwell “the lynchpin in the scheme that was making [Howard] wealthy,” and noted that evidence such as checks labeled “Finder Fee” and a pharmacy employee’s testimony that Stone got paid for every patient he referred offered proof of kickbacks paid and received. The Court also affirmed the money laundering con-

victions against Howard, stating his argument “necessarily fail[ed]” after affirming the kickback convictions. The Court also agreed with the government on cross-appeal that Bramwell’s three-year probation was too lenient a sentence in light of the advisory guidelines, which recommended 78 to 97 months in prison. The lower court characterized Bramwell as a victim in Howard’s scheme, noting her lack of criminal history and positive reputation in the community, and determined that sentencing Bramwell to a prison term would not serve as a deterrent to criminal behavior. Moreover, the lower court considered that imposing a felony on Bramwell would result in the permanent loss of her physician license. Considering the list of sentencing factors set forth in 18 U.S.C. § 3553(a), Carnes determined the lower court committed an abuse of discretion in its sentencing determination as to Bramwell, citing its failure to consider relevant factors, including improperly judging deterrence, giving significant weight to an improper factor, namely loss of her physician license, and committing clear error of judgment in affording significant weight to her pre-crime history and reputation as opposed to her involvement in the kickback scheme. The Court also noted the significant disparity in sentencing between Bramwell and Howard, who “played a far less important role than she did, and profited only a fraction as much.” The Court vacated Bramwell’s sentence and remanded the judgment to the district court for reasonable sentencing, which it defined only as “a non-token period of incarceration.” Jim Hoover is a partner at Burr & Forman LLP and works exclusively within the firm’s Health Care Practice Group and predominantly handles healthcare litigation matters.

New Clinical Guidance in Neuropalliative Care, continued from page 11 pursued if the surrogate is confident that this type of care would not be in line with the patient’s preferences, even if a degree of recovery is believed to be possible. “When treatments are physiologically futile, it is the clinician’s responsibility to remove the burden of decision-making entirely by explaining that such interventions will not be offered. It is counter to the principle of non-maleficence to offer such treatments, as they may cause harm in the absence of potential benefit. Futility exists in the context of all medical specialties; a specific example in the setting of neurologic disease includes cardiopulmonary resuscitation in the setting of cardiac arrest due to irreversible herniation.” The paper glosses over the role of the neurologist in “lawful physician-has-

tened death (LPHD).” Some states –and Washington, DC – now allow neurologists to approve requests for LPHD for adult patients with serious neurologic illnesses. They include California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Oregon, Vermont and Washington. Montana allows LPHD via court ruling. The authors noted an in-depth discussion of LPHD is beyond the scope of the position paper, referring readers to a 2017 AAN position statement on the topic. “I anticipate this will be an area of further discussion in the neurology and palliative care community,” Brizzi said, “as requests for hastened death are frequently encountered from patients with serious neurologic illness.”

The Financial Risks of Biologics by Jane


Made from a living organism or its products, biologics treat anything from cancer, rheumatoid arthritis, and asthma to wrinkles. They can also mean a large investment for a clinic to stock. Prolia, a biologic used to treat osteoporosis can run $2,000 per treatment. “It’s expensive and a doctor has to lay out that cost at the front end,” says Jeff Dance, MBA with Kassouf Healthcare Solutions. “That’s a risk.” As an alternative, a physician can choose the brown bag approach, in which case the patient absorbs the cost by purchasing straight through a pharmacy, only using the clinic to administer the dose. “Or physicians can refer them to an infusion center and let them take the risk,” Dance says. “In that case, there is no risk to the physician, but also no profit. That’s the zero neutral approach, but the patient still gets the care they need.” If a clinic chooses to undertake the risk of providing an expensive biologic, then some accounting pitfalls need to be heeded. “Are they willing to take the risk and have that initial cash outlay?” Dance asks. If a clinic purchases Prolia doses for patients, for example, that can mean a quick loss of $2,000 if a patient doesn’t show before the drug expires.

If the patient is scheduled too soon by the clinic between treatments, the reimbursement can be denied. “If the claim gets rejected, you eat that cost,” Dance says. “Staff has to pay attention and know what they’re doing or the practice is not getting paid.” The large expense on inventory can also make the profit/loss statement deceptive with the cash basis accounting used by most medical practices. If reimbursements get posted before the drug company invoices, physicians could perceive that entire reimbursement as profit. “So they would get inflated compensation unless they consider the expense of the drug, which is why the business managers need to alert physicians to how much expense has been reimbursed on the biologics but not invoiced,” Dance says. “Be careful of the timing of when you pay those invoices. Distributors give some nice terms of 60 to 90 days on biologics.” As an incentive, they offer early-payment discounts, which means the clinic may pay the hefty invoice before receiving reimbursement, leading to a bleaker financial picture than actually exists. Distributors also offer rebates if a practice orders over a certain amount during a quarter. “That rebate can affect your profits as well, because you’re

Jeff Dance, MBA

anticipating the rebate, but it may take 30 to 60 days as well,” Dance says. “The doctor basically finances the cost of the rebate until it arrives. It’s a carrot for the future. The practice is buying the drug at a loss to meet the volume threshold.” This means, for example, the clinic chooses to lose $200 per injection beyond the reimbursement through the quarter in expectation of the rebate in the next quarter that turns that into $100 profit per injection. “You’re carrying a loss in hopes of a little profit, so be careful from a cash standpoint,” Dance says, warning that anything may interfere with achieving that volume threshold, such as physician illness or a pandemic that shuts everything down. Dance recalls managing a practice

that had 15 days to go on the quarter and needing only 15 doses needed to reach the threshold. They decided on the $200,000 expense for that quarter in hopes of the $20,000 profit from the rebate in the next quarter. “The benefits outweighed the cost. The big question was whether or not we had enough room in the refrigerator to handle that volume,” he says. Refrigeration becomes crucial for the investment in biologics. Because they must be kept at a consistent temperature, the practice needs a reliable refrigeration source, a way to virtually monitor the refrigerator when the clinic is closed, and business policies to cover spoilage, which generally tack on a few hundred more onto to the premium. At one practice that carried biologics, the door was not shut tight on a Friday. By Monday, they had lost $20,000 in biologics. Practices just starting to offer biologics should expect about a two-quarter lag before seeing profits, and possibly longer if the time falls during the first quarter when patients are the main source of revenue as they pay off their deductibles. “It’s a significant cash outlay on the front end for biologics until things get rolling,” Dance says. “Even if you’re going through the proper steps, it’s a risk.”

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 JUNE 14 Sherrie Roberts of Lifestyle Management Remote Work A Side Effect of the Pandemic Is it Good or Bad?  JUNE 21 Ian Henyon of Birmingham Recovery Center Addiction is Mental Health  JUNE 23 Samantha Hill of Interior Elements Getting the Most from Your Workspace  JUNE 28 Tami Mayes Long of UAB Employee Assistance and Counseling Center The Connection Between Chronic Stress and Burnout  JULY 12 Andy Baer, MD of MagMutual Age-Related Cognitive Decline in Physicians TO VISIT OUR BLOG Go to and click blog on the far right column or go directly to blogpress/index.php While there, you are welcome to scroll down for past blog articles.

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Birmingham Medical News

U.S. News & World Ranks UAB Graduate Programs Near the Top The U.S. News & World Report Best Graduate School Rankings were released recently and many of the UAB graduate programs were ranked near the top. The School of Health Professions’ Master of Science in health administration remains ranked No. 1, while the school’s programs in physical therapy and operational therapy are No. 13 and No. 23, respectively. The School of Nursing is ranked No. 8 among public schools of nursing and No. 15 overall for master’s degrees. The Doctor of Nursing Practice programs ranked No. 5 in pediatric acute care, No. 6 in adult gerontology primary care and family nursing practitioner, and No. 11 in adult gerontology acute care by their respective peers. The master’s program in nursing administration ranked No. 4, while the degrees in family nursing practitioner and adult gerontology acute care were both ranked No. 7. The School of Public Health is ranked No. 19. The School of Medicine is ranked No. 26 for primary care and No. 32 for research. Three specialties — internal medicine, obstetrics and gynecology, and surgery — are ranked among the leaders in their respective fields. The data for the rankings came from statistical surveys of more than 2,150 programs and from reputation surveys sent to more than 23,200 academics and professionals, conducted in fall 2021 and early 2022.

Lavon Beard, PT, MBA

Princeton Baptist Medical Center Appoints Beard to Associate Administrator

Princeton Baptist Medical Center has named Lavon Beard, PT, MBA as its new Associate Administrator. With over 20 years of hospital experience, he has demonstrated the ability to lead diverse teams to accomplish common goals. After earning a Master’s Degree in Business Administration, followed by a second Master’s in Health Administration, both at UAB, Beard served in the UAB Physical Therapy Department for over 15 years. He joined Princeton in 2018. In his most recent role as Director of Patient Experience, he assisted clinical teams to achieve exemplary patient satisfaction scores for their departments. Additionally, he was responsible for all aspects of several departments, which included Dialysis and Endoscopy.

UAB Recognized for CAR-T Therapy The University of Alabama at Birmingham has been identified by Amitkumar Mehta, Emerging Therapy SoluMD tions (ETS) as a Program of Experience for Chimeric antigen re-

ceptor T cell therapy. CAR-T therapy is a path for T cells to fight cancer by changing them in the lab so they can find and destroy cancer cells. It is becoming an essential pillar of cancer care. “The UAB-BMT and Cell Therapy Program is the only state-of-the-art program in Alabama to offer CAR-T therapy for patients with some cancers,” said Amitkumar Mehta, MD, associate scientist in the O’Neal Comprehensive Cancer Center. “I am very proud to be part of the program.”

Keiser Joins IllumiCare Birmingham-based IllumiCare, a pioneer in point-of-care healthcare Ralph Keiser information technology (HIT), has named Ralph Keiser as Chief Strategy Officer. Keiser had been serving as a Board Advisor to the company for the past year. Prior to that, he was the Chief Executive Officer of EPSi, a division of Allscripts, until its sale to Roper Technologies in 2020. He brings 40 years of experience in HIT, having held management roles in a number of companies including Cerner, Eclipsys, Allscripts and Deloitte. IllumiCare will benefit from Keiser’s expertise as it continues to further itself as a leader in the HIT sector and expands into Life Sciences. In his new role, Keiser will be leading the development and execution of commercial strategy for 2022 and beyond. His immediate priority will be the successful launch of IllumiCare’s new clinical trial recruitment app.

Shirey Named New UAB School of Nursing Dean Following a national search, the University of AlMaria Rodriguez Shirey, PhD abama at Birmingham has named Maria Rodriguez Shirey, PhD as the new dean of the UAB School of Nursing. Shirey, who had been serving as the associate dean for Clinical and Global Partnerships at the UAB School of Nursing, succeeds Dean Doreen Harper, PhD, who is retiring after leading the Nursing School for 17 years. “Dr. Harper’s vision for the School of Nursing has brought international acclaim to UAB and its community and has produced countless nurse leaders who continue to transform health care,” said UAB Provost and Senior Vice President of Academic Affairs Pam Benoit. Shirey has been a tenured professor of nursing at UAB since 2013 and is board certified in advanced nursing executive practice and health care management. She previously chaired the school’s Department of Acute, Chronic and Continuing Care and was the founding director for the nurse-led Heart Failure Transitional Care Services for Adults Clinic at UAB Hospital. Her current roles include co-leadership of philanthropic grant processes for community-based projects in the school and interim co-director of the PAHO/ WHO Collaborating Center for International Nursing.


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New President of Medical Association of the State of Alabama Julia Boothe, MD, of Reform has begun her term as the new President of the Medical Association of the State of Alabama. Boothe is the founder of Pickens County Primary Care and Medical Provider Partner for SMART Student Health Clinics in Pickens County. She is board certified by the American Board of Family Medicine and holds the American Academy of Family Physicians Degree of Fellow, which is awarded for distinguished service and continuing medical education. “I am truly honored to lead the Medical Association as President during this important time for health care in our state. Our goal is to continue moving medicine forward, expand access to quality care for all Alabamians, and support medical professionals,” Boothe said. Boothe served the past year as President-elect of the Medical Association under President Aruna Arora, MD of Huntsville, whose term has expired. Boothe earned her Medical Degree and a Master of Public Health degree from UAB and completed her residency at the University of Alabama Family Medicine Residency Program, where she served as chief resident. She also serves as assistant professor adjunct in the Department of Medical Education at the University of Alabama School of Medicine. Julia Boothe, MD

Grandview Helps Employees Pay Down Student Loans Employees of Grandview Medical Center are now eligible for new benefits designed to help them eliminate existing student debt faster, pursue additional professional education, and advance their careers. Benefits include a new student loan repayment program that enables employees with outstanding student debt to consolidate their loans, reduce interest rates, and benefit from employer sponsored payments. For most clinical employees, Grandview will directly pay a portion of loan premiums as long as the employee remains current with payments, offsetting student loan balances up to $20,000 per employee. A new employee reimbursement program has been established for licensure or certification renewals required for all job classifications and can be used for any license or certification testing or renewal not already offered for free by the hospital. In addition, a long-standing tuition reimbursement program that provides employees up to $5,000 in tax-free reimbursement annually is being expanded and can now be used for continuing education related to any role within the hospital. Previously, employees could only use the tuition reimbursement program toward studies in their current field of work. “We appreciate our employees and

want to support and invest in them,” says Daniel McKinney, CEO for Grandview Medical Center.

New ECMO Machines at Children’s of Alabama Extracorporeal Membrane Oxygenation (ECMO) is a form of life support used in the most dire circumstances: when nothing else works. ECMO machines can support a patient’s heart and lungs, taking the blood out of the body through large IVs, giving it oxygen, removing carbon dioxide and returning it to the body. Patients who need it are desperate. Due to the critical functions ECMO machines address, it is important to have the latest technology, and with that in mind, the Children’s of Alabama ECMO program has replaced its entire eightmachine ECMO fleet with the newest ECMO equipment. Manufactured by Spectrum Medical, the new pumps offer advanced safety features and integrated technology that, among other options, allow the Children’s ECMO team to pull safety and quality reports. Children’s also has access to customer support 24 hours a day, seven days a week. It’s a significant upgrade from the program’s previous machines, which Children’s purchased in 2012. The Children’s ECMO program cares for about 50 patients each year, which is considered a high volume compared to other ECMO programs.

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