Precision Robotic S.I. Surgery Improves Outcomes
By Jane ehrhardt
“If you have a patient with a severe deformity or odd anatomy, you can actually have custom implants made now,” says John Kirchner, MD about the total talus procedure. Kirchner, an orthopedic foot and ankle specialist with Southlake Orthopaedics has performed around 400 total ankle replacements over his career and says the advancements keep coming.
Total ankle replacements began in the 1980s. But the first ones loosened easily and were abandoned. “In the early 2000s, it resurfaced with an implant that started restoring more natural anatomy, range of motion, and
By Laura Freeman
Alabama Bone And Joint Clinic neurosurgeon Winston Capel MD is pleased with the results he’s seeing with robotic S.I. joint surgery
“The S.I. joint is involved in about 75 percent of the back pain cases we see,” Capel said. “When the problem progresses to the point where conservative measures no longer bring relief, it may be time to consider surgery. The difficult part of this decision is that the chances for easing the pain and giving your patients a meaningful improvement in quality of life depends in large part on getting exactly the right placement for the implant. The anatomy can be complicated and it’s different in each patient.
preserving a mobile joint itself,” Kirchner says. However, if not set in perfectly, it resulted in loosening and subsidence, where the implant actually sinks into the bone.
But 2006 brought a breakthrough. “The way you cut the bone changed,” Kirchner says. “Instead of making just one big flat cut on the bone, we were doing angled cuts.” Then came patient-specific cut guides, and a new generation of replacements came about.
The personalized cutting blocks, based on CT scans and built-in 3D printers, are pinned in place on the patient to guide the saw blade as it cuts the bone. “You have much more pre-
“With traditional methods, you have to rely on x-rays and your own skills and experience, and hope the patient gets the good outcome you want. The implants cost around $3,000 each, so it’s something you need to get right the first time.”
Capel has found that getting it right the first time is simpler when he can do much of the more difficult work in advance using calculations from data input directly from the actual patient’s own imaging to preplan and guide the surgery.
“We explained to Brookwood Medical Center that the precision we get with robotics is becoming the standard of care for spinal surgery,” he said. “We’ve been impressed with the results we see using the Mazer surgical robot at Brookwood.
(CONTINUED
John Kirchner, MD
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Kim Chosen for Travelling Spine Fellowship
By Jane ehrhardt
Daniel Kim, MD, MSc, with Andrews Sports Medicine & Orthopaedic Center, became one of only three spine surgeons in the nation to be chosen as a Fellow in the 2024 SMISS Traveling Fellowship Program. “It’s a big honor because most of the previous fellows are typically from very prestigious fellowships and academic positions,” Kim says. “I’m humbled to be in such good company.”
The Society for Minimally Invasive Spine Surgery selects the Fellows from applicants among their more than 500 members. The immersive two-week program takes the Fellows to visit three prestigious medical institutions across the country.
“This is an opportunity to get handson experience and see how things are done at three of the leading spine facilities in the country,” says Kim, a complex and minimally invasive spine surgeon with Andrews Sports Medicine. “More importantly, this allows me to bring a national standard, if not international standard—like tip-of-the-spear type stuff—to our patients here in Birmingham.”
The travelling fellowship begins at the Hospital for Special Surgery. The
private, orthopedic-only hospital in New York City consistently ranks as the No. 1 orthopedic hospital in the United States and in the world. “People fly in from all over the world on a routine basis,” Kim says. “It’s kind of like the Mayo Clinic of orthopedics.”
Kim’s focus will be on the big picture of handling minimally invasive spine cases. “I’m looking at everything that might impact a better long-term outcome from the minute the patients enter the clinic building,” he says. “That encompasses anything from data handling to patient care to recovery procedures and staff workflows. It’s only for a few days at each place, but you get an idea from just being there.
“The next stop will be Washington University, an academic hospital in St. Louis. That’s where modern spinal deformity was revolutionized in the last few decades with Dr. Lawrence Lenke. They have a lot of thought leaders on both the neurosurgical and orthopedic side.”
Because Washington University is set among a diverse population, it will present the Fellows with different insights into producing the same top-tier outcomes as the Hospital for Special Surgery does for affluent patients. “Wash U has the re-
cord, name-brand recognition and the power to attract the top-insured population in their area, and yet it’s still an academic and tertiary care institution where they get people from all walks of life,”
Kim says.
After two days in St. Louis, the Fellows travel to Virginia Mason Franciscan Health in Seattle. “The spine program at
Virginia Mason has always been good,” Kim says. “Also, it has recently had an influx of some of the leading younger spine surgeons across the country, and they’ve been pushing the needle on value-based medicine and value spine care. The value-based focus on how to maximize outcomes and limit costs involves a new perspective on decision making and care
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Daniel Kim MD
Total Ankle Replacements Today,
continued from page 1
cise cuts,” Kirchner says. “The saw can’t twist on you easily so it can’t glance off and make a little bit of an incorrect cut.
“That precision has drastically cut surgery time. When I learned how to do this in the late 1990s, it took up to three hours for a simple ankle replacement. Now the implants are better and with the guides in position, it doesn’t take as long to get the resections done and the implants in. The surgery now takes around 45 to 60 minutes.”
Though the cuts are personalized, the implants generally come in an array of standard sizes. However, custom implants can now be made, as well. The Kinos replacement system uses 3D printers, making customization cheaper and far quicker.
The implants have not yet advanced enough to imitate all the movements of the natural ankle. “They don’t do sideto-side motion as such, but they have better mobility and longer survival than past implants,” Kirchner says.
Even the standard implants can offer better range of motion than most patients may expect. Some of that motion is a coupled inversion/eversion or swinging under/swinging out motion of the foot. “Because the cuts are more pre-
cise, you don’t take away as much of the bone, and you could actually preserve some of the natural motion from other joints that are still there,” Kirchner says.
Though they generally mitigate much of the pain suffered by patients, the implants still result in restrictions, primarily in impact activities, like running or jumping. “But most of the patients that need replacements have already altered their lifestyle because of the pain,” Kirchner says.
These newer implants generally last 12 to 15 years with good care, although even careful people can face a traumatic fall or car accident that disrupts the implant. But advances in revisions have created options. “Say you fall and your shin component has to be revised,” Kirchner says. “You can go from a standard to a custom-built implant component to compensate for the damaged bone.”
These highly customized revisions and the flexibility offered by 3D printers have opened up the possibility of total replacements to people who were previously denied the option. “Some of what couldn’t be done in the past with big bone voids or big angular changes can now be addressed,” Kirchner says. “These could be angular problems because of the way the bone healed when you had your original injury. And now we can address that more easily with the accurate placements.”
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The revisions are not so advanced yet as to change the restrictive eligibility guidelines. With the implants lasting up to 15 or so years, most patients are told to wait until their 50s or 60s. “Ankle replacements are sort of a doubleedged sword. You can’t keep replacing it, because of the bone,” says Kirchner. “Every time you replace it, you have to cut a little more bone to get a stable surface so the implant can stay on.”
Precision Robotic S.I. Surgery Improves Outcomes,
It differs from the DaVinci robot in that it’s more about advance planning to work out each move ahead of time, and then it guides you step by step through the procedure. You’re still there making the incisions and using the drill. It’s more work upfront with planning and programming, but you can double-check the details in advance, and it simplifies what you need to do on the day of the procedure.”
The response from patients has been very positive when learning that robotassisted surgery is being used to enhance the odds for success.
“It seems to give them more confidence that they are making the right decision to go ahead with the procedure. It also gives surgeons greater confidence that they will be able to make real improvements in their patient’s quality of life,” Capel said.
The criteria for deciding whether a patient is a candidate for this surgery includes confirmation testing and observation following the course of the condition.
“We try them with a lumbar injection that combines Marcaine and cortisone,” Capel said. “If the pain is relieved the first day by Marcain and by cortisone the next, that’s a positive indication that we have correctly identified the S.I. joint as the source of the problem.
“If the patient has failed to get relief from physical therapy and other conservative measures for over six months, surgery is likely the most promising next step to bring relief.”
Robotic S.I. surgery is usually done as an outpatient procedure with the patient ready for discharge by evening to recover at home.
“They go home with crutches and/ or a walker, and we follow their progress over the next four weeks. After five weeks, if they remain pain free, they can begin to
continued from page 1
return to the normal activities of everyday life,” Capel said.
Back pain is one of the most common complaints that bring patients to a doctor’s office, and it is also a frequent reason for lost work days and long-term disability claims. Because of the human ability to walk upright, putting the demands of gravity and the weight of carried objects on the lower back, the S.I. joint too often takes the brunt of pain and injury. However, work life in our modern world also puts plenty of stresses on the neck and thoracic areas of the spine. Having used the robot in a number of cases, Capel says its capabilities would also likely be well suited to other types of back surgery, though for the present, he is focusing primarily on using it for S.I. joint surgeries. About 95 percent of his work as a neurosurgeon involves surgery of the spine, but he also does cranial procedures when it’s his turn to cover on call emergencies. There are so many people living with back pain, and as of now, not many surgeons in this region are trained and adept at using the Mazer robot to ease their suffering. Winston Capel, MD is one of them.
The current alternative for ineligible candidates, no matter the reason, is to endure the pain and mobility challenges for potentially decades or get their ankle fused. That means when their age or advances in replacements makes them eligible, they still don’t qualify.
Kirchner sees that as the next challenge for the field. “You got your ankle fused in your 30s, back when we didn’t have any replacements, or got it fused after a fall,” he says. “Now you need to regain that mobile segment because other parts of your body are breaking down as the strain on backs, knees, and hips accrues over decades of compensating for a damaged ankle. We need to start thinking about patients with prior ankle fusions. What can we do with those who now need to get that motion back because of other physiologic comorbidities?”
Kim Chosen for Travelling Spine Fellowship, continued
from page 6
of spinal cases. In regards to value-based care, we need to ask ourselves how we make durable decisions for our patients, and be good stewards in terms of waste, along with applying the best practices in terms of value to the hospital or insurance company and to the patients. That’ll be interesting to see how they navigate their surgeries and their patient care with that in mind.”
While at each institution, the Fellows will not only interact with expert faculty but share cases and observe procedures.
“I’ll be learning from some of the top spine surgeons in the minimally-invasive world,” Kim says. “I want to learn how they make their surgical decisions and what enhances their outcomes in the preand post-operative phases that we’re not already utilizing in our practice; things like
different nutrition profiles or different indicators or testing we can do preoperatively to enhance outcomes.”
From the surgical observations, Kim sees benefits in simply watching how they set up their OR and what equipment they have. “I want to find any details we can add to our techniques to enhance our outcomes, and basically emulate the best,” he says.
“The value of the Fellowship won’t be about learning a procedure. We’re already performing most of the industry-leading advanced technology and technique procedures here in Birmingham, like AIassisted robotic surgeries and endoscopic spine surgeries. I’m just trying to hone and perfect the craft. I mean, the devil’s in the details of everything.”
Winston Capel, MD
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Federal Agency Deference Eliminated, Now What?
By Jim hoover
On June 28, 2024, the U.S. Supreme Court issued a decision that overrules the “Chevron doctrine.” This means that federal agencies are limited in their ability to rely on their own interpretation of the laws they administer. Under the Chevron doctrine, courts were required to uphold a federal agency’s interpretation of a statute as long as the agency’s interpretation was reasonable.
Chevron deference is a legal test that was established by the Supreme Court in the case Chevron U.S.A. Inc. v. Natural Resources Defense Council, Inc. The case was decided in 1984 and essentially held that when federal law is ambiguous, and a federal agency issues a regulation interpreting the ambiguity, courts must defer to the agency’s interpretation. Chevron deference has been integral to federal administrative law since the decision was announced. Federal courts have issued thousands of opinions relying on the deference.
The Supreme Court’s June 2024 ruling addresses two cases, Loper Bright Enterprises v. Raimondo and Relentless, Inc. v. Department of Commerce In both
cases, commercial fishing companies challenged the Department of Commerce’s rule that held fishing vessels responsible for the cost of federal observers used to monitor potential overfishing. The question at issue before the Court was limited to whether the Chevron deference should be overruled entirely or clarified.
The majority opinion held that Chevron deference is inconsistent with the Administrative Procedure Act (APA), a federal law that dictates federal agency procedure and instructs how courts can review federal agency actions. Specifically, Chief Justice Roberts stated that “agency interpretations of statutes—like agency interpretations of the Constitution—are not entitled to deference” and that under the APA it “remains the responsibility of the court to decide whether the law means what the agency says.” The Court rejected the notion that federal agencies are better equipped to determine ambiguous federal law than are courts even when the ambiguous federal law involves scientific or technical questions in which the agency has expertise. While the majority opinion made clear that courts should not defer to agency interpretation for an am-
biguous statute, courts can consider the agency’s interpretation if it falls within the agency’s purview explicitly granted by Congress.
The impact of the Supreme Court’s ruling is expected to create significant scrutiny on executive agencies such as the Department of Health and Human Services (HHS), which operates the Medicare and Medicaid programs. The likelihood of agency regulations being overturned by courts is expected to increase, and should incentivize health care providers and stakeholders to challenge undesirable agency regulations in court.
The ruling may impact the healthcare industry in numerous ways. There is a high likelihood of legal challenges to the Center for Medicare and Medicaid Services’ (CMS) statutory interpretations of ambiguous language in the Medicare and Medicaid regulations. For example, when HHS and its agencies made major changes in the past regarding prescription drugs, hospital, and physician reimbursement, or introduced new requirements for Medicare coverage, Chevron required courts to give agencies wide latitude and defer to the agency’s own interpretation. This insulated agencies from legal chal-
lenges. Now, however, providers should have greater ability to challenge HHS on reimbursement issues such as cuts to physician reimbursement, changes to outpatient and inpatient payment systems, and other billing and coding guidance. Additionally, when CMS made a determination whether or not an item or service qualified for Medicare or Medicaid coverage, courts generally gave great weight to the agencies’ understanding of their statutes. However, with the elimination of Chevron deference, providers may feel embolden to dispute coverage determinations because the courts will be the ones resolving such disputes without deferring to the agencies’ interpretation.
Another area that should see increased challenges to agency interpretation is health care fraud and abuse laws such as the Anti-Kickback Statute (AKS), Stark Law, the False Claims Act (FCA),
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Chronic Pain Management in a Value-Based Care Model
By ty thomas, md
In recent years, the Centers for Medicare & Medicaid Services (CMS) has been promoting value-based care (VBC) initiatives in an effort to improve the American healthcare system, and last year, CMS added pain management to the value-based care umbrella.
Value based care is a shift from a volume-based mindset to a value-based mindset. VBC aims to improve patient outcomes, enhance care quality, and reduce healthcare costs. We typically think of chronic disease conditions like diabetes, heart disease, COPD/asthma, obesity, kidney disease, mental health disorders, arthritis and cancer when we think of value-based programs because these are prevalent, have a large impact on quality of life, and have high costs. It makes sense then that CMS would try to tackle chronic pain from a value-based care position.
Chronic pain affects approximately 52 million Americans with a new case incidence rate of 52.4 per 1,000 persons per year. In comparison, diabetes incidence is 7.1, depression is 15.9, and heart failure is 10. Chronic pain patients utilize
healthcare often, and can cost the system upwards of $20,000 per year more than a non-chronic pain patient.
With this in mind, VBC for chronic pain makes sense and I agree with the approach. However, VBC models’ successes are anything but clear and there have been many failures. Likewise, the successes have been modest when it comes to cost savings and patient outcomes. The implementation of these programs have been complicated and labor intensive, often costing more to implement and manage than the value returned. For most primary care doctors, VBC has been a mandatory add-on required to meet quality reporting scores in order to optimize reimbursement, and not as a valuable tool to actively manage patients.
I think VBC models have been underwhelming because the programs are add-ons to doctors current existing daily patient loads. So doctors have been tasked to get annual wellness exams (AWE) on all their patients so these patients can be better risk stratified, but the tools to manage the risks are still not incorporated into a cohesive usable tool. For example, to maintain preferred status with pay-
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Ty Thomas, MD looks on as a staff member uses the system.
Chronic Pain Management in a
Value-Based Care Model,
ers, the AWE is pushed which is used by payers to maximize insurance premium revenue. However, the identification of multiple comorbidities does nothing in terms of outcomes if those risks are not actively managed by the patient and the doctor on an ongoing basis, which is a tall ask when the doctor’s workload has been added to and not augmented to accomplish this goal.
VBC has mostly been implemented via remote patient monitoring and chronic disease management programs. This has led to alert fatigue and nonmeaningful management. That requires more from the doctor who is already overloaded. This is where AI can help.
To make VBC work, we have to automate as much possible. And automating patient monitoring with built-in interventions using software and AI can be done. At my practice, we had to develop it to make it work for chronic pain management.
For us, chronic pain management is the disease management program. We spend time making the correct diagnosis, and if it’s a chronic pain syndrome like arthritis associated degenerative spinal pain (chronic low back pain), we know it’s a management goal and not a cure goal. We set up an individualized multimodal treatment program for the patient and we monitor our results closely, often daily. In this program, our patients journal in their pain diary. We track their pain scores and progress with a treatment plan involving medication, diet, exercise, meditation or other coping skills. It’s one thing to state these things in an office visit and hand out a summary to the patient, expecting them to implement this plan. In reality, patients need more guidance and support.
Many treatment programs fail because the patient didn’t understand the program, can’t afford it, or doesn’t have time. Most of the failures are due to patient noncompliance. They didn’t get their prescription filled, they haven’t been able to schedule PT due to work
continued from page 8
or child care, they just aren’t ready for a drastic diet plan change. All of these require a level of communication often not achieved in todays’ doctor office visit.
Having the program outlined with benchmarks and to-do’s, we can have the patient use our application to execute their plan. We communicate with the patient daily about how they are doing, program to-dos for the day like moving or exercise (even walk them through the specific movements), when to take medications, log any side effects like constipation, unsteadiness, and even guide them through meditation and self-coping skills. If the pain flare is bad, they have access to get in right away for a block or medication change before a trip to the ER or Urgent Care.
We tried to find this in a platform, but it didn’t exist in a way we thought it needs to be. So we developed our own. Our platform automates our multimodal plan. We know where the pitfalls are for our patients. We know what causes them to utilize other medical resources. We can build our individualized programs to intervene before our patients need to escalate care. Our platform communicates daily with our patients via personalized, individualized preprogrammed bots with defined engagement parameters, nurse monitors, and technology to read vitals, micro-expressions, and other behavior and mental health data. The result is a toolset that can be used to accomplish value-based care objectives. However, there still has to be a doctor ready to make a timely, meaningful intervention in order for that value to be realized.
I truly believe this is the future model of all medical care. It makes sense to convert our way of providing care based on actual value, something that has been missing from medicine since fee schedules took over, and started paying all doctors the same, regardless of outcome. This will replace most in-office medicine.
Ty Thomas, MD is the co-founder of Alabama Pain Physicians.
Federal Agency Deference Eliminated,
continued from page 6
and the Civil Monetary Penalties Law. Violators of these laws face civil and criminal penalties, as well as exclusion from federal healthcare programs such as Medicare and Medicaid. For years, HHS and its agencies have interpreted these statutes through the regular issuance of updated/revised regulations and guidance such as Special Fraud Alerts & Advisory Opinions. With the elimination or severe curtailing of agency deference, health care providers’ compliance and litigation strategies may change. There may be fewer enforcement actions or a reduction in settlement values due to the uncertainty about whether a court will uphold
an agency’s interpretation or disagree entirely with the agency’s interpretation and agree with the providers’ interpretation. Regulatory ambiguities will no longer be resolved by subject matter experts such as federal agencies, but by the courts and Congress. As a result, this shift in legal framework is expected to drastically increase federal litigation, with every single federal agency’s decision having the potential of being challenged in court.
Jim Hoover is a health care trial and compliance Partner at Burr & Forman LLP practicing exclusively in the firm’s health care group. Jim may be reached by telephone at (205) 458-5111 or by E-mail at jhoover@burr.com.
Information Blocking Disincentives are in Effect: What You Need to Know
By Beth neaL Pitman
This article is Part 1 of a two-part series on the information blocking disincentives for healthcare providers that took effect on Aug. 1, 2024, following publication of the final rule in July by the U.S. Department of Health and Human Services (HHS). HHS Access Initiative
Since 2000, with the implementation of the first Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules, HHS has been committed to ensuring access to healthcare and has focused on the impact that access to health records has on an individual’s quality of care.
The broad umbrella of access initiatives has included healthcare information technology (Health IT) interoperability with the 2009 introduction of the electronic medical record (EMR) Meaningful Use incentive program (through the HITECH Act) intended to encourage healthcare provider implementation of electronic health records. The Meaningful Use program was transitioned by the Centers for Medicare & Medicaid Services (CMS) to the Medicare Access and CHIP Reauthorization Act (MACRA) Merit-Based Incentive Payment System (MIPS) program, Promoting Interoper-
ability program and Affordable Care Organizations (ACO) shared savings program. The HHS Office for Civil Rights (OCR) access initiative was announced in 2019, with its aggressive enforcement activity followed by the 21st Century Cures Act (Cures Act) regulations setting interoperability standards and prohibiting information blocking practices.
As emphasized by HHS Secretary Xavier Becerra, “[w]hen health information can be appropriately accessed and exchanged, care is more coordinated and efficient, allowing the health care system to better serve patients. But we must always take the necessary actions to ensure
patient privacy and preferences are protected – and that’s exactly what this rule does.”
Interoperability and Access
The Cures Act, enacted in 2016, established provisions to promote interoperability and patient access to electronic health information (EHI). A critical component of the Cures Act is the prohibition of information blocking, which refers to practices that interfere with the access, exchange or use of EHI. The Office of the National Coordinator for Health Information Technology (ONC) issued regulations defining information blocking and establishing permissible exceptions. These regulations, effective April 5, 2021, were amended in December 2023 through the HTI-1 Rule, and HHS has proposed further amendments in the July 10, 2024 HTI-2 Rule. An enforcement structure for Health IT developers and Health Information Exchanges was finalized June 27, 2023, with enforcement against these Information Blocking Actors underway since Sept. 1, 2023.
Continuing HHS’ commitment to encourage permitted access to and exchange of EHI, the final rule specifically focuses
on establishing disincentives for healthcare providers found by the HHS Office of Inspector General (OIG) to have committed information blocking. Importantly, the Cures Act definition of healthcare providers is not limited to HIPAA-regulated providers and includes both individual providers and their group practices, hospitals or other organizations through which an individual renders services.
Finalized Disincentives
HHS has finalized three categories of disincentives applicable to healthcare providers determined by the OIG to have engaged in information blocking. These disincentives primarily target three major programs:
1. Medicare Promoting Interoperability Program
• An attestation of no information blocking is a foundational requirement for the Promoting Interoperability program.
• Under this program, eligible hospitals and critical access hospitals (CAHs) reporting Promoting Interoperability and found by OIG to have committed information blocking will be excluded
Beth Neal Pitman
F
Information Blocking Disincentives,
continued from page 1
from being considered meaningful electronic health record (EHR) users.
• This exclusion may lead to significant financial penalties, including a reduction of 75 percent of the annual market basket increase for eligible hospitals and a decrease in payment to 100 percent of reasonable costs for CAHs (from 101 percent).
• The exclusion applies to the reporting period during which the information blocking practice occurred.
2. Merit-Based Incentive Payment System (MIPS)
• Eligible clinicians and groups who are Medicare Part B providers and are determined by OIG to have engaged in information blocking will be denied the meaningful user status within MIPS. The final rule amends the MIPS definition of Meaningful User to exclude an information blocker.
• This denial will result in a zero score in the Promoting Interoperability performance category, significantly impacting the overall MIPS score and potential payment adjustments.
• Denials apply to the performance reporting period during which the information blocking practice occurred.
• Groups that are not information blockers will not be penalized for an individual clinician’s information
blocking actions, but will be required to submit MIPS reporting without the data from that individual clinician.
3. Affordable Care Organizations
• Medicare providers that are an ACO, ACO participant, or ACO provider or supplier found by OIG to have committed information blocking may be ineligible to participate in the CMS Shared Savings Program for at least one year.
• This will result in loss of revenue from the Shared Savings Program.
These finalized disincentives aim to encourage compliance with information blocking regulations and foster a culture of data sharing and interoperability in healthcare. Although enforcement disincentives became effective on Aug. 1, 2024, the ACO disincentive will not be imposed until the 2025 contracting year (Jan. 1, 2025).
Coming Up Next Month
Part 2 of Holland & Knight’s series will look at the implications for healthcare providers and best practices for consideration under the information blocking disincentive.
Neal Pitman is a partner in the Birmingham, Alabama, office of Holland & Knight.
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Despite Changes by Credit Agencies, Medical Debt is on the Rise
By Lauren Johnson
About 15 million Americans have more than $49 billion in outstanding medical debt, and a large number of those people live in the south and in lowincome communities, according to data from the Consumer Financial Protection Bureau (CFPB). The CFPB released this report a year after the three largest credit agencies stopped reporting balances under $500 in order to reduce the number of medical bills on credit reports.
While Jason Steadham, vice president of DiRecManagement, a collection agency based in Mobile, believes this was done in good faith to help people who have fallen into bad health, he’s seen negative effects since it was implemented. The patients who are struggling with greater debt didn’t experience any relief. Likewise, providers with smaller practices took a financial hit as fewer people paid their outstanding medical bills.
“While it may have been a good idea, the application of it has fallen victim to the law of unintended consequences,” Steadham said. “Some people don’t care about these small balances because they know there are no repercussions for not paying them, which hurts medical practices.
“The credit agencies also established a longer grace period, waiting one year before reporting medical debt. When the debt was on their credit, people were more likely to contact the provider or the collection agency. That started the conversation to get the insurance issues corrected before the timely filing limits fall out.”
Under today’s rules, a patient who received medical services won’t see the debt on their credit until one year later. If the patient was unaware of their bill until a year has passed, it’s typically too late for their insurance provider to pay for the medical service.
Additionally, within the past two years, the cost of living has increased which has caused a rise in bankruptcies, and this affects medical debt collections. Steadham, who’s been in the industry since 2002, has seen the correlation between the price of gas and collections.
“In the medical debt space, you’re dealing with unsecured debt. Medical collections live and die with discretionary income,” Steadham said. “As the price of gas goes up, collections go down, and vice versa.”
When the cost of living eats up more
income, people have a difficult time paying off their medical bills. Studies show that roughly 66 percent of bankruptcies are caused by medical expenses, making medical debt the leading factor for bankruptcy in the U.S. In 2024 so far, the U.S. Bankruptcy Court reported a 16 percent increase in bankruptcy, which is on top of a 16 percent increase in 2023.
“Bankruptcies are on the rise in the two years since the credit agencies stopped reporting medical debt under $500 so I would argue that this policy change hasn’t had a positive effect on people’s finances.”
Lawmakers have also proposed a new regulation that would remove all medical debt from credit reports, and Steadham is worried about the aftermath of this legislation.
“Debt collection is critical in keeping overall costs down,” Steadham said. “The higher the number of uncollectible accounts that are written off will directly affect the rates for people who have paid their bills.”
When providers are only paid for a portion of their service and still have to cover 100 percent of their expenses, they will be forced to raise their prices across the board so they can continue to practice,” Steadham said. “Healthcare costs are reduced because of the ability of the collection industry to bring in money. When the recovery rates are negatively affected, some hospitals and medical providers will start closing.
“If the consumer knows that the medical debt is not going to affect their credit score, they will likely pay another bill that will affect their credit score. We all want to see what’s best for our neighbor, but we have to remember that the provider is also our neighbor.”
Jason Steadham
Welcome Our Newest Provider
Wytch Rigger, MD
Cardiologist
Wytch Rigger, MD is a cardiologist practicing with Cardiovascular Associates and is affiliated with Brookwood Baptist Medical Center. Born and raised in Decatur, Georgia, he received a bachelor’s degree of science in biology at Ursinus College (Collegeville, PA). He earned his doctorate degree in medicine and completed his residency at the Medical College of Georgia at Augusta University. He earned his fellowship in cardiovascular disease at the University of Florida. He is board certified in internal medicine, echocardiography and nuclear cardiology and is a member of the American College of Cardiology.
Dr. Rigger specializes in the following:
• Heart failure
• Coronary artery disease
• Valvular heart disease
• Advanced cardiac imaging
• Atrial fibrillation
• Chest pain
• Cardiac-obstetrics
• Echocardiography
• Preventative cardiology
• Cardiac CT
Dr. Rigger is now accepting new patients.
Employment Contracts Can Allow Predictability in Uncertain Situations
By ansLey Franco
“With the advent of larger companies merging and acquiring smaller practices, the need to have an employment agreement in place is more important than ever,” Medovation Clinical Research CEO Helen Combs said.
An employment contract is a legally binding agreement that goes beyond the basic terms of an offer letter to cover a wide range of employment conditions and expectations. Commonly included components are a detailed job description, compensation details, confidentiality clauses and dispute resolution.
Both employees and employers may be wary of employment contracts. Still, Wallace Blizzard, partner at Wiggins, Childs, Pantazis, Fisher & Goldfarb in Birmingham, said it allows for early conversations at the beginning of a professional relationship that creates certainty for everyone.
“Typically speaking, I think the temperament of most practices is just to provide an offer letter for everyone on the team who is not a provider,” Combs said. “We’re advocating that anyone who is in a position of management or leadership should have an employment contract.”
In comparison, an offer letter includes the position title, start date, salary, basic benefits and at-will employment. “The offer letter gets you the job, but the day after, you could be fired at will without a contract,” Blizzard said.
“We just want to call attention to make sure people understand that, independent of what that letter may spell out or promise, it’s not legally binding where it will protect the employee,” CEO of Urology Clinics of North Texas Jason Biddy said.
“Like a prenup agreement, employment contracts protect both parties and allow for predictability if things don’t work professionally in the long run,” Blizzard said. “Each employment contract is different, and the structure is dictated by the company and potential employees.
“It’s best addressed from the front end when everyone is in a good mood. If you agree to this process before the employee starts work, everybody is more willing to give and compromise, and it’s easier to create this sort of certainty rather than after the fact when people get mad and threaten litigation.”
Combs said “employees who are not providers, like office administrators and front office workers, are given access to confidential information, financials and legal insight within the practice. These are not just positions that are able to be terminated easily. If there is a termination, they need to be dealt with thoughtfully, and a contract typically allows for that.”
“A company and employee should both want a contract to protect their interests,” Biddy said. “Employers benefit from the set performance metrics, noncompetes and confidentiality clauses, while employees have exit agreements spelled out ahead of time.”
“Just coming to work knowing what happens if it doesn’t work out is just a massive stress relief, and it also gives an employee that has one a little more currency,” Blizzard said.
When Biddy was on the job market himself, he would eliminate a company that did not feel an employee contract was appropriate.
Combs also had a contract in place at her previous company. “It was extremely helpful when I left my last role to be able to organize my exit both from an operational perspective and a company perspective. They could find someone to replace me, and it was clear.”
Brian Stone, MD Testifies Before Senate Committee
Walker Baptist Medical Center Medical Staff President Brian Stone, MD was recently selected to testify before United States Senate Committee on Health Education, Labor, and Pensions at a hearing that focused on strategies Congress could adopt to address the shortage of minority healthcare professionals.
Stone is also a member of the Consortium on Disparities of Urologic Conditions, an organization whose mission is to develop strategies to improve disparate outcomes in underserved populations with urologic diseases, the current
focus being prostate cancer.
Stone has been a member of the medical staff at Walker since January 2009 and is the founder of Jasper Urology Associates, which opened in 2008.
Garrett Joins Andrews Sports Medicine
Christopher Garrett, MD has joined Andrews Sports Medicine. He is an Orthopaedic Surgeon, who specializes in sports medicine, hip preservation and arthroscopic treatment of the shoulder, elbow, hip and knee. In addition, he serves as team physician for Spain Park High School.
A recent graduate of the American Sports Medicine Institute, Garrett obtained his fellow-
ship training in orthopaedic sports medicine where he received clinical and surgical training from Drs. Lyle Cain, Jeffrey Dugas and Benton Emblom.
Garrett completed his orthopaedic surgery residency at Orlando Health. He is currently accepting new patients at Andrews’ Birmingham and Hoover Highway 150 clinic locations.
Kassouf Earns National Awards
Kassouf was recently honored with three national awards recognizing both the firm’s revenue growth and culture. The awards include INSIDE Public Accounting’s Top 300 Firms, Accounting Today and Best Companies Group’s Best Firms to Work For, and COLOR Magazine and Best Companies Group’s Inclusive Workplaces.
“These honors represent excellent client service, team development, and personal effectiveness, which are building blocks of our firm vision,” said Managing Director Jonathan Kassouf, CPA, PFS.
Wallace Blizzard Helen Combs
Jason Biddy
(left to right) Senator Raphael Warnock and Brian Stone, MD.
Christopher Garrett, MD
The Kassouf team at a food bank drive.
Steve
VICE
Jason Irvin
CREATIVE DIRECTOR
Katy Barrett-Alley
CONTRIBUTING WRITERS
Jane Ehrhardt, Ashley Franco, Laura Freeman, Lynne Jeter, Marti Slay
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UAB Highlands Obtains 0.55 T Siemens Freemax Unit
UAB Highlands MRI Imaging Center has acquired a new 0.55 T Siemens Freemax Unit, a smaller, more efficient, and greener MRI machine.
UAB is one of the few leading academic institutions which has access to this advanced MRI technology, others being the University of California San Francisco and the University of Michigan. The lower cost to purchase and operate has the potential to expand MRI access to traditionally low resource areas of the state.
This cutting-edge MRI machine leverages artificial intelligence to help increase quality patient care and reduce the environmental footprint of UAB’s
imaging services. It provides high-quality imaging results with less energy and less helium, which is significant since healthcare is estimated to be responsible for up to five percent of global emissions.
Although the machine is smaller in overall size, it has a larger than average bore size of 80 centimeters, which allows more access to imaging a variety of patients and will improve access for high BMI and claustrophobic patients. The lower field strength creates less artifact from metal, creating opportunities for improved imaging of patients’ with artificial joints, hardware, and other metal implants.
The unit uses less energy with a larger than average bore size.
Alabama Healthcare Hall of Fame Inducts 13 Individuals
13 healthcare professionals were recently inducted into the Alabama Healthcare Hall of Fame.
The 2024 inductees include:
• Regina Benjamin, MD, MBA, the first African-American president of the Medical Association of Alabama and the nation’s 18th U.S. Surgeon General.
• Joan Bergman, PT, PhD established the first hospital-based physical therapy at the Crippled Children’s Clinic and Hospital and founded a physical therapy education program at UAB.
• Sumpter D. Blackmon, MD practiced medicine in Alabama’s Black Belt region and was a key figure in sustaining John Paul Jones Hospital in Camden.
• Kenneth Brewington, MD served as
vice president of medical affairs and later president of Mobile Infirmary.
• The late Elsie Jean Cowsert, MD practiced internal medicine at Providence Hospital in Mobile and worked to desegregate hospital facilities in Mobile.
• Joy Deupree, PhD, MSN, CRNP cofounded the Nurse Practitioner Alliance of Alabama.
• Will Ferniany, PhD, MSHA, who retired in 2022 as CEO of UAB Health System.
• Marnix E. Heersink, MD established numerous healthcare organizations in Dothan, and whose $100 million to the University of Alabama resulted in the naming of UAB’s Marnix E. Heersink School of Medicine.
• The late Joseph Henry Johnson, MD
established the Alabama School for the Blind and the School for the Deaf.
• Max Michael III, MD served as the dean of UAB’s School of Public Health for 16 years, longer than anyone else to date.
• Elizabeth Barker Morris, BSN, RN served as the executive director of the Alabama State Nurses Association and was instrumental in establishing the Alabama Healthcare Hall of Fame.
• Kent G. Palcanis, DDS, MSD was UAB’s associate dean of academic affairs where he restructured the dental school curriculum.
• David R. Thrasher, MD, whose work to educate the public about COIV-19 was honored by Gov. Kay Ivey and the Alabama Legislature.
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