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Contents Acknowledgements Editors Erin Stewart Ethan James

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Executive Corner

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Letter from the President

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Cover Story

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The Golden Rule GHA Chair and St. Mary's Health Care System CEO on patient care and a simple philosophy

Designers Carley Elsberry Je Sunderland Contributing writers Stacey Abrams Chuck Adams Tyra Brown Patty Gregory Brian Kemp Rhett Partin Linda Perez-Campanucci Earl Rogers Erin Stewart Je Sunderland

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Our Hospitals

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W. Daniel Barker Leadership Award Philip R. Wolfe, FACHE, Gwinnett Medical Center

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Distinguished Service Award Starr H. Purdue, Navicent Health

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Community Leadership Award Floyd Medical Center Diabetes Prevention Program

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Donated Chapel Opens its Doors WellStar North Fulton patients to benefit from new space

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Names in the News

Contact Us Georgia Hospital Association 1675 Terrell Mill Rd Marietta, GA 30067 Phone: 770-249-4500 Fax: 770-955-5801 Email: estewart@gha.org www.gha.org

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Features

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From Hospital Hero to Hospital CEO Continuing a Legacy Profile: Q&A with St. Mary's Good Samaritan Hospital President Tanya Adcock Opioids in Georgia

All rights reserved. No part of this publication may be reproduced, stored in, or introduced into a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without prior written permission. For permission requests, please contact estewart@gha.org.

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How Georgia hospitals are responding to an epidemic that kills more people than cars, guns or breast cancer each year

Building Their Cases 31 Giving Every Georgian the Opportunity to Thrive 32 Investing in Georgia's Rural Health Care System

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GHA Now

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2018 Legislative Summary Tremendous Opportunity for Rural Hospitals Georgia Communities Depends on Hospitals Georgia Hospital Association Report Indicates $49 Billion Economic Impact

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Georgia Hospitals Making a Difference Hospitals Prepare for Flu Season Pay Attention to Hospital Quality Measures New Payments for Non-Face-to-Face Services in 2019 Medicare Physician Fee Schedule Proposed Rule 2019 GHA Membership Meetings Save the Dates


Executive Corner Each year brings many changes and transitions in health care and 2018 has been no different. The opioid epidemic continues to wreak havoc on communities all over the nation. Many counties in Georgia have filed lawsuits against opioid manufacturers over damage caused by the opioid epidemic. At the hospital level, our members are implementing several strategies to combat this crisis. You can read more about their efforts, including standardizing prescribing practices and creating new policies for pain management, in this issue (page 26). Our cover story (page 4) features a profile on St. Mary’s Health Care System President Montez Carter, FACHE, who, since 1966, is only the fourth CEO of the system. You’ll see how following a simple philosophy, anchored by the respect of others, elevated him to where he is today. We are pleased that both of Georgia’s gubernatorial candidates, Stacey Abrams and Brian Kemp, submitted pieces on their health care visions (pages 31-32). Regardless of who wins the election in November, it is reassuring to know that health care and access to care are issues at the forefront of their minds. Speaking of politics, it is hard to believe we are nearing the end of 2018 and are already gearing up for the 2019 legislative session. To educate yourself on our issues and the status of bills related to those topics, I invite you to check out a summary of the 2018 session, which is included in this issue (page 33). On behalf of more than 170 Georgia hospitals, thank you for your support of these institutions and the important work they do.

To find out more about your community hospitals, please visit us at www.gha.org.

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Cover Story

St. Mary's Good Samaritan Hospital Board members and hospital staff celebrate the hospital being named Georgia's Small Hospital of the Year in 2014.

The Golden Rule GHA Chair and St. Mary’s Health Care System CEO on patient care and a simple philosophy By Erin Stewart

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Montez Carter’s first action after being appointed chair of the Georgia Hospital Association was to establish a quality committee to improve patient care in all Georgia’s hospitals. Along with GHA’s advocacy efforts on behalf of hospitals, Carter said, the committee would be a way for the Board to come together to provide even more resources in addition to hospitals’ current quality improvement efforts. “The Board is even more focused on how to improve alignment among all the hospital members with GHA,” he said. “We really want to build that partnership to decide how to make improvements in certain areas. It will also help us prioritize what initiatives GHA-member hospitals participate in.” Those who know Carter are likely familiar with his passion for quality and ensuring that patients receive the best care. It has been a driving factor throughout his career, from his first job as a clinical coordinator of pharmacy services to his current one as the president and chief executive officer of St. Mary’s Health Care System in Athens. As only the fourth CEO of the health system since 1966, Carter believes the secret to the long tenures of the health system’s past leaders is simple. “It’s the right fit in terms of both an organization that fits the personal and long-term goals of the CEOs who were here,” he says.


Having taken over the role in December 2017, it is too soon to know whether Carter will have as long a period of leading the health system as his predecessors, but his career path seems to have perfectly guided him to this role. During his first job as a clinical pharmacist at Greenwood Leflore Hospital in Greenwood, Miss., Carter gained experience on the frontlines of a patient care environment and worked with all types of staff, including medical, nursing, imaging and laboratory. “My role as a clinical pharmacist was to be part of the patient care team,” he says. “I did a lot of work with quality improvement, patient safety goals and Joint Commission accreditation. I think each of these things gave me the opportunity to gain an appreciation for working closely with patients and discerning what is best for them.” After being promoted to the director of pharmacy services at Greenwood, Carter was able to continue working closely with patients. He was also fortunate to work closely with a mentor, Jerry Adams, whom he credits with giving him opportunities to learn about all aspects of health care, from medical record coding and planning operations to environmental and dietary services. “I was able to get a full picture and understand everything it takes to care for a patient, from support services to clinical services,” said Carter. This experience and knowledge proved beneficial in all aspects of his career. By the time he was vice president of operations of St. Mary’s Health Care System, Carter was administratively responsible for several departments of the hospital, including imaging services, laboratory services, rehabilitation services, public safety, environmental services, pharmacy and emergency preparedness.

St. Mary’s Health Care System President and CEO Montez Carter

“The path my career took, going from my role as a frontline clinician to a departmental director to a vice president to my current role as president, has allowed me to really walk in the shoes of staff at every level,” he said. Understanding each role and learning how best to make patients comfortable no doubt contributes to better overall care. Another important relationship, says Carter, is the one he has with his employees. He works hard to maintain a high level of respect with his colleagues. Hearing and having empathy for his colleagues is something he takes very seriously and attributes to successfully being able to provide high quality care to patients. “I think of my granddad saying, ‘Do good, and good will follow.’ It’s very basic, but important – treat people like you want to be treated. I believe that a lot of the basic elements of leadership come down to how you treat your colleagues and people you interact with, whether they are your colleagues or patients and families. People want to be treated with dignity and respect. They want to be heard.” Working with a lot of people means working with diverse backgrounds, says Carter.

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“Providing quality health care is about using the many talents of those individuals and bringing them together in a way that is best for the patient.”

Montez Carter, Chief Nursing Officer Titus Gambrell (right), and members of St. Mary's Family Birth Center launched the annual Prevent Child Abuse Athens Pinwheels for Prevention campaign this spring.

Carter says he is best able to connect with his colleagues by learning why they are working in their current positions and hearing their thoughts on what the hospital is doing well and what it could be doing better. These discussions help him work more closely with staff who are directly involved in patient care, thus allowing him to better connect with the patient experience of the hospital. In fact, he says, his role over the years has evolved from that of taking care of patients to taking care of people who are taking care of patients.

“I always tell our staff members that they represent St. Mary’s to everyone who comes through our doors,” he said. “When our patients come in, it is at a very vulnerable time, and it’s not me they see when they check in at registration. And I’m not at the bedside, delivering medications or meals – that’s our team. That’s why I try to connect with them on a personal level – to learn how to better serve our patients by seeing if there is any way I can help our team members do their jobs better.” Carter and the health system are also looking outside the hospital to increase the supply of future physicians. St. Mary’s and the Augusta University/University of Georgia Medical Partnership established the region’s first medical residency program to increase the supply of physicians for the state. Now in its fourth year, the program is also working to keep residents in more rural areas. To help with this, the program partners with TenderCare Clinic, a federally qualified health center in Greensboro, to establish a rural medicine rotation. Residents spend one month in an ambulatory practice at TenderCare and one month at St. Mary’s Good Samaritan Hospital in Greensboro to get a feel for what is like to practice in those different settings. “Our goal is to give residents a rural medicine experience,” said Carter. “For some of them, it will be the right fit. We think that our program is unique in that it will drive residents to consider practicing in a rural community when they may not have considered it otherwise.” Like so many other hospitals in both rural and non-rural areas, St. Mary’s treats a high number of uninsured and underinsured patients. According to Carter, the way to endure this challenge while meeting the needs of those patients is balance and efficiency. “The health system must find ways to meet the growing health care needs of the community while being creative in dealing with changes in profit margins,” he said. “Service lines that have historically been profitable but are now being squeezed means we have to be creative in how we fill needs and live out our mission. It’s a balancing act. At the same time, we understand that we have to be sustainable for the future, so we’re always looking at how to be more efficient in how we deliver care.”

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With a service area of 14 counties and a mix of rural and suburban areas, St. Mary’s Health Care System and its three hospitals (St. Mary’s Sacred Heart Hospital in Lavonia; St. Mary’s Good Samaritan Hospital in Greensboro; and St. Mary’s Hospital in Athens) treat a wide range of patients. The health system handles various needs in the communities related to differences in access to care and population types. “Process improvement is important because we don’t want to sacrifice quality for cost,” Carter said. “We need to look for new and innovative ways to deliver health care.” Looking at the services provided by St. Mary’s, one can already see many innovations at work. From advanced 3D mammography to telemedicine capabilities that bring specialty care to rural areas, the health system is greatly investing in making sure it can provide the services the community needs. The health system’s neuroscience center, through a partnership with a local neurosurgeon group, has implemented a program that “has taken our stroke care to the next level and has allowed us to advance our care that rivals that of much larger communities,” said Carter. To help maintain the balance of offering advanced care while being cost efficient, St. Mary’s relies heavily on the St. Mary’s Foundation. Many times, there are services the hospital would like to provide but economically it may not make sense to because of the margin involved. “Our foundation has been vital in helping us fill those gaps to provide services that we otherwise may not be able to,” said Carter. For example, with the foundation’s help, the health system was able to purchase a biplane imaging machine for its neurovascular program. Biplane imaging is advanced technology that allows doctors to use 3D images to plan and perform noninvasive surgery. Additionally, the foundation is in the process of helping the health system purchase a second 3D mammography machine to meet the high demand of the community. Yet another example is the establishment of telemedicine in rural areas so that specialty services can be available in these communities. Perhaps the most impressive venture the foundation assisted with was the building of the new St. Mary’s Good Samaritan Hospital in Greensboro in 2012. The new hospital replaced a facility, Minnie G. Boswell Memorial Hospital, that had been built in 1949. Thanks to a thriving relationship between the hospital and community, the importance and necessity of building the new hospital was well understood. St. Mary’s Foundation and community members raised more than 18 percent of the funds needed to build the new hospital and provide high-quality services. “The hospital is very unique in terms of the quality of health care provided for a rural community,” said Carter. “The technology that the hospital has – it wouldn’t be what it is without those funds. The hospital would have been built, but the level of care would have been different.” It is clear that St. Mary’s Health Care System is having a positive impact on each of its patients and communities. As far as what the future holds, evolution is key, according to Carter. “Health care is always changing,” he said. “Our future depends on being able to evolve with that change. But, even as we adapt, we can never lose sight of delivering quality care to our patients.”

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Our Hospitals

W. Daniel Barker Leadership Award: Philip R. Wolfe, FACHE, Gwinnett Medical Center Phil Wolfe has served as president and CEO of Gwinnett Medical Center (GMC) since 2006. During his tenure, he has helped the hospital achieve significant milestones in terms of its growth and increased involvement in the community. The hospital’s outreach in the field of sports medicine is just one illustration of this development. In 2013, to better treat concussion injuries and provide more comprehensive sports rehabilitation, GMC opened the Concussion Institute. Just three years later, in 2016, GMC enhanced its care of children and young adults when it added pediatric services to its ImPACT (Internal Medicine Pre-operative Assessment Consultation and Treatment) testing, which GMC began offering in 2002. Pediatric patients would now be able to take advantage of the technology, which is a computerized neurocognitive assessment tool to help health care providers evaluate and manage concussions. To elevate and extend access to sports medicine care and ensure compliance with Georgia Code, Wolfe helped orchestrate an agreement between GMC and Gwinnett County Public Schools (GCPS) to provide sports medicine services. The agreement includes 19 traditional high schools and approximately 19,000 student athletes. GMC continued its expansion of concussion treatment when it unveiled a Care-A-Van in 2017, a mobile unit that includes a concussion education and baseline testing center, as well a full-service athletic training room equipped to provide a full range of care for sports-related injuries. Throughout his leadership of GMC, Wolfe has recognized that providing quality care to the community is dependent on the hospital having enough staff to meet demands. Through his past involvement as a board member with Gwinnett Technical College (GTC), Wolfe not only helped ensure the quality education of future health care workers, but he also addressed the workforce shortage. He played an instrumental role in the creation of GTC’s Life Sciences Center, which provides the region’s most advance life and health sciences educational programming and facilities. Additionally, GMC relies on the talented graduates of GTC to grow its workforce and continue to provide care to the community.

From L-R: GHA President Earl Rogers, Gwinnett Medical Center's Philip Wolfe, and 2018 GHA Chair Montez Carter.

In 2014, Wolfe and his leadership team established residency programs at GMC as another way to alleviate the workforce shortage and keep medical graduates in Georgia. This year, the hospital graduated its first full class of family and internal medicine residents. Thanks to the success of the program, it has received support from the Governor’s office, the Board of Regents and the Physicians Shortage Task force.

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Our Hospitals

Distinguished Service Award: Starr H. Purdue, Navicent Health Starr Purdue has served on the Navicent Health Board of Directors since 2001 and has served as its chair since 2009. During her tenure as chair, she has been instrumental in leading Navicent Health’s growth and prominence throughout the central and south Georgia region. Under her guidance, the health system has received many regional and national awards, and recognition in the areas of leadership, quality, equityof care, and community and citizenship endeavors. Purdue, a Macon native, has helped advance health care services for patients in central and south Georgia by helping the health system expand services and enhance its facilities and technology.

From L-R: GHA President Earl Rogers, Navicent Health's Starr Purdue, and 2018 GHA Chair Montez Carter.

Her commitment to improving lives is evident in the development and improvement of high-quality health services offered by Navicent Health. She helped cultivate the development of several services and programs, including pediatric services through the construction of the new Beverly Knight Olson Children’s Hospital, Navicent Health and its associated pediatric emergency room; the creation of Autism and Dvelopmental Center, Navicent Health; the construction of and consolidation of oncology services at Peyton Anderson Cancer Center, Navicent Health; the addition of a heliport at The Medical Center, Navicent Health; and the construction of an inpatient hospice facility at Pine Pointe, Navicent Health. Purdue’s focus on relationships with community partners has fostered a collaboration between Navicent Health and hospitals in surrounding counties. These beneficial partnerships have helped expand access to care beyond the Macon area and the walls of Navicent Health so that patients in these areas can remain close to home for high quality care. Under Purdue’s leadership, Navicent Health developed several programs to address health disparities in the community andsocial determinants that may otherwise impede the ability to access care. Healthy Communities, Navicent Health is a program that partners with public and private organizations to address social factors that lead to poor health. MedLaw, Navicent Health is a team of legal, social and medical workers who provide free legal services to qualified patients. The expansion of primary care and preventive services in low-income neighborhoods has been made possible through a partnership with the health system and community health centers. Purdue has championed these efforts and has been a key player in uniting the health system with area partners.

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Our Hospitals

GHA presented the Community Leadership Award to Floyd Medical Center for helping individuals with prediabetes and diabetes have access to programs to improve their health.

Community Leadership Award: Floyd Medical Center Diabetes Prevention Program To address the prevalence of diabetes in the community, Floyd Medical Center’s education and corporate health departments joined together to offer diabetes screenings around the community to identify individuals at risk of developing diabetes. Those who met the criteria for prediabetes were then offered free participation in the Centers for Disease Control and Prevention’s (CDC) Diabetes Prevention Program (DPP). This program, recently implemented at Floyd, is a partnership of public and private organizations working to make it easier for those with prediabetes to have access to evidence-based, affordable, lifestyle change programs to reduce their risk of Type 2 diabetes. Another way Floyd is actively combating diabetes is its participation in a Department of Public Health (DPH) pilot project, CATAPULT. This new health care model consists of eight components (Commit to participating; Assess your practice or system; Train or be trained; Activate; Create a plan of action; Promote understanding; Leverage data systems; and Test and implement) and its goal is to reduce hospitalizations by 2020 for 1) Type 2 diabetes by 25 percent and 2) hypertension by 10 percent. As part of its involvement in this initiative, Floyd staff received DPP training to begin to provide diabetes education classes to its employees as well as the community. To further enhance diabetes education in the community, the hospital’s diabetes education department began offering a series of outpatient classes. Recognized by the American Diabetes Association, the classes provide diabetes self-management materials to ensure that diabetic patients can take control of their health. As additional support, the hospital also sponsors a diabetes support group in which members can discuss their issues and learn from each other.

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Our Hospitals

New Chapel Opens its Doors WellStar North Fulton patients to benefit from donated chapel By Linda Perez-Campanucci

WellStar North Fulton Hospital has a new interfaith chapel thanks to donations from the WellStar Foundation and WellStar team members. The chapel, located on the first floor near the main lobby, serves as a peaceful location for prayer and meditation that is easily accessible by hospital patients, visitors and team members. Last year, WellStar North Fulton team members donated $23,000 through the WellStar Foundation’s Team Member Giving program and in Fall 2017, the WellStar Foundation Board of Trustees allocated $75,000 to fully fund the project. Furniture and artwork were generously donated by DeKalb Office Solutions. WellStar North Fulton’s Patient and Family Advisory Council (PFAC) was also instrumental in the planning of the chapel.

The new chapel at WellStar North Fulton Hospital offers patients and their loved ones a peaceful space for spiritual healing. The hospital chapel was made possible by donations to the WellStar Foundation.

“The generosity of WellStar team members is inspiring to me both as a member of this community and the WellStar Foundation Board,” said Carole Kell, WellStar Foundation Board of Trustees Chair. “It’s because of their dedication, as well as the support of thousands of individuals who believe in the power of philanthropy, that we were able to fully fund this meaningful project. The chapel at WellStar North Fulton Hospital will be a safe space for everyone in the hospital to decompress and heal – the impact it will have on those who find comfort in it is immeasurable.” In addition to the chapel, WellStar North Fulton recently welcomed The Reverend David Anthony Spencer, Jr. as the new full time Chaplain at the hospital.

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Our Hospitals

Names in the News January Navicent Health CEO Dr. Ninfa M. Saunders, FACHE was named to Becker’s Hospital Review’s annual list of “130 Women Hospital and Health System Leaders to Know.” Tift Regional Health System CEO William “Bill” Richardson retired after almost 30 years of serving as CEO and more than 40 years in health care. Archbold Medical Center and Redmond Regional Medical Center were presented the inaugural Donate Life Hospital Award from LifeLink of Georgia at GHA’s Patient Safety and Quality Summit.

February Cartersville Medical Center CEO Keith Sandlin, FACHE, retired after 32 years of serving as CEO and more than 40 years in health care.

Jason Smith was named the chief operations officer at Piedmont Athens Regional Medical Center. Clinch Memorial Hospital partnered with Coffee Regional Medical Center to strengthen the delivery and quality of health care for patients in Homerville and Clinch County.

Piedmont Columbus Regional earned the Joint March Commission’s Gold Seal of Approval® and the J. Christopher Mosley began his role as the chief American Heart Association/American Stroke executive officer of Cartersville Medical Center. Association’s Heart-Check mark for Advanced Certification for Primary Stroke Centers. Columbus Regional Health became Piedmont Columbus Regional after announcing a Navicent Health partnered with Charlottecollaboration with Piedmont Healthcare. based Atrium Health to enhance access, affordability and equity of care in central and South Georgia Medical Center opened a hybrid south Georgia. operating room. Colquitt Regional Medical Center opened the Edwards Cancer Center.

Eastside Medical Center opened a new heart and vascular clinic.

Sudhakar Jonnalagadda, M.D., was named president of the medical staff at Coffee Regional Medical Center.

Phoebe Putney Health System’s Sleep Program earned accreditation status by the Accreditation Commission for Health Care.

St. Francis Hospital earned its chest pain center accreditation from the American College of Cardiology.

WellStar Cobb Hospital became the first hospital in the state of Georgia to receive the Excellence in Spiritual Care Award from the HealthCare Chaplaincy Network.

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Piedmont Rockdale Hospital earned its chest pain center accreditation from the American College of Cardiology. Chris Dorman began his role as the chief executive officer of Tift Regional Health System. WellStar Kennestone Hospital Interim President Mary Chatman was officially named the hospital’s president and senior vice president. South Georgia Medical Center was recognized by the March of Dimes and the American College of Obstetricians and Gynecologists for reducing early elective deliveries.

April Piedmont Healthcare completed the purchase of Clearview Regional Medical Center, renaming it Piedmont Walton Hospital. A $15 million donation from the Marcus Foundation enabled the creation of the Marcus Stroke Network, a collaboration among Grady Health System, Emory University School of Medicine, Boca Raton Regional Hospital and the American Heart Association/American Stroke Association. The network targets stroke disability and death rates in the Southeast. WellStar Health System opened an outpatient surgery center at its Vinings Health Park. Southern Regional Medical Center was awarded a $10,000 grant from Huggies to establish a No Baby Unhugged program, which is part of Huggies’ mission to support hospitals, nurses and newborns in NICUs.

Piedmont Columbus Regional and Children’s Healthcare of Atlanta announced a formal affiliation agreement with a goal of better serving children and families in the Columbus area. Shepherd Center Chair James Shepherd, Shepherd Center Co-Founders Alana Shepherd and Harold Shepherd and WellStar Health System CEO Candice Saunders were named Most Influential Georgians by JAMES Magazine.

May Eastside Medical Center opened a new hybrid operating suite and electrophysiology lab. Evans Memorial Hospital commemorated its 50th year. Floyd Medical Center, Piedmont Henry Hospital, Piedmont Columbus Regional and Redmond Regional Medical Center received the Get with the Guidelines-Stroke Gold Plus Quality Achievement Award. St. Mary’s Hospital received the Get with the Guidelines Resuscitation Gold Award. Piedmont Rockdale named Jeff Cole, M.D., as its chief medical officer.

June WellStar Cobb Hospital celebrated its 50th anniversary. Doctors Hospital of Augusta earned a Level II trauma center designation from the American College of Surgeons. Previously, the hospital had been a Level III trauma center for four years.

Phoebe Putney Health System named its medical director of neonatology, Dr. Jack Owens, as chief WellStar Cobb Hospital named Callie Andrews quality officer. its president. Andrews had previously served as the hospital’s COO. Piedmont Atlanta, Piedmont Henry, Piedmont Fayette, Piedmont Mountainside and Piedmont Newnan achieved certification for the first time to the Insurance Service Office (ISO) 9001: 2015 Quality Management System.

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Piedmont Newnan Hospital received the Get with the Guidelines-Stroke Gold Plus Quality Achievement Award.

Navicent Health received the American Hospital Association’s 2018 Equity of Care Award.

The Georgia Department of Public Health designated Effingham Health System as one of 12 Remote Stroke Treatment Centers in Georgia.

Optim Health System named David W. Perry as chief executive officer.

August

September Navicent Health Baldwin named Todd Dixon its chief executive officer. Northside Hospital Healthcare System Chief Executive Officer Robert Quattrocchi was named a Top CEO in the Glassdoor Employees’ Choice Award, ranking no. 32 on a list of 100 CEOs in the United States. Cartersville Medical Center received a Level III trauma center designation from the Georgia Department of Public Health. South Georgia Medical Center received the Get with the Guidelines Resuscitation Gold Award.

July Polk Medical Center Chief Nursing Officer Tifani Kinard was named administrator of the hospital while continuing to serve as its CNO. Fairview Park Hospital named Dr. George Eric Harrison as chief medical officer.

DeKalb Medical and Emory Healthcare finalized a strategic partnership, making DeKalb part of the Emory Healthcare system. Karen O’Neal was named interim chief executive officer of Candler County Hospital. Doctors Hospital of Augusta celebrated the 40th anniversary of the Joseph M. Still Burn Center.

October The WellStar Breast Health Continuum of Care at WellStar Kennestone Hospital received its second consecutive American College of Surgeons’ National Accreditation Program for Breast Centers Accreditation. Colquitt Regional Medical Center Chief Executive Officer James L. Matney was appointed to the Center for Rural Prosperity by Gov. Nathan Deal. Memorial Health University Medical Center earned a place in the American Heart Association roster of hospitals recognized for achievement in the Get With The Guidelines - Heart Failure healthcare quality program.

Member of GHA? Did you know the Daily News Clips and GHA This Week are available to all employees of GHA member hospitals? If you would like to receive them, contact Erin Stewart, estewart@gha.org. 14

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Features

From Hospital Hero to Hospital CEO By Jeff Sunderland

While attending Howard University, Adriene Kinnaird received an invitation that changed her life. Kinnaird, now CEO of Select Medical Specialty HospitalMidtown Atlanta, had the pleasure of meeting Professor Mattie Tabron, Ed.D., while studying political science with the hope of becoming a lawyer. Dr. Tabron gave her a tour of the radiation oncology department. “I instantly fell in love [with health care] after speaking with some of the patients who were fighting for their lives,” said Kinnaird. But that wasn’t the only influence her professor had on her career development. She arranged for Kinnaird to be an intern for the CEO of Howard Hospital. “I knew then that I wanted to work clinically helping others, but eventually I wanted to work on the administrative side of things, where I could have even greater impact by making decisions that would affect patient outcomes,” added Kinnaird. Dr. Tabron may have introduced Kinnaird to health care, but it was meeting a 25-year-old patient that kept her in the industry. The patient had been born with a cancer, known as Wilms tumor, that begins in the kidneys. “The one thing that keeps me in health care through the many changes and challenges is a promise I made to one of my patients who was 25 years old and dying from bi-lateral breast cancer after having a Wilms tumor as a baby,” added Kinnaird. “The promise was that I would always give back to others, especially those sick and in need.” That kind of relationship with patients helped her garner one of the state’s most prestigious health care awards. In 2005, she was honored as one of the very first recipients of the prestigious Georgia Hospital Association Hospital Hero Awards. The award recognizes the amazing hospital workers in Georgia who go the extra mile to improve lives. “My general philosophy for life has been to provide extraordinary service to all mankind. Therefore, to be honored was unexpected, yet appreciated,” said Kinnaird, who won the award while working at Atlanta Medical Center. “It is difficult to explain all the emotions associated with this honor. I can simply say it was one honor I will never forget.” Now, years later, after working in various health care positions in several different states, she was thrust into her first official chief executive officer role.

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“First and foremost, I love what I do. Leading a team that is dedicated to improving the quality of life for critically ill patients is a privilege and honor,” said Kinnaird. “Select Specialty Hospital-Midtown Atlanta is one of nearly 100 critical illness recovery hospitals operated by Select Medical in the U.S. We are deeply committed to delivering an exceptional patient experience. This means we are always striving to set the standard for quality, safety, best practices and innovation. This pledge of excellence for our patients, their families and each other is what makes Select Medical such a great place to work.”

The Kinnaird File 1. What is the best advice you have received in your career? There is no limit! 2. What are the keys to your success? Always have someone willing to provide an honest assessment and feedback. 3. Do you have any advice for people aspiring to be a CEO? You can be the CEO in any role. Stay in the learning mode, accept tasks that others may not want to do and continue to build relationships. Stay focused on what you want by building blocks along the way with the ultimate goal of being CEO. 4. What are your hobbies? Sewing, golf and shopping. 5. Anything personal you would like to say? After more than 30 years in the health care arena and with the many changes that have occurred, I still remain enthusiastic about the future of health care and the continued transition toward care for all in need.

BE MORE. DO MORE. Don’t let regulatory or reimbursement challenges impede your health system’s success. AGG’s team of multifaceted healthcare attorneys works with hospitals to keep a pulse on what the law demands and prescribes the right course of action.

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Features

Newly renovated patient room at Roosevelt Warm Springs Rehabilitation and Specialty Hospitals.

Continuing a Legacy By Erin Stewart Before Franklin Delano Roosevelt made history with the institution of the New Deal and even before he was the governor of New York, the nation’s 32nd president was diagnosed with polio. At the age of 39, he sought relief from a number of symptoms, including facial paralysis, bowel and bladder dysfunction, numbness, and paralysis below the waist. In the early 1920s, the owner of a resort in Georgia enticed him to come experience the earth’s natural pools in Warm Springs. The high mineral content in the water was rumored to have healing powers and reportedly provided Roosevelt the solace he had so desperately sought. According to biographer Hugh Gregory Gallagher, in these pools, Roosevelt could walk, exercise his legs and reap the benefits of hydrotherapy, a type of alternative physiotherapy that uses water for pain relief and treatment. “Losing the ability to walk is difficult for anyone, but to lose it later in life at that age is especially difficult,” said David Mork, chief executive officer of Roosevelt Warm Springs Rehabilitation and Specialty Hospitals (RWSH). “So, for him to be able to get that exercise, I can only imagine the relief he felt.” Roosevelt continued to visit Warm Springs through the years and is said to have made 41 trips in all. Many of these visits occurred during his term as governor of New York (1929-1932) and later during his four terms as President, the first of which began in 1933. By using the warm springs, “his confidence grew, and he developed a lot of respect for the warm springs pools,” said Mork.

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In fact, Roosevelt was so intrigued with the potential benefits of hydrotherapy that he purchased the property in 1926, and, the following year, established the Georgia Warm Springs Foundation, converting the property into a hospital and a prominent polio treatment center. Many polio patients followed in Roosevelt’s path, seeking treatment there and continued to do so after his death in 1945. Since the polio vaccine was discovered in 1954, the hospital transitioned to treating patients with post-polio symptoms and those with spinal cord injuries, strokes and other disabilities. In the mid-1970s, the State of Georgia took over operations of the Foundation hospital and turned it into a medical rehabilitation facility.

David Mork and Dr. Matt Roosevelt (FDR's greatgrandson) with key staff members at Roosevelt Warm Springs Rehabilitation and Specialty Hospitals.

Over the years, the hospital was challenged financially and struggled to stay viable. By 2013, there were discussions about closing the doors. This meant that patients who needed this type of rehabilitation or long-term care would have to travel to Atlanta, a long distance for many families. Working with the state to create a better solution, Augusta University Health was tapped to take over operations. “We visited the site and worked with state officials,” said Mork. “As we really got to know the place, it was evident how much of an impact the hospital has in the community of Warm Springs and how important it is. We knew we couldn’t let it close. That would have been a terrible shame.” In 2014, AU Health officially took over operations, and the next year helped secure legislative funding to assist with $25.8 million in renovations to the hospitals on the historic campus. In 2017, the revitalization project was completed. Improvements were made to about 90,000 square feet of health care space, resulting in a new state-of-the-art imaging suite for radiology, increased bed capacity, and private rooms that will accommodate as many as 16 patients on ventilators. In addition, a beautiful, welcoming main entrance and patient drop-off area was constructed at the front of the building and an advanced rehabilitation center was opened. “There’s just something about it, the hospital that Roosevelt built,” said Mork. “We all felt that way, and everyone figured out how we could make it work.” “We’re now self-sufficient,” he continued, referring to the fact that when the hospital was state-run, it was supported by tax dollars. “We generate revenues that support us onsite, so it’s a win for everybody.”

“Teaching the next generation of caregivers is a part of Roosevelt's legacy I think he'd be proud of.” David Mork, CEO Roosevelt Warm Springs Rehabilitation and Specialty Hospitals twentyfourseven Fall 2018

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For more than eight decades, Roosevelt Warm Springs has provided a comprehensive, individualized style to medical rehabilitation for patients, enabling them to return to the most independent lifestyle possible in their homes and communities. Conditions most commonly treated in Roosevelt Warm Springs Rehabilitation Hospital include stroke, brain and spinal cord injuries and neuromuscular diseases. As many as 340 patients undergo rehabilitation in Warm Springs each year. About 160 patients are admitted to Roosevelt Warm Springs Long-Term Acute Care Hospitals. These patients usually have a need for ventilator weaning or have complex conditions or illnesses involving their respiratory system, cardiovascular/ peripheral vascular system, infectious diseases, or complex wounds and require a level of care comparative to an ICU.

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Patients in various stages of recovery come to the hospital for treatment. The historic pools that Roosevelt and former patients used are now part of a public museum, but the springs are no longer part of the main hospital campus. “These days, you don’t see many rehabilitation facilities with pools,” said Mork. “Treatment has changed, so it’s not as practical, especially with the one-on-one care that is required.”

David Mork, chief executive officer of Roosevelt Warm Springs Rehabilitation and Specialty Hospitals

The rehabilitation side of the hospital treats patients who have rehabilitation needs but who may also have other issues, requiring care 24 hours a day. Patients on the long-term acute care (LTAC) side have a longer average length of stay, about 25 days. Once they become stronger and meet certain criteria, they may be transferred to the rehabilitation hospital. Patients suffer from difficult conditions brought on either by accidents or medical conditions. “There is a spirit of compassion and healing here,” said Sonal Nakrani, director of professional services for RWSH. “Patients who come here can heal not only their bodies, but also their minds.” Healing of the mind is something the hospital takes very seriously. In addition to providing 24/7, one-on-one care for patients’ physical recovery, Mork says the rural setting is a big part of a patient’s total recovery. “For the patients, as much as for their families, it’s a whole different feel for them when they come here,” he said. “We have the same types of doctors, nurses and therapists as what you would find in an urban setting, but it’s a little more relaxed. I think the laid-back setting certainly plays an important role in patients’ recovery.” One of the biggest challenges the hospital faces, according to Mork, is staffing. But there are a couple of things working in the hospital’s favor. For one, “our relaxed rural setting can be a big draw for potential doctors and nurses,” said Nakrani.


Another is the hospital’s robust teaching program. More than 85 students from the Augusta University College of Nursing, Medical College of Georgia and College of Allied Health Sciences participate in long-term acute care and rehabilitation training each year at Warm Springs. They gain valuable experience through hands-on care in the hospital. “By training more rehabilitation nurses and physicians, we are ensuring that we can keep providing this important care to this community and surrounding areas,” said Mork. “Teaching the next generation of caregivers is another part of Roosevelt’s legacy that I think he’d be proud of.” When Roosevelt’s great-grandson, Dr. Matt Roosevelt, recently traveled from San Diego to visit Warm Springs, Mork and the hospital staff had the opportunity to demonstrate how the Roosevelt legacy is being established today through the work of AU Health and the new leadership at RWSH. During his visit, Dr. Roosevelt, who is the only physician on the Roosevelt Warm Springs Foundation Board, met with current and former patients, as well as several of the health sciences students. Shortly after the visit, the Roosevelt Warm Springs Foundation committed $62,000 to help refurbish a historic cottage for student housing and assist in the purchase of special equipment for patient swallowing studies. “The visit was great because it allowed us to strengthen our longstanding connection with the Roosevelts,” said Mork. That connection and the legacy the hospital lives by is something that will take the hospital into the future. The hospital’s goal, says Mork, is to expand its ability to take more patients. One thing is certain – Mork feels like he is in the right place at the right time.


Features

Profile: Q&A with St. Mary’s Good Samaritan Hospital President Tanya Adcock In 2011, Tanya Adcock was honored as a Georgia Hospital Association (GHA) Hospital Hero for performing CPR on and ultimately helping to save the life of a man who had a heart attack at a tractor pull competition deep in the countryside south of Greensboro. At the time a palliative care coordinator for St. Mary’s Hospital in Athens, the Oconee County native was known for her brilliant patient care and willingness to go the extra mile to help patients and staff. Seven years later, her career has come full circle, as she now serves as the president of St. Mary’s Good Samaritan Hospital in Greensboro. twentyfourseven staff talked with her about her new role. twentyfourseven: What made you want to work in health care? Tanya Adcock: I always wanted to be a nurse. I know that’s probably a very cliché statement, but it’s true. All through middle and high school, I knew exactly what I wanted to do, which was to help people. I wanted to be a labor and delivery nurse, so that’s what I did for the first 12 years of my career. twentyfourseven: What have you learned throughout your career that has helped you in your role as president? TA: Don [McKenna, former CEO of St. Mary’s Health Care System] was very specific in making sure that everyone knew that St. Mary’s wasn’t looking for someone to fill the shoes of Montez [Carter, GHA Chair, past president of St. Mary’s Good Samaritan Hospital and current St. Mary’s Health Care System CEO.] They were looking for a president – someone who could lead the hospital well and continue the positive results that resulted from Montez’s leadership. With my background in nursing and palliative care, I know what it is like to work on the frontlines of health care. Now, in this non-clinical role, I feel like I appreciate those staff members more because I’ve been where they have been and know what they are going through. I’ve carried out that work myself. So, I feel like I have a different level of respect from my team because I’m not asking them to do anything I wouldn’t do myself. Another thing is, during times when we’re really busy, I can go out and help staff. For me, the most important thing is not to forget where I came from.

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twentyfourseven: Have there been any situations where you have thought, “I’m really glad I’m a nurse”? TA: Yes, on a daily basis! I think if I would allow myself to, I would be out with the patients every day, but I have to remind myself that’s what the team is there for. As president of the hospital, my primary obligation is to provide an environment where that team can thrive. I need to make sure they have the resources to provide the best patient care possible. But occasionally there are days where my nursing background comes in handy. Like when our emergency room is busy, when they need to get patients upstairs to a floor, I will push a bed upstairs. We all work together. twentyfourseven: Have you received any advice in your career that you apply regularly? TA: I think the best advice that I’ve ever received is just to stay humble and stay true to yourself. No matter what your position is or what your title is, stay humble and don’t forget where you came from. twentyfourseven: How do you connect with your staff? TA: I listen to them. And you know, listening doesn’t always mean that you’re going to give them the answer they want. But I really try to truly listen to what their needs are and what their perceived needs are. Above everything, I really try to be present with them because for me that’s very important. There are days that I have to stay in my office all day, because I have obligations I have to meet. But it’s very important for me to be out and rounding and to be present with them. twentyfourseven: What do you do to connect with the community? What is the hospital doing? TA: Greene County is probably the most engaged community that I have ever seen. They take pride in the hospital and we fully welcome and invite their engagement. We have an incredibly active Board of Directors, Foundation Board, and Auxiliary. The community is amazing at communicating what they need and working with us to make it happen. We have services at Good Samaritan that are very rare in rural hospitals. That’s because we’re part of St. Mary’s Health Care System and because the community provides tremendous support that makes it possible for us to go above and beyond the norm for a small, critical access hospital. They are very proud of their community hospital and have a lot invested in it. twentyfourseven: What are some of the services the hospital provides? TA: We are able to provide 3D mammography. We also have the REACH telemedicine equipment [which allows the diagnosis and treatment of stroke patients from anywhere, at any time through a computer and webcam] so it helps with early intervention for patients who are having a stroke. Thanks to the generosity of our community, we also offer high-speed CT and nuclear medicine services. We also provide total knee and total hip replacement surgeries. We have orthopedic surgeons coming here to do those total joint surgeries. Patients don’t have to travel as far for care. That’s our goal, for patients to be able to be treated locally. The beauty in being part of St. Mary’s Health Care System is that if patients have needs greater than what we can provide, we can transfer them to the flagship St. Mary’s campus in Athens.

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twentyfourseven: Are there any new initiatives that the hospital is focused on? TA: We are in the process of implementing an additional telemedicine system in the hospital called InTouch, and the first area of specialty that we’re going to focus on is cardiology. Patients can stay local in the community and have a cardiology consult via telemedicine with our cardiology group, Oconee Heart & Vascular Center (OHVC), which is located in Athens. For the hospitalists to have access to a cardiology consult through telemedicine is going to be another huge benefit to the Greene County community. In addition, one of OHVC’s founders, Dr. John Layher, will be coming in November to operate a full-time cardiology satellite office here in Greene County. That’s very exciting and almost unheard of for a community our size. twentyfourseven: What are your other goals personally and for the hospital? TA: My other goal personally, is just to get established in the position I’m in and to take Good Samaritan to the next level. It is a hospital that has done great for five years but we face more and more health care challenges every day. So we’re going to have to come up with more innovative ways to provide medicine in a rural setting. We have to take what Montez did such a phenomenal job already establishing, and just continue to build on that. My roots are very deep; I’m from Oconee County. So I’m not someone who is looking to move around to advance my career in health care outside of the St. Mary’s family. That’s not to say that I don’t want to continue to grow. In the St. Mary’s family, in addition to becoming the President of Good Samaritan, you become a member of the senior leadership team, which really is an honor to be a part of that team at the executive level. twentyfourseven: You mentioned the health care struggles that all hospitals are facing. How do you deal with the high rates of underinsured and uninsured patients? TA: Being part of St. Mary’s Health Care System, we’re very mission-driven. So we do have a lot of charity care, a lot of indigent care. We are very blessed at Good Samaritan to have our own foundation and they have an unbelievable commitment to the hospital and the community that we serve. There are a lot of things we would not be able to do if not for being part of the health system and having the foundation. Philanthropy is crucial in health care these days, especially in a rural setting. Philanthropy is one of the ways that we’re able to add all these service lines that other providers wouldn’t be able to. twentyfourseven: Are there any specific initiatives that the Foundation has done or does annually that helps the hospital? TA: If it weren’t for philanthropy, we would not have our 3D mammography. We also do a service every October where we provide free mammogram screenings to women who could not get a screening otherwise because of insurance. Out of the 32 free mammograms, we did identify one lady who had breast cancer. And without us having that 3D mammography machine, and the ability to provide those free mammograms, the likelihood of that early detection would not have happened. Also the telemedicine, the InTouch system that we’re getting ready to implement, we’re able to do that because of the foundation. And the community had a huge part in raising the funds to build the new hospital.

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Features

Opioids in Georgia How Georgia hospitals are responding to an epidemic that kills more people than cars, guns or breast cancer each year By Patty Gregory The summer of 2017 brought a wave of overdoses to Central Georgia, where there was an outbreak from fake pain pills. Of the approximately 30 overdoses, five deaths were associated with the pills. According to Dr. Chris Hendry, chief operating officer of clinical enterprise systems for Navicent Health in Macon, “It affects all demographics and socioeconomic levels,’’ he said. “It doesn’t just affect metropolitan areas.” More than 15 of those overdose cases were treated at The Medical Center, Navicent Health’s emergency center (EC) within 48 hours, and their care, Hendry said, cost hundreds of thousands of dollars. The yellow pills were identified as containing two synthetic opioids, cyclopropyl fentanyl and U-47700. “Our EC was used to managing the routine, ever-growing number of overdoses, but we’d never seen that kind of cluster of overdoses until then,” said Hendry. Now, he says, it’s leveled off to the “usual cadence of overdoses.” The usual cadence of overdoses is a depressing, yet ubiquitous scenario in emergency departments (ED) around Georgia. According to Atlanta-based health care consulting firm Alliant Quality, from 2009 to 2014, Georgia led the nation in the rate of increase in the number of patient encounters related to opioids. Alliant Quality’s Michael Crooks, PharmD, says that prescriptions for drugs such as fentanyl, methadone and hydrocodone increased 300 percent nationwide since the early 1990s. Those prescriptions are fueling this epidemic. University of Georgia pharmacy professor Henry Young says the opioid epidemic hasn’t unfolded in the same way as other drug-related tragedies. Typically, a person’s initial exposure happens when a doctor prescribes the opioids in a legitimate medical situation. However, a friend or family member is the most likely source and the least likely source is dealers or strangers, even in cases where people are using painkillers for some reason outside of what they’ve been prescribed for. Approximately 80 miles south of Macon in Thomasville, Ga., Archbold Medical Center has created an Opioid Council and implemented a new educational process for their physicians.

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“We are working with our medical staff to standardize the prescribing practices and patient management to minimize the risk of opioid dependency and adverse outcomes,” says Chris Newman, vice president of ancillary services at Archbold. “From a pharmacy standpoint, we are focusing on prevention of overutilization and the use of the Prescription Drug Monitoring Program to monitor high-risk patients.” Recent legislation strengthened the Georgia Prescription Drug Monitoring Program (PDMP), an electronic database used to monitor the prescribing and dispensing of controlled substances. The goals of the PDMP are to help eliminate duplicative prescribing and overprescribing of controlled substances; provide a prescriber or pharmacist with critical information regarding a patient’s controlled-substance prescription history; and protect patients at risk of abuse. The team at Archbold is hopeful the program will help address the opioid issue in this state like it has in many others. “The implementation of a PDMP has proven to help other states track controlled substance prescriptions,” said Coy Irvin, M.D., Chief Medical Officer at Archbold. “The program provides health authorities information about prescribing and patient behaviors that may contribute to the epidemic.” Phoebe Putney Health System Medical Director for Emergency Services James Black, M.D., says now providers will be required to enroll in a PDMP; however, when one drug source gets stricter, abusers will find easier ways to get them. “We’ve actually seen people circling our parking lot, looking to see which physicians are working in the ED to help them determine if there’s someone new who could prescribe opioids. They come in not telling us what hurts; instead, they ask directly for pain medicine. If they don’t get it here, they go to the next stop. Patients with these kinds of behaviors are willing to travel.” Black, who treats patients at both of Phoebe’s emergency departments in the Albany area, helps lead efforts to coordinate with other hospitals in the region and uses outreach and education to prevent patients from gaming the system. And he’s encouraged. “They [the other hospitals] have all been willing to share their strategy openly,” says Black. “That kind of transparency among providers is helping us to be better coordinated, which is important because we have to be on the same page if we have any chance of keeping up with the addicts.” Phoebe Putney has established a special committee to create systemwide policies for pain management and to determine how the hospital manages short- and long-term pain. The new policies used to be suggestions, but they are now part of the health system’s employment agreement. “There’s been a big swing in the pendulum in how we address acute pain and how much pain medicine may be necessary,” Black says. “It involves a lot of education, not only in the community, but in the health care industry as well.” Data from the Centers for Disease Control and Prevention (CDC) shows deaths related to prescription opioids are still rising; however, they are not rising nearly as rapidly as deaths related to street drugs fentanyl and heroin. That is evident in downtown Atlanta, where street drugs are still the majority of what Grady Health System’s Chief of Emergency Medicine Dr. Hany Atallah sees when it comes to overdoses.

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Atallah says he has seen a 15 to 20 percent increase in the number of heroin patients in the ED over his 15 years at Grady. “The opioid crisis is a significant burden on the ED beyond even the overdose issue,” says Atallah. “We are seeing people come in with health issues related to long-term drug use depending on whatever type of drug they’ve been using.”

Hospitalizations related to opioid use and misuse in Georgia have skyrocketed, from about 302,000 in 2002 to 520,000 in 2012, an increase of 72 percent in 10 years. The cost of opioid-related inpatient care more than doubled from 2002 to 2012, rising to more than $15 billion in Georgia alone. In 2017, Navicent Health saw 128 cases of overdoserelated admissions with a total health cost impact of $1.6 million.

According to Atallah, of the 3,000 patients who come through the Grady ED each week, 10 to 12 percent have a drug-related issue. Grady is one of just a few hospitals in the country to have specially trained staff in the ED who try to connect patients with a community-based program for substance abuse issues. They also established an opioid treatment clinic approximately a year ago at their outpatient behavioral health center that treats patients with a combination of counseling and the nonhabit-forming medication Suboxone. Additionally, Grady EMS providers carry NARCAN, also known as naloxone hydrochloride, and find themselves distributing it more and more frequently. According to a recent white paper on the heroin epidemic by the Georgia Prevention Project, more than 1,300 Georgians die each year from prescription opioid and heroin overdoses. Many of these deaths could be avoided with the use of naloxone, the antidote that reverses opioid overdose without significant negative side effects. The U.S. loses someone every 12½ minutes to an opioid overdose with more than half of those overdoses happening at home. In April, the U.S. Surgeon General issued a public health advisory recommending that first responders, parents, and educators have easy access to naloxone, as well as training in how to administer the drug. Georgia had already ensured its residents had this access when, in January 2017, the Department of Public Health issued a standing order to allow “eligible persons” (family members, friends, co-workers) to obtain naloxone over-the-counter from pharmacies and undergo training, as well as become familiar with the signs and symptoms of an opioid overdose. When the cluster of overdoses happened in the summer of 2017, Navicent Health initiated public service announcements and got involved in legislative efforts backing the PDMP, a huge step, according to Hendry. During that cluster, they ended up working with several state and county agencies to get the word out about what was going on, a collaboration Hendry says really “lit a fire.” “The way we approach pain consults and general pain control while in the hospital setting is changing,” Hendry says. “We’ve created an opioid stewardship committee chaired by a leading physician expert on addiction and a nurse practitioner with significant expertise around pain management. They’re looking at standardizing our order sets around best evidence-based care guidelines with a huge emphasis on non-narcotic pharmaceutical regimens and non-pharmaceutical pain management.”

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Additionally, Navicent Health is developing a physician opioid-use dashboard in order to track how much physicians are prescribing. The Macon health system is also part of a statewide collaborative where hospitals from Georgia and beyond share what they’re doing to educate physicians around prescribing, as well as resources available when they identify patients with an addiction issue. Collaboration just may be the tourniquet needed to help abate this epidemic. Expanded prescriber education and prescription oversight from the hospital all the way to statewide level are seemingly helping to turn the tide. According to a report by the Institute for Human Data Science, total opioid prescriptions filled in the U.S. decreased by 12 percent from 2016 to 2017. Georgia experienced a decline of more than five percent. It’s movement in the right direction for, hopefully, some respite from the “usual cadence of overdoses.” GHA’s participation in efforts to combat the crisis include participation in State Attorney General Chris Carr’s Opioid Task Force and advocating for legislation that helps address the crisis. “We’ve been actively involved in the various bills that have moved through the legislative process at the state level, including measures to increase accessibility to naloxone,” said GHA vice president of government relations Anna Adams. “This is a drug that can reverse the effects of an opioid overdose, and we’ve already seen numerous benefits from its use.” Another bill contained legislation that requires prescribers to check the PDMP database prior to writing a prescription for opioids or benzodiazepines, “which will better help providers monitor use of opioids and hopefully highlight any misuse,” said Adams.

your community counts on you. you can count on us. By taking on work for our hospital clients, we helped them increase patient collections by 6 percent in 2017.* No wonder we’ve become the most selected vendor among community hospitals.† | FREE UP Learn more at athenahealth.com/georgia

* athenaNet data, 2017 † “US Hospital EMR Market Share Report,” May 2018. © 2018 KLAS Enterprises, LLC. All rights reserved. www.KLASresearch.com

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Features

Building Their Cases

GHA invited Georgia’s gubernatorial candidates to write about health care policy and their visions for what the future holds as we move into a new generation of state leaders. On the following pages, you can read about their plans for the future of health care in our state.

Stacey Abrams, Democratic Nominee for Governor www.staceyabrams.com

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Brian Kemp, Republican Nominee for Governor www.kempforgovernor.com


Giving Every Georgian the Opportunity to Thrive By Stacey Abrams Every Georgian deserves the freedom and opportunity to thrive, but access to quality, affordable health care keeps too many from succeeding—and surviving. While campaigning, I met a woman named Jo, who knows firsthand how a lack of health care can stop Georgians from living prosperous lives. When Jo had a severe heart attack seven years ago, the health insurance she received through her employer saved her life. But when she retired, Jo’s coverage dissolved, and she could not afford the immense out-of-pocket costs. Thankfully, Jo’s doctor was gracious enough to continue caring for her, despite her inability to pay. But there are millions of Georgians without that option. Vulnerable populations, such as children and those who need mental health services, are in distress because Republican leaders in Georgia have failed to deal with our state’s health care challenges head on. This is why one of my first actions as Governor will be expanding Medicaid in Georgia. It’s a moral and economic imperative for our state. Georgia has lost at least seven rural hospitals in recent years. Not only does this impact patients who have to travel further to obtain care, but it also means job losses for the medical professionals who were once employed by these hospitals. No one should have to leave the place they love to receive vital services or obtain a job. As an attorney who specialized in health care finance, I understand the vital role that Medicaid expansion would play in improving both Georgia’s health infrastructure and economy. Medicaid expansion will draw $3 billion per year into our state. That’s $8 million per day to pay for Georgia’s doctors, nurses, and hospitals. It will also create 56,000 jobs—60 percent of which will be outside Metro Atlanta. And that only scratches the surface of the benefits of expansion. Our state has one of the highest maternal mortality rates in the nation and more than half of Georgia’s counties do not have an OB-GYN provider. We must work to ensure better outcomes for mothers and their babies, and this starts by giving them access to high-quality care. As governor, I will leverage state and federal programs to incentivize more doctors and medical personnel to take jobs in underserved areas, and I will work with practitioners to reduce our maternal and infant mortality rates. Mental health services are also an important part of our health care system. Though these services often go underfunded and undervalued, I know firsthand how important it is for individuals to get the mental health services they need. Growing up in a working poor family, we lacked health insurance and reserved doctor’s visits for serious illnesses only. As a result, my brother Walter went undiagnosed for bipolar disorder, which led to him self-medicating with drugs and eventually being incarcerated. Georgia deserves a governor who is committed to underserved communities and understands that mental health needs must be addressed by the health care system, and not the criminal justice system. Together, we have the ability to build a stronger, brighter Georgia where everyone has the opportunity to thrive. To achieve this, we must be willing to step boldly into our future and ensure that all Georgians have access to quality health care. We must make this vision a reality for the millions of Georgians who are ready for change for themselves and their families.

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Investing in Georgia’s Rural Health Care System By Brian Kemp Over the last decade, eight rural hospitals have closed their doors – unable to make ends meet due to a variety of factors: substantial amounts of uncompensated care, an inability to recruit providers, or just a general lack of services that can be profitable for a health system. As a former hospital board member, myself, I know firsthand what it takes to keep a hospital’s doors open – and as Governor, I will take this experience and apply it to efforts to mitigate the crisis that rural Georgia faces. In 2016 and, subsequently, in 2017, the General Assembly took a tremendous step forward in saving Georgia’s ailing rural hospitals from financial peril and closure. The Rural Hospital Tax Credit – championed by my good friend and Lieutenant Governor nominee Geoff Duncan – was the first meaningful investment that the state made in rural Georgia’s health system in decades. Since that tax credit was put in place – and with some tweaks – countless hospitals have been able to reap the benefits of community benefactors and corporations. Hospitals are able to use this funding to make financial decisions that will directly benefit their hospital – paying off short and long-term debt, financing new treatment modalities, or bringing in experts to identify efficiencies. We know this program works – despite some who seek to eliminate it. Our ticket is committed to expanding this program from its current cap of $60 million to $100 million to ensure that every rural hospital has the ability to access funds to ensure operations and keep small-town Georgia thriving. The state cannot stop there. With a growing economy, we need to continue to invest in other means to ensure Georgia’s rural health care ecosystem, and this starts with provider recruitment. Access to care is at the top of mind and I speak to countless Georgians who drive an hour or more to see their primary care physicians, or pregnant families who have to traverse multiple county lines to visit their OB-GYNs. We can, and must, do more to create better access to care. Georgia has 79 counties without an OB-GYN, nine without a primary care physician, and 64 without a pediatrician. As Governor, I plan to seek out ways to incentivize students in our medical schools to practice in rural Georgia through enhanced loan forgiveness programs for practicing in rural areas. I will prioritize the investment with OB-GYNs and pediatricians because without families settling in rural Georgia, there is no hope for the future. We must also make sure there is an appropriate regulatory framework and infrastructure for telemedicine to exist where it becomes impractical for specialists and others to travel to consult. Georgia’s electric cooperatives are best suited for providing the infrastructure – and I look forward to working with the legislature to tackle rural broadband as it is critical to health care access in rural Georgia. In my time as Secretary of State – and again through this campaign – I visited all 159 counties. I have sat with families struggling to make ends meet, met with businesses looking for ways to keep their doors open, and toured hospitals on the verge of closure. Rural Georgia is in the midst of a crisis, but I firmly believe that, under our “New Day in Rural Georgia” platform, rural Georgia’s brightest days are ahead.

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GHA Now

2018 Legislative Summary During the 2018 Legislative Session, GHA advocated on behalf of our more than 170 members on important issues such as preserving the Certificate of Need (CON) process, rural issues, distracted driving, access to care, and insurance. Certificate of Need GHA continued to advocate for no erosion of the CON process and successfully defended against 13 pieces of legislation introduced to deteriorate the state health-planning process. Georgia’s CON program helps to contain the costs of care by preventing over-utilization and unnecessary duplication of services; ensures the continuation of the high-quality care that hospitals provide to all patients by balancing profitable and unprofitable services; and protects access to care for the indigent, uninsured and Medicaid populations by discouraging unfair competition from facilities that serve few, if any, such patients in need. Rural Issues Rural hospitals throughout Georgia continue to be at a crossroads between providing care and ensuring fiscal sustainability. With high demand in the emergency department, insufficient compensation, limited access to physicians, and patient populations with higher percentages of health disparities, rural hospitals struggle to keep their doors open. GHA supported House Bill 769, which was the culmination of work completed in 2017 by the House Rural Development Council. HB 769 creates a new CON exemption for micro hospitals located in rural counties and also includes language to increase the Rural Hospital Tax Credit to 100 percent and make S-Corps eligible donors. Distracted Driving For many years, Georgia continued to see significant increases in vehicle crashes, fatalities and bodily injury. The vast majority of those increases have been rear-end crashes, single-car crashes and crashes by drivers ranging from 15 to 25-years-old. State and local law enforcement have stated that these incidents are a clear indication of driver inattention. The 15 states that have passed hands-free driving laws saw a 16 percent decrease in traffic fatalities in the two years after the law was enacted. In addition, traffic fatalities were reduced even further in subsequent years. GHA supported House Bill 673, also known as the “Hands-Free Law,” which was passed by the Georgia General Assembly and signed into law by Governor Nathan Deal and took effect on July 1, 2018. Insurance GHA continued to advocate for hospitals on insurance and reimbursement issues, including surprise billing legislation. Surprise billing typically occurs when a patient receives services at an in-network hospital, ambulatory surgery center or other health care facility from a physician that is out-of-network. If the physician doesn’t have a contract with the insurer, the insurer pays the physician an amount less than what is billed and the physician sends the patient a bill for the outstanding balance. GHA opposed House Bill 799, which creates certain requirements for out-of-network hospitals prior to post-stabilization care, namely a provision requiring hospitals to notify the health plan when an out-of-network patient arrives in the emergency department and before administering any post-stabilization care. GHA supported House Bill 519, which would establish certain clinical review criteria for step therapy protocols. Specifically, it would require that insurers offer coverage of certain lifesaving drugs to patients without forcing them to first try a less expensive drug and have it fail. None of these bills passed and we expect to see them again in 2019.

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GHA Now

Tremendous Opportunity for Rural Hospitals By Chuck Adams Many of us never think of a hospital until we need one. But when a family member or friend has a medical issue, we expect high-quality, affordable care close to home. Access to care has become difficult for many communities with the unfortunate closure of seven rural hospitals since early 2013. This represents a loss of almost 10 percent of all rural hospitals in Georgia. These closures, coupled with the fact that many others have had to reduce services, mean many patients must travel great distances to receive care. Losing even more of our rural facilities would be detrimental to the state of Georgia. Thankfully, our lawmakers realize the importance of hospitals in a community and went to work to help make Georgia a leader in rural health care. During the 2016 General Assembly, the state legislature passed the Rural Hospital Tax Credit Program, which has provided a remarkable opportunity for Georgia’s rural hospitals. Legislative improvements made in 2018 such as making the tax credit equal to the amount donated resulted in the program being an overwhelming success for hospitals and taxpayers. Millions of dollars have been donated to our hospitals, helping them provide better access to care, make important infrastructure upgrades, and improve facilities that will directly benefit the hospitals. The hospital tax program is a win-win for hospitals as well as the patients they serve. The program awards state income tax credits to individuals and corporate taxpayers who contribute to the 58 qualified rural hospital organizations (RHO) in Georgia. According to Georgia HEART (Helping Enhance Access to Rural Treatment), from 2018 through 2021, Georgia taxpayers can access a maximum of $60 million of RHO tax credits each year. The General Assembly placed limits on individuals and corporations to ensure that as many Georgians as possible could support rural hospitals. The 2018 cap was met within days of the legislative effective date, illustrating the fact that communities all over Georgia recognize the importance of rural hospitals and the care they provide. More than 90 percent of all donations came from individuals. Because of the tax credit’s popularity, hospitals and services like Georgia HEART will begin accepting applications for 2019 credits as early as October 1.

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It is no secret that hospitals are important to their communities. Beyond caring for the sick and injured, in many regions, hospitals are the largest employer. This is especially true in rural areas. The latest Georgia Hospital Association Economic Impact Report indicates our hospitals have made a $49 billion impact on the economy, with rural hospitals accounting for over $5.5 billion of the total. Rural hospitals provide almost 30,000 full time jobs and support almost 70,000 jobs in their respective communities. The Georgia Hospital Association encourages all Georgians and corporations to consider donating in 2019 to receive this tax credit. Please contact your local hospital or www. georgiaheart.org to find out how you can support these vital community resources. Charles T. Adams, FACHE is executive vice president of the Georgia Hospital Association.

Colquitt Regional Medical Center in Moultrie is one of many rural hospitals in the state of Georgia to benefit from the Rural Hospital Tax Credit.

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Georgia Communities Depend on Hospitals Georgia Hospital Association Report Indicates $49 Billion Economic Impact By Earl Rogers

Each day, thousands of individuals pass by one of Georgia’s nearly 200 hospitals. Many of us may not think about hospitals until we, or people we know, require emergency care, surgery, outpatient treatment, or one of many other hospital services. For most of us, hospitals exist “just-in-case.” “We may not clearly see how hospitals benefit us when we are not using them for healing purposes. But think about where we live, work and play. Thriving communities are a result of strong economies,” said Montez Carter, 2018 chair of the Georgia Hospital Association (GHA) and chief executive officer of St. Mary’s Health Care System in Athens. What does this have to do with hospitals? Hospitals greatly contribute to the economic health of their communities by generating billions of dollars for the economy every year. Examine the impact of Georgia hospitals on local and state economic activity and you will find that they benefit just about all of us, whether directly or indirectly. Aside from impressive statistics, like the delivery of more than 120,000 babies and having nearly 5.3 million emergency room visits in 2016, Georgia hospitals also contributed $49 billion to local and state economies in the same year, according to the most recent economic impact report by GHA.

“A hospital is more than just a place to treat patients. It helps communities thrive.” Montez Carter 2018 GHA Chair

“A hospital is more than just a place to treat patients. It helps communities thrive. Hospitals are important to communities’ economic, social and overall well-being,” said Carter. Hospitals are immensely advantageous to the local and state economy. In 2016, hospitals spent more than $21.7 billion to operate. These expenditures generated an estimated $49 billion in state and local economic activity, which translates to $2.40 for every $1 of hospital expenditures. A majority of hospital revenue is spent on wages and salaries. In fact, hospitals are a major source of jobs for their communities. In 2016, hospitals directly provided more than 150,500 full-time jobs.

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When an employment multiplier is applied to this number, it indicates that hospitals supported more than 366,000 full-time jobs in the state. The employment multiplier considers the “ripple effect” of direct hospital expenditures on the economy, such as medical supplies; durable medical equipment and pharmaceuticals; and retail establishments that depend on the hospital and its employees for business. The GHA economic impact report also measures hospitals’ direct economic contributions to Georgia’s working families. Using a household earnings multiplier, the report determined that hospitals generate more than $19.1 billion in household earnings in the state. The household earnings multiplier measures the increased economic contributions from individuals employed directly or indirectly by hospitals through daily living expenditures. Despite their economic contributions, Georgia hospitals continue to face financial challenges. Georgia residents who are uninsured or underinsured and unable to pay hospital bills continue to add to the uncompensated care problem hospitals, both rural and non-rural, face. In 2016, Georgia hospitals absorbed more than $1.8 billion in costs for care that was provided but not paid for. In the same year, Georgia’s uninsured rate was 12 percent, the third highest in the nation. Only Texas and Alaska had higher uninsured rates, at 15 percent and 14 percent respectively. Additionally, Medicaid pays Georgia hospitals only about 87 percent of actual costs, meaning hospitals lose 13 cents on every dollar spent treating a Medicaid recipient. Unfortunately, many hospitals have been forced to close due to dire fiscal strain. Since 2012, nine Georgia hospitals have closed and others, especially those in rural areas, are fighting to keep their doors open. The most recent Georgia Department of Community Health Hospital Financial Survey shows that, in 2016: • 40 percent of all hospitals in Georgia had negative total margins; and • 63 percent of rural hospitals in the state lost money in the same year. “When hospitals continually lose funds, it creates an intense financial strain that only worsens year after year,” said Carter. “As we have seen over the past few years, eventually, hospitals have no choice but to close when they cannot recoup lost funds. Then, access to care becomes a larger issue.” Uncompensated care is not the only ongoing challenge hospitals encounter. Physician shortages and access to care are very real problems in rural communities. This is where a healthy economy greatly helps. When a community’s economy is healthy, it becomes more appealing to physicians, as well as attractive to new businesses and infrastructures.

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“Hospitals are addressing the workforce shortage by increasing the amount of medical school residents through additional graduate medical education (GME) programs,” said Carter. Currently, 16 hospitals have GME programs, one of which is at a rural hospital. “Homegrown” physician programs are working to attract doctors to the rural communities in which they were raised and educated. Medical schools all over the country have established incentives and efforts to attract medical students back to their hometowns to practice. According to Augusta University, the implementation of dedicated rural admissions tracks have helped increase graduates in rural medicine. The programs recruit students from rural and underserved areas in order to return those students back to those areas. By addressing the workforce shortage, hospitals can make sure they keep their doors open and continue to be financial assets to their communities. The closure of a hospital not only means an increased lack of access to care, but also may mean fewer dollars going into the community, which can jeopardize the livelihood of residents and businesses. “All over the state, hospitals are doing everything they can to stay viable to ensure their stability as well as remain economically beneficial,” said Carter. “Their contributions to local and state economies ensure the fiscal and social health of their communities.”

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Georgia Hospitals Making a Difference By Tyra Brown According to the Georgia Department of Public Health (DPH), more than 800,000 Georgians are living with diabetes and 450,000 Georgians have prediabetes. The diabetes and prediabetes incident rates are expected to only get worse, with the diabetes population projected to grow by more than 32 percent over the next five years. What can hospitals do to help stop this trend? A recent review of community health needs assessments completed in Georgia reveals that more than half of health systems are concentrating on diabetes as a focused community initiative. Health systems in Georgia are being recruited to either implement the National Diabetes Prevention Program or start a Diabetes Self- Management Education and Support program within their organizations. These programs motivate individuals to make lifestyle changes to reduce the progression to Type 2 Diabetes and to build the self-management skills necessary for reducing complications related to diabetes. The Georgia Hospital Association Research and Education Foundation (GHAREF) is partnering with the Georgia DPH to decrease the Georgia diabetes incidence rate. Why these specific programs? The National Diabetes Prevention Program (DPP) promotes lifestyle changes that help to delay or prevent the onset of Type 2 Diabetes. DPP is a program led by the Centers for Disease Control and Prevention (CDC) that brings evidence-based lifestyle change programs to local communities. The 22, one-hour sessions during the year educate patients about diabetes and provide the opportunity for peer-to-peer learning. Under the guidance of a certified lifestyle coach, participants discuss healthy eating choices, increasing physical activity, coping skills, stress management and problem-solving. The Georgia DPH Chronic Disease Prevention section is aiming to provide lifestyle coach scholarships to individuals working with organizations interested in implementing DPP. Lifestyle coaches are required to attend a training with a CDC-recognized entity before they can facilitate the program. The Georgia DPH works with Emory University’s Diabetes Training and Technical Assistance Center to provide a three-day course to its partners.

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Floyd Medical Center and Tanner Medical Center are the only two facilities in Georgia to receive the full recognition for the DPP. The hospitals were recognized at the 2018 GHA Annual Summer Meeting. “This designation is reserved for programs that have effectively delivered a quality, evidence-based program that meets all of the standards for CDC recognition,” stated Ann Albright, Ph.D., RDN director of the division of diabetes translation for the CDC. “The sustained success of the lifestyle change program makes an invaluable contribution to the prevention of Type 2 Diabetes, both in the community and nationally.” Several health systems and hospital are working toward achieving their full recognition status, including: • Emory Healthcare • Kaiser Permanente • Northeast Georgia Medical Center • Phoebe Putney Health System • Piedmont Columbus Midtown The DPP is an evidence-based intervention grounded in research funded by the National Institutes of Health that showed, among those with prediabetes, a 58 percent reduction in the number of new cases of diabetes overall, and a 71 percent reduction in new cases for those over age 60. Once the health system receives full recognition as a DPP, it may become a Medicare Diabetes Prevention Program (MDPP) supplier. MDPP suppliers earn performance-based payments through the Centers for Medicare and Medicaid Services (CMS) claims system. Medicare payments to hospitals can be up to $670 per beneficiary over two years, depending on beneficiaries’ attendance and weight loss. What does this mean for beneficiaries? As of April 1, 2018, eligible beneficiaries have coverage of MDPP services with no cost sharing through Medicare-enrolled MDPP suppliers. The Diabetes Self-Management Education and Support (DSMES) program assists participants in achieving better blood glucose control by self-managing their diabetes through knowledge, skill and life choices. The DSMES program teaches seven self-management behaviors: • Healthy eating: Making healthy food choices and learning about portion sizes • Being active: Incorporating daily physical activity to improve overall health and blood glucose control • Monitoring blood glucose: Daily monitoring to control blood glucose and lower complication risks • Problem-solving: Making daily activity changes to regulate glucose levels • Taking medications as prescribed: Effective drug therapy to reduce the risk of complications and elevated blood glucose levels • Coping in a healthy way: Understanding the lifestyle changes needed to manage diabetes • Reducing risks of developing complications: Risk reduction behavior to reduce the risk of diabetes

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The Diabetes Self-Management Education and Support participants who implement the seven self-management behavior changes have a greater chance of controlling their diabetes. Research shows that diabetes intervention programs have a lasting effect on the Type 2 diabetes incident rate. By implementing the DPP and/or the DSMES program, health systems can decrease overtreatment and make prevention of diabetes much more effective and patient-centered. Patients take ownership of their health and learn what is necessary to prevent or treat their chronic illness. The lifestyle interventions implemented during the formal diabetes intervention programs also result in better mental health, reduced cardiac risk, enhanced quality of life and weight loss. “The Georgia Hospital Association and the Georgia Department of Public Health have an aggressive goal to enroll 10 hospitals per year for the next three years into either the Diabetes Prevention Program or the Diabetes Self-Management Education and Support program,” said GHA Population Health and Quality Improvement Advisor Tyra Brown. “We hope our members will strongly consider these programs as mission-compliant, mission-critical parts of their community health plans."s.” Health systems interested in implementing the DPP or the DSMES program should reach out to Tyra Brown at tbrown@gha.org for more information.


GHA Now

Hospitals Prepare for Flu Season By Jeff Sunderland

During last year's flu season, hospital emergency rooms were inundated with patients exhibiting flu-like symptoms.

Last winter proved to be the deadliest flu season in four decades. The Centers for Disease Control and Prevention (CDC) estimated that 80,000 Americans died from the flu and its complications.

In addition, hospital emergency rooms (ER) were inundated and handled the influx of patients by adding extra staff and resources, including a mobile ER at Grady Health System. “GHA is working closely with state agencies and hospitals to prepare for the upcoming flu season, which is October through May,” said GHA President Earl Rogers. “Flu shots are available and the CDC recommends getting vaccinated by the end of October. Not only does it protect you, it helps stop the spread of the virus and protects seniors and infants who are highly vulnerable to the flu.” Augusta University Medical Center and its Children’s Hospital of Georgia – the state’s public academic health system – saw an increase of as many as 100 patients a day in the ER with flu or flulike symptoms during the peak of the 2017-18 season. James Wilde, M.D., an Augusta-based emergency physician and infectious disease specialist at Children’s Hospital of Georgia, says getting the flu vaccine is the first line of defense. Other precautionary measures, such as staying away from sick people, frequent hand-washing and covering coughs, can help stop the spread of flu. Though hospitalizations were up last year, most healthy people do not require a visit to the doctor for the flu, Wilde points out. “A few days of bed rest, accompanied by lots of fluid and Tylenol® or Motrin® should suffice. Unless you have underlying conditions or are over age 65, you just have to let it run its course. “Another key point for the public to understand is that antibiotics kill bacteria but will do nothing for the flu and, potentially, could make things worse,” said Wilde. “The flu is a virus, and even antivirals, like Tamiflu®, may only shorten symptoms by a day or two. That difference may be important for people with underlying medical conditions but is hard to justify in the healthy.”

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Individuals who think they may have the flu should follow the recommendations of the CDC for when to go to the hospital. According to the CDC, symptoms in adults that warrant an emergency room visit include trouble breathing, chest pain, and persistent vomiting. Those who do not have the flu, but go to the ER, risk catching it from those who do. However, anyone who is concerned about a serious or life-threatening illness should go to the ER. “According to the Centers for Disease Control and Prevention, last year was the worst flu season in years, mainly due to a predominant influenza A H3N2 strain,” said Roger Lovell, M.D., infectious disease specialist at Piedmont Athens Regional Medical Center. “The flu vaccine for 2017-18 was only 25 percent effective against that H3N2 strain.” Flu activity in the U.S. is expected to pick up as the temperatures start to fall. Once that happens, hospitals statewide will begin implementing policies to safeguard visitors, including preventing children under the age of 12 from visiting loved ones who are patients. “It’s important to note that it takes about two weeks after you receive a flu vaccine for protective flu antibodies to develop in the body,” said Piedmont Walton Hospital Infectious Disease Specialist Suji Mathew, M.D. “This is why we recommend getting the flu vaccine earlier in the flu season (preferably by the end of October, if possible). However, getting vaccinated later can still be beneficial.” He continued, “Unfortunately, people who get sick with the flu can infect others even before their symptoms first appear. If you get sick with flu symptoms, you should stay home, minimizing contact with other people, except to seek medical care.”

Brasfield & Gorrie supports the Georgia Hospital Association and celebrates its mission to advance the health of individuals and communities. Together, we can make a difference. From top: Northside Hospital East Cobb Medical Center, Marietta, GA Piedmont Fayette Hospital ED and Inpatient Expansion, Fayetteville, GA Hamilton Medical Center MICU and ER Renovation, Dalton, GA

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Pay Attention to Hospital Quality Measures By Rhett Partin The nation’s largest hospital payer and regulator has over a dozen initiatives linking reimbursement to quality of care as defined by specific measures. While CEOs understand the concepts of the Centers for Medicare and Medicaid Services (CMS) value-based purchasing and pay-for-performance incentives, some do not understand the expanse of these programs or the fiscal implications across the continuum of care. The Georgia Hospital Association (GHA) and its Platinum Sponsor, Draffin & Tucker, joined forces to show how all these programs cumulatively affect hospitals’ bottom lines. Draffin & Tucker partners Bert Bennett and Wes Sternenberg conducted an analysis and, together, we assessed the fiscal implications of CMS’s quality-based reimbursement programs. Services across the health care enterprise, including outpatient, skilled nursing, behavioral health, hospice, home health, and rehabilitation, must deal with the effects and changes brought about from these initiatives. The analysis examined publicly available data from 2016 hospital cost reports and found that an average, medium-sized hospital, along with its accompanying outpatient, post-acute and related services, has $55 million dollars in Medicare revenue at risk annually. This data is based on dozens of participation, process and outcomes measures scattered among 14 separate programs. The average hospital experiences a net loss of 0.4 percent, or $220,000 of net income. If a loss of 0.4 percent of net income is not enough to garner the attention of hospital executives, below are 10 reasons why Medicare’s quality-based reimbursement measures warrant further scrutiny. 1. The analysis is inconclusive because not all data was publicly available prior to the assessment. Thus, results may actually be worse. 2. The loss of $220,000, or 0.4 percent, is just an average. Many hospitals are losing even more. 3. The average total hospital margin on patient care is only 1 percent to begin with, so a loss of 0.4 percent equates to a 40 percent reduction. 4. Georgia hospitals collect only 96 percent of their costs for Medicare; therefore, any loss is harmful. 5. Hospitals that participate in Medicare Part B billing have additional risk exposure due to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

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6. Hospital-based skilled nursing facilities and ambulatory surgery centers were not included in the results above, but are now positioned to have an additional 2 percent to 4 percent at risk. 7. The “upside” reward portion of the quality measures is approximately 1.7 percent, so therein lies the opportunity cost. 8. Additional Medicare quality-based reimbursement initiatives are in the works. 9. There are public relations concerns associated with media messaging that a hospital is being penalized or is otherwise losing money due to lower quality scores. 10. If major commercial health insurance plans propose the same 12 initiatives in their hospital contracts, the same 0.4 percent reduction in net income cost could have a much greater impact. The most recent related legislation, MACRA, passed the U.S. Congress with enormous bi-partisan support, 484 to 45. Additionally, on August 9, 2018, CMS proposed a rule that would require all accountable care organizations (ACOs) to assume more risk associated with their quality measures. Regulatory payment changes, more than a dozen Medicare programs, risk-based contracts with commercial payers and full-blown population health management through ACOs are just a few hospital payment reduction mechanisms branded as “quality” programs that, likely, are here to stay. Be familiar with your quality measures across the entire continuum of care and throughout the health care system. Implications for patient care are obvious, but implications on your bottom line are not. Rhett Partin is the senior vice president of clinical services and public health for the Georgia Hospital Association.

There are no shortcuts in healthcare construction. Whether it’s a new 200-bed urban health center or rural critical access replacement hospital, healthcare projects demand the highest attention to detail. Hoar’s healthcare experts bring unrivaled experience to the job, coupled with a passion to serve and a natural ability to embrace challenges.

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New Payments for Non-Face-to-Face Services in the 2019 Medicare Physician Fee Schedule Proposed Rule By Scott Clay, Zach Doolin, and Martie Ross, PYA The Centers for Medicare & Medicaid Services (CMS) recently published its 2019 Medicare Physician Fee Schedule Proposed Rule (Proposed Rule). In this article, PYA, a professional services firm with expertise in health care consulting and certified public accounting, summarizes the rule and offers its insights. CMS is expected to publish the Final Rule around Thanksgiving. In the Proposed Rule, CMS explains that, “[i]n the years since 2012, we have acknowledged the shift in medical practice away from an episodic treatment-based approach to one that involves comprehensive patient-centered care management, and have taken steps through rulemaking to better reflect that approach in payment under the [Medicare Physician Fee Schedule].” Consistent with this philosophy, CMS continues its march forward in the 2019 Proposed Rule, including new reimbursement for a wide range of non-face-to-face services. Medicare Telehealth Services Each year, CMS considers whether to expand the list of Medicare-covered telehealth services, i.e., those telehealth services for which payment is made only if furnished to a beneficiary located in certain types of originating sites. For 2019, CMS proposes to expand eligible covered services to include prolonged preventive services. CMS also clarifies the difference between Medicare telehealth services and other services generally described as “telehealth.” The former, CMS notes, refers to “a discrete set of physicians’ services that ordinarily involve, and are defined, coded, and paid for as if they were furnished during an in-person encounter between a patient and a health care professional.” By contrast, the latter refers to “services that are defined by and inherently involve the use of communication technology.” These services, CMS explains, are not subject to Social Security Act restrictions and may be reimbursable without regard to the patient’s location. Remote Patient Monitoring Current Procedural Terminology (CPT®) is a registered trademark of the American Medical Association. Insurers use the codes to help determine the amount of reimbursement providers will receive for services rendered. In 2018, CMS began reimbursing for remote patient monitoring (RPM)

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under CPT® 99091. In a recent white paper, we detailed the billing requirements for this code. For 2019, CMS proposes adding three new RPM codes: CPT® 990X0: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment. CPT® 990X1: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. CPT® 994X9: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month. The first two codes are reimbursement for the practice expense associated with furnishing RPM services; no physician work is required to bill for either code.The proposed reimbursement for CPT® 990X0 is approximately $21, and $69 for CPT® 990X1. CPT® 994X9 offers an alternative to—not a replacement for—billing CPT® 99091 for professional services associated with RPM. The following illustrates the differences between the two codes:

CMS provides no detail in the Proposed Rule regarding the billing requirements for the three new RPM codes beyond the code descriptions above, leaving many unanswered questions. For example, what level of supervision is required for clinical staff under CPT® 994X9? What constitutes “interactive communication with the patient/caregiver?” Hopefully, CMS will identify and address these issues, giving providers greater confidence as they develop and expand RPM programs. Virtual Check-In Presently, CMS has not made separate payments to physicians for brief check-in services furnished using communication technology to evaluate whether an office visit or other service is warranted. If the physician decides to see the patient, CMS considers the check-in bundled into the payment for the resulting visit. If, however, the check-in does not lead to an office visit, the physician goes without payment for the time and effort associated with the check-in. In the Proposed Rule, CMS acknowledges the problems this reimbursement model creates: To the extent that these kinds of check-ins become more effective at addressing patient concerns and needs using evolving technology, we believe that the overall payment implications of considering the services to be broadly bundled becomes more problematic.

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Effectively, the better practitioners are in leveraging technology to furnish effective check-ins that mitigate the need for potentially unnecessary office visits, the fewer billable services they furnish. Given the evolving technological landscape, we believe this creates incentives that are inconsistent with current trends in medical practice and potentially undermines payment accuracy. To address this, CMS proposes to pay for check-in services under Healthcare Common Procedure Coding System (HCPCS) code GVCI1. HCPCS codes are used to identify products, supplies and services not included in CPT® codes.The reimbursable service is narrowly defined: Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management [E/M] services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. CMS proposes to pay approximately $15 for this service based on the low work time and intensity and to account for the resource costs and efficiencies associated with the use of communication technology.CMS also propose to make separate payment when a physician uses recorded video and/or images captured by a patient under another new code, HCPCS GRAS1. This reimbursable service also is narrowly defined: Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with verbal follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. CMS proposes to pay approximately $13 for this service. Although it proposes to move forward with new reimbursement for virtual check-ins, CMS seeks comment on how to prevent billing abuses. Specifically, CMS asks whether there should be frequency limits on these check-ins, whether the proposed time periods for bundling the service (i.e., 7 days and 24 hours) are appropriate, and whether providers should be required to secure consent from the patient or caregiver. Also, with respect to GRAS1, CMS seeks comment on whether the service may be offered to new patients. Interprofessional Internet Consultation Because specialists receive no reimbursement for time spent consulting with treating practitioners regarding specific patients, specialist input often requires scheduling a separate patient visit when telephonic or internet-based interaction between the specialist and the treating practitioner would suffice. To address this, CMS proposes new reimbursement for interprofessional consultations under six codes: CPT® 994X6: Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 or more minutes of medical consultative time (reimbursement approximately $27). CPT® 994X0: Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes (reimbursement approximately $27).

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CPT® 99446: Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review (reimbursement approximately $18). CPT® 99447: Same as CPT® 99446, except 11-20 minutes (reimbursement approximately $36). CPT® 99448: Same as CPT® 99446, except 21–30 minutes (reimbursement approximately $54). CPT® 99449: Same as CPT® 99446, except 31 or more minutes (reimbursement approximately $73). CMS explains this reimbursement is not intended for activities undertaken for the benefit of the practitioner, such as information shared as a professional courtesy or as continuing education. Also, because these codes concern services furnished without the beneficiary present, CMS proposes to require the treating practitioner to obtain and document verbal beneficiary consent prior to the provision of services. Chronic Care Management Presently, there are three codes under which a practitioner may bill for chronic care management: CPT® 99490, CPT® 99487, and CPT® 99489. Each of these codes reimburses for time spent by clinical staff furnishing care management services under the general supervision of a physician or other qualified health care professional. CMS now proposes to reimburse for care management services personally provided by a physician or other qualified health care professional under CPT® 994X7. The billing requirements for this new code are otherwise the same as CPT® 99490, except CPT® 994X7 requires a minimum of 30 minutes of services over a calendar month. CMS’ proposed reimbursement for CPT® 994X7 is appropriately $74, compared to approximately $43 for CPT® 99490. Bundled Episode of Care for Management and Counseling Treatment for Substance Abuse Disorders Noting “[t]here is an evidence base that suggests that routine counseling, either associated with medication assisted treatment (MAT) or on its own, can increase the effectiveness of treatment for substance use disorders (SUDs),” CMS seeks comment regarding separate payment for a bundled episode of care for management and counseling for SUDs. The agency does not offer any specific proposal to which to react; instead, CMS asks for stakeholder feedback regarding how to define and value the bundle and what conditions of payment should be attached. CMS’ proposal to make a single payment for a specific bundle of care management services for beneficiaries with SUDs differs from their approach to care management services for beneficiaries with chronic conditions. With regard to the latter, CMS has given providers broad latitude in developing and implementing individual care plans, paying them based on the amount of time devoted to these activities. In the context of SUDs, however, CMS is considering a more prescriptive approach, paying providers based on providing a defined scope of services over a specified time period. PYA assists organizations in defining and developing telehealth strategies and performs valuations of telehealth arrangements. For more information, contact PYA at 800-270-9629.

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GHA Now

2019 GHA Membership Meetings Save the Dates Patient Safety & Quality Summit January 9-10, Greensboro, GA Trustee Conference January 11-13, Greensboro, GA GHA Annual Summer Meeting June 26-28, Amelia Island, FL Center for Rural Health Annual Meeting August 21-23, St. Simons Island, GA

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