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May/June 2019 December 2009 >> $5



Spring Medical Conferences Takeaways…

Unmatched by Previous Stroke Treatments, Thrombectomy Dramatically Improves Outcomes Stroke is the leading cause of adult disabilities and the fifth leading cause of death in the U.S. In Northwest Arkansas, stroke victims have access to leading edge stroke treatments including endovascular thrombectomy that can quickly and effectively treat stroke victims so they can return to their normal lives, sometimes within a day. ... 3

Long-acting IUDs: Gaining Control of Fertility Greater use of long acting reversible contraception (LARC) such as intrauterine devices (IUDs), which can provide five to ten years of fertility control, could help prevent large numbers of unintended pregnancies, give women control ... 4

AR Medical Society, AR Nurse Practitioners Association and ARMGMA offer Education, Networking & Support By BECKY GILLETTE

Editor’s note: This spring has been a busy and productive time for medical associations in Arkansas. Annual meetings have been held for the Arkansas Medical Society, the Arkansas Nurse Practitioners Association and the Arkansas Medical Group Management Association that provided opportunities for participants to network, learn and advocate for their professions. Arkansas Medical News attended all three meetings and is pleased to bring you highlights.

Arkansas Medical Society (AMS), Little Rock, April 26.

The recent session of the Arkansas Legislature was one of the most challenging ever, said AMS Director of Legislative Affairs, H. Scott Smith, JD. (CONTINUED ON PAGE 6)

Arkansas Medical Society’s Scott Smith addresses crowd.

Reimagining Residency AMA’s Next Push in Transforming Physician Training By CINDY SANDERS

In 2013, the American Medical Association (AMA) announced an ambitious effort to accelerate change in medical education. Starting with 11 founding medical schools on a mission to better prepare physicians to meet the future of medicine, the initiative has now grown to 37 participating schools. Yet, residency training has not mirrored those transformations … until now. The AMA recently launched a five-year, $15 million Reimagining Residency grant program to rethink how graduate medical education (GME) could best address the workforce needs of the current and future healthcare system, better support physician well-being and enhance preparedness to practice. It’s the next phase in the AMA’s quest to transform physician training. Susan Skochelak









Reimagining Residency, continued from page 1 “When we really looked deeply at the changes being made in medical schools, we realized we’ve brought these now thousands of students through changes in undergraduate medical education (UME) but hadn’t changed residency,” said Susan Skochelak, MD, group vice president for Medical Education with the AMA and the driving force behind efforts to transform the way physicians learn and train to meet the demands of a rapidly evolving healthcare system. Skochelak said the first cohort of students who benefitted from curricular innovations are now interns. “Each subsequent year, there will be thousands more students coming through these new med school programs,” she pointed out. Skochelak said the concern was there would be an implicit message that the training they undertook during medical school didn’t really matter if they arrived at residency only to find no disruption in the status quo. “The next logical step is to say it’s a continuum of training and to bring these same principles and concepts of education forward to residency,” explained Skochelak. “We want to make a better handoff – a better connection – from medical school to residency in terms of learning approach.” She added practitioners must take the important new concepts that are part of health system science and understand how quality, safety and patient-centered care are implemented in daily operations

to ensure readiness for practice. Skochelak continued, “We want to support a positive learning environment … not just for students but for faculty and staff, as well.” Building off the successful model used to transform UME, Skochelak said those chosen for the new residency grant funding will join an AMA-convened consortium. “The best way, we’ve proven, to accelerate the change is to bring people together in a community of innovation,” she explained. The group will evaluate successes and lessons learned and work together to broadly disseminate successful initiatives to residency training programs across the country. In late 2018, the AMA announced the new program. At the beginning of this year,

Since 1996!

with the Letters of Intent was broader than just traditional residency programs. It says that people are really interested and excited to move forward with innovation and change,” she added. Skochelak said about 20 percent of the Letters of Intent addressed physician burnout. Other workforce issues including addressing provider shortages and ideas tied to the impact of social determinants were also recurring themes. The eight proposals selected will share in the $15 million set aside to fund the initiative and will be divided up over five years. Like the medical school programming, Skochelak anticipates there will be a year of planning prior to implementation with these new residency learners followed over subsequent years. After selection, the eight institutional partners receiving grants will meet to agree upon standardized criteria for student assessment, resident selection procedures, onboarding and transitions, core curriculum in health systems science and common evaluation standards to measure performance. No matter which eight are ultimately chosen, Skochelak said she is excited about the depth and breadth of ideas and the response from the larger medical community. “Clearly, it indicates we’re in a climate where people know we can improve and do better, and they want to partner with others who can really help them reimagine residency,” she concluded.

the organization put out a call for innovative proposals with a bold vision to promote systemic change in GME with Letters of Intent due Feb. 1, 2019. Last month, that large pool was narrowed down to 30 applicants who have been asked to submit full proposals. Skochelak said she anticipates eight will be selected for funding with the announcement coming in June at the 2019 AMA Annual Meeting in Chicago. The response has been tremendous. “We had more than 250 entities write Letters of Intent,” Skochelak noted, adding the entries represented more than 300 organizations including state medical societies, specialty societies, consortiums, nonprofits and others. “We’re really very intrigued with the fact that the response

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Unmatched by Previous Stroke Treatments, Thrombectomy Dramatically Improves Outcomes

Interventional Neuroradiologist Mark Moss provides leading edge procedure for stroke victims By BECKY GILLETTE

Stroke is the leading cause of adult disabilities and the fifth leading cause of death in the U.S. In Northwest Arkansas, stroke victims have access to leading edge stroke treatments including endovascular thrombectomy that can quickly and effectively treat stroke victims so they can return to their normal lives, sometimes within a day. Mark Moss, MD, an interventional neuroradiologist at Washington Regional’s Northwest Arkansas Neuroscience Institute in Fayetteville, said a series of well-conducted randomized trials in 2015 concluded convincingly that endovascular thrombectomy dramatically improved the outcomes of eligible patients with strokes from a large vessel occlusion. “The success of endovascular therapy for ischemic stroke treatment (thrombectomy) is now irrefutable, making it an ac-

cepted standard of care,” Moss said. “It is very gratifying to have patients who were previously unable to talk or move their arm to shake your hand and say, ‘Thanks,’ sometimes immediately after the proce-

dure.” When a patient arrives with symptoms of a severe stroke, protocols are initiated to ensure immediate evaluation by ER personnel and stroke neurology which

includes advanced brain imaging. Eligible patients will then receive the clot busting drug alteplase and/or proceed to the neurointerventional radiology suite for thrombectomy. The time window for stroke endovascular therapy plays an important role in the clinical outcome. A new major recommendation increases the time window from 6 hours to 24 hours for selected patients with acute ischemic stroke to receive mechanical thrombectomy. Moss said the new recommendation will result in more patients becoming eligible for thrombectomy since more patients will be treated based on clinical presentation and advanced imaging rather than a time cut-off alone. Moss graduated from the University of Arkansas for Medical Sciences College of Medicine in 2000, and completed his medical internship, radiology residency (CONTINUED ON PAGE 5)

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Long-acting IUDs: Gaining Control of Fertility By BECKY GILLETTE

Greater use of long acting reversible contraception (LARC) such as intrauterine devices (IUDs), which can provide five to ten years of fertility control, could help prevent large numbers of unintended pregnancies, give women control over spacing of pregnancies, reduce abortion rates and save taxpayers the costs of providing assistance to low-income mothers and children, said Nirvana A. Manning, MD, OB\GYN, who is an associate professor at the University of Arkansas for Medical Sciences (UAMS) DeA. Manning, partment of Obstetrics Nirvana MD, OB/GYN and Gynecology. “It helps prevent unintended pregnancies in an economical and efficient way,” Manning said. “If I were to break down the benefits of this in a younger population, it is a way to control the frequency with which you have children in an easy to adhere to way. You don’t have to remember to take a pill every day. It has been liberating for women. It is the most effective form of birth control because there is no user error. And it is completely reversible. As soon as you decide you want a child, you have it removed in a clinic visit, and fertility is immediately restored.” However, although it is becoming the standard of care, misconceptions about IUDs have kept them from being adopted more widely. “I tell patients, ‘This it’s not your mother’s IUD,’” Manning said. “There have been so many improvements to this form of contraception in the past 20 years. Education would help people understand the many benefits to this option. I do think it has several great points. IUDs are my first-line contraception solution.” Some IUDs release hormones and some don’t. Nexplanon, which is a small rod that is inserted into the inside of a woman’s arm, lasts for three years and releases the hormone progesterone. The LARCs with hormones can have other benefits such as reducing heavy menstrual bleeding. The wall of the uterus is thinned, so there is less bleeding frequency and duration. The hormonal LARCs are FDA-approved for women with heavy, painful menstrual circles. “When people go into it with appropriate expectations, they are happy with it,” Manning said. “If the device has progesterone only, you can expect a period of up to three months of irregular spotting. It is not heavy bleeding, but a nuisance. It is enough for using a panty liner or teen tampon. After about three months, the vast majority of people will bleed less frequently and less heavily. About 30 to 40 percent of people will have no bleeding at all, but unfortunately I can’t guarantee that.” Manning believes another advantage of using an IUD is that there would be significantly fewer hysterectomies because 4



it can help prevent heavy bleeding in the peri-menopausal stage. Another misconception about IUDs is that it can’t be used with women who have not had children. It is effective in nulliparous, as well as adolescent women. “It is safe and effective,” Manning said. “It should be routinely offered to younger women because the adolescent and teenage population is not historically good at taking birth control pills. We always have a conversation with patients that even with a LARC, they still need condoms to prevent STIs.” Often parents bring daughters to have an LARC implanted before college so the women can get five years of protection without having to take a pill every day. There is also one IUD that offers ten years of protection that is non-hormonal for those who don’t necessarily want any hormones. “It doesn’t offer some of the benefits like the bleeding reduction,” Manning said. “But it is a very effective and safe contraception for ten years. Most all insurance including Medicaid will cover the device and visit. Another advantage is you don’t have to go to a pharmacy and get birth control every single month.” There is another common misconcep-

tion that an IUD can’t be offered after an ectopic pregnancy. That is false. There are also some women who can’t take oral contraceptives because of high blood pressure. The combined hormonal pills have the propensity to make hypertension worse. “That is a benefit of progesterone-only agents,” Manning said. “Women can use these and their blood pressure will not be elevated. There is also a subset of the population at risk for deep vein thrombosis and pulmonary embolism from oral contraceptives.” Manning advocates women consider having an LARC implanted immediately after delivering a baby. Several private insurance companies have started providing coverage for these immediate post-partum IUDs. “Medicaid covers this option in 43 other states, so we are hoping we can get them to cover this option in Arkansas, as well,” Manning said. “It could really have a profound social and health impact in these women’s lives. Unintended pregnancy rates are five times greater at the poverty line or lower. And there is a higher unintended pregnancy rate the first year post-partum. By helping with birth control post-partum,

women can space pregnancies at a rate they feel comfortable with and that they can control.” Manning said it is the wave of the future for people to be able to control their family size in a safe and effective way giving women empowerment over their reproduction. “If we can get more buy in and make sure people are informed about this, the fears and misconceptions will be dispelled and that would make a profound impact on our teen pregnancy rates and the spacing of pregnancies, especially for those atrisk poverty line women. This could make a profound impact downstream, for sure.” Manning recommends that physicians who provide women’s health from menarche to menopause should offer this as an option to patients. If they receive the appropriate training, family practice doctors can perform the procedure. If a family practice doctor doesn’t feel comfortable providing the service, patients can be referred to an OB\GYN. “There are many family practice doctors who specialize in women’s care,” she said. “The risk is low, but we certainly want it to be done under trained hands.”

State Medical Society Elects Officers The Arkansas Medical Society (AMS), a physician group advocating for health care improvements statewide, met recently at the Doubletree Hotel in Little Rock to elect new officers, attend educational programs, and discuss advocacy efforts from the 92nd General Assembly. Stuttgart family physician Dennis Yelvington, MD, was named president of the group. Dr. Yelvington has been a member of the AMS for 34 years and has held numerous offices, including a seat on the Board of Trustees since 2007 representing the physicians and citizens of Southeast Arkansas. During his oath of office, Dr. Yelvington pledged to help the Arkansas Medical Society to shine a bright light on the way forward for physicians. His emphasis on the importance of the work the organization does to protect Arkansas’ patients was a theme that echoed throughout the meeting. Other newly-elected leaders include President-Elect Chad Rodgers, MD (Little Rock); Vice President Seth Barnes, MD (Hot Springs); District Trustees Stacy Zimmerman, MD (Searcy); Willard Burks, MD (Wynne); Darrell Over, MD (Pine Bluff); Donya Watson, MD (El Dorado); Randy Walker, MD (DeQueen); Nannette Vowell, MD (Malvern); Appathurai Balamurugan, MD (Little Rock); Dirk Haselow, MD (Little Rock); James Hunt, MD (Little Rock); Naveen Patil, MD (Little Rock; Alan Schumacher, MD (Bentonville); Kathleen Conner, Student Trustee (UAMS – Little Rock). In addition to the specific duties of each office, these physicians will work to continue the medical society’s mission of improving Arkansas health care through legislation, education and the day-to-day support of patients and medical practices. Significant legislative advances for Arkansas patients and physicians supported by AMS in the past include: establishing a statewide trauma system, passage of the Clean Indoor Air Act, funding tobacco prevention and cessation programs, funding cancer research, providing vision screening in schools, and protecting an Arkansan’s right to choose their physician through “Any Willing Provider” legislation. The Arkansas Medical Society is a voluntary professional association, established in 1875, representing more than 4,000 physicians and medical students as well as the patients and communities they serve.

Immediate Past President Lee Archer, MD passes the gavel to newly sworn-in president, Dennis Yelvington, MD.

Dennis Yelvington, MD is sworn in as president of the Arkansas Medical Society by Immediate Past President Lee Archer, MD, while several past presidents and new Board of Trustees f the organization look on.



Unmatched by Previous Stroke Treatments, continued from page 3 and neuroradiology fellowship at UAMS. At age 46, inspired by the remarkable developments in the field of endovascular neurosurgery witnessed in the past decade, he did an endovascular neurosurgery fellowship at the Medical University of South Carolina. His family, wife Wendy and daughters Madylin and Isabelle, stayed behind in Fayetteville while he did his second fellowship. “It was very hard leaving them for 18 months, but it would have been virtually impossible to convince my teenage daughters to leave their friends, especially for my older daughter who was going into her senior year of high school,” Moss said. “Thankfully, I have a very supporting strong family.” Moss said the thrombectomy procedure is a safe, but complex procedure that requires an experienced team to deliver and needs to be performed with great rapidity. Moss works with Mehmet Akdol, MD, who is also an interventional neuroradiologist, at the Northwest Arkansas Neuroscience Institute clinic, which is located adjacent to Washington Regional Medical Center. In addition to treating stroke, Moss and Akdol offer minimally invasive options for diagnosing and treating conditions of the brain, neck and spine including brain aneurysm and arteriovenous malformation. Using specialized imaging guidance and a small incision, the interventional neuroradiologists can perform complex procedures without open surgery – allowing patients to recover more quickly. “We are very fortunate at Washington Regional Medical Center to have two dedicated state-of-the-art biplane neurointerventional radiology suites, as well as a full staff of highly skilled nurses and technicians,” Moss said. “We also have a dedicated 20-bed neuro intensive care unit. My partner, Dr. Akdol, and I provide 24/7 365 days a year coverage for neuro intervention.” Other procedures they do include treating atherosclerosis of the brain and neck with angioplasty and stenting. And

they use embolization to treat aneurysms, blood vessel malformations and tumors. The aneurysm treatment is also called aneurysm coiling or flow diversion (pipeline stent). The coils or stent are used to block flow into the aneurysm to prevent it from rupturing, producing bleeding and brain damage. Moss said the ongoing development of endovascular tools has led to successful treatments of lesions once deemed nonoperable or only surgically approachable. There is a very short recovery time for patients treated for a unruptured aneurysm, dural arteriovenous fistula and

arteriovenous malformation embolization. Typically, these patients spend one night in the hospital for observation and go home the next day. Moss, who grew up in Russellville, became interested in medicine at an early age. “Growing up, many of my parents’ friends were physicians, and my mom and dad would often tell me how much they respected them and what they do,” Moss said. “One of these friends happened to be a radiologist and under his guidance I began volunteering at our local hospital during my freshman year at high school, which furthered my interest in the medi-

cal field.” Moss said there are many people who have influenced him. “My parents instilled in me the virtue of hard work and that nothing comes easy,” Moss said. “My wife and daughters are amazing people I am so grateful for. Throughout my medical career, I have been privileged to learn and work with many gifted physicians such as Dr. Eddie Angtuaco – a brilliant passionate man who inspired me to be the best I could be.” During his free time, his interests include alpine and rock climbing, hiking, wake surfing and landscaping.


CANCER EXPERT. We are proud to welcome Jonathan Pagan, M.D., M.S. to CARTI, Arkansas’ largest network of cancer providers. After graduating from University of Arkansas for Medical Sciences, Dr. Pagan went on to complete his residency at Vanderbilt University in Nashville. He is excited to return home and begin serving the cancer patients of Arkansas. Dr. Pagan is now accepting new patients at the CARTI Cancer Center in Little Rock.

Keep your finger on the pulse of Arkansas’ healthcare industry.

JONATHAN PAGAN, M.D., M.S. Radiation Oncologist

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Spring Medical Conferences Takeaways…, continued from page 1 “We had our hands full, both from the sheer volume of bills we were working and from the intensity of controversy surrounding some of the bills,” Smith said. “Scope of practice bills are always difficult and keep us busy during any legislative session, but this year there was no letting up. It seemed as though the votes just kept coming, back-to-back-to-back, without much time to breathe between the votes.” Despite being time consuming, Smith said most of their legislative efforts turned out well. One major loss was that optometrists can now perform surgery. “That was a bad bill,” Smith said. “We fought it, but we lost. We did have good resolution regarding almost all of the scope of practice bills. There were a number of Advanced Practice Registered Nurse bills that didn’t pass. There were some Certified Registered Nurse Anesthetist bills that didn’t pass.” Telemedicine is an issue AMS has been dealing with for the past three sessions now. One of the telemedicine companies was trying to pass a bill that would allow a physician-patient relationship to be established just over the phone. “We think that is a bad idea,” Smith said. “That bill failed. We also worked with the Arkansas Hospital Association and helped pass a bill that pertains to basic fairness in contracting. Then, we also got a bill passed prohibiting a requirement for prior authorization for medication assistance treatment for opioid addiction. When you are dealing with opioid addiction, there are some medicines that help. The bill prohibits insurance companies and government programs, like Medicaid, from creating a hurdle for physicians to access FDA-approved medications for opioid addiction. It also requires at least one of those medications to be on the lowest cost tier that is available.” Also speaking at the AMS meeting was Kevin O’Dwyer, General Counsel, Arkansas State Medical Board (ASMB), which has a Pain Management Committee that tracks doctors who are overprescribing opioids and other controlled substances and meets with the ones who are nearing the threshold of “gross negligence” in order to Kevin O’Dwyer discuss the issue. “What the board has been doing is sending doctors with complaints about over prescribing, but who don’t quite meet the threshold of gross negligence and ignorant malpractice, to the Pain Management Committee,” O’Dwyer said. “We decided to start sending the people who might not have been in violation to the Pain Management Committee in hopes of educating them and hopefully preventing a future problem.” One red flag for physicians who may be overprescribing is if they have patients who travel long distances to see the physician. A cash-only clinic raises suspicion. O’Dwyer said another issue that might raise concern is if the physician is in a spe6



cialty that should not be writing a high number of pain medicine prescriptions. These red flags are not necessarily indicative of a violation. If the state’s Prescription Drug Monitoring Program indicates a certain physician is one of the top prescribers in the state or in his\her specialty, that might start an investigation. And law enforcement agencies are getting more aggressive with their investigations in order to stop the opioid problem. “It is a balancing act for all of us,” O’Dwyer said. “We don’t want to swing so far the other way that it hurts patients. Doctors need to read the Medical Practice Act and follow that. Document the justification. There need Julie Ponder speaking to the Arkansas Nurse Practitioner Association. to be details in their record regarding the justification for the King said the medical community has prescription. That is really what we are a great opportunity to engage with and looking for.” educate their patients. Justin C. King, Assistant Special “You’re talking about a trusted proAgent in Charge, Little Rock District Offession of people who know the hazards fice, U.S. Department of Justice, Drug and dangers of prescription drugs,” King Enforcement Administration, said some said. “They should know their patients, medical professionals don’t understand and if they don’t, they should ask queshow overprescribing of opioids can lead to tions. Doctors should ask, ‘Do you think people becoming addicted and then turnyou are becoming addicted to these pills?’ ing to more dangerous substances such as Arkansas is the second highest opioid preheroin and fentanyl. scribing state. We all have to do more. It “People find a place where a doctor is important to partner with the medical is not as diligent about prescribing,” King community to educate and protect the said. “They put the doctors in a position population.” doctors aren’t prepared for because docKing said they are excited the meditors expect their patients to be honest. Not cal community is having these conversaeveryone on pain pills is an addict, but we tions with law enforcement. see a high percentage of heroin addicts “We want to be partners with the who start out with pain pills. Doctors start medical community for Arkansas to lower to say ‘No,’ or people can’t afford the pills, prescribing rates,” he said. and we see them moving over to getting heroin.” Arkansas Nurse Practitioners A problem with purchasing heroin is Association (ANPA), April 12that it can be cut with fentanyl, which is 13, Little Rock a lot cheaper to produce than heroin and ANPA President Julie Ponder, APRN, even more dangerous. who is an ER nurse practitioner at Arkan“It is all about the drug traffickers sas Heart Hospital, said this is the fourth making money,” King said. “That polyyear for their annual conference and they drug organizations are also controlling feel it was definitely another great success. meth and cocaine. They want to get as “We were able to give not only genmany people dependent on their products eral Continuing Education (CE) contact as possible. We see a lot of counterfeit opihours, but also offer pharmaceutical CE oid pills produced in clandestine labs in hours,” Ponder said. “So, we were able Mexico. People may think they are getting to give more CE hours than originally exa diverted pharmaceutical, but it might be pected. That was exciting for us. Another pure fentanyl.” thing is every year we have strived for 200 King said there has been a significant attendees and finally did that this year increase in the availability of heroin, cowith 202 in attendance. As an association, caine and methamphetamine. Today’s we have grown to a membership of 410. methamphetamine is even stronger and That was another accomplishment for us more potent. with our association being only four years

old. We are a newer association for all NPs, and this conference was an opportunity to bring us all together to educate and network with one another.” Ponder said they were disappointed legislation to remove requirements that NPs have a collaborative practice agreement with physicians failed to pass. They got farther than in the past, but it failed by one vote to get out of an Arkansas House committee. Ponder said removing the collaborative practice agreement would increase access to care for many individuals, especially because Arkansas is so rural. “In some counties there is only one physician and multiple nurse practitioners who could help to meet that shortage,” Ponder said. “NPs feel like in rural areas we can help with primary care coverage. There are not enough physicians out there to provide care to these Medicaid recipients. Should NPs be primary care providers? We’re here and we can help fill the gap.” During the committee hearings, a doctor from Hot Springs made the statement that dog trainers at Petco require more training hours than NPs. That is not true. “NPs complete a four-year bachelor’s education program with clinical hours, and then have clinical experience hours,” Ponder said. “The Arkansas Board of Nursing requires 2,000 RN experience hours before a NP is licensed. NPs must complete a Master or Doctorate level education program with classroom and precepted NP practice hours before applying for NP license. We are very safe in our practice and know when to refer patients for specialist care. We don’t work outside of our knowledge and ability.” The keynote speaker at the conference was Family Nurse Practitioner Margaret Fitzgerald, DNP, president, Fitzgerald Health Education Associates, LLC, who has published eight books and hundreds of articles. Fitzgerald said NPs should be provided more autonomy so they can provide care in areas that are underserved. “Legislation needs to be updated to be more reflective of contemporary NP practices,” Fitzgerald said. “There are 26 states where NPs have full practice authority that allows them to expand their services to underserved populations.” Nurses often are seen by patients as being particularly empathetic and under-




Spring Medical, continued from page 6 standing. “We are socialized from the beginning of nursing education to provide that high touch, high emotional connection type of care,” Fitzgerald said. “It is not to say other disciplines are not so socialized, but that is really, really at the core of our education.” Fitzgerald has been asked if NPs are trying to replace physicians. “No, we are not,” she said. “In this great country there are so many people who live in healthcare underserved communities or can’t get adequate care because of financial, language and cultural barriers. Everyone in this nation deserves to be well served by the healthcare community. NPs are trying to take a bigger piece of pie, but there are plenty of pieces of pie. We work collaboratively with physicians and others in the profession. That will continue as NPs to work to achieve full practice authority.” There can be incredible collaboration between MDs and NPs. Fitzgerald gives as an example a MD and NP who practice in urology. When the MD is in the OR doing what he does best, the surgical part, the NP is back in the office evaluating patients who will likely be surgical candidates at some point. One day the urologist is in the OR doing surgery, and the NP calls him and says, ‘Mr. X is in the ER and has a kidney stone. I’ve seen him, done the diagnosis, and booked him for surgery after you finish this case.” Fitzgerald said in that case, the patient who needed an emergent surgical procedure got to the OR an hour earlier because of the collaboration. The patient avoided another hour of suffering pain and the surgeon’s time was used more efficiently.

Arkansas Medical Group Management Association, April 16-17, Fayetteville

The major topics at the MGMA Spring Annual Conference included patient experience, burnout and wellness, healthcare marketing, healthcare fraud and IT security. AMGMA President Diana McDaniel, who is also Vice President of Operations at Arkansas Children’s NWA

Hospital, said one of the best parts of the conference was seeing the interaction between their members as they discussed how they are handling challenges. “I heard numerDiana McDaniel ous conversations about PASSE (Provider-Led Arkansas Shared Savings Entity), recently passed state legislation and marketing strategies,” McDaniel said. “Hearing those conversations lends itself to one of the hottest topics requested for this year: wellness and burnout. Our members are overwhelmed with the rapid changes coming with the business of healthcare and are also concerned about the burnout of physicians at their practices. With the high cost of turnover, they are looking for ways to bring a sense of balance to their practice. Wendy Ward, PhD, a UAMS psychologist, led a great session on finding your wellness gaps and developing strategies for better balance.” McDaniel said patient experience seems to be a topic every year as healthcare administrators are hungry for tools to use when teaching their staff about best practices when interacting with patients and families. “We had two sessions on experience at this year’s conference, one by Jim Bryant, Chik-Fil-A operator, and another by Stephen Dickens of SVMIC,” McDaniel said. “There is a strong desire from our membership to stay on top of fresh ideas and approaches to customer service in the healthcare setting. Sharing ideas about what is working well and what is not working well is one of the benefits of attending the conference.” McDaniel said being part of MGMA allows insight into how different policies and business challenges are handled by rural, private, academic, and non-profit healthcare setting. The membership networking lends to resources for managing the healthcare business pace. “The state conference is a great setting to find professional colleagues dealing with the same challenges,” she said. Participants also heard from Drew (CONTINUED ON PAGE 8)

NEW RULE STRENGTHENS CONSCIENCE PROTECTIONS FOR HEALTH CARE PROVIDERS AND WORKERS The Department of Health and Human Services (“the Department”) recently announced its “Final Conscience Regulation” (the Rule), which broadens protections for individuals and health care entities that refuse to perform, assist in the performance of, or undergo certain health care services or research activities to which they may object for religious, moral, ethical, or other reasons. The Rule, which was issued on May 2, 2019, clarifies conscience rights that broadly protect individuals, health care entities, and providers from discrimination in health care by government-related entities “because of the exercise of religious belief or moral convictions.” A similar expansive rule was announced in 2008, but was replaced by a more limited interpretation of existing Federal laws in 2011. This new Rule effectively replaces the 2011 regulations with broader protections for conscience objections. Its purpose is to protect the conscience and associated anti-discrimination rights of individuals, and health care entities, as well as protect patients from being subjected to certain health care or services over their conscientious objection. Examples of the types of objections contemplated by the Rule are procedures such as abortion or sterilization services, and situations related to assisted suicide or euthanaThe Authors: sia. What does the Rule do? The Rule implements existing Federal laws and regulations to strengthen the enforcement of Federal conscience and anti-discrimination laws related to the Department, its programs, and recipients of Department funds. Perhaps most notably, the Rule delegates authority to the Office for Civil Rights (OCR) to engage in compliance reviews, conduct investigations, supervise and coordinate compliance by the Department, and use enforcement tools otherwise available to address violations and resolve complaints. OCR will now have enforcement authority to protect conscience protections created under the following Federal statutes and existing regulations:

Lynda M. Johnson, Partner

• The Church Amendments, which protect entities and individuals who hold religious beliefs or moral convictions related to abortion or sterilization services from discrimination by entities that receive certain Federal funds, and in health service programs and research activities funded by HHS. • The Coats-Snowe Amendment, which provides conscience protections for health care entities related to providing abortions, or training, referrals for abortions or training, or accreditation standards related to abortion.

Timothy C. Ezell, Partner

• The Weldon Amendment, which protects health care entities from discrimination that do not provide, pay for, provide coverage of, or refer for abortions under programs funded by the Department’s appropriations acts. • Affordable Care Act conscience protections regarding abortion coverage, assisted suicide, and provisions prohibiting the discriminatory denial of a religious exemption from the individual mandate. • Certain conscience protections under Medicare Advantage and Medicaid, such that the status of patients as beneficiaries with certain self-determinable rights does affect provider’s conscience rights regarding assisted suicide, euthanasia, or mercy killing.

Amie K. Alexander, Associate

• Conscience protections concerning advance directives with respect to certain HHS funded programs. • Conscience protections for Global Health programs administered by HHS or funded by HHS appropriations. • Conscience exemptions for patients from certain specified health care services, such as compulsory medical screening, examination, diagnosis, or treatment. • Conscience protections for religious nonmedical health care institutions and patients who seek religious nonmedical care. What steps should Providers take to ensure compliance? Providers should seek Counsel in taking steps to come into compliance with the new Rule. To begin, Providers should talk with Counsel about taking the following steps: 1. Implement a non-discrimination policy. 2. Implement policies and procedures for providing accommodations for individuals who request an accommodation. 3. Maintain records evidencing compliance, including any complaints, statements, policies, notices, procedures for accommodating protected individuals’ religious beliefs or moral convictions, and records of requests for such accommodations and the response to such requests. 4. Provide certifications and assurances of compliance requirements which are now required as a condition of receiving federal funding. 5. Develop and post compliant notices which inform employees, contractors, and others of their rights under Federal conscience and anti-discrimination laws. 6. Be prepared to respond appropriately to any inquiries from the Office for Civil Rights, which is delegated broad enforcement authority by the Rule. The new regulations go into effect on July 1, 2019.

A group of Arkansas MGMA members takes a break from meetings. arkansasmedicalnews






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Voytal, Associate Director, Government Affairs, for the national MGMA. Voytal said beginning this year, physician practices have new reimbursement opportunities for communications-based services, including telephone interactions and patient-submitted photos. “These services offer more flexibility to physician practices because CMS determined that these services are not considered to be Medicare telehealth services and therefore not subject to the restrictive statutory rule on originating site limitations and rural geographic requirements,” Voytal said. “The first new code is for ‘virtual check-ins’ (HCPCS code G2012), which is defined as a brief communication technology-based service by a physician or other qualified health care professional who can report evaluation and management services to established patients.” The second new code is for use of storage and forwarding technology (HCPCS code G2010) for the remote evaluation of recorded video and/or images submitted by an established patient including interpretation and follow-up with patients within 24 hours. Voytal said the new virtual-care codes indicate that CMS is finally recognizing group practices for the work they do outside of traditional office visits, though beneficiary cost-sharing obligations may create frustrating collections situations. “MGMA sees these new codes as a step in the right direction since they offer physician groups more options in providing services to their patients,” Voytal said. “However, one of the top advocacy priorities for the association is for Congress to amend current law to remove site restrictions for Medicare telemedicine payment. This greater flexibility would allow physician groups freedom to offer the right kind of care to their patients.” Voytal said as the leading voice for medical group practices in the country, MGMA remains committed to advocacy in 2019 that pushes for regulatory relief for group practices that participate in federal healthcare programs. “It is the position of the association that the federal government needs to reduce excessive and arbitrary mandates and one-size-fits-all regulations that impede health care innovation while supporting high quality, cost effective care delivery,” Voytal said. “More specifically, MGMA advocates for a simpler, more streamlined MIPS program that rewards outcomes, fair payment for medical groups that treat complex patients, an overall reduction in prior authorization requirements, and added flexibility to Medicare telehealth rules.”

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GrandRounds Dr. Jonathan Pagan Joins Radiation Oncology Department at CARTI Cancer Center LITTLE ROCK – CARTI Cancer Center has added radiation oncologist Jonathan Pagan, M.D., M.S. to its staff. He comes to CARTI from Carson City, Nevada, where he served as radiation oncologist for CarsonTahoe Radiation Oncology. He is now acPagan, cepting new patients at Jonathan M.D., M.S. CARTI Cancer Center, 8901 CARTI Way, Little Rock. Dr. Pagan has served as a member of the American Society of Radiation Oncology (ARRO) Global Health Subcommittee and the Arkansas Healthcare Access Foundation. Dr. Pagan earned his medical degree from the University of Arkansas for Medical Sciences where, as the highest ranking student in his class, he received the Barton Foundation Scholarship. This scholarship is awarded to students who completed the prior year of medical school with a 4.0 GPA. He completed his residency in radiation oncology at Vanderbilt University in Nashville, Tennessee. He received his Masters of Science from Georgetown University in Washington, D.C. and his Baccalaureate

Degree in Biological Sciences from the University of California, Irvine.

Baptist Health Neurosurgery Arkansas Welcomes Dr. PB Simpson Jr. LITTLE ROCK – Dr. PB Simpson Jr., who has been in practice for more than 40 years, has joined Baptist Health Neurosurgery Arkansas on the campus of Baptist Health-Little Rock. Simpson received his medical degree from the University of MissisDr. PB sippi and is board certiSimpson Jr. fied in neurosurgery. He has a conservative practice philosophy, believing that surgery should only be an option if the benefits outweigh the risks. Baptist Health Neurosurgery Arkansas, established in 2004 as a multidisciplinary approach to the treatment of brain and spine disorders in the state, is open Monday through Friday from 8 a.m. to 5 p.m. in Medical Towers I, Suite 750, 9601 Baptist Health Drive. The clinic utilizes state-of-the-art technology including navigated minimally invasive spine surgery through the Mazor X Robotic Guidance Platform as well as computer-assisted surgery and neuro-endoscopic brain surgery. For more information about Mazor X, avail-

able to only a small number of spine and orthopedic hospitals in the U.S., visit

Mercy Hospital NWA Announces New Directors ROGERS – Eric Pianalto, president of Mercy Hospital Northwest Arkansas in Rogers, recently announced two new directors who will lead the hospital’s surgical and support services. Jennifer Summers has joined Mercy Hospital as its director of surgical services. Most recently, she was operations manager of surgical services with Erlanger Health System in Chattanooga, Tennessee. Summers has 15 years of experience in health care, including eight years in nursing and seven in operations management. She earned a Bachelor of Science in nursing from Blessing Reiman College of Nursing in Quincy, Illinois. Amanda Jenkins was promoted to director of support services. A Mercy coworker since 2013, Jenkins has served in a variety of technology-related positions, most recently as director of Healthcare Technology Management. Her previous experience includes 10 years in communications-related roles with two municipals governments. She will complete a bachelor’s degree in business administration and human resources management at Columbia Southern University in Orange Beach, Alabama, this fall.

UAMS Establishes Center for Dietary Supplements Research

LITTLE ROCK - A new center to provide regulatory agencies, industry and the public with credible information and assessments related to the safety of dietary supplements has been established by the colleges of Public Health and Pharmacy at the University of Arkansas for Medical Sciences (UAMS). The Center for Dietary Supplements Research is co-directed by Bill Gurley, Ph.D., and Igor Koturbash, M.D., Ph.D., and will provide expert opinions, risk communication, and professional and educational services related to the safety of dietary supplements. Gurley is a professor and vice chair of the Department of Pharmaceutical Services in the College of Pharmacy and chairs the UAMS Institutional Animal Care and Use Committee. Gurley has been conducting research into the safety of dietary supplements for more than 20 years. Koturbash is an associate professor and vice chair of the Department of Environmental and Occupational Health in the College of Public Health. About 70 percent of adults in the United States consume dietary supplements and 20 percent of those include herbal dietary supplements. This center will be a resource for information and technical expertise on these products, while at the same time working with industry experts, regulatory agencies, researchers and the public to deliver evidence-based, accurate information. The center specializes in various critical issues regarding single- and multi-component dietary supplements, from conducting pre-clinical toxicological safety assessments to generating expert reports and scientific publications said Gurley. The center will be housed in the College of Public Health and will maintain three core units – a Pharmacological Core, a Toxicological Core, and an Administrative Support Core. Gurley will lead the Pharmacological Core and Koturbash will lead the Toxicological Core. Others involved in the center include: • Mitch McGill, Ph.D., assistant professor in the Department of Environmental and Occupational Health in the College of Public Health, will provide expertise on hepatoxicity, or drug-induced liver injury. • Marjan Boerma, Ph.D., associate professor in the Department of Pharmaceutical Sciences in the College of Pharmacy, will provide expertise on cardiotoxicity, or drug-induced damage to the heart muscle. • Joseph Su, Ph.D., professor in the Epidemiology Department in the College of Public Health and co-leader of the Cancer Prevention and Population Sciences Program in the UAMS Winthrop P. Rockefeller Cancer Institute, will provide expertise on the epidemiology of dietary supplements. For more information about the center, visit arkansasmedicalnews


GrandRounds UAMS Researcher Johann Granted $1.47 Million to Continue Cutting-Edge Lung Cancer Clinical Trials LITTLE ROCK — Physician-scientist Donald J. Johann Jr., M.D., has been awarded a $1.47 million grant from the Food and Drug Administration (FDA) to continue a clinical trial to determine if new approaches can be developed to monitor and screen for lung cancer with a blood test. Johann is an associate professor in the departments of Biomedical Informatics and Internal Medicine in the College of Medicine at the University of Arkansas for Medical Sciences (UAMS). Johann says we’re coming into the long-promised ‘future’ of cancer treatment and that for the last 50 years, the holy grail of cancer research has been being able to detect the presence of cancer with a simple blood test, known as a liquid biopsy, and treat cancer patients on an individualized basis, which is precision medicine. Recent advancements in genetic sequencing technology, computational science and the ability to manage massive amounts of data have made this type of research possible he said. The vision is to combine the power of these approaches with clinical knowledge to improve outcomes. This is the future of

cancer medicine, and he says it’s all doable. An innovative and important aspect of this approach is called bioinformatics, a new field in research that uses computational tools to assess medical and public health information, often on a large scale, looking for previously unrecognized patterns that can affect medical and public health science in a broad range of ways. Lung cancer is the leading cause of cancer-related deaths in the United States and the world, and the incidence in Arkansas has been higher than the national average for the past 20 years. Researchers believe precision medicine is key to changing these statistics. The current standard treatment for early stage lung cancer is surgical removal of the tumor, with the addition of chemotherapy/radiation when the cancer has spread to nearby lymph nodes. However, the cancer often returns after two to the three years and is deadly. With Johann’s clinical trial, the surgeons are taking samples of the tumor at the time of its removal. Back in the lab, Johann’s team is running genetic sequencing on the tumor and re-growing it using different methods. Once the sample tumors are big enough, the team tests existing drugs and novel combinations of existing drugs on the

tumors to find the most effective treatment. This information is analyzed and stored so that if that individual patient’s cancer comes back, their doctors will know the best medicines to use. The information is also compiled in large datasets so that researchers can look for aggregate patterns and identify trends regarding which treatments work best for different types of tumors. The idea is that now scientists will be able to genetically test a tumor to identify the best course of treatment for that individual patient. Liquid biopsies are important because the average diagnosis for lung cancer patients is about age 70. Patients are often in poor health in addition to battling cancer, and traditional invasive biopsies can lead to complications or death. Patients in Johann’s clinical trial are giving blood samples at multiple stages of treatment. The research team is determining whether the cellular material shed by tumors into blood can help doctors detect cancer earlier and monitor patients during cancer treatments to improve outcomes. Again, compiling big datasets plays a role. The liquid biopsy part of Johann’s lung cancer work is also being supported by the Blood Profiling Atlas in Cancer (BloodPAC), a nonprofit consortium

for data sharing between stakeholders in industry, academia and regulatory agencies with the goal of making liquid biopsies a reality. BloodPAC is also supporting liquid biopsy clinical trials at Memorial Sloan Kettering Cancer Center for prostate cancer, University of Southern California for breast cancer, and University of Pennsylvania for pediatric cancers. Johann’s work on lung cancer has been underway for three years. During previous phases, his team developed the advanced bioinformatics and infrastructure at UAMS that are necessary to handle the large datasets involved in this research, and he brought firsthand knowledge of the latest molecular technologies to UAMS. Johann completed fellowships in hematology oncology and clinical proteomics, both at the National Institutes of Health in Bethesda, Maryland. Johann earned his medical degree at Case Western Reserve University in Cleveland, Ohio. He became a physician as a second career, prior to attending medical school he was an engineering group leader for the Unisys Corp. and worked on advanced avionics projects.

Stephanie Stank Cell: 870.974.3777 ARKANSASMEDICALNEWS





GrandRounds UAMS Celebrates Grand Opening of New Pine Bluff Regional Campus PINE BLUFF – After an eight-month construction project, the University of Arkansas for Medical Sciences (UAMS) South Central Regional Campus in Pine Bluff celebrated its grand opening in a spacious facility on the Jefferson Regional Medical Center campus. The 33,000-square-foot space on the bottom two floors in the Jefferson Professional Building II provides room for the merger of UAMS’ three Pine Bluff clinics along with its physician residency program, a medical library, classrooms and administrative offices. The ribbon-cutting ceremony was attended by Lt. Gov. Tim Griffin; University of Arkansas System President Donald R. Bobbitt; Ph.D. UA System Trustee Stephen Broughton, M.D.; Brian Thomas, president and CEO of Jefferson Regional Medical Center; Sterling Moore, vice chancellor for UAMS Regional Campuses and other dignitaries. The three-story building at the corner of West 40th Avenue and Mulberry Street is 10 years old and has been unoccupied except for a Jefferson Regional clinic on the third floor. UAMS will lease the bottom two floors from Jefferson Regional. In addition to providing patient care, the campus trains family medicine residents and educates nurses, pharmacists and other health professionals. The Pine Bluff campus was first established by UAMS in partnership with Jefferson Regional in 1973. In 2006, an 8,000-sqaure-foot expansion including two annexes was built. The new renovations are the first major facilities changes since that expansion. The Family Medical Center-Pine Bluff provides primary care medical services to patients of all ages — including pediatric care, treatment of immediate medical needs and ongoing management of chronic conditions such as asthma, diabetes, hypertension and arthritis. The clinic also does minor surgical procedures. It serves 11 Arkansas counties: Arkansas, Cleveland, Drew, Garland, Grant, Hot Spring, Jefferson, Lincoln, Lonoke, Prairie and Saline.

Shuk-Mei Ho, Ph.D., Named UAMS Vice Chancellor for Research LITTLE ROCK – Internationally renowned scientist Shuk-Mei Ho, Ph.D., has joined the University of Arkansas for Medical Science (UAMS) College of Medicine as its vice chancellor for research. Ho is a passionate and visionary leader. Shuk-Mei Ho, Since 2005, she was Ph.D. the Jacob G. Schmidlapp Professor and chairwoman of the Department of Environmental Health,




University of Cincinnati College of Medicine. She recruited over two dozen faculty members, and successfully renewed three times an Environmental Health Sciences Center grant named Center for Environmental Genetics (P30), funded by the National Institute of Environmental Health Sciences. She built a Council on Education for Public Health-accredited Public Health Program, ushered in next-generation sequencing and big data science, and brought in close to $40-million extramural funding for research and infrastructure advancement to the university. In 2011, she was appointed director of Cincinnati Cancer Center and later named the Hayden Family Endowed Chair for Cancer Research. She led consortium members in the Cincinnati Children Hospital Medical Center, UCHealth, and the University of Cincinnati work towards the goal of attaining NCI designation. Her national and international network runs deep and broad. Her passion in promoting inter-/crossinstitutional research is reflected in her proven record of building discipline-diverse teams that serve the larger scientific community well in the nation. Her global perspectives and interests is a unique strength for her success as an institutional builder across national boundaries, enjoying productive international research collaborations in multiple countries including Canada, Czech Republic, Denmark, China and Sweden. In total, Ho is a champion for trans-disciplinary collaboration and cross-institutional partnerships, and a true believer of “the whole is always greater than the sum of its parts.” Ho received her bachelor’s and doctoral degree from the University of Hong Kong. Her research interests pertain to the role of hormones and endocrine disruptors, and the interplay between genetics and epigenetics, in disease development as well as how early-life experiences can be a root cause in later development of cancers, asthma, neural disorders and other complex chronic diseases. Her work – published in more than 240 articles – has pioneered the fields of environmental epigenetics and developmental origins of adult disease. Past president of the Society for Basic Urological Research, Ho is active in the American Urologic Society, Endocrine Society, Society for Basic Urologic Research, Society of Toxicology, and American Association for Cancer Research. She chairs countless scientific reviews and policy committees for the National Institutes of Health and the U.S. Department of Defense. She is a former member of the Integration Panel of the Department of Defense Congressionally Directed Prostate Cancer Research Program and the National Academy of Science Committee of Emerging Science for Environmental Health Decisions. Ho serves as a charter member of the National Advisory Environmental Health Sciences (2016-2020)

and a member of the External Expert Panel for the O’Brien Urology Research Centers (U54). In 2007, the Ohio Senate, during its 127th General Assembly, recognized Ho’s research linking chemical exposure while in the womb and prostate cancer development later in life as an Outstanding Achievement and honored her as one of Ohio’s finest citizens. She also received the Women in Urology Award from the Society of Basic Urologic Research and the Society of Women in Urology in the same year. Ho won the first Mentor of Excellence Award from the Prostate Cancer Foundation in 2013. She was recognized by the University of Cincinnati with the 2015 George Rieveschl Award for Distinguished Scientific Research, and by the College of Medicine with a Lifetime Achievement Award. In 2017, she also received the Daniel Drake Medal, the highest honor awarded by the College of Medicine based on outstanding achievements in biomedical science.

several peer reviewed journal articles and has participated in several breast imaging reader studies ranging from computer aided detection to digital breast tomosynthesis. Dr. Smith-Foley earned her medical degree from the University of Arkansas for Medical Sciences. Board certified in diagnostic radiology with a subspecialty in breast imaging, she completed her radiology residency at the University of Tennessee Graduate School of Medicine in Knoxville, Tennessee. She completed her fellowship in breast imaging at the Fred Hutchinson Cancer Research Center at the University of Washington in Seattle, Washington. She earned her bachelors of science in biology from University of Central Arkansas in Conway, Arkansas, where she now serves as a member of the UCA Foundation Board. Patients do not need a physician referral to visit The Breast Center at CARTI. To make an appointment, call 501.537.MAMO or visit

Dr. Stacy A. Smith-Foley Named Medical Director at New Breast Center at CARTI LITTLE ROCK – CARTI has announced the opening of The Breast Center at CARTI. From routine mammography screenings to the early detection and treatment of breast cancer and benign breast disease, The Breast Center provides comprehensive breast care services in a tranquil, spa-inspired environment. The Breast Center will open in June 2019 and be located at 8901 CARTI Way, Little Rock. The Breast Center will feature leading-edge 3D screening mammography, high resolution breast MRI, more comfortable exams with the SmartCurve paddle and Mammopad, risk assessment and genetic testing, diagnostic mammography, ultrasound and breast needle biopsies. In addition to offering screening and diagnostic services, The Breast Center will provide an unparalleled experience including dedicated front door parking, personal iPad check-in, private dressing rooms and soft waffle-weave robes in each mammogram suite, and same day scheduling and results for diagnostic patients. The Breast Center will be led by Stacy Smith-Foley M.D., a dedicated breast imager with more than a decade of clinical experience in Arkansas, Oklahoma and South Carolina. Smith-Foley is a leader in her field as an active member of the HologStacy Smithic Scientific Advisory Foley M.D. Board, the Society of Breast Imaging and the National Consortium of Breast Centers. She is on the speaker’s bureau for Myriad Genetic Laboratories, Inc. Dr. Smith-Foley has co-authored

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