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FOCUS TOPICS CARDIOLOGY HEALTH LAW

January/February December 2015 2009 >> $5

PHYSICIAN SPOTLIGHT PAGE 2

Randy Jordan, MD ON ROUNDS Proposed Penalties for Medicaid\Medicare Overpayments Could Bankrupt Some Providers False claims could cost $11,000 each plus three times the amount of the claim Medicare and Medicaid abuse by providers takes away billions of dollars of taxpayer money that is meant to provide vital medical care. But a new proposed regulation from the U.S. Department of Health and Human Services Office ... 3

Westside Free Medical Clinic: Still Serving Those in Need After 45 Years LITTLE ROCK--When the Westside Free Medical Clinic was launched around 1970 through Catholic Social Services (now Catholic Charities of Arkansas), it had a simple yet vital mission: Meet the critical medical needs of poor people with little or no access to healthcare ... 5

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Arkansas Heart Hospital Implants State’s First CardioMEMS Device New diagnostic tool for congestive heart failure promises great improvement in treatment By BECKY GILLETTE

Congestive heart failure (CHF) is one of the most difficult conditions to treat, and also the most expensive medical diagnosis resulting in the highest costs to Medicare in the United States. The American Heart Association estimates there are $31 billion in annual direct and indirect costs in the U.S. At the current rate, treatment costs are expected to double by 2030. “If we don’t rein this in, the average cost per taxpayer could be $244 per year in 2030,” said Stephanie Spencer RN, BSN, CHFN, the CHF clinical coordinator at the Arkansas Heart Hospital Clinic (AHHC), Little Rock. About 25 percent of all heart failure admissions will be back in the hospital within 30 days. That is because the disease is so difficult to manage. In mid-November, a new device called CardioMEMS HF System that (CONTINUED ON PAGE 6)

HealthcareLeader Daniel Knight, MD Chair, UAMS Department of Family and Preventive Medicine By BECKY GILLETTE

The shortage of family and primary care doctors in Arkansas has become an even more critical problem with 219,000 people added with the private option expansion of Medicaid in Arkansas, many of whom were without access to healthcare in the past. Addressing the need is going to take more equitable reimbursement for primary care, said Arkansas Academy of Family

Physicians (AAFP) President Daniel Knight, MD, Garnett Chair and chair of the Department of Family and Preventive Medicine at the University of Arkansas for Medical Sciences (UAMS). “With more primary care doctors needed in our system because of the Affordable Care Act (ACA), I hope to continue to promote family physicians getting more of what they need in the way of financial resources to adequately (CONTINUED ON PAGE 8)

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PhysicianSpotlight

Randy Jordan, MD Chief Medical Officer, Jack Stevens Heart Institute By BECKY GILLETTE

Randy Jordan, has been part of a twofold revolution in cardiology. In addition to the tremendously significant improvements in cardiac patient care in the past 30 years, the management of cardiology practices has also changed significantly. Jordan is president and one of the founding members of CHI St. Vincent Heart Clinic Arkansas, the largest cardiology practice in the state. Over the past couple of decades there has been ongoing consolidation in many medical practices, particularly in specialties. “We merged some groups and added new members and became a 30-physician group,” Jordan said. “More recently we have followed a national trend and aligned with a hospital to deal with falling reimbursement and to meet the demands of medical care today. Since our integration with CHI St. Vincent Health System three years ago, we have partnered with four cardiovascular surgeons and formed the Jack Stephens Heart Institute at CHI St. Vincent.” Being a larger group has allowed them to hire professional management, and to effectively deal with the regulatory environment of modern healthcare. It has also improved the access to capital needed to move into Electronic Health Records (EHRs) and purchase very expensive

equipment. Jordan said call has also improved compared to the days when two or three partners had to handle everything. As chief medical officer for the Jack Stevens Heart Institute, Jordan spends about half of his time doing administrative work. “The challenges of healthcare today

are that it is very difficult for hospitals to meet the quality expectations in the environment of reduced reimbursement, and the only way they can do that is by having the cooperation of physicians,” Jordan said. “We integrated with CHI St. Vincent with a focus on helping bring improved quality to CHI St. Vincent and the patients whom we serve while at the same time reducing cost and improving value.” The practice of medicine is really challenging today. Nationwide, hospitals are having a tough time. Some hospitals in Arkansas have closed and many of the smaller hospitals are particularly challenged. Some of those are looking to the bigger hospital systems to collaborate with or manage their hospitals. CHI St. Vincent is owned by Catholic Health Initiatives (CHI), one of the largest hospital systems in the country. Jordan and his colleague, Marsha Atkinson, vice president of cardiovascular services at CHI St Vincent, work on a national level within CHI to bring consistency and quality to cardiovascular services at all CHI hospitals while at same time trying to contain spending by using cost effective equipment and devices, and sharing best practices to accomplish those goals. Jordan has seen a huge evolution in cardiovascular care during the 30-year span of his career. Coronary angioplasty was just starting when he was a fellow.

There have been life-saving innovations including the development of coronary stents, internal defibrillators and percutaneous valve replacement, as well as a host of drugs to treat hypertension, hyperlipidemia and heart failure. “Open heart surgery had just gotten well established when I started,” Jordan said. “Since then we have seen some decline in the need for open heart surgery because of the rise of percutaneous procedures. These procedures represent a revolution for the patient in terms of their time for recovery and have tremendously reduced costs.” Thirty years ago someone might have been hospitalized three days for a heart procedure that today takes only a couple of hours. Today there are a lot of changes going on in the field of medicine, and much of it has been focused on controlling costs and implementing best practices. “The pressures to reduce cost and improve quality have caused a huge amount of stress in the system,” Jordan said. “I don’t see that changing for quite some time. I think we will have these pressures for several years to come.” While Jordan’s family is from Hot Springs, he lived in many places growing up with a father in the Air Force. “But Arkansas has always been home as I spent summers with my grandparents,” Jordan said. “My father retired just before I started college and moved back to Hot Springs. I went off to college at Northwestern University in Evanston, Illinois, and then came back to Arkansas to start medical school at the University of Arkansas for Medical Sciences. I’ve been here pretty much ever since.” Jordan has been married nearly 40 years to Janet Bossard, the sister of his college roommate in Illinois. Her father was a physician in Indiana. “I found what he was doing was really interesting,” Jordan said. “It looked a lot more interesting than biophysics, which was what I was studying before medicine. When I was an intern in internal medicine, cardiology was a big part of that. The cardiology faculty members were people I identified with. There were a lot of interesting things going on in cardiology at the time. I found it fascinating and challenging.” Jordan has served as governor of Arkansas for the American College of Cardiology, and president of the Arkansas affiliate of the American Heart Association. He and his wife live in the country, have two adult children, and enjoy spending leisure time boating on area lakes.

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Proposed Penalties for Medicaid\ Medicare Overpayments Could Bankrupt Some Providers False claims could cost $11,000 each plus three times the amount of the claim By BECKy GILLETTE

Medicare and Medicaid abuse by providers takes away billions of dollars of taxpayer money that is meant to provide vital medical care. But a new proposed regulation from the U.S. Department of Health and Human Services Office of Inspector General (OIG) implementing a portion of the Affordable Care Act (ACA) has caused alarm in the healthcare community because of the draconian penalties involved for failure to return alleged Medicare and Medicaid overpayments promptly. Some estimates of Medicare fraud alone are $80 billion per year. But the new rules could have unintended consequence including putting legitimate healthcare companies out of business for unintentional errors. “My understanding of the proposed regulation is that if an overpayment is not returned within 60 days of ‘identification’ by a provider, the overpayment is subject to false claims liability under the federal False Claims Act (FCA), which would allow recovery of up to Lynda M. $11,000 per claim, plus Johnson three times the amount of money received in payment of the claim,” said Lynda M. Johnson, an attorney with Friday, Eldredge & Clark LLP, Little Rock. “Certainly this is a severe penalty and could bankrupt many providers.” Johnson said the overwhelming majority of overpayments are received not due to fraud, but because of an honest mistake. The stiff penalties seem to come with the underlying assumption that all overpayments are a deliberate attempt to defraud the government. Johnson said the most important thing providers can do to protect themselves from potentially crippling fines is to implement effective compliance programs to focus on improving their billing practices. Most importantly, try to avoid billing mistakes, which can lead to overpayments being received. The atmosphere of declining reimbursements while providers are expected to improve quality and service has added a great deal of strain to manage-

ment of healthcare facilities. It takes attention away from focusing on patients. “Unfortunately, all resources are limited and any resources that must be devoted to additional compliance efforts may result in a decrease in resources available for patient care, a result which is not good for anyone,” Johnson said. “The providers I work with every day are trying to deliver the best patient care they possibly can with a continually shrinking stream of revenue from government payers, while, at the same time, dealing with more and more regulatory burdens.” Providers should be aware that the Department of Justice (DOJ) is closely monitoring these issues and recently intervened in an action filed in New York, said P. Delanna Padilla, an attorney with Wright Lindsey & Jennings, Little Rock. “The ACA has a P. Delanna defined 60-day period Padilla in which overpayments must be reimbursed to the government,” Padilla said. “A provider’s failure to so reimburse could lead to stiff penalty assessments and can be considered a violation of the FCA. This provision of the ACA is being taken seriously and will become of great concern to providers who repeatedly fail to reimburse the government for overpayments.” If providers fail to comply with the repayment rules under the ACA, they face the potential penalty of being banned from billing Medicare or Medicaid. Padilla said this would have catastrophic consequences to most providers. Additionally, the penalties themselves can stack up all too easily. While many consider the penalty amounts to be excessive, Padilla said providers should be prepared to pay those types of sums if they knowingly and willingly withhold repayment. There is concern that the new rule is an attempt to make healthcare providers settle cases rather than risk penalties that could bankrupt their organizations. Healthcare providers are keeping an eye on the first complaint under this proposed rule that was filed by the New York State Attorney General’s office charging Healthfirst with failure to return overpayments.

Padilla said the big issue in this case is that the hospital network, Continuum, which accepted patients covered by the Healthfirst Medicaid managed care plan, did not repay 300 overpayment claims until it received a demand concerning the overpayment. The DOJ intervened in the case and took the position that Continuum intentionally and fraudulently delayed the repayments as Continuum had undertaken an internal review and uncovered more than 900 improperly billed claims totaling more than $1 million in overpayments. “Although Continuum had begun making repayments, the DOJ’s position was that the internal review occurred in February 2011 and repayments were not completed until March 2013,” Padilla said. “This amount of time is obviously well beyond the 60-day repayment period. The DOJ further alleged that Healthfirst, because of its billing practices, caused Continuum to submit erroneous

claims to Medicaid, which were the basis for the overpayments. When the DOJ intervened in this action, the maximum penalty under the FCA was requested ($11,000 for every improper overpayment, plus treble damages). Thus, the proposed amount of the fine was almost $30 million.” Providers need to initiate compliance programs, if they do not already have them, to ensure that the billing is performed properly and accurately. “Although the possible penalties could be astronomical, providers need to be able to trust that their billing is being performed accurately and timely,” she said. “If they have compliance programs in place, then generally this potential headache would be avoided. Providers and their employees need to be fully aware of the potential for audit, either under ACA or HIPAA. Compliance truly is no longer discretionary; it is mandatory.”

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Hot Button Legal Issues to Watch in 2015 By CINDy SANDERS, ELISABETH BELMONT & JOEL HAMME

Already one of the most highly regulated industries in America, 2015 looks to be another active year across healthcare’s legal landscape. Two past presidents of the American Health Lawyers Association, Elisabeth Belmont and Joel Hamme, took time to share insights and predictions for the coming year. Subsidies in the Health Insurance Exchanges Under the Affordable Care Act, individuals with incomes between 100 and 400 percent of the federal poverty level are eligible to receive federal tax credit subsidies for purchasing health insurance on the exchanges. Hamme noted that in King v. Burwell, the Fourth Circuit court ruled the IRS acted lawfully in interpreting such subsidies were permissible not only for state exchanges but also for federally run exchanges and those that are a federal-state partnership. However, the Supreme Court has agreed to review this decision. Hamme explained, “Of the 50 states and the District of Columbia, only 17 have state established exchanges; 7 have partnership exchanges and the remaining 27 are federally operated. Thus, if the Supreme Court were to overturn the Fourth Circuit’s decision, individuals in two-thirds of the 51 jurisdictions would be ineligible for subsidies for purchasing health insurance on the exchanges.” He added that while there was some debate as to how detrimental such a decision would prove to be to the ACA, certainly it would be a major setback. “The King case essentially represents the last major legal hurdle for the ACA. If the subsidies challenge fails, ACA opponents will be relegated to trying to repeal or significantly modify the ACA by legislative and executive branch actions.” Medicaid Eligibility Expansion Since the Supreme Court ruling that mandatory Medicaid expansion wasn’t permissible, 29 states voluntarily have authorized Medicaid eligibility expansion or obtained federal approval of an alternate expansion plan to take advantage of generous federal financial support tied to the program. However, Hamme pointed out, the 2014 election results impacting governorships and state legislatures seem to have strengthened the numbers of those opposing such expansion in several states that were still weighing the options. “In at least one state, it is conceivable that Medicaid eligibility expansion will be rescinded after having been implemented,” he said. Hamme continued, “For 2015, the key Medicaid eligibility expansion development will be whether the slow erosion of state opposition to expansion continues as states decide that they do not want to forego the financial advantages of expansion or whether this erosion is abated by those fiercely opposed to the ACA.” He 4

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About the Experts Elisabeth Belmont, Esq. serves as corporate counsel for MaineHealth, ranked among the nation’s top 100 integrated healthcare delivery networks. She is a member of the Board on Health Care Services for the Institute of Medicine and its Committee on Diagnostic Error in Health Care. Belmont is also a member of the National Quality Forum’s Health IT Patient Safety Measures Standing Committee. In addition to serving as a past president of the American Health Lawyers Association, she is also the former chair of the organization’s HIT Practice Group and the current chair of the Inhouse Counsel Program. In 2007, Modern Healthcare named her to their list of “Top 25 Most Powerful Women in Healthcare.” Joel Hamme, Esq. is a principal with Powers, Pyles, Sutter & Verville in Washington, D.C. He joined the firm in 1998 and focuses his practice on long term care, Medicare and Medicaid reimbursement issues, provider licensure and certification matters, and litigation in his areas of expertise. He is a member of the District of Columbia and Pennsylvania bars, as well as the bars of the Supreme Court of the United States and numerous federal appeals courts. A past president of AHLA, Hamme is a frequent speaker and lecturer on healthcare issues and has authored numerous articles and book chapters relating to healthcare law.

added it will be interesting to see how flexible the federal government might be with respect to work and work search requirements and beneficiary cost-sharing obligations for states that are seeking waivers for alternate expansion models. ACA Going Forward As Hamme pointed out, the ACA has already generated several legal decisions and navigated a number of political and operational obstacles in its relatively short life. However, a number of hurdles … including the decision on exchange subsidies and the law’s unpopularity among large swaths of the public … remain. “During 2015, interested observers should look to various barometers to assess whether the ACA is working … and equally important … whether it is gaining the public acceptance needed to assure its political survival,” Hamme said. He added some of those measures would include the administration of the exchanges, whether offerings to consumers were deemed acceptable in terms of plan choices and affordability, a continued decline in the number of uninsured, and whether or not the ACA could continue to withstand legal and political assaults. “Like 2013 and 2014, the coming year will witness numerous developments that will lead either to the ACA’s longterm viability or its premature demise,” Hamme concluded. Fraud and Abuse On Oct. 31, 2014, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released the FY-2015 Work Plan. Always eagerly anticipated, the document gives insight into the OIG’s planned reviews and activities with respect to HHS programs and operations. Belmont noted, “In the introduction to the Work Plan,

OIG stated that, in the coming year, the agency plans to continue to focus on issues such as emerging payment, eligibility, management, IT security vulnerabilities, care quality and access in Medicare and Medicaid, public health and human services programs, and appropriateness of Medicare and Medicaid payments.” Belmont highlighted a few areas of interest for this year: Hospitals: With 22 substantive areas under review, the OIG is deeply engaged with hospital reviews both on the billing and payment side, and quality of care issues, which are a particular priority for current Department of Justice (DOJ) and OIG enforcement efforts. OIG continues to scrutinize CMS contractors’ implementation of outlier reconciliation (of which the OIG has been critical for many years) and remains intensely interested in inpatient versus outpatient payments, the “two midnight” rule for inpatient admissions, and cardiac catheterizations. Hospice: Hospice billings for general inpatient care, a focus of relators and the DOJ, is under close review by the OIG. Freestanding Clinic Providers: OIG continues to examine certain payment systems such as provider-based services and freestanding clinic payments, with an eye toward reducing disparity of payments based on site of service. Laboratories: OIG added a review of independent clinical laboratory billing requirements, without further specifying the billing requirements at issue. This may coincide with increased local coverage determinations by contactors, OIG enforcement against clinical laboratories under its Civil Monetary Penalties Law authority, and OIG’s general heightened scrutiny of technical billing and payment compliance by clinical laboratories, especially specialty laboratories. Accountable Care Organizations: OIG

intends to conduct a risk assessment of CMS’ administration of the Pioneer ACO Model. Medicaid Managed Care: OIG added a review of state collection of rebates for drugs dispensed to Medicaid managed care enrollees. Medicare Part D: This is an area where there will be continuing scrutiny of the quality of Part D data submitted to CMS. The OIG also plans to follow up on the steps CMS has taken to improve its oversight of Part D sponsors’ Pharmacy and Therapeutics Committee conflict-of-interest procedure in the wake of the OIG’s critical 2013 report. Health Information & Technology “Data now is recognized as one of a healthcare organization’s most valuable assets, especially as a result of the transition to a more analytically driven industry,” Belmont said. “Given the increasing importance of data to a healthcare organization, it is advisable for the organization to implement appropriate data governance best practices.” With the accumulation of data also comes an obligation to make sure protected health information (PHI) stays protected. “In 2015, healthcare privacy and security compliance will continue to expand with respect to the scope, number of enforcement bodies and increased enforcement activity, and overlapping sets of requirements,” Belmont said. “In addition to the requirements of the HIPAA Privacy and Security Rules, healthcare providers also will need to navigate requirements promulgated by the Federal Trade Commission, Centers for Medicare and Medicaid Services, Office of the National Coordinator, and state attorney generals. Additionally,” she continued, “increasing exposure for privacy and security breaches may occur as the result of state common or statutory law, despite there being no private right of action with regard to HIPAA violations. As a consequence, healthcare organizations and practitioners need to manage the complex daily operational processes required to maintain appropriate privacy and security of protected health information and devote necessary resources to ensure regulatory compliance.”

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ARKANSAS on the MEND

BY BECKY GILLETTE

Westside Free Medical Clinic: Still Serving Those in Need After 45 Years By BECKY GILLETTE

LITTLE ROCK--When the Westside Free Medical Clinic was launched around 1970 through Catholic Social Services (now Catholic Charities of Arkansas), it had a simple yet vital mission: Meet the critical medical needs of poor people with little or no access to healthcare. “Sister Concetta Mazzetti was the force behind establishing this mission,” said Clinic Director Karen DiPippa, a pharmacy technician who has a background in health education, and a master’s degree in theology. “It originally stared as an acute Westside Free Medical Clinic is run by Director Karen DiPippa (left) and Flora Lopez, program assistant. care clinic. We soon found out Free clinics like Westside wouldn’t that it doesn’t help to have the clinic if patients simply don’t qualify for exist without the generosity of the medical tients don’t have access to prescriptions. healthcare insurance. That community. So we started a charitable licensed pharincludes students, and visit“I cannot praise or thank our volmacy, as well.” ing family. We have tried to unteers enough for their gift of service,” Through the years thousands of peomeet the needs of the time. DiPippa said. “We rely on physicians, inple have come through the doors for needs Right now it is the greatest cluding specialists, pharmacists, RNs and as simple as a sinus infection or treatment need for patients with no in- Chris Williams, a valued volunteer and Flor Lopez, program assistant. APNs who all take time from their busy for illnesses like diabetes that can be fatal surance. They can’t even get lives to help others. They all do so much. if not properly treated. Today, the clinic that would mean coverage for all, DiPippa their foot in the door.” We could not do anything without the volsees about 1,265 patients per year for sersaid the ACA isn’t enough. The clinic has seen patients die beunteer staff. They are really the heart of the vices including primary care, pharmacy “We have sort of had health insurcause they didn’t get timely care. clinic. We also get assistance from students services and patient education. ance reform, but not true healthcare re“Over the years, we have seen pafrom the University of Arkansas for MediWestside holds five regular clinics form,” DiPippa said. “Healthcare costs tients without health insurance who did cal Sciences School of Medicine, College a month, and specialty clinics such as a have escalated just ridiculously from not want to incur the debt of an emerof Nursing, and School of Pharmacy, in dermatology clinic and eye exams for diawhen I started. I’ve seen medicines that gency room which they couldn’t pay and addition to students from the University betic patients. Westside also contracts out were a manageable price, and somehow suffered early death for conditions easily of Arkansas Little Rock School of Nursdental services when funding from the Toin these last 20 years have quadrupled in treated,” she said. “These patients had ing. Our pharmacists have a time intensive bacco Settlement funds through the Arprice. These medicines cost only pennies families that depended on them, were shift because they are at the clinic the latest, kansas Department of Health allows. The to make it 20 years ago, and now they cost working, yet didn’t have employer covfilling prescriptions after the patients have Diocese of Little Rock funds the remainfour times as much.” ered insurance. We had a patient treated seen the doctor or APN.” ing costs to run the clinic. Ellen Lamb, PD, has been a pharmafor hypertension who also had stage four It is an all-volunteer staff except DiPcist volunteer at the clinic since 1973 when melanoma. We were able to diagnose and ippa and her “right hand,” program asher son was only a year old. Over the refer her to a specialist, but it was too late. sistant Flora Lopez, who is bi-lingual. Her years she has gotten tremendous satisfacWe’ve also seen a patient driving to get an main responsibility is to work with the tion from helping people who fall through inhaler die of an asthma attack by hitting Hispanic\Latino community and handle the cracks. For example, some are over a tree on the way. That shouldn’t happen the eye and the dermatology clinic staffthe limit for drugs on Medicaid. with the advances we have in medicine.” ing and scheduling. She is assisted by 15 “Hopefully with ACA, that has DiPippa said she couldn’t praise the Volunteer volunteer interpreters, most of whom are changed,” she said. Affordable Care Act (ACA) enough beMore specialists are needed certified as medical interpreters. With her busy work schedule, how cause it has made a difference in people in areas such as ENT, neurology, As the Hispanic population has inhas she found time to volunteer for so having access to life-saving care. She hopes gynecology, and orthopedics. creased in Little Rock, there has been a many years? that Arkansas continues the private option Medical volunteers in all spedemand from Hispanic Latino families. In “It is one of those things that when Medicaid expansion because the lives of cialties are always needed. If you 2002 Westside started one clinic a month the clinic director Sister Concetta was the 211,000 covered people are at stake. aren’t close to Little Rock, there for the Hispanic\Latino families. calling to get me to work, it was the Lord The private option is in doubt because of are approximately 20 other chari“With the ACA, 75 percent of our calling me, so how could I say no?” Lamb the number of legislators who campaigned table clinics across the state where English-speaking patients were able to obasked. “So that is why I’ve been doing it against it who were elected. Opponents you can make a difference voluntain insurance,” DiPippa said. “We were all these years. When you see how much have said that while the program costs teering. See Arkansas Association really happy about that. That is a good what we are doing means for people, it is nothing to the state now, in future years of Charitable Clinics. thing. We still have some people who, for a very rewarding situation.” when the state is required to pay a portion one reason, or not aren’t covered. They of the cost to subsidize premiums, it could Donate might be new to the area, in between be too expensive. But DiPippa said she Westside Free Medical Clinic To Learn More: Go online to coverage, or maybe they have been acunderstands the state would be allowed to Diocese of Little Rock Arkansas Charitable Clinics, cepted for the private option Medicaid opt out later if it gets too expensive. P.O. Box 7239 expansion, but have not found a provider. While all charitable clinics would be www.aacclinics.com Little Rock AR 72217-72239 But a large percentage of immigrant pavery happy to be out of business because

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Arkansas Heart Hospital Implants State’s First CardioMEMS, continued from page 1

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promises to help better manage fluid status in heart failure patients was implanted into the first patient in Arkansas. Wilson Wong, MD, did the procedure at Arkansas Heart Hospital. Clinical trials indicated CardioMEMS reduced hospital readmissions by 37 percent. CardioMEMS consists of an implantable pulmonary artery (PA) sensor, a delivery system, and Patient Electronics System. The sensor about the size of a paper clip has a thin, curved wire at each end, and Stephanie Spencer RN, BSN, CHFN Arkansas Heart Hospital Clinic (AHHC) Congestive Heart Failure (CHF) Clinical requires no batteries or wires. Coordinator and Michael Huber, MD, Medical Director of AHHC It is implanted during a right CHF Clinic, believe that the new CardioMEMS system will heart catheterization procedure improve their ability to treat patients, resulting in fewer hospital for permanent placement. The readmissions and far lower costs. delivery system is a long, thin, flexible catheter that moves These are the most labor-intensive through the blood vessels and is designed patients in a medical practice, Huber said, to release the implantable sensor in the far and this device can help simplify their asend of the PA. sessment. Spencer said by monitoring the PA Indications for the device call for the pressure and heart rate in NYHA Class III patient being diagnosed with stage three heart failure patients, the tool gives cliniCHF and one hospitalization for CHF in cians valuable objective information about the past 12 months. the fluid load in the heart. Implantation is pretty simple through “This is a most important tool that the groin. Huber said once the device is can help us address the readmission rate,” put in, the patient can take readings at Spencer said. “Without a tool like this, home by using land line or cellular connecwe must rely on the patient’s ability to tions to send a few minutes of pulmonary or compliance with weighing themselves pressure readings to the website. When every day, or calling us if they feel bad. clinicians see that heart failure is getting Patients can swing back and forth from worse, more diuretics or other heart failhaving fluid overload to being dehydrated. ure medications can be introduced. Sometimes patients don’t know if they are “Initially patients take readings once a overloaded or not. They will call and say day, but once they are stable, readings can they just don’t feel good. They might have be taken once a week,” Huber said. “Carother issues like pneumonia or pleural dioMEMS helps our team keep heart faileffusions. This device lets us know if it is ure patients out of the hospital and allow heart failure or not, and how to treat it them to have a meaningful and good qualmore effectively. It gives us objective data ity of life.” about how to treat a patient.” The clinic sees patients from all over With the Affordable Care Act (ACA), the state. hospitals can receive penalties of up to “We manage large numbers of pathree percent of Medicare revenue if they tients,” Spencer said. “A lot of my patients fail to keep within the bounds of national can’t make it to Little Rock. It is really bur30-day readmission rates for CHF, which densome for them to get to me. With this now is at 23 percent. device, we have the potential to manage pa“The ACA shifted the focus to quality tients farther away by coordinating patient control instead of volume management,” lab results with family doctor visits.” she said. Spencer said it is really exciting to see The device is revolutionary, said Mithe potential outcomes from using this tool chael Huber, MD, director of the AHHC that can save lives, including decreased CHF Clinic. costs to taxpayers and better health for “This is an early warning system,” patients. Huber said. “It will revolutionize the way “Each time heart failure patients go we manage heart failure patients. We can into the hospital, their prognosis worsens,” catch them before they get so bad they she said. “We know if they are going into have to go into the hospital. It can give us the hospital over and over, they will not do the earliest indication heart failure is startwell. On average if a CHF patient has four ing to go in a bad direction. Class three hospitalizations in a year, that gives them a heart failure patients are having sympmean survival rate of only six months. If we toms like shortness of breath every day are able to better manage them with this just doing what they need to do to live a device and keep them out of the hospital, life. These patients are hard to manage betheir prognosis would ostensibly improve.” cause even when they do all they can like watching their weight and their diet, they often wind up coming back into the hospiFor more, visit: www.arheart.com tal because they can’t get it right.” arkansasmedicalnews

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Opposition Persists on Mandatory Flu Shots for Healthcare Workers UAMS Medical Center sees 92 percent compliance with flu shot By BECKY GILLETTE

Less than half of U.S. residents received the influenza vaccine shot this past year, some because of doubts about its effectiveness and concerns about potential side effects. But some healthcare workers who decline the flu shot are finding that it could cost them their job. More than a 1,000 healthcare workers in Rhode Island signed a petition protesting the state’s strict law for flu vaccinations for healthcare workers, claiming this violated the HIPAA patient privacy law. A pregnant nurse in Chicago filed a wrongful termination lawsuit in 2013 after she was fired for refusing the flu shot. But that case was dismissed by the court. University of Arkansas for Medical Sciences (UAMS) Medical Center CEO Roxane A. Townsend, MD said they receive few complaints from workers because most understand that this is a requirement of employment, just as is being immunized for Hepatitis B and measles. There are workers who don’t take the flu shot for health reasons such as allergies to eggs or formaldehyde. They aren’t fired, but must wear a facemask. “Wearing a mask is difficult for the caretakers, but our primary concern is to protect patients and other employees,” Townsend said. “We don’t want someone to come to work and potentially transmit that virus before they have realized they have the flu.” Townsend doesn’t consider the requirement a violation of HIPAA. Often patients and staff wear masks for many reasons. “At a teaching facility like this where there are many students and faculty, there is not a bright line between those who have direct interaction with patients and those who don’t,” Townsend said. “So we encourage everyone to take the flu shot. This year we had 92 percent compliance with all our employees, which total more than 10,000. The only employees who don’t get vaccinated are those who have a reason not to. We are pretty impressed with our compliance rate.” Hospitals without at least a 90 percent compliance rate can be penalized, since it is one of the quality measures that affects reimbursement by the Centers for Medicaid and Medicare Services. Minor side effects can include arm soreness and a slight increase in temperature. More serious concerns are an allergic reaction or contracting Guillain-Barré Syndrome (GBS), which results in the body’s immune system attacking part of the peripheral nervous system. GBS can lead to paralysis. “We have much better diagnostic capabilities now and better supportive care for GBS,” Townsend said. “Many people do recover from GBS.” Jennifer Dillaha, MD, medical director for the immunization program at Arkansas Department of Health, said the risk of GBS arkansasmedicalnews

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from the flu vaccine is one in a million vaccinations. There is a higher risk of GBS from flu than from the flu shot. “There was a Canadian study published last year in The Lancet Infectious Diseases that found that the risk of GBS was 15.81 times more likely with influenza illness compared to the risk with influenza

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vaccine,” Dillaha said. “Of all the GBS cases, 1 percent was found to be caused by the influenza vaccine, while 17 percent were found to be caused by influenza illness. The remainder was caused by a variety of other causes.” For healthcare workers and others with an egg allergy, Dillaha recommends an

D E E P

egg-free formula that is approved for adults through age 49. But many allergists and primary care providers are giving the standard inactivated flu shot to people with a history of egg allergies. “Even though egg is listed on the ingredients, it is present in only trace amounts, (CONTINUED ON PAGE 8)

B R E AT H . . .

C A R T I C A N H E L P Y O U B R E AT H E E A S I E R .

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Opposition Persists, continued from page 7

Healthcare Leader: Daniel Knight, MD,

and most people don’t react to it,” Dillaha said. “If you are concerned about it, see an allergist or primary care doctor with experience in the recognition and management of severe allergic conditions. They can you give the shot and then monitor you for 30 minutes. Once you have safely received the shot, you can feel confident about getting it the next year.” The U.S. government has a National Vaccine Injury Compensation Program created to pay for illnesses caused by vaccinations. But an AP article in November 2014 concluded that the program is overwhelmed with delays in receiving compensation stretching ten years or longer. The fund was established primarily for children injured by childhood vaccinations, but now is dominated by people who got GBS after receiving the flu shot. Also controversial is the effectiveness of the vaccine that is manufactured ahead of the flu season before it is certain which flu viruses will dominate. In years where this is a good match between the vaccine and the strains of flu in circulation, the flu vaccine is 50 to 70 percent effective in preventing the disease. If you do get the flu, the vaccine greatly reduces the risk of severe illness. Studies have shown that vaccination is associated with approximately a 70 percent reduction in flu-related hospitalizations for adults and an 80 percent reduction in flurelated deaths.” Dillaha said that in the 2013-2014 flu season the FluMist nasal vaccine was not effective against the predominant H1N1 virus.

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For more, visit: www.cdc.gov/flu/

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The strain included in the vaccine was not a good match for the circulating flu strain. “The manufacturer is looking at trying to understand why that has happened, whether it was a flaw in the manufacturing of their vaccine or some other reason,” Dillaha said. Healthcare workers being required to get the immunization is a patient safety issue that Dillaha considers on par with washing your hands. It just makes sense. In addition to the dangers of employees transmitting a virus, often healthcare facilities are short staffed. “Employees have pressure or personal drive to come into work when they are not well because there are very sick people that we need to take care of,” Dillaha said. “Although we may not feel sick enough to stay home, sometimes we still have the flu. If people are partially immune to the flu, they may not have such a severe case that they would be too sick to come to work. But they could still be contagious.” Healthcare workers are at an increased risk for being exposed to the flu because of the people served. And if there is influenza pandemic, every healthcare worker will be needed. “We really need the healthcare workforce immunized because many times the pandemic will show up in an unpredictable way,” Dillaha said. “Healthcare professionals need vaccines in order to take care of the sick population.”

care for their patients,” Knight said. “It is problematic that Congress, Medicare and private payers have not been willing to fully support primary care to the extent that is needed to provide chronic and preventive care. Over the past two years, we have seen projects such as AR Medicaid Patient-Centered Medical Home Project and the Medicare Comprehensive Primary Care Initiative that have begun to do this, but it hasn’t been as universal as it needs to be. “We will continue to try to increase the number of medical students choosing family medicine and family care as their specialty. It has been dropping since 1998 when the previous gatekeeper role was rejected.” Knight said family doctors are now seeing patients who have been uninsured for years getting critical care for illnesses such as hypertension and diabetes control. But having services covered by insurance is of no value if patients can’t find a family doctor. UAMS has seen a small, but significant, uptick in the past couple years in interest by medical students in family medicine, and a significant increase in the number of applications to family medicine residencies in the state. Knight said UAMS is also working with the two osteopathic medical schools in the state to increase the number of graduate medical slots, especially for primary care. A large number of family doctors are nearing retirement age and will need to be replaced. That could increase primary care shortages from what they are today, which is estimated at greater than 500 statewide, with the problem especially acute in rural areas. “Most rural areas have a lot of Medicare\Medicaid patients, so reimbursement is not as good as in urban areas where there are more people with commercial insurance,” Knight said. “Therefore, trying to keep a rural practice open is hard. There are many considerations for physicians locating in a rural area. Are the schools good? Are there enough things for the family to do? You have to consider the whole family, not just the physician.” Knight said UAMS has not always had a focus on primary care. In the past, there has been more effort placed on tertiary care. But Knight said both at UAMS and nationally, there is increased recognition of the importance of primary care. “UAMS is building several new family medicine clinics in Central Arkansas,” he said. “We are soon going to open another outlying clinic. We also want to affiliate with other providers throughout the state to be partners who can help make their practices grow and thrive. We can offer help with services for things like management and Electronic Health Records (EHRs).” To help promote the Primary Care Medical Home (PCMH) initiative, the AAFP has been working with Community Care of North Carolina to help develop an organization in Arkansas to provide care management assistance to practices. The

academy is also exploring how to improve working with Advanced Practice Nurses (APNs). “We believe APNs are a very important part of the team who should be included,” Knight said. “We also believe APNs should be supervised by physicians. We want them to be in a team. A lot can be done with physicians supervising rural APNs virtually with telecommunications. But a barrier is that we are finding many APNs don’t want to practice in rural areas, either. They have the same issues as physicians.” Knight came from a family with a lot of bankers, but he didn’t find business very fulfilling. He loves working with people, and has an aptitude for science. He felt like medicine was a merger of those two things. “Medicine is very stimulating,” Knight said. “I originally chose family medicine because I liked the interactions with people in it and the variety in it.” It was a long road to leadership in family medicine. He earlier worked in private practice and as an ER doctor. After being hired for a job at UAMS, he fell in love with academics even though he took the job at a time of challenges. “We were in dire trouble the minute I walked in door,” he said. “I had to work hard to revamp some procedures. I got a big taste of leadership, and found I enjoyed it. That is what led me into the chair position.” Knight said his management style initially was top down and domineering. “Then I went to some leadership training and got feedback from my supervisors, and began to change my management style,” Knight said. “Now I feel that I am a very collaborative manager. People don’t work for me; they work with me. I have an idea of what needs to happen, but I let staff members use their skills and assets to be the best they can be. I think overall we are much more successful now with great overall leadership.” UAMS is undergoing reorganization right now. “It is a lot of change,” Knight said. “We are trying to come out with a system that is more patient-focused. We will be providing a large amount of care to a larger patient population. We have developed policies and procedures that flow across the enterprise improving access and services for patients. We have developed a patient portal for EHRs that has been a good thing for patient communication with providers.” One of the accomplishments he is most proud of is taking on a research team when he became chair. That has grown to include five PhD/EdD full-time researchers and a staff of 40 doing research in early childhood development. “We hope to expand more into clinical research in the next few years,” Knight said. Knight was born at St. Vincent’s in Little Rock, and loves traveling when he has the opportunity. In addition to statewide vacations, he has traveled to China, Peru, Africa, Australia and New Zealand. arkansasmedicalnews

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The Secret Suffering of Doctors

Ophthalmologist pens book about the looming crisis in medicine, a remedy for burnout By JULIE PARKER ARKER

Missed family gatherings and soccer games, frustration with bureaucracy, dwindling self-worth and utter exhaustion often overshadow the initial call to heal others. In the environment of protracted work days, countless rounds, scarce breaks, and pagers ringing incessantly have led many physicians to opt for early retirement, second-guess their chosen profession, and/or suffer professional burnout. Alarmingly, more than 400 doctors commit suicide annually; the suicide rate is four times higher for women physicians than women in other professions. According to a recent Medical Economics survey, more than one-third of physicians reported that if they could go back in time, they would choose a different specialty – or a different career altogether. With an estimated 90,000 too few physicians practicing by 2020, America’s doctors will continue to work overtime to meet the demand. “Most of us followed a calling to serve others Dr. Starla through practicing mediFitch cine,” said Starla Fitch, MD, author of Remedy for Burnout: 7 Prescriptions Doctors Use to Find Meaning in Medicine (Langdon Street Press, 2014). “We’ve dedicated our time, talent and treasure to healing others, but as we (did), many of us forgot how to heal ourselves.” Encountering burnout led to an experience for Fitch, a board-certified ophthalmologist specializing in oculoplastic surgery, which renewed her spirit. One result: she established the popular lovemedicineagain.com, an online community to help medical professionals reconnect with their passion for the practice after surviving life-altering burnout. A featured blogger for Huffington Post, certified life coach and CBS contributor, Fitch wrote Remedy for Burnout to benefit colleagues and doctors-in-training. “The level of burnout among physicians is at an all-time high,” said Fitch. “A great many of my burned-out colleagues are frustrated with the changes in the relationships within medicine.” One such dysfunctional relationship: the tie between doctors and insurance companies. Case in point: a large managed-care network recently removed Fitch’s practice from its list of preferred providers. “Had we not taken good care of our patients? Weren’t we available for those patients 24/7? Did patients complain that arkansasmedicalnews

.com

my partners and I didn’t deliver quality care? No. No. And no. The managed-care network decided to provide the types of services we provide,” Fitch explained. “It opted to move the services in-house to save money, regardless of the consequences to its patients.” The impact of that decision? One affected patient had been diagnosed with eyelid cancer. Surgery had been scheduled to remove the growth, followed by another surgery for reconstruction, Fitch said. “The loss of continuity that has emerged in our healthcare system hasn’t only disrupted our patients’ health,” she said, “it’s disrupted physicians’ quality of care.” Fitch’s personal prescriptions call for doctors to: Develop resilience. Practice faith, which Fitch describes as “front and center faith … the kind we doctors have when we make that first incision and trust we’ll be able to later close the wound.” Cultivate self-worth. “Too often, we see ourselves incorrectly,” explained Fitch. “Instead of looking in the mirror and seeing the specialness we possess, we allow

what we think other people think about us to enter the equation.” Promote creativity. “Your staff has more creative tips up their sleeves than you can imagine,” said Fitch. “Brainstorm with them on ways to improve patient flow, appointment time congestion, or any number of things that will allow for happier employees and healthier patients.” Fitch also included a section on interpersonal prescriptions, encouraging physicians to: Foster support. “’Grinning and bearing it’ isn’t a successful coping mechanism,” said Fitch. “The stigma around doctors asking for help lingers, unfortunately.” Embrace compassion. When Fitch asked a colleague advice he would give his 29-year-old self, the doctor said: “Try to be more empathetic. That’s more important than anything else. Having some idea of a patient’s situation really changes the way you treat people.” Encourage connection, “the spark that ignites when you have a conversation in the doctors’ lounge and you laugh at the same jokes, commiserate over the same wins or losses of sports teams, or offer congratulations or condolences for the highs and lows we all experience,” she said. “These relationships have a profound impact on doctors’ lives and are, therefore, the ones that need fostering.” Going forward, Fitch hopes physicians find their own personal remedy to overcome burnout. She uses “entrain-

ment,” a word from the biomusicology world that means “the synchronization of organisms to an external rhythm, often produced by other organisms with which they interact socially.” “Sometimes when I’m in the OR, I ask the anesthesiologist to slightly turn down the volume of the patient’s pulse oximeter,” she said, “as I can feel my own pulse trying to keep time with the patient’s rhythm.” Fitch encourages physicians to “be brave and reach out to others in the community.” “Together,” she said, “we can all find meaning in medicine.”

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GrandRounds Parkey Named Incoming Executive Director for St. Bernards Medical Group JONESBORO — Lydia Parkey of Jonesboro has been named incoming executive director for St. Bernards Medical Group, the area’s largest voluntary association of physicians. A 2005 graduate of Samford University in Birmingham, Ala., she has a Lydia Parkey Bachelor of Arts degree in journalism and mass communications. Parkey recently moved to Jonesboro from Washington, D.C., where she worked for eight years on Capitol Hill, most recently as the director of scheduling for Sen. John D. Rockefeller IV of her home state of West Virginia. In Jonesboro, she has worked in the office of the president and CEO of St. Bernards Healthcare. Parkey is active in the community as a member of the Downtown Jonesboro Association, the St. Bernards Advocates, the Jonesboro Young Professionals Network and the St. Bernards Women’s Council. Her husband, Justin, is a Jonesboro native and is an attorney at Waddell, Cole & Jones, PLLC. The Parkeys are members of Southwest Church.

Advanced Practice Nurse Joins Sparks Adult Medicine Specialists FORT SMITH – Elaine Thrift, MSN, APN, FNP-BC, has joined Sparks Health System. Thrift specializes in Endocrinology and has extensive experience in the treatment of patients with Type I and Type II Diabetes, including insulin Elaine Thrift pump management and thyroid disorders. Thrift also has more than 25 years of experience in nursing and caring for residents of the River Valley.

Online Event Calendar To submit or view local events visit the Arkansas Medical News website.

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In her free time, the Mulberry, Ark., native enjoys running and training for half-marathons and spending time with her family. Thrift will see patients alongside Doctors Charles and Holly Jennings, Jon Harper, and Richard Hinkle, Jr., at Adult Medicine Specialists. For more information on the services the clinic provides, please call (479) 709-DOCS.

neck surgery in 2012. She completed a fellowship in pediatric otolaryngologyhead and neck surgery at McGill University Montreal in Quebec, Canada in 2013 and one in rhinology and allergy at the University of Pittsburgh Medical Center in 2014. She is a member of the American Rhinologic Society and American Academy of Otolaryngology.

Change of Leadership for Cooper Clinic

South Central Telehealth Forum to be Held March 2

FORT SMITH - A change of leadership has been announced for the physician-owned medical group, Cooper Clinic, P.A. Douglas J. Babb, CEO, has chosen to retire at the end of the year, and Curtis Ralston, Chief Operating Officer, has been Curtis Ralston named as his successor. The announcement was made by Michael Callaway, MD, current President of the Board of Directors, and Daniel Mackey, MD, incoming Board President. Babb had advised the Board of Directors earlier this year of his intent to retire and has worked with Board members to implement an orderly succession plan. Babb assumed the CEO position in July, 2007. His history of leadership included serving as Executive Vice President and Chief Administrative and Legal Officer at Beverly Enterprises and Senior Vice President at the Burlington Northern Santa Fe Corporation. Ralston, a CPA and native of Oklahoma, joined Cooper Clinic in 2011 as Chief Financial Officer. He most recently served the group as Chief Operating Officer. Ralston earned his Master’s and Bachelor’s Degrees in Accounting from Oklahoma State University and has 19 years of accounting experience, including nine years in CFO positions in the healthcare industry. He and his wife, Brent, have two children.

Otolaryngologist Alissa Kanaan Joins UAMS LITTLE ROCK – Alissa Kanaan, MD, an otolaryngologist, has joined the University of Arkansas for Medical Sciences (UAMS) and will see patients at the Ear, Nose and Throat Clinic in the Jackson T. Stephens Spine & Neurosciences Institute. Dr. Alissa Kanaan, an instrucKanaan tor in the Department of Otolaryngology – Head and Neck Surgery in the UAMS College of Medicine, offers endoscopic nasal and sinus surgery and treatment for chronic sinusitis, nasal obstruction and fungal sinusitis. She received her medical degree at the American University of Beirut in Beirut in 2007, where she also did an internship in general surgery in 2008 and residency in otolaryngology-head and

LITTLE ROCK – The third annual telehealth conference for the Arkansas, Mississippi and Tennessee region promoting the use of telecommunications technologies to support distance health care will be March 2 at the Hilton Jackson Hotel in downtown Jackson, Mississippi. The South Central Telehealth Forum is organized by the University of Arkansas for Medical Sciences (UAMS) Center for Distance Health and the South Central Telehealth Resource Center, which serves Arkansas, Mississippi and Tennessee. Experts from the region will give presentations, lead discussions and network about telehealth. The cost is $160 per person. An early bird rate of $135 is available through Feb. 1. For more information and to register, go to learntelehealth.org/sctf2015 and click on “Conference Registration,” or call (855) 664-3450. Nationally recognized reimbursement expert Nina M. Antoniotti, R.N., M.B.A., Ph.D., will be the keynote speaker. She is the program director of the Marshfield, Wisconsin-based Marshfield Clinic TeleHealth Network. Antoniotti has been involved in the development of national technology and operational guidelines for telehealth standards and has presented at regional and national telehealth and technology conferences in the areas of integration, business plan development, clinical services, evaluation, Health Insurance Portability and Accountability Act (HIPAA) and needs assessment. The conference also will feature nationally recognized speakers and panelists from the South Central region of Arkansas, Mississippi and Tennessee. Discussion panels will focus on clinical, education, administrative and technical aspects of developing telehealth programs and will demonstrate regional programs. For more information or to register for a workshop, go to: learntelehealth. org/sctf2015 and click on “PreConference Registration.” The cost is $45 per person. Several technology vendors and other businesses and organizations also will have booths and exhibitions at the conference. Continuing education credits will be offered. Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.

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Stacy Sells, Breast Cancer Survivor

Beating

the

Odds

“When I was diagnosed with stage IIIB inflammatory breast cancer, I knew I was in for the fight of my life. And I said, ‘time out – if I have cancer, I’m going to UAMS.’ My comprehensive care included chemotherapy followed by a double mastectomy, radiation and reconstruction. It gave me incredible comfort to know that I had a team of brilliant doctors who are among the best in the U.S. Today I am grateful to be a cancer survivor, always mindful of how precious it is to be alive.”

UAMShealth.com/cancer

“Every morning I wake up and am thankful for UAMS. They pulled me through, and it’s a new day.”

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10/14/14 1:01 PM

January-February 2015 AMN  

Arkansas Medical News January-February 2015

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