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HEALTHCARE SPOTLIGHT PAGE 3

Robert Cosby,

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ON ROUNDS

In March, the Alabama Medical Group Management Association (MGMA) held their winter conference at the Hyatt Regency Wynfrey Hotel in Hoover. The conference was well attended. “We had 264 people,” said Jason Biddy, practice administrator at Urology Centers of Alabama. “A good portion of those were new members.” A group of Auburn students also attended. The students had the opportunity to see how their studies were applied in the real-world while interacting with working administrators. 62 vendors participated in the conference. Traffic was brisk at the vendor booths, with one vendor saying he had as many visitors the first morning as he had for the entire conference last year. Cynthia Taylor with AMT Staffing agreed. “The conference has been great,” she said. “I’ve

The Early Stage of Understanding Alzheimer’s “It’s an exciting time. There has been a great deal of recent progress in understanding the mechanisms involved in the development of Alzheimer’s,” neurologist and neuroscientist Erik Roberson, MD, PhD, and UAB associate professor of neurology said ... 9

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NEUROLOGY

Say that you have patients who don’t have health insurance. They’re not eligible for Cooper Green Mercy Health Services, the Veterans Administration, Medicaid/ Medicare, or for a subsidy through the Affordable Care Act. They are one of the many patients who fall between the cracks when it comes to receiving medical care ... 11 FOLLOW US

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Researching Therapeutics to Prevent Alzheimer’s By laura Freeman

Today, 89,000 people in Alabama suffer the devastating effects of Alzheimer’s disease. That number is expected to triple by 2050 unless medical science can find an effective way to stop it. UAB is participating in the first national clinical trial of a drug aimed at preventing the irreversible damage of AD before symptoms arise. “Advances in PET scans allow us to see accumulations of amyloid protein in the brain long before memory loss becomes apparent. The investigational drug targets that protein, and we’re hoping it will reduce or slow buildup to possibly prevent damage or delay the disease,” UAB principle investigator David Geldmacher, MD, of the Memory Disorders Division said. (CONTINUED ON PAGE 12)

David Geldmacher MD

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HEALTHCARE SPOTLIGHT

Physician Sets Sail for Adventure By Cara Clark

to get the patient to safety.” Cruise doctors have to be prepared for everything from jelly fish stings to medications left behind to viruses and critical illnesses. It’s the ship doctors’ job to officially release the boat before it is allowed to leave port by messaging the captain that all is well. “One man had a heart attack walking up the gangway after a day trip ashore, and we had to call an ambulance from a foreign port,” Cosby said. “There are specific protocols to follow with the port master and ship liaison to hold a ship.” Cosby says while laws in the U.S. prohibit withholding care when patient is in serious distress, that doesn’t apply at some of the ports of call. It’s the duty of the ship physician to determine if the quality of care is more hazardous in the available medical facility at port or whether the passenger should remain on board for assured care. One person aboard a ship came to Cosby with a stomachache that he later learned was pain related to metastatic cancer. “A lot of people come on a ship as a last hurrah,” Cosby said. “They want to entertain their family and celebrate near the end of life. What can you do for someone with metastatic cancer in the middle of the

ocean? “The average age of guests is 70 years. That means you have a lot of seriously ill people. You wonder if they are making good decisions about coming on board a ship.” With wet decks and rough water, slip and falls are a natural consequence often exacerbated by excessive amounts of alcohol. Broken bones are common when the human form hits a wooden deck at high velocity. Sea sickness, too, is a natural consequence for some. All officers are required to complete courses in Crowd Management, Crisis Management and Human Behavior, and Advanced Shipboard Environmental Training. “Crew come from 50 different countries and, of course, speaks many languages, although English is required for all,” Cosby said. “There is a wide range of English proficiency, however, often making medical life difficult. Sometimes interpreters are necessary to take care of guests or crew.” Cosby also has intensive training as a ship’s officer, including studying and learning the ship’s method of tracking the flow of garbage, as well as lifeboat drills and even sanitation courses. Some doctors will travel for six to nine months at a time, but Cosby prefers two or three weeks. “It’s a flavor of the exotic to travel like this,” Cosby said. “If you target what you really want to do and focus and work hard to get that, you can have some interesting experiences.”

As spring settles in Alabama amid dogwoods and azaleas, locum tenens physician Robert Cosby, MD is enjoying the balmy Caribbean as part of a unique fraternity of maritime medicine. This April, Cosby is traveling to various ports of call, including the Virgin Islands, Puerto Rico, and Belize. He is serving as an officer for Carnival cruises, something he does periodically to keep things lively. Cosby refers to himself as an itinerant worker, a term that seems counterintuitive in reference to an MD, but there is some truth to his description. Robert Cosby, MD aboard ship. The longtime medical professional is an ER doctor at times, to be intubated and sedated. a cruise ship officer at times, an Army mediWith the boat still 190 miles away from cal specialist, and he has even spent a stint Galveston, Texas, Cosby worked with the as a circus physician. It’s a nomadic lifestyle crew to coordinate a rescue helicopter inin keeping with the Latin “locum tenens,” tercept, requiring hours of work to remove meaning “to substitute for.” lines and superstructure to open the space Cosby finds filling in where help is for the helicopter to hover and disembark needed both stimulating and interesting. the critical patient. “One of the factors that attracted me to “Two paramedics rappelled to the deck medicine was the flexibility,” he said. “I with a basket to pick up the patient,” Cosby realized early on that with a medical docsaid. “We had to call out a fire team because torate degree, you could work just about if the helicopter crashed on deck, we would anywhere. I have used that over the years have had a massive fire. Paramedics were by the grace of God to travel and work.” hanging off the side of the basket at midnight Cosby first encountered the idea of maritime medicine at a conference in Seattle. He attended a session organized by a doctor who located physicians for locum tenens positions on Hawaii cruise ships. “At that time, my practice in Tarrant city, but I had also joined the National Guard and had drills on weekends,” Cosby said. Still, he managed to find time to pursue this intriguing path. Cosby has since worked for three different cruise lines, first with American Hawaii intercostal cruises, trekking from port to port and circling back [customized consulting for your practice] to Honolulu. His second voyage was even more of an adventure, as he flew to Newport News, Va. to board a ship that was MIPS Readiness Assessment being refurbished in transit to Hawaii via the Panama Canal. Incentive Optimization During his time at sea, Cosby has learned that in close quarters, a simple virus becomes disastrous. APM Opportunities “Because a ship is a closed environment, we try to be careful to screen people Reporting Plan Development who come on board,” Cosby said. “If they have a fever or diarrhea, we recommend they not get on, or they have to be quarantined. As the ship’s physician, I have to be Trust our experts to support your vision and deliver very concerned with the guests, passengers, and crew catching the virus.” personalized service to your business. When the ship is at sea, anything can happen. One 20-something passenger embarked on five-day cruise, despite her renal failure and dependence on dialysis. She had hoped having dialysis the day before leaving would allow her to stretch until the cruise 2101 Highland Avenue South, Suite 300 | Birmingham, AL 35205 | (205) 443-2500 | www.kassouf.com ended, but instead was severely ill and had

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ALLERGY & ASTHMA

New Guidelines Help with Control of Peanut Allergy Editor’s note: In this month’s allergy section, we focus on peanut allergies, starting with a look at the new guidelines for early introduction of peanut-containing foods to potentially prevent allergies. Then, we review a new oral immunotherapy (OIT) treatment as a means of eliminating the allergy in current sufferers. By Ann B. DeBellis

In January, the National Institute of Allergy and Infectious Diseases (NIAID) published an addendum to 2010 guidelines for the diagnosis and management of food allergy in the United States. The addendum is specific to U.S. guidelines for preventing peanut allergy. The update came on the heels of the February 2015 New England Journal of Medicine article that outlined the results of the Learning Early About Peanut Allergy (LEAP) trial. That trial was based on a prior observation that the prevalence of peanut allergy was 10 times higher among Jewish children in the United Kingdom compared with Israeli children of similar ancestry. In Israel, peanut-containing foods are introduced in the diet when infants are approximately seven months of age and

Summary of Addendum Guidelines Addendum guideline

Recommendations

1

Severe eczema, egg allergy, or both

Strongly consider evaluation by sIgE measurement and/or SPT and, if necessary, an OFC. Based on test results, introduce peanut-containing foods.

4–6 months

2

Mild-to-moderate eczema

Introduce peanut-containing foods

Around 6 months

3

No eczema or any Food allergy

Introduce peanut-containing foods

Age appropriate and in accordance with family preferences and cultural practices

consumed in substantial amounts. In the United Kingdom, children typically do not consume any peanut-containing foods during their first year of life. In the LEAP trial, 640 children between the ages of four and 11 months with severe eczema, egg allergy or both, were randomized to consume or avoid peanut-containing foods until five years of age to determine the prevalence of peanut allergy. “Researchers found that regular consumption of peanut-containing foods beginning early in life reduced the risk of developing peanut allergy by 81 percent,” the report

states. “Based on those findings, the addendum provides guidelines to pediatricians and to parents for early introduction of peanut-containing food to infants with peanut allergy,” says Carol Smith, MD, of Birmingham Allergy & Asthma Specialists. “Early introduction of peanut can prevent peanut allergy in many infants.” In the first guideline, the expert panel recommends that infants with severe eczema, egg allergy or both be introduced to age-appropriate peanut-containing food as early as four to six months of age

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Earliest age of peanut introduction

Infant criteria

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to reduce the risk of peanut allergy. Other solid foods should be introduced first to show that the infant is developmentally ready. The panel also recommends evaluation with peanut sIgE and skin prick testing to determine if the peanut should be introduced. “This guideline also instructs parents to check with their infant’s healthcare provider before introducing peanutcontaining foods,” Smith says. Guideline two suggests that infants with mild to moderate eczema or any food allergy have age-appropriate peanut(CONTINUED ON PAGE 8)


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ALLERGY & ASTHMA

New Therapy for Peanut Allergy Gives Hope to Children and Families By ann B. DeBellis

Peanut allergy is the leading cause of anaphylaxis and fatal outcomes from food reactions in children. A new oral immunotherapy (OIT) treatment is proving to be a safe and effective way to eliminate the effects of the allergen in many sufferers through controlled exposure to peanuts. “There has been a big emphasis on peanut allergy because peanut is so hard to avoid,” says Carolyn Comer, MD, Medical Director of the OIT program at Alabama Allergy & Asthma Center in Birmingham. “The gold standard treatment right now is avoidance of the allergen and having epinephrine available for emergencies. Unfortunately, deaths can occur from anaphylaxis even when epinephrine is used.” Recent studies at Stanford and Duke universities have shown that if you give allergic children a slowly increasing amount of peanut orally over time with careful monitoring, it can be added back safely into the diet of children with severe peanut allergy. Currently, children can safely begin OIT as early as 4 years of age. To qualify for OIT, a child must have a history of peanut reaction with ingestion and a positive skin test and/or elevated

Carolyn Comer, MD discusses OIT treatment with a patient.

specific IgE to peanut in the blood. Dosing starts with a small amount of peanut protein and increases over time. “One peanut kernel has, on average, 250 mg of peanut protein. Our protocol begins with 2 mcg and builds every one to two weeks until 2,000 mg of peanut protein is reached

once a day, the equivalent of eight peanuts,” Comer says. “The build up process takes six to seven months on average and can be individualized as needed. At-home maintenance of 2000 mg once daily is continued indefinitely. We will follow the child’s specific IgE blood levels for pea-

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nut and skin reactivity, and their numbers should decline over time. Some children’s levels will go down to zero, which is fantastic.” The initial dosing and subsequent increase in dosing are done in Comer’s office with one-on-one monitoring by medical staff who are appropriately trained with equipment readily available to treat anaphylaxis. Total focus is on the child to ensure they are monitored and safe. Comer points out that when safety guidelines for at-home dosing are followed, OIT is less risky than allergy immunotherapy (allergy shots). “There is still a risk of reaction, but we keep safety at the forefront,” she says. Comer says there is a lot of anxiety around peanut allergy, but OIT offers the chance to eliminate those fears. “Studies have shown that OIT can be 85 to 90 percent effective for desensitization to peanut over time with many of these children freely eating peanut in their diet,” she says. “OIT gives the child and family another alternative besides strict avoidance. Studies show that if the child continues to take a daily dose of peanut, she is protected from accidental ingestion and cross contaminant. Unfortunately, if the daily dose is discontinued, there is no guarantee that the child will have sustained unresponsiveness.” Successful results from OIT can be life-changing for patients. “The child can go out with friends and family members without the worry of accidental ingestion and anaphylaxis. Even if the child never wants to freely eat peanut, OIT takes away the fear factor of accidental ingestion,” Comer says. “It also helps eliminate food allergy bullying, which happens to more than a third of children and teens with food allergies. For these reasons, we plan to offer OIT to other food allergens, such as tree nuts, milk, and egg, in the near future.” Additional treatment options for food allergies currently are being studied. As these treatments become available, Comer and her colleagues will continue to offer OIT as an option for managing food allergy. “We know it improves the quality of lives of children and their families,” she says. “OIT for peanut allergy still is not a mainstream practice with a lot of allergists, but we believe it gives the allergic child the freedom to be normal.”

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Enforcement Trends: Five Lessons from Recent OCR Resolution Agreements By: Beth Pittman, CHPC with Waller

Since January 2017, the Department of Health and Human Services Office of Civil Rights (OCR) has entered into two Resolution Agreements for HIPAA violations, one Resolution Agreement for failure to timely report a breach, and one of only three Civil Money Penalties (CMP) imposed for HIPAA violations since 2009. In 2016, OCR entered into 12 Resolution Agreements. That was at least double the number in prior years. Lesson One: If you are investigated by OCR for a HIPAA violation, be responsive. Failure to timely respond to OCR notices may result in full imposition of CMP. Children’s Medical Center of Dallas was unable to reach a resolution with HHS and delayed requesting a hearing before an ALJ on the proposed CMP. The organization was required to pay the full of the CMP, or appeal the CMP. Resolution Agreements are CMP and could not assert affirmative defenses, arguments for waiver or reduction substantially less than the full CMP which is based on a fine assessed for each day of the violation. For a violation classified as “reasonable cause” (as opposed to “willful”), the minimum fine is $1000 per day with a calendar year cap of $1,500,000. OCR does not limit violations to the breach, but typically finds additional violations; some stretching over several years. In settlement discussions, OCR considers the financial condition of the organization; an important mitigating factor for small or distressed facilities. This is not considered in assessing CMPs. Lesson Two: Conduct a comprehensive security risk analysis and implement corrections. Overwhelmingly, the top violation found by OCR was failure to complete an accurate and comprehensive enterprise wide security risk analysis (“SRA”), implement an enterprise wide security risk management process and corrections to identified risks and vulnerabilities. Absence of a SRA was a factor considered by OCR in proposing the settlement amount and corrective action plan reached in many Resolution Agreements. In the Resolution Agreement with Memorial Healthcare System, OCR noted violations that extended into the organized health care association (OHCA) when an affiliated physician group’s former employee login was used for over a year to access PHI to commit fraud. OCR recognized that the absence of a SRA, in-

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cluding all affiliated organizations within the OHCA, was a significant omission. Inadequate system audits and access controls would have been identified and could have prevented the breach. Lesson Four: Encryption and device tracking. More than half of the 2016-2017 Resolution Agreements addressed the failure to encrypt and then track mobile and portable devices on which ePHI is stored. If encryption is not implemented, then you must document the reason, and the alternative equivalent used. Monitoring movement of mobile and portable devices is a critical safeguard. In each instance, the loss or theft of the device occurred because it was left in an insecure or unmonitored location. Lesson Five: Business Associate identification and management is critical. One of the largest settlements to date, $5.5 million reached with Advocate Health, was based in part on failure to have a business associate agreement with a billing company service provider. A covered entity, as well as its business associates, is liable for the HIPAA violation of the business associate. It is important not only to enter into business associate agreements but to also monitor and verify a business associate’s HIPAA compliance. Other Enforcement Risks: False Claims Act and overpayment risks are associated with HITECH meaningful use attestation of HIPAA compliance. Not only may failures in HIPAA compliance result in an investigation by the OCR, you may also be at risk in audits by the Department of Health and Human Services Office of Inspector General (OIG), False Claims Act actions or for Medicare Overpayments initiated by the government or whistleblowers. Payment of an incentive under the HITECH EHR Incentive program is conditioned on certification of compliance with specific HIPAA technical security requirements, including performing a security risk analysis. This may also be a material factor going forward in the amount of reimbursement paid by CMS. The OIG 2017 Work Plan specifically targets audits of EHR incentive recipients “to determine whether they adequately protect electronic health information.”

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had the opportunity to meet people from all over the state. They’re given me good feedback, letting me know what their needs are. “A lot of people have stopped by our booth. People seem more engaged with the vendors this year. I have a lot of leads.� This was the first Alabama MGMA conference for Ron Prevatte who recently joined Integrated Solutions. “It’s been a great opportunity to meet new people as well as existing clients who I had not met face to face,� he said. The conference, which was titled Leadership Through Chaos, focused on a number of issues that are relevant to practice administrators in today’s environment. Cameron Cox, the CEO of MSOC Health, talked about social media and dealing with online reviews. Jerry Callahan, CPA and Margaret Cook, MBA of Kassouf & Co gave a talk on benchmarking for process and practice improvement. Adele Allison, of the DST health solutions division, hosted breakout sessions on contract negotiations and on MACRA. There were also talks on financial management; workplace violence; organizational governance; digital security; relative value units; ACOs and RCOs; and the Trump administration’s impact on healthcare. “I think that a lot of administrators are interested in learning what to expect from the new Trump White House,� Jason Biddy said. “People are trying to understand what’s going to be repealed and what it will be replaced with. “Healthcare is no longer boring,� said Helen Combs, the administrator of Alabama Allergy & Asthma Center. “We

now have some new initiatives that are bringing to light all sorts of quality measures. Federal healthcare reform started out under the Bush administration with PQRI which was a voluntary process for clinical reporting. We’ve now moved into a system where providers are incentivized to report on quality or meaningful use, which means the payers are measuring the quality of our outcomes, some of that based on cost. Then we’re moving into MACRA which is merit-based or advanced alternative healthcare models. And where we’re going to end up is affordable quality healthcare. “One of the challenges we face is to make sure the physicians fully understand the long-term impact of merit-based pay. And we have to focus on how to implement this. Gone are the days where we can just ignore these issues.� Richard Sanders of The Sanders Law Firm spoke on the final morning, giving a thorough analysis of the Republican proposals regarding the transition from Obamacare. The practice administrations in attendance all walked away with an enhanced understanding of current issues along with tools for working through them. “This was my first time attending the MGMA Alabama winter conference,� said Jennifer Wood, CPC who is the administrator for Premier Medical. “The conference was a great event that provided an invaluable networking experience and the ability to learn from some of the highest caliber medical practice managers in the state of Alabama.�

New Guidelines Help, continued from page 4

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Birmingham Medical News

containing foods freely introduced in the diet, together with other solid foods and in accordance with family preferences and cultural practices. “The child’s healthcare provider can advise parents of the severity of the child’s eczema, at which time they can determine whether they should introduce peanut-containing foods at home,� Smith says. The third guideline suggests that infants without eczema or any food allergy have age-appropriate peanut-containing foods freely introduced in the diet, together with other solid foods and in accordance with family preferences and cultural practices. “These guidelines definitely give us promise,� Smith says. “We now have evidence that children develop allergies early in life. If we can identify those high-risk infants and introduce peanut before they develop an allergy, we hope that they can maintain their tolerance for life. We can induce tolerance through exposure, but they must continue the exposure to sustain tolerance to the allergen.� Smith says that additional studies are under way – LEAP-On which demonstrated the durability of oral tolerance to peanut achieved in the LEAP trial, and the Inquiring About Tolerance study which assessed the potential benefits of

Dr. Carol Smith and a parent discuss his child’s peanut allergy treatment.

early introduction of six allergenic foods in a non-high risk cohort. “People are still looking at issues such as how long can tolerance be maintained and can we do this with other allergenic foods such as eggs, milk, soy and seafood,� Smith says. “Questions are still out there, but the findings seem promising. The key is to get the children tested early.�


NEUROLOGY

The Early Stage of Understanding Alzheimer’s By Laura Freeman

“It’s an exciting time. There has been a great deal of recent progress in understanding the mechanisms involved in the development of Alzheimer’s,” neurologist and neuroscientist Erik Roberson, MD, PhD, and UAB associate professor of neurology said. “We still don’t have definitive answers about the fundamental cause of most cases, but we are finding important clues Erik Roberson, MD, about the process, parPhD ticularly in genetics.” Roberson’s research centers on the basic science of age-related cognitive impairment, particularly in Alzheimer’s disease and frontotemporal dementia. “Only a small percentage of cases have a direct genetic link inherited through families that show a high incidence of early onset Alzheimer’s,” he said. “However, there are more than 30 genes associated with the disease that can change during a lifetime. If triggered, they can become involved in the progression of the disease.” In recent years, better technology and large studies have allowed Alzheimer’s pa-

tients to be characterized and common genetic risk factors to be identified. Imaging advances are also now allowing changes in the brain to be detected years before symptoms appear, opening the door to investigation of treatment strategies that might stop or slow the process. “People may carry a combination of genes for risk factors, but like smoking and lung cancer, not everyone who smokes gets cancer and not everyone who has the genes gets Alzheimer’s,” Roberson said. “We know there is a genetic association, but it doesn’t tell us how it happens. This is where basic science is active now. We are looking at what genes are doing in the brain and trying to determine how things go wrong. Why do some people with genetic risk factors get Alzheimer’s and others don’t? “This is where a personalized medicine approach can be useful. Some people may have risk factor A or B, or a combination of C and D. There are different pathways, and they may need different treatments.” Age could be the greatest risk factor for Alzheimer’s. Symptoms usually appear after the age of 65. What happens between birth and the senior years that triggers the genes involved in the destruction of the brain’s memory centers?

As we age, the brain suffers a variety of insults from injuries and infections to vascular damage, and even a type of insulin resistance that can create problems supplying the brain’s high demand for energy. Brain chemicals and proteins that were normal in childhood can become elevated in later years, perhaps not so much due to overproduction as to the body’s failing systems for clearing them. “As AD progresses, two major proteins show up in lesions within the brain. An excess of amyloid beta proteins build up as cotton-ball-like plaques between brain cells. Finding effective treatments to prevent this buildup has been a primary focus of research,” Roberson said. “Our lab is working on another target for new therapeutic strategies. Tau is a microtubule-associated protein that accumulates within the brain cell itself, taking on the cell’s shape to become a neurofibrillary tangle. Although amyloid and tau proteins tend to accumulate in different areas of the brain, there appears to be an interaction between the two. “In mice bred without tau, amyloid beta doesn’t seem to have such a toxic effect. Reducing tau seems to be protective. We’re looking at the role of tau in neuronal excitability and its function in

neuronal dendrites, but mice seem to do fine without it. That suggests reducing tau in humans could be an option. We want to learn more about why reducing tau is beneficial and the best ways to target it therapeutically. We’re looking at the relationship between tau and amyloid proteins, as well as tau and the Fyn protein, which also seems to be involved. We’ve identified compounds that may block the tau and Fyn interaction. This is another avenue for new therapies that might give us a way to intervene in the progression of the disease,” Roberson said. Alzheimer’s disease is the sixth largest killer of Americans. It can kill in as little as five years from the onset of symptoms, or it can be a long, slow agony for patients and their families. It robs patients of the memories and relationships that make them who they are. It steals years of productivity from both patients and caregivers, and the emotional and financial impact on families can be devastating. The big picture of what causes Alzheimer’s disease is unclear and challenging, like beginning a thousand-piece puzzle. But the good news is that basic science is identifying some of the corner pieces and fitting them into place. Piece by piece, the solution will come.

Birmingham Medical News

APRIL 2017 • 9


Study Finds Injuries Related to Extreme Conditioning on Par with Other Exercises By Ann DeBellis

With the increased popularity of extreme conditioning programs (ECPs), a group of Birmingham physicians noticed an increase in the rate of injury among participants of these programs. A crosssectional study determined that the injury rate related to ECPs was no greater than the same injuries in other sports. However, information from the study is enabling fitness trainers and physicians to prevent and manage injuries related to the programs. Andrews Sports Medicine & Orthopaedic Center in Birmingham and Iron Tribe Fitness representatives worked together on the study, along with Kyle Aune, MPH, an epidemiologist at the American Sports Medicine Institute. “The medical community’s original reaction to these condi- Benton Emblom, MD, right, and Kyle Aune at the American Sports Medicine Institute tioning programs was, I think, unfairly dismissive in the beginning. Physicians saw an uptick in injuries from extreme conditioning were dismissing any those programs, probably because the criticism of the program. That was the imprograms were becoming more popular, petus for our study.” not because they were more dangerous,” To gather information, investigators he says. “On the flip side, supporters of sent an online survey to participants at all

Iron Tribe gyms in the Birmingham area. “The Iron Tribe staff was incredibly helpful with the study because they saw the value of being proactive in identifying possible weaknesses or dangerous activities that might be slipping under their radar,” Aune says. The positive finding from the study was that the injuries are not occurring at the extreme rate that has been reported in various media. “We did find that the shoulder is a susceptible area for ECP participants,” Aune says. “If you have had a previous shoulder injury, you are eight times more likely to sustain a new shoulder injury during this program. With that in mind, we recommend that these gyms screen all new athletes to assess their functional abilities and to pinpoint any weaknesses they may have.” The study also revealed four specific exercises that were more likely to result in injury – squat cleans, ring dips, overhead squats, and push presses. “The common denominator in these exercises is that they all focus on the shoulder. We suggest that trainers be careful when they program those ex-

ercises and anything else that may result in shoulder-heavy workouts, especially among people who have functional limitations from a previous injury,” Aune says. The final recommendation from the study is to emphasize form and technique, because most people attribute the cause of their injury to overexertion, fatigue, or improper technique. “If you are tiring because you overexert yourself with improper form, that can lead to injury,” Aune says. Orthopedic surgeon Benton A. Emblom, MD, of Andrews Sports Medicine & Orthopaedic Center said they wanted to participate in the study to identify injury rates and patterns related to these exercises to have a better understanding of the types of injuries that are occurring in the ECPs. “We didn’t do the study to discourage participation in these programs,” he says. “There is a lot of benefits from these exercises, but we saw injury patterns in people of certain ages and activity levels that were concerning. We want to be aware of that.” Rotator cuff and bicep tendon injuries are the most common in ECP participants. “A lot of these athletes use heavy weights and do high repetition, explosive overhead lifting. That can cause injury to (CONTINUED ON PAGE 12)

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JCMS Project Access

New Initiative Provides Care to Low-Income Patients with primary care homes, the specialist Project Access through a grant program, can focus treatment solely on the problem and some area hospital systems have prowithin his specialty. vided financial support. As a non-profit, Say that you have patients who don’t Another benefit for volunteer speProject Access is looking for broad-based have health insurance. They’re not elicialists is that they can chancommunity support from other hospitals, gible for Cooper Green nel all charity care from community groups, businesses and indiMercy Health Services, their office through Project viduals. the Veterans AdministraAccess and limit donated “We’re also looking for additional tion, Medicaid/Medicare, charity care to match their physicians and service providers and or for a subsidy through business’s budget. The phywe’d love to get more people involved the Affordable Care Act. sicians are asked for a onein the program,” Ferguson says. “You They are one of the many year commitment to Project don’t have to be a member of the Medipatients who fall between Access and they can specify cal Society. We just began the program in the cracks when it comes how many patients they are October and currently have about 50 volto receiving medical care. willing to see during that unteer providers from independent offices A recent initiative from one-year period. in local communities. UAB Health System the Jefferson County MediIrby Ferguson The Community Founis now fully onboard, so it includes many cal Society, collaborating dation of Greater Birmingphysician specialists from their system. with several community ham provided the initial funding for St. Vincent’s Hospital and onsite providpartners, is named Project Access and is aimed at connecting those patients with primary, ancillary, pharmacy services, and specialty care from hospitals and physicians who volunteer for the program. The Project Access concept originated in Buncombe County (Asheville) North Carolina more than 20 years ago and has been implemented in some 40 cities across the U.S. “We started talking with our community partners about implementing Project Access in Birmingham about 18 months ago” says program director Irby Ferguson. “Our effort is designed to help those patients obtain specialty care and ancillary care and to help them establish a medical home if they do not have one.” Process Access is intended to provide care primarily to patients from Jefferson County, but because Birmingham’s metropolitan area stretches to Shelby, Blount, and several other counties, there are occasions where patients from adjacent counties can also qualify. Besides helping low-income individuals, the services also provide a cost savings to hospitals. “The great thing about the program from a hospital’s standpoint,” Ferguson says, “is that patients who have unmet health needs no longer have to show up in the ER because they have nowhere else to go. Patients can be redirected to Project Access where they can locate and establish a medical home to receive ongoing primary care services. Primary care providers then make referrals for specialty and ancillary care as needs are presented.” LET US HANDLE THE NUMBERS, “The program is beneficial to specialists as well,” says Martha Wise, executive Y O U H A N D L E T H E H E A LT H C A R E director of JCMS. “Specialists don’t have to provide primary care for the patient. They need only provide care in their specialty. For example, an orthopedic surgeon might see a patient in the emergency room who suffered a broken leg that requires surgery. Patients who have no primary care home often ask the specialist about their other health problems.” 205.323.5440 This can put the physician in the w w w . p e arcebevill.com awkward position of having to give advice or write prescriptions for conditions 110 OFFICE PARK DRIVE, SUITE 100 | BIRMINGHAM, AL 35223 outside his specialty. By pairing patients By Dale short

ers have been supportive of our program and provided financial support as well. St. Vincent’s has also made free medications available through their Dispensary of Hope pharmacies. “Project Access is a good program because it’s a community problem being addressed by the whole community, and it’s a wonderful way for the entire community, from primary care doctors, specialists, community clinics and hospital systems--even those who normally compete with one another--to become involved. They get together and reach an agreement on the best way to provide care for patients who are falling through. It ends up being a really beautiful blend of best health care practice, best business practice, and mission. So, it’s a win-win for just about everybody.”

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Researching Therapeutics to Prevent Alzheimer’s, continued from page 1 “To this point, once brain cells are damaged, we haven’t found a way to replace them. So it seems that, like polio, the most effective cure is prevention. That’s the direction research is pivoting,” Geldmacher said.

The A4 study (Anti-Amyloid in Asymptomatic Alzheimer’s) was recently featured in Newsweek. UAB was selected as one of the clinical trial sites across the country that together will be recruiting 1,000 participants for the study. It is es-

timated that 10,000 volunteers will be screened to find around 10 percent who qualify. “Since we are recruiting healthy volunteers, we will need to do screenings and PET scans to determine which people are

Study Finds Injuries Related Conditioning, continued from page 10 soft tissue in the shoulder,” “When you put one workout Emblom says. “The overall on the board for 300 members rate of injury was not much in the gym, that workout is not different than normal acgoing to be exactly right for tivities and exercises. It’s every person,” Sottung says. just specific injury patterns “We educate our coaches to that tend to show up in know the abilities and goals of these types of programs.” our clients so they can adjust Kyle Sottung, Dithe workout and exercises to rector of Product Develfit the capacities of the peoopment for Iron Tribe ple in the class. A program is Fitness, is encouraged by only good if it can be scaled the study findings, and his to fit every person at the gym. team plans to use the inThat’s how we deliver an information to minimize individual experience for each juries in Iron Tribe gyms. client who comes in.” “We are using a consisEmblom, too, is encourtent approach in our 43 Kyle Sottung, standing, directs a fitness class at a Birmingham Iron Tribe Fitness center. aged by the study. “Trainers gyms around the country. have learned that certain inWe deliver the same projuries can occur with specific gramming and coach development for all exercises and they’ve done a good job tional Movement Screen, reorganized our gyms, and our coaches go through modifying workouts to prevent injury,” our programs to offer an option that extensive training and deliver the same he says. “I think the crux of what we’ve does not include the barbell and some of workouts so we can control quality from seen is there are certain injury patterns the potentially injurious exercises, and a central point,” he says. “We evaluate that tend to spike with these programs. added equipment such as dumbbells, asour athletes when they start the program Fortunately, they are repairable and give sault bikes, and battle ropes which give so we can keep them safe and sustainthe athletes the ability to return to those great intensity with a lower risk of inable. We are using the information from programs if they desire. But more imporjury.” this study to help reduce our low injury tantly, the injuries can be prevented if you Although Iron Tribe offers a group rates even further. We have started imare aware of what potential injuries are program, they will make changes to adapt plementing screening tools like the Funcout there. That’s the main thing.” the program to fit every participant.

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showing accumulations of amyloid proteins that indicate the developing plaques of the disease process. Another key part of the A4 study is looking for clues as to why AD rates are higher among African American and Hispanic populations,” Geldmacher said. “Washington University in St. Louis found that plaque development can begin as early as a decade before symptoms appear. That fact, combined with the ability of PET scans to detect those plaques early, gives us a window of opportunity to test therapies that might be able to slow or stop the buildup before the amyloid protein triggers a cascade of changes that cause irreversible damage. “If we can remove amyloid proteins or block future buildup, we might be able to take a therapeutic approach to AD that is much the same as we take in controlling cholesterol to prevent heart disease,” Geldmacher said. Amyloid protein, though the most familiar suspect in the development of Alzheimer’s disease, is not the only factor involved. Other proteins and more than 30 genetic changes can also play a role, which may eventually reveal why some populations are more likely to develop the disease than others. “Tau, the other protein most suspected of being involved in the development of AD, is also being studied by UAB researchers. Substances that seem to reduce it have been identified and we hope that within a few years we will be testing medications that target that protein to see if we can find more therapies to prevent Alzheimer’s disease. “We’re also looking at other drugs to ease symptoms in people who already have AD. Most medications used to manage it have been around a while, and we hope to see improvements,” Geldmacher said. “Sleep problems are common due to a breakdown in melatonin cycling that disrupts circadian rhythms. If we can find better ways to regulate the sleep cycle so patients are better rested, it may help to avoid difficulties that occur when fatigue becomes a problem, especially late in the day. Low light levels at twilight and in the evening add to confusion by making it harder to distinguish what is happening. Surroundings that look less familiar in a darker room, combined with fatigue, can make the end of the day a difficult time. “To help patients, their caregivers and families avoid distressing situations and better manage the daily routine, the UAB Memory Disorders Division is using telemedicine to coach caregivers on how to interact with patients more effectively,” Geldmacher said. “Caring for people with AD and treating the disease after it has progressed is challenging for everyone. That is why I am so hopeful that we can spare future generations by finding a prevention strategy that works.” If you are interested in volunteering for the A4 study, you can learn more about how to enroll by going to the website A4study.org.


False Claims Retaliatory Discharge Claims by Jim

Hoover

An often overlooked and under publicized provision of the False Claims Act (“FCA”) is the retaliatory discharge prohibition. This is probably because retaliatory discharge claims do not grab headlines by winning multimillion dollar verdicts or settlements. While a former employee may have legitimate arguments that he was retaliated against, a retaliatory discharge claim is filed as a routine part of a qui tam action in almost every qui tam lawsuit if the relator is a former employee. Accordingly, it is important to understand the basics about retaliatory discharge claims. While most people in the health care industry understand that the FCA prohibits individuals and companies from submitting claims for payment that involve some type of error that causes the claim to be false, many are unaware that an employee is protected from retaliation for trying to bring false claims to light. More particularly, the anti-retaliation provision of the False Claims Act protects employees, contractors or other agents of a company from being “discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment by his or her employer” because the employee, contractor, or agent investigated, reported or sought to stop a company from engaging in practices which defraud the United States government. Specifically, to prove that a company retaliated against an employee, in violation of 31 U.S.C. §3730(h), an individual must prove that: (1) the employee engaged in protected activity; and (2) the employee was discriminated against because of the protected activity. The amendments to the 2009 Fraud Enforcement and Recovery Act (“FERA”) expanded the scope of the FCA’s retaliation protections. FERA clarified that not only are efforts to stop violations of the FCA protected so are actions taken in furtherance of a qui tam action itself. An employee has up to three years after the date of the retaliation to initiate litigation. For purposes of FCA retaliation, “protected activity” occurs when the employee opposes the company’s attempt to get a false or fraudulent claim paid or approved by the government, and where that opposition to fraud “reasonably could lead to a viable FCA action,” or when litigation is a reasonable possibility. An employee’s efforts to investigate potential fraud may also constitute protected activity. To demonstrate that he/ she was discriminated against “because of” conduct in furtherance of a False Claims Act suit, an employee must show that the employer had knowledge of the protected activity and that its retaliation was motivated, at least in part, by the individual’s engaging in the protected activity. The damages available to a successful relator are generally designed to “make the employee whole.” Possible damages include: (1) reinstatement with the same seniority sta-

tus the employee would have had but for the discrimination; (2) two times the amount of back pay plus interest on the back pay; and (3) compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees. Notwithstanding the expanded rights of a relator, the federal courts still limit retaliatory discharge claims. One such limitation comes in the form of a reasonable belief that the relator’s employer was committing fraud against the government. This issue was recently addressed by the Seventh Circuit Court of Appeals, which upheld a lower court’s dismissal of a relator’s retaliatory discharge claim in a FCA action where the government had declined to intervene. The Court noted that the determination of whether an employee’s conduct was protected turned in part on whether “a reasonable employee in the same or similar circumstances might believe that the employer is committing fraud against the government.” Citing the fact that the relator did not have “any firsthand knowledge of the obligations to the government,” the Court held the relator had no reasonable basis for such a belief. Although the reasonable belief requirement is not a new standard, the Seventh Circuit’s holding is useful guidance for analyzing the “reasonableness” of a belief. The court noted that there are two prongs to the reasonable belief standard. First, the employee must have a good faith belief the employer is committing fraud. Second, a “reasonable employee in the same or similar circumstances might believe, that the employer is committing fraud against the government.” In the recent Seventh Circuit Court case, the Court commented that while the relator might have subjectively believed the employer was committing fraud, the Court determined the relator’s claim did not meet the second part of the test. The Court focused on “the facts known to the employee at the time of the alleged protected activity.” According to the Court, the relator failed to prove that a reasonable employee would have believed the employer was defrauding the government because the relator admitted he did not read the contract with the government and thus did not know the underlying basis for what made the claims false at the time his employment was terminated. Accordingly, the relator lacked firsthand knowledge of the employer’s contractual obligations with the government. The takeaway for health care employers from this case is that even if a relator subjectively believes a defendant is committing fraud, court’s may not recognize “protected activity” if there is no reasonable basis for the belief the employer is committing fraud.

Jim Hoover is a partner in the Health Care Practice Group at Burr & Forman LLP and exclusively represents health care providers in false claims litigation and regulatory compliance matters.

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Addressing Health in the Community with Innovation & Insight really improve health, you have to address the social determinants.” Artiga coauthored the KFF issue brief, ‘Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity,’ with Harry Heiman to explore both the problem and potential solutions. In the brief, the authors wrote, “Based on a meta-analysis of nearly 50 studies, researchers found that social factors, including education, racial segregation, social supports, and poverty accounted for over a third of total deaths in the United States in a year.” To address this issue, communities are utilizing innovative measures including ‘health in all policies’ and ‘place-based’ approaches. The former has been gaining traction over the last two decades and encourages policymakers and decisionmakers to consider health consequences in non-health sectors. Much like an environmental impact study, a health assessment evaluation might engage education leaders to consider the consequences of vending machine contents or a developer to consider the health impact of installing sidewalks. An example of a place-based approach is the Philadelphia Healthy Corner Store Initiative, which has brought healthier foods to more than 600 corner

By CINDY SANDERS

As America rethinks the care delivery system yet again, there is a growing recognition that health happens in neighborhoods and on playgrounds … through vending machines and water pipes … and at bus stops and in classrooms all across the nation. Experts focused on population health recognize access to healthcare providers is only one driver of outcomes, albeit an important one. Yet, they believe moving the needle on health in the United States will require addressing socioeconomic and environmental factors outside of what has traditionally been considered the healthcare system. “What we’ve seen is that under the Affordable Care Act there have been large gains in coverage,” said Samantha Artiga, director of the Disparities Project for the Kaiser Family Foundation (KFF). However, she continued, “There’s a growing recognition that health coverage is one key component, but there are a variety of Samantha Artiga other components, too. Health is influenced by a broader array of factors. To

stores and resulted in a 60 percent increase in the sales of fresh produce. “As we documented in the brief, we’ve seen initiatives in a number of sectors,” Artiga noted. “We’ve also seen how to better integrate social determinants within health.” Rebecca Tyrell, a senior consultant for Advisory Board with deep expertise in population health, agreed social determinants are increasingly becoming part of the health equation. “Providers who have typically not been in the business of talking to patients regularly about non-clinical needs are now asking how to screen for issues and then Rebecca Tyrell how to access resources,” she said. “The issue at hand is how do we connect the dots?” Yet, she said, effective community partnerships make sense on multiple levels. She recently penned ‘Building the Business Case for Community Partnership: Lessons from the BUILD Health Challenge’ to explore steps to extend care, engage patients, and improve cost and quality. With limited time and a heavy clinical burden, Tyrell said a number

of hospitals and practices are turning to non-clinical staff members to create an inventory of resources and link patients to needed services. “In many cases, they are high school-educated individuals who are well connected in the community and have a familiarity with the community resources,” she noted. An innovative program by ProMedica in Ohio looks to destigmatize hunger. Tyrell said the system has partnered with community agencies to bring food pantries onsite to the hospital campus. Every primary care visit includes two simple questions to screen for food insecurities. Those identified as being at risk are given a food prescription. “They are trying to medicalize the issue and connect patients directly to food rather than referring them to an outside entity,” explained Tyrell. “It also plays a big role in reducing the stigma.” Tyrell counsels clinical clients to assess needs and start with one project. Transportation, she noted, is a relatively low-lift barrier to address through ride share services or community transportation resources. “Start with whatever seems feasible with whatever resources you have available,” she noted. “You can always scale your efforts from there.” She added, “Don’t be overwhelmed by the (CONTINUED ON PAGE 16)

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The Literary Examiner BY TERRI SCHLICHENMEYER

Twisted True Tales from Science: Medical Mayhem by Stephanie Bearce; $8.95; 160 pages Ugh, you’ve been feeling kind of sick. years of trial and error” before scientists How did this happen? You’re usually and doctors figured out how to use some of careful about these things. You wash your the medicines we have now. In the meanhands, and stay away time, anything from bad from ailing friends, tooth or head-butt to but there it is. Sniffles, skinned knee or finger cough, run-down tired, cut could kill a person. ugh. So while you’re reTo avoid the worst, cuperating, read Twisted ancient docs devised True Tales from Science: tools to bore holes into Medical Mayhem by skulls, Egyptians relied Stephanie Bearce, and on amulets and mouse you’ll feel happy that paste (which is just what you didn’t live in ancient it sounds like), Native times. Americans used tobacco Long ago, before as medicine, and Roman hospitals and docphysicians sometimes tors, needles and IVs, gave their patients clay ancient people didn’t to eat for whatever ailed know about germs or them. Yummy. microbes. They thought Treatment was Stephanie Bearce evil spirits or curses often worse than the illbrought illness, so they ness, and some “cures” treated patients with things that were somewere really strange. Legend says that men times disgusting. Even so, folks often died of in Arabia sometimes volunteered to go on ailments that you would hardly notice. a diet of only honey. After they died, they Says Bearce, “It took thousands of literally became medicine. Animal poop

Weily Soong, MD Maxcie Sikora, MD John Anderson, MD Meghan Lemke, MD Sunena Argo, MD Amy CaJacob, MD William Massey, MD

was often used as medicine, too, especially when mixed with other things. Who would admit to being sick if they had to take medicines like that? Slowly, as time went on, though, we humans learned a thing or two. Dead bodies taught early doctors about muscles, blood, and bones. Some folk cures turned out to be correct. Laboratory work and the invention of microscopes proved that fungus, germs, bacteria, and disease were real. Vaccines were developed to avoid further sickness, and we learned how to avoid getting sick in the first place. Much as I enjoyed this book, the subtitle is a bit of a misnomer: there’s not a lot of mayhem inside Twisted True Tales from Science: Medical Mayhem. But that’s okay. Author Stephanie Bearce adds enough cringey, disgusting, but oh-so-fascinating chapters to satisfy any kid who’s looking for those exact things –

and yet, what your child will read isn’t just gratuitously icky. The chapters inside this book describe things that really happened, plagues that changed entire continents, accidents that furthered human knowledge, and Bearce uses that info to explain how those events affected everything afterward. Kids will get a good overview of how far we’ve come, medically speaking and, for the extra-curious, there’s a great bibliography in the back for even more information. While it’s absolutely not for the squeamish, the nine-to-14-year-old with an inquisitive mind and historical interest will love every page of this fun book. He’ll say that “Twisted True Tales from Science: Medical Mayhem” is wicked sick. Terri Schlichenmeyer is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.

Patricia Luthin, CRNP Blake Youngblood, CRNP Jamie Johnson, CRNP Michelle Payne, CRNP Annie Ketcham, CRNP Erin McKeown, CRNP

What Does the Pollen Count Really Mean for Patients? By: H. Wayne Shew, Ph.D. NAB Certified Pollen Counter, Alabama Allergy & Asthma Center Collection Station Alabama Allergy & Asthma Center provides the daily pollen count for Birmingham and the surrounding area. The pollen collection station is located on the roof of the Homewood office, and the daily count is certified for accuracy by the National Allergy Bureau (NAB). So why do we count the pollen, and what does it really mean for patients when the pollen level is high, moderate, or low? We report pollen and mold spore counts to the NAB as the number of pollen grains or spores per cubic meter of air. This data is then translated into “levels” based upon the NAB’s scale and statistics from the certified counting stations across the nation:

High levels - fall between the 75th and 99th percentile Very high levels - above the 99th percentile (99% of the counts are below this level) The pollen levels are based on the concentration of pollen in the air. The pollen count is not a measurement of, or correlated with, the health effects that these allergens may have on people. A “low” pollen count does not always correlate with a low level of symptoms, just as a very high count does not necessarily mean a higher level of significant health effects. The higher the number of pollen grains in the air, the more precautions allergic patients should generally take. Those who experience allergy symptoms should stay aware of the pollen levels, even when they reach low, so they can begin their appropriate medications and precautionary measures as early as possible.

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Low levels - concentrations less than the median or 50th percentile (half of the counts were below the median) Moderate levels - concentrations that fall between the 50th and 75th percentile

Homewood • Hoover • Chelsea Cullman • Alabaster • Trussville

Birmingham Medical News

APRIL 2017 • 15


Addressing Health in the Community with Innovation & Insight, continued from page 14

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range of possibilities or options. There will always be more needs in your community than you’ll be able to address right away.” While more individuals, including policymakers, now recognize health happens in a broader context than the narrow constructs of the delivery system, Artiga said that piece should not be underestimated. “When looking at what’s at stake in the current environment, the potential coverage losses under the American Health Care Act could make it more challenging to address social determinants of

health because the health coverage piece provides a connection point to assess needs and to connect individuals to broader services in the community.” Even if there are more hurdles to clear in the future, Tyrell said she believes efforts to integrate health would continue to gain momentum. “Regardless of your political affiliation, we’re all focused on how to lower the cost of care while improving quality, and addressing the social determinants of health is a key lever to doing that because it allows us to go further upstream.”

Social Determinants: A Technological Approach Trenor Williams, MD – founder and former CEO of clinical HIT and advisory management firm Clinovations before selling it to The Advisory Board Company in 2015 – has recently launched Socially Determined. The company features a service-enabled tech platform that integrates the social determinants of health with clinical data through the use of comprehensive care pathways and advanced analytics. Noting he feels passionately both personally and professionally about the role social determinants play in an Trevor Williams, MD individual’s health, Williams explained his new venture was born of three beliefs. The first, he said, is that social determinants “have a legitimate impact on healthcare outcomes, healthcare utilization, and healthcare spend.” Number two, Williams stated, is the belief “that despite our best efforts, we don’t capture that information for each of our patients; and even if we do, it’s not in a codified and consistent way.” He continued, “That feels like there’s a real business opportunity to do the right thing in healthcare, especially when you layer on the third piece … there are more and more risk-based contracts. We decided to launch Socially Determined to try to be part of the solution.” In conversations with municipalities, health systems, community organizations and insurers, Williams said there is a broad acceptance that social risk factors do matter and most stakeholders are trying to figure out where investments should be made to result in a demonstrable difference. “We believe a part of the solution is going to be enabled by technology,” Williams noted. But, he pointed out, the first step is to get the data. He said the three key sources of data are clinical information from providers and insurers, public data from municipalities and sources including the CDC, and from an often overlooked source … patients, themselves. “There is so much in healthcare where we’re designing solutions about them not with them,” he said of patient input. “We believe strongly that they are a valuable and critical component of this solution.” The second step, Williams said, is to make sense of the data through risk scoring. Patients are scored in four major categories and subcategories and also receive a global score. A patient without a car, for example would have a higher transportation risk. In addition to the individual score, Williams said health systems could look at larger populations like Medicaid patients and discern patterns, such as finding more than a third have food insecurities. “Health systems need help prioritizing the investments they make and the resources they put to use,” he noted. The third, and perhaps most difficult piece, is putting together a care management and referral plan based on the data. Williams was quick to say this piece couldn’t fall solely on the physician but would require a broader care team including social workers and case managers. By overlaying community resource information into a technology platform that works with current EHR systems, Williams said it becomes possible to link patients at the point of care to critical supports within the community. “We believe that this area outside of the hospital, outside of the clinic – in the community – is the place that’s going to make a real difference in healthcare outcomes and people’s lives,” he concluded.


What was in the GOP Bill and Why Did it Fail? By Rich Sanders

After House Speaker Paul Ryan pulled the American Health Care Act (AHCA) bill, there are questions as to whether the Patient Protection and Affordable Care Act (PPACA) will ever be repealed or reformed. The AHCA legislation, which did not entirely match President Trump’s campaign promises regarding the PPACA, managed to alienate both liberals and conservatives. Over two dozen Congressional Republicans opposed the AHCA because it did not sufficiently repeal existing law. Tom Price, MD, a former orthopedist and the new Secretary of Health and Human Services, is likewise opposed to government interference in the health insurance system. While in Congress, Price advocated repeal of the PPACA, but he is now hesitant to embrace a strategy of repealing the PPACA entirely. To understand the Republican bill, it is essential to organize its contents into the static and dynamic — what the AHCA would change, and what it would not.

What the AHCA Will Change. The AHCA would repeal the tax penalty for not having the minimum essential coverage (the individual mandate), but it would apply a late enrollment penalty for individuals buying non-group coverage who have not maintained uninterrupted 12-month continuous coverage. Retroactive to January 1, 2016, the AHCA reduces the tax penalty for large employers not providing health benefits to zero. The AHCA would also repeal tax credits for low-wage small employers, effective January 1, 2020. It does not repeal premium subsidies. Instead, the AHCA would modify PPACA premium tax credits for FY 2018-FY 2019 to the amount for younger adults and reduce the amount for older adults, which also will apply to coverage sold outside of exchanges and to catastrophic policies. In 2020, the AHCA would replace incomebased tax credits with flat tax credits based on age, and the eligibility for new tax cred-

its phases out at income levels between $75,000 and $115,000. Proposed changes to Medicaid under the AHCA would likely have the most significant impact on Alabama Medicaid. Since the Alabama General Assembly and Gov. Bentley have been steadfast in expanding Medicaid, these proposed changes are particularly important. First, as of January 1, 2020, the incentive for Alabama to expand Medicaid would likely removed: the AHCA would eliminate enhanced match for Medicaid expansion except for individuals enrolled through expansion as of December 31, 2019 who did not have a break in eligibility of more than one month. For those states that already expanded Medicaid, the AHCA

will limit the enhanced match rate transition to the CY 2017 levels of 80 percent, instead of phasing up the match equal to the PPACA enhanced match rate. The impact on Alabama’s pending move to Medicaid Regional Care Organizations (RCOs) is likewise significant. The AHCA would convert federal Medicaid financing to a per capita cap beginning in FY 2020. This block grant system, endorsed by Secretary Price, may lessen or eliminate the need for Alabama to seek a CMS waiver for its RCO system.

What the AHCA Would Not Change. Though there are crucial changes proposed in the new AHCA, a number of policies of the Obama Administration would be untouched. The PPACA’s requirement to cover ten essential health benefit categories was unchanged. Likewise, a list of popular insurance requirements and prohibitions would remain intact, including the requirement for maximum out-of-pocket limit on cost sharing, the requirement for individual and group plans to cover preventative benefits with

no cost sharing, as well as the requirement to provide dependent coverage for children up to age 26 for all policies, group and individual. In addition to these requirements remaining from the PPACA to the AHCA, there are a number of prohibitions that will remain in place, including the prohibition on lifetime and annual dollar limits, the prohibition on pre-existing condition exclusion periods as well as the pre-existing exclusions of those periods for pregnancy, prior C-section, and history of domestic violence. Lastly, the prohibition on gender rating will remain unaffected by the AHCA. Finally, the PPACA no-cost preventative benefits available to Medicare enrollees, reductions to Medicare provider payments, and increase of Medicare premiums for higher-income beneficiaries all remain unchanged by the proposed AHCA. It is easy to see why both conservative Republicans and liberal Democrats joined forces in opposing the bill. The AHCA cut many aspects of the PPACA to the dismay of Democrats, but substantial elements of the PPACA remain to the disappointment of Republicans. Whether or not the two parties can come together and forge a consensus remains to be seen. Rich Sanders is President of The Sanders Law Firm, P.C. which represents healthcare providers in corporate and regulatory matters.

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Birmingham Medical News

APRIL 2017 • 17


Sleep: A Preventative Measure By Amita Chhabra MD

At one point or another, everyone has had a two-cup coffee day. What makes you reach for that second cup? Perhaps it’s the belief that the extra caffeine may jolt us into having a more productive day. That may just be a tale some live by. However for most, night-time has become a cycle of sleep deprivation and poor sleep patterns. Unfortunately, there is no amount of caffeine that can compensate. In the outpatient setting, we see patients who would like to address complaints of fatigue, anxiety, obesity, and hypertension. We often preform extensive workups of thyroid, mood, and other organic causes to explain causes of ongoing fatigue. We could avoid testing by asking a simple question: How do you sleep? The CDC recommends adults get between seven to eight hours of continuous sleep. In some cases, that is just not possible. If you’re anything like me, I’m happy to have four continuous hours of sleep after the birth of our daughter. However, there are some glorious nights when a full night’s sleep changes your entire day. It has been studied 40 percent of adults report falling asleep during the day, without realizing it, at least once a month. This is called microsleep. It typically occurs when a person will momentarily fall asleep in a conversation, while listening

to a lecture, or even while driving. Microsleep is different than narcolepsy. It is typically characterized by not understanding an explanation, or having to repeat phrases, or even “zoning out� while driving. A person who does not have restorative sleep falls victim to continuous sleep deprivation. They can experience these episodes of microsleep without carrying the diagnosis of narcolepsy. The same person who experiences an episode of microsleep, may not have those symptoms the

next day after a full night’s rest. Poor sleep is linked to many chronic health conditions. Patients can be evaluated by asking a few simple questions to aide in their overall health. What time do you go to bed? Do you wake up feeling refreshed? How many times is your sleep interrupted during the night? Have you

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Amita Chhabra, MD, is a family practitioner with BHC – Hoover Primary Care. She is board-certified and completed her residency from the Tuscaloosa Family Medicine Residency Program.

Sleep Study By Stuart J. Padove, M.D. with Medical West Sleep Medicine

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been told that you snore? These key questions that can lead to the diagnosis of sleep deprivation or sleep deficiency without invasive testing. If patients aren’t getting the required amount of sleep, providers should introduce recommendations regarding sleep hygiene. Put simply, sleep hygiene prepares the brain for sleep. Sleep hygiene consists of having a routine at bedtime that should be consistent on the weekday and weekends. Avoid screen time, strenuous exercise, and heavy meals at least one hour before bed. It’s important to note that alcohol, nicotine, and caffeine are stimulants that work against the winding down of the brain and body. These kinds of stimulants should be strictly avoided before bed. It is no secret that cardiovascular disease, diabetes, obesity, and depression can all be exacerbated when sleep is compromised. A sufficient amount of sleep may just be a preventative measure for many patients.

About one-third of the population has some form of insomnia at any given time, and 10 percent of that group has chronic insomnia. According to the National Sleep Foundation, 75 percent of Americans say they’ve had at least one symptom of a sleep problem a few nights a week or more within the past year. While there are 88 kinds of sleep disorders, at the Medical West Sleep Center we most commonly see individuals with symptoms of insomnia; sleep apnea; narcolepsy; and restless legs syndrome and/or periodic limb movements. When a patient comes in with sleep problems, we begin with a review of the

person’s symptoms. We schedule a sleep study if we determine it’s needed. A sleep study is a non-invasive, overnight exam that allows doctors to monitor a patient while he sleeps. An EEG monitors his sleep stages and the cycles of REM and non-REM or NREM sleep during the night, to identify possible disruptions in the sleep pattern. A sleep study will also measure things such as eye movements, blood oxygen levels, heart and breathing rates, snoring, and body movements. Once we’ve diagnosed the problem, we can offer a treatment protocol. Stuart J. Padove, MD practices with Medical West Sleep Medicine.

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A Pediatrician’s View on Healthcare Reform By Andrew Wes Stubblefield, MD, FAAP

I am not an idealist. In fact, I would consider myself a realist. Our health care system in the United States has real problems. We are not getting what we pay for. However, I am opposed to the recent proposals by Congress as part of a solution to these problems. I am a pediatrician in Florence. I am a father, an Alabama native, and a taxpayer. I grew up in rural Alabama and I believe I understand what Alabama needs. The recent legislation that failed to pass the U.S. House of Representatives was certainly not what our state needs. The bill would have made considerable cuts to Medicaid and other federally funded programs. To understand the impacts, you must

recognize how important Medicaid is to our children and our economy. Did you know that the majority of people covered by the Medicaid program are children? About 625,000 of Alabama’s 1.1 million children are covered by Medicaid or ALL Kids? That’s about 57 percent. Both programs are substantially underwritten by the federal government. About 44 percent of the more than eight billion dollars in federal funding in Alabama’s budget is for Medicaid alone. Alabama has one of the leanest Medicaid programs in the country with administrative overhead rates that are less than the rates of typical private insurance companies. There isn’t any belttightening to do. If Medicaid is cut, services are cut. People will lose insurance. Over the past few years, we have in-

creased the number of children with health insurance to 95 percent. This is the highest level in history. Why should children have insurance? It’s about a return on investment. The facts are clear. Because Medicaid and ALL Kids cover important services for children such as routine health, developmental, hearing and vision screenings, children are better able to be healthy and ready for school. And because these programs also cover children when they are sick, they are more likely to go to the doctor for care when they need it. Most importantly, studies have shown that insured children are more likely to attend school, graduate from high school, go to college, earn more in wages, pay more in taxes, and become healthy, successful adults than their unin-

sured peers. That is a return on investment. We need productive adults in Alabama’s work force and healthy children are more likely to be healthy adults. I urge you to join me in urging our elected officials in Washington to start over and instead consider health care reform proposals that will move children’s health care coverage forward, not backward.

matology at Oklahoma University Health Sciences Center in Oklahoma City. She has been in private practice in Birmingham for 25 years. Goli is a member of the American College of Rheumatology, American Medical Association and the Alabama Society of Rheumatic Disease.

cine, part of the Department of Medicine at UAB, have received R35 grants from the National Heart, Lung and Blood Institute, part of the National Institutes of Health. Steven Rowe, MD, director of the Gregory Fleming James Cystic Fibrosis Research Center, received an Emerging Investigator grant of $6.5 million. Rowe’s research program will strive to make decisive advancements in the understanding of airway diseases linked to genetic and acquired CFTR dysfunction (the protein that is responsible for cystic fibrosis).

J. Edwin Blalock, PhD, Nancy E. Dunlap, MD, Endowed Chair in Pulmonary Disease, received an Outstanding Investigator award of $6.14 million. Blalock’s laboratory has identified a novel biomarker for a number of pulmonary diseases, including COPD, cystic fibrosis and ARDS. Gang Liu, MD, associate professor of medicine, received an Emerging Investigator grant of $5.2 million. Liu’s research program will center on the role of pulmonary metabolic dysregulation in the cause and development of lung fibrosis.

Andrew Wes Stubblefield, MD, FAAP, serves as vice president/president-elect of the Alabama ChapterAAP. In private pediatric practice at Infants’ & Children’s Clinic in Florence, AL, Dr. Stubblefield has been heavily involved in both his local community and the state pediatric community, serving on the medical staff of his local hospital, the board of Alabama Community Care, a probationary Alabama Medicaid regional care organization, and the Executive Board of the Alabama Chapter-AAP since 2008, where he has defined himself as a leader and fierce advocate across numerous child health policy areas.

GRAND ROUNDS

Goli Joins Grandview Prameela D. Goli, MD, FACR, has joined the medical staff at Grandview Medical Center where she will practice rheumatology with Grandview Medical Group. She is Board Certified in Rheumatology. Goli completed her residency in internal mediPrameela D. cine at Texas Tech Univer- Goli, MD, FACR sity Health Sciences Center in Lubbock, TX. She completed a Fellowship in Rheu-

UAB Pulmonary Investigators Receive Grants Three investigators from the Division of Pulmonary, Allergy and Critical Care Medi-

Life doesn’t pause for pain. Neither should you. Aches and pains limit more than your range of motion. At Sherrill Orthopedics, we’ve dedicated ourselves to one practice: getting rid of pain for good. We offer advanced orthopedic care, with both surgical and non-surgical options. Each treatment plan is specially designed for you and your needs. Don’t let pain stop you from living your life; talk to one of our board-certified orthopedists today. Call 205-822-4357 or visit sherrillorthopedics.com to book an appointment or for more information.

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Birmingham Medical News

APRIL 2017 • 19


GRAND ROUNDS

Alabama Most Stressed State in US

Blue Cross and Blue Shield of Alabama Receives Award

Despite our warm climate and rural areas, Alabama is one of the more stressed states in the US according to a survey conducted by personal-finance website WalletHub. Alabama’s overall score made it the most stressed state in America. Stress Levels in Alabama (1=Most Stressed, 25=Avg.): • 17th –Hours Worked per Week • 4th –Adults Getting Adequate Sleep • 4th ¬– % of Adults in Fair/Poor Health • 9th – Job Security • 2nd – Median Credit Score • 6th – % of Population Below Poverty Line • 7th – Divorce Rate • 10th – Crime Rate per Capita • 2nd – Psychologists per Capita

Blue Cross and Blue Shield (BCBS) of Alabama has received the Brand Excellence Award for Member Retention from the Blue Cross Blue Shield Association. Blue Cross and Blue Shield of Alabama is the only Blue Plan to win a total of 22 Brand Excellence Awards since the inception of this annual awards program. BCBS of Alabama received the award for having an especially high percentage of members renew their coverage in the past year.

Ronson and McAlexander Open New Practice Cardiovascular & Thoracic Surgery, a new practice with Russell Ronson, MD and William McAlexander, MD, has opened at Brookwood Baptist Medical Center.

Ronson and McAlexander have over 20 years combined experience in general and cardiothoracic surgery. Ronson is Russell Ronson, currently the chief carMD diovascular and thoracic surgeon for Brookwood Baptist Medical Center and conducts minimally invasive, as well as robotic surgeries. McAlexander has William had a successful career McAlexander, for 11 years in private MD practice specializing in general, thoracic, and vascular surgery. McAlexander completed his cardiothoracic fellowship in January when he joined Ronson. For more information or to book an appointment, please call (205) 877-2627 or visit bbhcarenetwork.com.

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Centor Receives Award Robert Centor, MD, professor in the Division of General Internal Medicine in the Department of Medicine at the University of Alabama at Birmingham School of Medicine, has been named the recipient of the Robert J. Glaser Award from the Society Robert Centor, for General Internal MediMD cine (SGIM). The Glaser award recognizes outstanding contributions to research, education, leadership and mentoring in medicine, and is presented at the SGIM annual meeting. In his 23 years at UAB, Centor has been a central figure in academic medical leadership. He served as regional dean and executive director of the Huntsville Regional Medical campus from 2004 to 2017. He served as chair of the Board of Regents for the American College of Physicians which recognized him with its highest distinction, Master of the ACP. He has received multiple awards for teaching from UAB medical students, including the Argus award for best overall attending physician, the Best Campus Attending Award and Best Overall Teacher for the Department of Medicine. He has also received the UAB Presidential Award for Excellence in Teaching and The Ellen Gregg Ingalls/ UAB National Alumni Society Award for Lifetime Achievement in Teaching. Centor’s seminal findings on Group A streptococcal pharyngitis were published over 35 years ago, and the clinical prediction rule that now bears his name, Centor’s Criteria, has been replicated worldwide and is embedded in clinical guidelines.

Cockrell Joins Birmingham Heart Joshua Cockrell, MD has joined Birmingham Heart Clinic. Cockrell earned undergraduate degree in microbiology at Mississippi State University. He completed his doctorate at the University of Mississippi Medical Center in Jackson, where he also Joshua Cockrell, completed his internal MD medicine residency, and his cardiology and interventional cardiology fellowships. Cockrell is board certified in internal medicine, cardiovascular disease and interventional cardiology. He is also a member of the American Medical Association, the American College of Cardiology, the American Society of Nuclear Cardiology, and the Society for Cardiovascular Angiography and Interventions. His professional interests include radial access for cardiac catheterization and coronary interventions, treatment of coronary and peripheral artery disease, echocardiography, treatment of venous diseases, and nuclear cardiology.


GRAND ROUNDS

New Cavity Treatment Offers No Drilling

Tour de Blue Benefits Prostate Screening

A new clinical trial at the UAB School of Dentistry is offering patients with cavities in-between teeth a new, less painful treatment option. The new treatment, called resin infiltration, is a way to treat small cavities in-between teeth. Normally, the only way to access these cavities is by numbing a patient with a shot and drilling away tooth structure to access the cavity. Resin infiltration allows the dentist to slide a plastic perforated sheet between the teeth with the cavities. “When we develop cavities between teeth, sometimes we have to go through the tooth, and we end up damaging healthy tooth structure,” said Augusto Robles, DDS, assistant professor and director of Operative Dentistry Curriculum. “This new system allows us to skip the drilling and helps us preserve that structure.” The cavity is first cleaned by pushing a gel that prepares the surface to accept the resin infiltrant through the perforated sheet. The tooth is then filled by pushing a liquid resin through the perforated sheet. A dental curing light is then applied to the tooth to cure the resin, and the treatment is complete. There is no drilling necessary, and the procedure is typically completed without any anesthesia. “I never thought this would be possible for dentistry,” Robles said. “In my 24 years of practicing, this changes everything we’ve done so far. It’s marvelous.” Patients interested in participating can schedule a free screening appointment by emailing SODBiohorizons@ uab.edu. There is no cost to participate in the study.

The 10th annual Tour de Blue century ride will be held on April 29. The ride, which starts and finishes in Moody, has several distance options (101, 76 & 50 miles). Funds raised from the event support the non-profit Urology Health Foundation‘s prostate cancer screening and awareness efforts across Alabama. The foundation, founded in 2003 by Thomas Moody, MD, will hold free prostate cancer screenings in 14 Alabama counties this year. If an abnormality is found and the patient is unable to afford treatment, the Urology Health Foundation will assist in helping to find treatment at no cost to the patient.

UAB Medicine Again Named Great Place to Work in Health Care UAB Medicine has been named one of the “150 Great Places to Work in Healthcare” by Becker’s Hospital Review for the fourth year in a row, the only Alabama-based health care entity to be so honored. UAB Medicine encompasses UAB Hospital, The Kirklin Clinic of UAB Hospital, UAB School of Medicine, University of Alabama Health Services Foundation, UAB Callahan Eye Hospital and UAB Health System. Becker’s Review cites UAB Medicine for offering employees paid parental leave of up to four weeks, on-site exercise classes and an on-site daily farm stand for fresh produce from March through November each year. The medical center also provides employees with financial assistance during crisis periods through the UAB Benevolent Fund Emergency Assistance Program.

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Birmingham Medical News

APRIL 2017 • 21


GRAND ROUNDS

Pino Joins Grandview Jorge A. Pino, MD, FACP, FACE has joined Grandview Medical Group located in the Grandview Physicians Plaza. He is Board Certified in Endocrinology. Pino received his medical degree from the Universidad del Valle in Jorge A. Pino, Cali, Columbia and comMD, FACP, FACE pleted his residency in internal medicine at the VA Hospital, Tulane University. Pino also completed an endocrinology and metabolism fellowship at University Hospital in Birmingham. Pino is a member of the American Thyroid Association, American College of Endocrinology (Fellow), American Association of Clinical Endocrinology, Endocrine Society, American Diabetes Association, American College of Physicians (Fellow), Jefferson County Medical Society and the Medical Association of the State of Alabama.

Greg Brown Named Administrator of St. Vincent’s Blount Greg Brown, MS has joined St. Vincent’s Health System (STVHS) as administrator of St. Vincent’s Blount, a 25-bed hospital located in Oneonta. Most recently, Brown served as administrator for Clinch Memorial Hospital in Georgia. PreGreg Brown, MS viously he was a director for multiple services lines at Phoebe Putney Memorial Hospital in Albany, Georgia including physical medicine, cardiac testing, cardiopulmonary rehabilitation, and neurosciences. Brown holds a Master of Science degree from West Virginia University and a Bachelor of Science degree from Frostburg State University. He is currently pursuing a doctorate degree in

Exercise Physiology. Brown has held a number of community and professional leadership roles, including serving as a board member of the Clinch County Chamber of Commerce, as a trustee for the Georgia Hospital Association Center for Rural Health, and as a member of the Georgia Academy for Economic Development. He has been recognized as “Boss of the Year” by the Albany Areas Chapter of the International Association of Administrative Assistants.

New CEOs Named at Shelby Baptist and Walker Baptist Medical Centers Mike Rickman has been named chief executive officer at Shelby Baptist Medical Center where he succeeds Bob Phillips, who recently returned as chief executive officer at Walker Baptist Medical Center. “Mike and Bob are Mike Rickman proven leaders,” says Keith Parrot, President of Brookwood Baptist Health. Rickman most recently served as regional chief development officer for Bob Phillips the Tenet Eastern RegionCentral Division. Before joining the regional leadership team, he served as chief development officer of Brookwood Medical Center. Before joining Tenet, Rickman was co-founder and chief operating officer for Practice Partners in Healthcare, a startup company focused on the management and minority ownership of Ambulatory Surgery Centers. He also previously served as senior vice president of the ambulatory surgery division of HealthSouth Corporation. He holds a bachelor’s degree in accounting from Auburn University and a

master’s degree in business administration from the University of West Alabama. He is affiliated with the Ambulatory Surgery Center Association and the American Association of Ambulatory Surgery Centers. Bob Phillips is excited to return to Walker Baptist where he spent several years as CEO before joining Shelby Baptist. Previous to joining Walker, he was as executive director of operations for Baptist Health Centers. He began his career in healthcare in 1997 with North Mississippi Health Services in Tupelo, Mississippi after completing an administrative residency with that organization. Phillips holds a bachelor’s degree from Washington and Lee University and master’s degrees in healthcare administration and business administration from UAB. He recently served as the Chairman of the Alabama Hospital Association Image Task Force and Price Transparency Task Force and he currently is a member of the Board of Directors of the Greater Shelby Chamber of Commerce.

Beth Dorsett, CMPE Joins Pearce Bevill Beth Dorsett, CMPE has joined Pearce, Bevill, Leesburg, Moore (PBLM) as a healthcare advisor. Moore, a University of Alabama graduate, comes to PBLM with over 30 years experience in healthcare, primarily in the areas of practice Dorsett, management, hospi- BethCMPE tal operations, practice start-ups, development of new service lines, and administration. As a PBLM advisor, Dorsett will be responsible for complete medical practice consulting; practice start-ups; strategic planning; business office accounting assistance and training; staffing and human resources assistance.

Freeman Earns Designation Brent Freeman, corporate director of internal audit and compliance for the DCH Health System, has earned the designation Certified in Healthcare Compliance. Compliance professionals promote organizational integrity by asBrent Freeman suring that health care providers follow federal, state and local regulations. The CHC certification program is managed by the Compliance Certification Board (CCB)®, which develops criteria to determine competence in the practice of compliance and recognizes individuals who meet these criteria.

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