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Advancements in Ankle Arthroplasty Are Changing Lives By ann B. DeBellIS
Ankle arthroplasty can relieve pain and maintain motion in an arthritic ankle joint. The procedure is an alternative to ankle fusion which also can relieve pain but eliminates motion in the joint. New surgical techniques and advancements in orthopaedic technology are redefining ankle arthroplasty, including the development of an innovative total ankle prosthesis which has helped to boost the resurgence of these replacement surgeries over the past decade. John Kirchner, MD, of Southlake Orthopaedics in Hoover has Close up of the prosthesis been doing total ankle replacements for about 11 years. The number of procedures has increased to about four or five each month, and he has about 300 active implants. Kirchner says the number one reason for ankle replacement surgery is arthritis resulting from a traumatic injury that leads to a loss of cartilage. “When a person moves at a slight jog or a fast walk, the ankle joint has six times the amount of body weight force going through it. That’s a lot of stress in a small surface area,” he says. “Most people and a lot of physicians are still are not aware that ankle arthroplasty Dr. John Kirchner prepares to implant prosthesis in Nannie
Managing Patients, Not Illness John Farley, MD, has been an internal medicine physician for 23 years and has seen the feefor-service concept of primary care become akin to running on a treadmill ... 4
(CONTINUED ON PAGE 10)
Addressing Adolescent Angst in a Digital World
BBH Service Center Improves Transitions of Care for Medicare Patients
The Truman Show, a satirical 1998 ﬁlm, followed the everyday life of ﬁctional character Truman Burbank as he grew up in front of millions as the unwitting and unsuspecting ‘star’ of a television program ... 6
By martI WeBB Slay
When higher quality care meets higher revenue for physicians, it’s a win all the way around. Brookwood Baptist Health (BBH) has managed to achieve this with the development of a cost-effective program for discharged Medicare patients that is proving successful at reducing readmission rates. Transitional Care Management Services has been a reimbursable service since January 1, 2013. Under the Physician Fee Schedule (PFS), Medicare pays for two CPT codes (99495 and 99496) that are used to report physician or qualifying non-physician practitioner care management services for a patient following a discharge from a hospital, SNF, or CMHC stay, outpatient observation, or partial hospitalization.
(CONTINUED ON PAGE 17)
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2 • AUGUST 2017
Birmingham Medical News
A Time to Heal: War Zone Experience Transforms veteran in some way and may not even realize it. They have a dad or brother or friend who has served and might not even talk about it.” U.S. veterans are facing a crisis of mental health concerns. Roughly 20 veterans commit suicide daily, and new troops continue deploying for conflicts overseas. “I took a class to be an Army suicide prevention trainer to go to different units to teach,” said Lee, whose promotion from second lieutenant to captain is currently in the works. “It’s important not only to work with veterans facing these issues now, but to make them aware before they even deploy.” Though Lee’s unit deploys in October, she’s not yet on the roster of troops headed to the other side of the world. “I know my number will be coming back up soon, and I’m ready,” she said. “I like the idea of deploying. At the end of the day, I’d rather be home, but it’s a great honor to deploy. Now, in my new capacity, I’ll be able to go out on combat stress teams to do interventions right there on the battlefield. It will be very fulfilling.”
By Cara D. Clark
Mary Lee, MSN, was trained to carry an automatic weapon in a mission to protect and defend. Currently a first lieutenant in the Army Reserve, when she joined the armed forces in 2007, her objective was to be a solider, part of a band of brothers — and sisters — whose relationships transcend bloodlines. She deployed to Iraq in 2009 as an Army specialist, and in her work as a photojournalist found her true calling. Now a nurse practitioner in the residency program at the Birmingham VA Medical Lee in Iraq Center, Lee had been tasked to an Army combat support hospital in Baghdad when Mary Lee, MSN Lee, whose unit is part what she witnessed through of the Bravo Company 75th her camera lens changed her Combat Support Hospital based in Tuslife focus. deployed with committed suicide,” Lee caloosa, is committed to making veterans “I saw how the Army healthcare syssaid. “I ended up getting my MSN in psythe focus of her work. tem took care of soldiers,” Lee said. “It chiatric health and did clinical trials with “A couple of people I’ve known perwas very interesting for me in Iraq to see veterans again. Halfway through the prosonally have been affected by suicide,” a nurse taking care of a patient. It was algram, I talked about a VA residency and Lee said. “That makes me more vigilant most a deeper commitment – this was not post graduate training as a third phase as a about asking questions and assessing vetjust a patient to her but a fellow soldier. A nurse practitioner. By the end of Septemerans. People know or are attached to a nurse is trained to heal, but she is trained ber, I will be done.” first as a soldier to kill and defend herself.” The dichotomy of healing in a time of killing was not lost on Lee, who says there’s a clear internal struggle. Through her father, a Navy veteran, and her brother-inlaw, an active duty Air Force fighter pilot, Lee developed respect for the discipline and camaraderie of military culture. “There’s a deeper commitment when caring for your own,” she said. “You understand as a fellow service member what that person is going through. It’s not like a hospital where family can visit. You have to be everything for that patient.” Back in the states in 2010, Lee enrolled in a collaborative partnership with As we all know, healthcare reform has significantly changed the the UAB School of Nursing and the Birbusiness of medicine. The lawyers at Cloud Willis & Ellis have years mingham VA Medical Center, which earned the prestigious designation as one of experience advising business clients on a broad spectrum of of 15 VA Nursing Academic Partnership legal issues. We can provide the insights and legal guidance needed sites in the U.S. in 2009. She further rein every aspect of your business from corporate drafting, such as fined her objective to become a psychiatphysician agreements, to medical collections. Our Firm offers “inric-mental health nurse practitioner with house counsel” services to assist medical practices in conducting the VA and is the only student to complete business in a changing medical industry. the VANAP undergraduate and graduate programs (VANAP-GE) and to become a PMHNP resident. The UAB School of Nursing also is to get our legal expertise working for you. one of only four sites in the country that has a graduate residency program for BIRMINGHAM • MOBILE • NASHVILLE mental health nurse practitioners. After finishing nursing school in 2012, Lee’s 205.322.6060 • C LO U D WILLIS.C O M personal experiences pressed her to focus on that growing need. No Representation is made that the quality of the legal services to be performed is greater than the quality of legal services performed by other lawyers. “The husband of one of the girls I
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Birmingham Medical News
AUGUST 2017 • 3
Managing Patients, Not Illness By ann B. DeBellIS
John Farley, MD, has been an internal medicine physician for 23 years and has seen the fee-for-service concept of primary care become akin to running on a treadmill. Over the past several years, he has transformed his practice, Birmingham Internal Medicine Associates (BIMA) into one of patient management instead of focusing on how many patients can be seen in a day. “My goal is to restore the physicianpatient relationship to one of trust and communication. It will be based on managing care 24/7 and moving away from the transactional fee-for-service model,” Farley says. “The fee-for-service model rewards physicians for volume, not for quality of patient care. As a result, we fill up our schedules every day to generate revenue which results in shorter visits and difficulty for sick patients to get timely care. They end up seeking care from more expensive providers such as urgent care clinics and emergency rooms.” Innovation is coming, but the change is being led by entrepreneurs instead of doctors. “Well-intentioned laws like the Stark laws and HIPAA are innovation killers,” Farley says. “They make it hard for doctors to develop innovative care models without breaking these laws.” Farley has a vision for building a better primary care delivery model and has begun to implement those ideas into his practice. “First, we need to kill the idea of the doctor visit,” he says. “Currently, it is how we are paid, but it is the root of all evil. We need to change the model from one of episodic sick care with the occa-
John Farley, MD, of Birmingham Internal Medicine Associates, examines a patient at his clinic.
sional physical to a patient management model.” Under such a model, insurance companies would pay physicians a monthly fee to manage patients’ care 24/7. The fee would be based on patient age and the degree of his medical problems. The fee would be adjusted for hitting or missing quality and cost parameters. Physicians would still be incentivized to work hard because the larger the panel of patients, the more revenue would be generated. “In this team-based model led by a physician, nurses and nurse practitioners would see patients with simple illnesses like sinus infections and urinary tract infections. The doctor would review
their work and be available to consult on complicated cases. In our practice, RNs and nurse practitioners see most of our patients which allows me to treat the sickest ones,” Farley says. “They would be seen the same day which should reduce emergency room visits and hospitalizations.” Over the years, Farley and his staff have worked to bring about transition at BIMA with the goal of improving the care they provide. Their first major change was the adoption of an electronic medical records system over 10 years ago, prior to it being required by the government. “We also pushed a patient portal long before it was in style. We now have more than 70 percent of our patients using our
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portal to get test results and to schedule appointments,” he says. “This has cut down on our number of incoming and outgoing phone calls. The portal eliminates the middle man as well as any delay and the potential for medical errors.” Electronic appointments and online appointment scheduling are also available, and a virtual office visit program allows patients who have been seen in the office in the past year to go online and be treated, for a small fee, for simple problems without an office visit. “We also started a case management and quality department that allows nurses to follow up on our hospitalized patients and schedule appointments at our clinic within seven days of discharge,” Farley says. “Data shows that such follow up has decreased readmissions to the hospital within 30 days of discharge.” BIMA has also opened a daily walkin clinic every morning from 7:30 to 9:00 a.m. Patients can come to the clinic during that time without calling. “The walkin clinic has significantly decreased urgent care and emergency room visits as well as middle-of-the-night calls to the physician,” Farley says. “Patients don’t mind waiting if they know they can be seen the next morning.” These changes at BIMA have been positively received by patients. “Everything we’ve done is tied to our goal of providing more convenience for patients, increasing quality, and lowering cost. When we come across high-cost providers for testing, we switch to providers who provide services at a lower cost because many patients have high deductibles and increased out-of-pocket expenses,” Farley says. “We have attracted tens of thousands of new patients and are adding one to two physicians a year.” BIMA has partnered with St. Vincent’s Health System which also is looking at the utilization model. “We have learned a lot from Ascension Health Care, the parent company of St. Vincent’s, and I’m excited about what they are doing. I believe the old system is backwards and I can’t stay on that treadmill. I want to change from a sick care system to a well care system, really bend the model and solve the primary care shortage. I want to offer better customer service to our patients at the right place, the right time, and at the right cost,” Farley says. “Our business plan focuses on quality. If we focus on that, everything else will take care of itself.”
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Emerging and Reemerging Pediatric Infectious Diseases By Laura Freeman
Learning to calm childhood fears comes with the job of being a parent. When little ones wake from bad dreams, it’s up to mom and dad to turn on the lights, chase away the shadows, and help them feel safe. However, for too many children, the dangers lurking in their environment are far more than phantoms. They are at risk from preventable infectious diseases that can kill or injure them for life because their parents were too afraid to have them protected by vaccines that are safe and effective. “Emerging diseases like Zika, EV-68, MERS and Ebola and reemerging resistant infectious diseases are threats we have to fight. Losing children to preventable diseases when vaccines are available or having them injured for life is such an unnecessary tragedy,” David Kimberlin, MD, David Kimberlin, MD co-director of the Division of Pediatric Infectious Diseases at Children’s of Alabama and professor
of pediatrics at UAB, said. “The recent measles outbreak in Minnesota is an example of what can happen when enough children are left unprotected.” Heavy lobbying by antivaccine activists in the immigrant Somali community had raised fears to the point that a large population of unprotected children only needed one vulnerable child encountering the germ to ignite an outbreak. “This generation of parents doesn’t fully realize the risks they are taking when they don’t vaccinate. They are too young to remember iron lungs from polio or babies dying from measles. Public health has done its job so well that younger adults haven’t seen how bad these diseases can be,” Kimberlin said. In addition to having served as president of the Pediatric Infectious Diseases Society (PIDS), Kimberlin is the editor of the American Academy of Pediatrics’ Red Book, which establishes which vaccines should be given, when and to whom. “When doctors talk about vaccinations, we need to remember to speak in the language regular people use,” Kimberlin said. “‘The science is settled. Vaccinations don’t cause autism.’ Repeat it again, over and over, whenever the sub-
ject comes up.” After the theory of a vaccination-autism link was thoroughly debunked, activists have continued to base their concerns on the logic fallacy assuming that because two things happen near the same time, one must cause the other. However, it is a coincidence of timing. Most vaccinations begin when the child’s immune system has reached the optimum stage of development. That same stage of development is when symptoms of autism become more apparent compared to expected behaviors at that age. In fact, recent research has found indications of autism in much younger babies as well as a correlation with fevers in mothers during pregnancy. Many suspect genes have been linked to autism, but why they seem to affect some children and not others is an open question. A great deal of additional research will likely be needed before the causes of autism are definitively identified. We can’t yet tell parents exactly why autism happens. What we can tell them as a proven fact is that infectious diseases could kill or permanently injure their children, and the best way to protect them from that danger is to use vaccines that
have a proven track record of being safe and effective. “With everything in life you have to balance benefits against risks,” Kimberlin said. “You need water to live, but you can drown if you fall in a mud puddle. The few side effects we occasionally see from vaccinations are usually very minor and we have medical resources to deal with them. The benefits are overwhelming. The best way to protect your children is to vaccinate them,” Kimberlin said. Also in the news are infectious diseases affecting children that aren’t understood well enough yet for vaccines to be available. “Zika emerged in Brazil last year to cause serious health issues in infants born to women who contracted the disease while pregnant. By the end of the season, it had reached the southern coast of the United States. So far this year, we haven’t received enough data to know whether the strain we were following along the coast was eradicated or burned itself out, or if we might see it reappear later in the season. The situation will be monitored closely while researchers continue to work on vaccines and other interventions,” (CONTINUED ON PAGE 12)
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Birmingham Medical News
AUGUST 2017 • 5
Addressing Adolescent Angst in a Digital World Jess. P. Shatkin, MD, MPH, a member expert of the American Academy of Child and Adolescent Psychiatry, noted growing The Truman Show, a satirical 1998 film, up in a digital age is very different than what followed the everyday life of fictional charparents and providers experienced in their acter Truman Burbank as he grew up in own adolescent years. Whether because of front of millions as the unwitting and unsusmore stressors, improved diagnostics or a pecting ‘star’ of a television program. combination of both, adoWhen the film debuted, lescent depression and anxireality television was still ety are on the rise. in its infancy. While there “Most of our studies had been a few shows over suggest that about 15-17 the years depicting clips of percent of kids will have had police stings or funny vida major depressive episode eos, Jersey Shore and Keeping by the time they hit 18,” Up with the Kardashians were said Shatkin, professor of still several years away, and Child & Adolescent PsychiFacebook, Twitter and Insatry and Pediatrics at New tagram were unknown comYork University and vice modities. chair of Education for the Today’s teens have NYU Child Study Center. grown up as conscious ac“Almost a third – 32 tors in their own reality percent – of adolescents beshows with carefully culti- Dr. Jess Shatkin, NYU professor Child & Adolescent Psychiatry tween 14 and 18 will meet vated selfies and no detail of and Pediatrics and author of the DSM (Diagnostic and Statoo small to share and like. upcoming book ‘Born to be Wild.’ tistical Manual of Mental Yet, the unrelenting access Disorders) criteria for an comes with its own pitfalls anxiety disorder,” he continued. “Depreswhere cyberbullying can quickly escalate, sion is high, but it looks like anxiety is higher and it’s all too easy to believe everyone else’s … and both are troubling.” life is picture perfect. By CINDY SANDERS
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Shatkin said depression and anxiety have increased with each successive generation since behavioral health professionals began monitoring such statistics at the end of World War II. While he was quick to say data on the effects of social media is still emerging, he noted the larger the audience to witness mistakes and failures, the worse kids are going to feel about those missteps. “We know now that the brain’s pain sensors not only respond to physical pain but also to emotional pain,” he explained.
Teens as Risk-Takers Shatkin said teens taking risk is part of the natural evolutionary order. For millions of years, he noted, the young utilized their strength, energy, speed and fearlessness to hunt and stay up all night to protect the village from wild animals and other dangers. “Our brains and our bodies evolve much more slowly than our society is moving,” he said of those ingrained risk-taking behaviors necessary for surviving in the wild but not required in today’s modern world. Additionally, Shatkin said societal changes are now happening much more rapidly. “Kids have the opportunity to be exposed to a lot more than they ever have before,” he pointed out. Shatkin – author of the forthcoming book “Born to Be Wild: Why Teens Take Risks, and How We Can Help Keep Them Safe,” which comes out in early October – explained the adolescent paradox is that despite great strength, teens are also incredibly vulnerable. That hardwired risk-taking coupled with frontal lobes that are still developing can lead to unsafe behaviors that have real-world consequences without the maturity to fully discern the range of outcomes. For example, he continued, “We need to teach our kids media literacy.” Shatkin pointed out how many commercials, television programs and videos sell sex or glorify risky behaviors. “Companies have a right to do it, but we should teach our kids to be savvy,” he stated. “Technology is here to stay,” Shatkin continued. “We’ve given our kids this great opportunity, but it’s like put-
ting kids in a swimming pool with sharks. We have to learn to limit it.”
Early Intervention Although it’s never too late to talk to teenage patients about safe behaviors, introducing guardians to evidence-based parenting strategies while children are still young has proven to be most effective. “We know that certain types of parenting work better than others,” pointed out Shatkin. He added providers play a critical role in presenting and reinforcing these concepts. Clinical and developmental psychologist Diana Baumrind outlined three basic types of parenting – authoritarian, authoritative and overly permissive. Shatkin said evidence over time has shown authoritative parenting … the midpoint between overly strict and no rules … produces the best results not only in young children but as those kids grow into teens and begin spending more time with friends. Shatkin said authoritative parents are supportive but also set strong limits. They are warm and affectionate but not overly permissive, use effective communication tools, and try to ‘catch’ their children being good. “Fewer than one in five of our parenting commands should be negative,” Shatkin said. “If there’s one thing we know about kids, and people in general, it’s that we’re motivated by reward … and never is that more true than during our teen and early adult years because of high levels of dopamine,” he explained. While rewards for meeting or exceeding behavior standards are most effective, Shatkin said that doesn’t mean privileges can’t be taken away when needed. The ubiquitous phone offers both carrot and stick. First, he said parents should be very clear when presenting a child with a phone what the expectations and limitations are. “The phone is a reward so you set it up as a reward,” Shatkin said of advice to share with parents. He added (CONTINUED ON PAGE 10)
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The pregnancy risk women don’t know to avoid By Laura Freeman
Pregnant women take vitamins to avoid neural tube defects such as spina bifida. They avoid drinking to prevent fetal alcohol syndrome, and if Down’s syndrome is a concern, they may have amniocentesis. But only 10 percent know that finishing their toddler’s cookie could put them at risk for contracting a virus that causes more long-term problems and childhood deaths than any of the above. By age 40, 60 percent or more of the US population has contracted cytomegalovirus (CMV) at some point in their lives. If this happens to women when they are pregnant, or if they are infected by a new strain or have a recurrence at that critical time, their child is at risk of being born with congenital CMV. For an adult or a child, a CMV infection might not even be noticed, or they may just feel like they have a cold. But for a baby who contracts it in the womb, congenital CMV can be devastating. It is the largest nongenetic cause of sensory loss and mental disabilities in children. “On average, one out of 150 babies in the United States is born with a congenital CMV infection,” Karen Fowler, Dr. PH said. “10 to 15 percent of those children
will develop significant problems. The most common risk is deafness, but children may also have neuromuscular and developmental deficits, vision problems, small head size and seizures. Karen Fowler, Dr. PH Those most affected may die before they are born. “We don’t know yet why some children exposed to the virus show no noticeable harmful effects while others suffer profound problems. That’s one of the questions we are working to answer Exposure any time during pregnancy can affect the fetus, but there are some indications that the most profound cases tend to occur when exposure happens early in pregnancy during critical stages of brain and organ development. As a part of the investigative team at what is arguably the world’s most highly regarded CMV research program, Fowler is well placed to find those answers. At Children’s of Alabama and UAB, she and her fellow researchers, Suresh Boppana, MD; William Britt, MD; Shannon Ross, MD; David Kimberlin, MD are following in the footsteps of CMV pioneers who have been making breakthroughs against
the virus for the past 50 years. A major recent contribution by Fowler and Boppana is a screening test that can quickly detect with 97 percent accuracy whether an infant has a congenital CMV infection. In the past, testing with cultures took time and was rarely done unless pediatricians had reason to suspect the infection. About 90 percent of infected infants are asymptomatic at birth but may develop late onset hearing loss that may not be detected until it has already begun to interfere with language skills. “It would be wonderful if screening for CMV could be available to all babies at birth,” Fowler said. “If we know about the infection we can treat it promptly with an antiviral which can make a difference in the outcome. Our researchers have shown that ganciclovir can improve hearing, and by extending treatment from six weeks to six months, we can extend improvements for 24 months or more.” A new study is looking at whether the oral drug valganciclovir will show similar benefits in improving outcomes. “We hope to eventually find a vaccine that we can give women before they become pregnant so they won’t be infected or pass the infection to their babies,” Fowler said.
Tests are available to determine whether a patient has had CMV in the past, but women should not deliberately contract a CMV infection hoping to acquire antibodies before they become pregnant. There are multiple strains of the virus, and even if they are immune to one strain, they can still become reinfected with another. “CMV is transmitted by body fluids—saliva, urine and sexual contact,” Fowler said. “Having another child at home or working closely with children can increase the risks of transmission. “We recommend that pregnant women be extra vigilant about hand washing and using hand sanitizers, particularly when they are around small children, after changing diapers or picking up toys or other things that might have had mouth contact. That includes not eating leftovers or using the same utensils. Goodnight kisses should be okay—but on the forehead, not the mouth. “Sometimes, even with the best efforts, infections can happen, but women say that knowing about CMV gives them something they can do to try to avoid it and to have the peace of knowing they did their best.”
Birmingham Medical News
AUGUST 2017 • 7
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UAB Bolsters Percentages While Prepping for MIPS By Jane Ehrhardt
Though the Merit-based Incentive Payment System (MIPS) for Medicare physicians does not take effect until 2019, UAB Medicine has already executed several successful campaigns to improve processes that will raise their MIPS rating. The rating will rely on submitted data that will correlate into a score that ranks each physician among every other clinician in the Medicare system. “If you fall below the average, you get a penalty, and if you’re above the average, you get an increase,” says Stephen W. Stair, MD, FACP, the medical compliance officer and clinical associate professor with UAB Medicine. Stephen Stair, MD, FACP “And it’s a pretty significant amount if you’re not ready for it.” As an academic hospital with over 100 qualifying physicians, UAB Medicine must submit their MIPS results on their physicians as a group rather than individually. “We’re all under one tax ID number,” Stair says, adding that their efforts this year are related to PQRS, but will be instrumental in defining their MIPS score in 2019. “UAB Medicine already ranks high among academic institutions, but we want to continue to work toward improvement.” PQRS (Physician Quality Reimbursement System) is one of Medicare’s current reporting systems for determining reimbursement rates and will be melded into MIPS, along with several other current reporting systems, such as Meaningful Use. CMS created a category titled Quality which replaces PQRS and will count toward 60 percent of a physician’s score in the first year. UAB has focused on making progress in this area during the past year. UAB Medicine made the diabetes eye exam a primary target for improvement. “This is a challenging measure because patients have eye exams outside UAB,” Stair says. “And obtaining the documentation of the exam is a necessity.” Academic hospitals nationwide averaged 50 percent compliance for the eye
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exam among qualifying patients. UAB reached only 26 percent in 2015. “This is one of the few areas we struggled in,” Stair says. “However, we managed a dramatic improvement. Last year, we reported at 45 percent. We’re doing an innovative outreach.” The increase stems from a broad push to educate patients. UAB emailed patients a video on the importance of the dilated-eye exam and the need for their eye doctor to send the results to UAB. Flu shots had also been a trouble spot. Other academic institutions averaged 63 percent compliance among qualifying patients while in 2015, UAB sat at 54 percent. The problem ran twofold. First, many Alabamians believe the flu shot makes them sick or has no effect. Also, there are a number of pharmacies and groceries where UAB patients could get the shot without notifying UAB. “We did a huge system-wide initiative,” Stair says. They emailed 104,000 patients debunking the myths surrounding flu shots, and then followed up with a phone campaign to everyone over the age of 50. Of the 54,000 who were called, 14,167 people responded to the automated question about getting a flu shot. If they answered yes, that met the Medicare measure as patient-reported compliance. The massive outreaches have not been cheap. “This is what’s required now for population medicine,” Stair says. “You have to invest. The return on investment will be large, because not only do we have healthier patients, but the MIPS scoring could save us four to nine percent on all of our Medicare reimbursements.” The largest jump in reporting for UAB has come from their BMI (body mass index) screening and follow-up. If the patient falls above a certain BMI level, Medicare requires patients to receive nutrition and exercise education. “Many times, we talk about weight loss to the patient, but we don’t document it,” Stair says. So UAB added a checkbox for physicians to click in the notes section of the EHR chart. “Now that’s a codified data point, and we can easily pull the analytics.” Previously, UAB had to rely on clinicians typing in a note about having discussed the issue. As a result of that EHR modification, the UAB Medicine BMI reporting percentage skyrocketed from 38 to 78 percent in one year, which is well over the 64 percent average reported by academic hospitals in 2015. “It takes a lot of effort from many areas to make this happen,” Stair says. “It’s been a really interesting data-driven process for us. It’s validated all the work we’ve done for so many years in primary care, and the importance of primary care in taking better care of patients.”
Reverse Total Shoulder Replacement a â€˜Game Changerâ€™ for Patients By Ann B. DeBellis
Thousands of people undergo conventional anatomic shoulder replacements each year for relief from arthritis pain, but for those who also have rotator cuff tears, the conventional procedure may not be the best option. A reverse total shoulder replacement can relieve arthritis pain in these patients and may provide better outcomes following surgery. â€œA reverse total shoulder replacement doesnâ€™t replace the rotator cuff. It is designed to accommodate for the lack of a rotator cuff,â€? says Wayne McGough, MD, of Andrews Sports Medicine & Orthopaedic Center. â€œWith the reverse shoulder replacement, you can knock out two birds with one stone. It is a complete shoulder replacement, so it will alleviate the arthritis pain, and it is potentially more successful in patients with rotator cuff issues because it relies on different muscles to move the arm and it is intrinsically more stable than an anatomic total shoulder.â€? According to the American Academy of Orthopaedic Surgeons, the conventional shoulder replacement device mim-
Dr. Wayne McGough talks with a patient about an upcoming surgery.
ics the normal anatomy of the shoulder: a plastic cup is fitted into the glenoid, and a metal ball is attached to the top of the humerus. It also uses the rotator cuff muscles to function properly. In a reverse total shoulder replacement, the socket and metal ball are switched. The metal ball is fixed to the
socket, and the plastic cup is fixed to the upper end of the humerus. In a patient with a large rotator cuff tear and cuff tear arthropathy, these muscles no longer function. The reverse total shoulder replacement relies on the deltoid muscle, instead of the rotator cuff, to power and position the arm.
â€œThe surgery typically is done on patients with significantly limited shoulder motion due to a large irreparable rotator cuff tear. A person can have arthritis in the shoulder and a functioning rotator cuff and still sometimes maintain a reasonable range of motion. If a person has a large cuff tear, however, he or she will usually have a very limited range of motion,â€? McGough says. â€œI tell my patients to pursue this surgery if their primary goal is pain relief with a secondary goal of range of motion. If they donâ€™t have much pain but want more range of motion and function, they may not be as happy with the outcome. Studies show that most people end up with slightly less range of motion than with an anatomic replacement.â€? The FDA approved reverse total shoulder replacement surgery in 2003. With people staying more active as they age, reverse total shoulder replacement has become a more popular procedure in recent years. â€œOur population is living longer and staying active longer than ever before,â€? McGough says. â€œGiven the high inci(CONTINUED ON PAGE 12)
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Advancements in Ankle Arthroplasty Are Changing Lives, continued from page 1 is an option for arthritic ankles. An increasing amount of literature has documented proof that it is an excellent alternative to ankle fusion in the correct patient.” Kirchner’s surgical team uses the Salto Talaris® total ankle prosthesis. Modeled after the human anatomy, it provides surgeons the ability to reproduce the natural flexion and extension axis of the ankle. Maintaining the natural motion of the ankle may reduce the stress on the medial deltoid ligament complex while allowing the replaced ankle to mimic the same motion as the opposite healthy ankle. “That will allow for a more natural gait for the patient post operatively,” he says. Another reason for success with this ankle arthroplasty procedure is the difference in how the bone is contoured during surgery. “Instead of doing a large block cut, we contour the bone with multiple small cuts, similar to setting a diamond. That allows the implant to resurface the rounded talar dome,” Kirchner says. “While all implants have polyethylene bushings, the talar component of the Salto Talaris is cobalt chrome, and the tibial base is titanium. With those three components, the implant requires much less joint resection than older model implants. The Salto Talaris requires less joint bony resection which leaves more of the patient’s own bone available in case a revision is necessary.” The standard recommendations for ankle arthroplasty surgical candidates
suggest someone age 50 or older with a normal body mass index. The candidate must not be diabetic and cannot have an open injury with infection. “The surgery is good for people for whom we can preserve a mobile segment so they aren’t putting stress on their knees, lower back or remaining ankle joints,” Kirchner says. “A successful replacement gives the patient better movement and a better lifestyle.” Nannie Fox of Luverne, Alabama, is looking forward to better mobility following her recent ankle arthroplasty surgery at Southlake Orthopaedics. Kirchner
performed the surgery at the end of June, and Fox is biding her time while her ankle heals enough to begin physical therapy. Fox’s ankle problems began when she was a majorette in college. “I stepped in a hole while I was marching and broke my ankle. Years later, I fell at church and broke my leg and the same ankle. I’ve had trouble ever since,” she says. “It never healed correctly which has caused pain in my hip and knee on that side. I’ve had two knee replacements, and the right knee was sore.” A surgeon in Montgomery suggested an ankle fusion, but she kept searching
for other options. She found information about ankle arthroplasty and thought that procedure could offer a better outcome in most cases with the same amount of recovery time and physical therapy. “I cancelled my fusion surgery and found Dr. Kirchner online. I made an appointment, and here I am. He and his staff were great, and I have been pleased with my care.” Fox will be in a wheelchair for another four weeks, but she is optimistic about her outcome. “I hope I can be normal again,” she says, “and I will do the necessary physical therapy to get there.”
Addressing Adolescent Angst, continued from page 6 it should be clearly communicated that having a phone is a privilege that the adolescent must continue to earn, or it can be taken away for a period of time. However, he continued, it’s most effective if the period is relatively brief and if children have a way to earn back the privilege. Shatkin said if a phone or other privilege is taken away for more than a day, kids forget the ‘why’ of the punishment and just think parents are just being mean, which diminishes the impact of the lesson. “Use these as teasers to get them to the zone where you want them to be,” he said of taking away privileges.
Warning Signals Pediatricians and other primary care
providers are often a first line of defense for young patients feeling anxious or experiencing depression. Shatkin encouraged providers to reach out routinely to parents and patients to see if there are any red flags that should be addressed. Warning signals include a persistent change in mood, crying or tearfulness, changes in sleep patterns or complaints of not being able to sleep, hanging out with a new group of friends not known to parents, no longer engaging in activities or with people they used to enjoy, expressions of anxiousness, physical changes like weight loss/gain or appearing ‘spaced out,’ and slipping grades. “If a parent is concerned … if a pediatrician feels out of their depth … then absolutely
get a consultation with someone trained in child and adolescent psychiatry,” said Shatkin. He praised the movement toward colocation with primary care and behavioral health providers under one roof. However, he also said the increasing need to address emotional and behavioral issues has been coupled with a shortage of child psychiatrists. “From a mental health perspective, there’s a huge workforce issue,” Shatkin noted. He advocated for providing physicians, nurses and therapists with a better grounding in diagnosis and treatment of mental health issues. “The earlier we intervene, the better kids do,” said Shatkin. “We need to catch more in the primary care office.”
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BY STEVE SPENCER
Hillbilly Elegy: A Memoir of a Family and Culture in Crisis By J. D. Vance This is one of the most meaningful Ohio where Papaw found work in a steel books I have ever read. mill. Like so many hill people who miJ. D. Vance grew up in a poor dysgrated to the Midwest in the 1950s, they functional family. He barely knew his fabrought with them their culture of hard ther, who was gone before Vance was out drinking and hot tempers. of diapers. His mother, a mercurial drug When Vance’s mother was still a and alcohol abuser, child, Mamaw told was married five times Papaw that if he came before Vance turned home drunk again, she 18. While living with would light him on file. one man, she married And a few days later another who she had when drunk Papaw known for a week. stumbled in the door, And yet, in spite of she was good to her this chaos, Vance manword, dowsing him in aged to graduate from kerosene and about Ohio State and go on to light a match when to finish at Yale Law Papaw escaped. School. Crazy as Mamaw Vance tells his permight have been, Vance sonal story in a straightcredits her and Papaw forward way without with instilling him with sugar-coating, melothe pride and work ethic J.D. Vance drama or judgement. that helped him escape There are moments of pain followed by poverty. When Vance came home from the warm and often funny episodes. His family first grade depressed that he didn’t undermay have been dysfunctional, but they were stand a word his teacher used, Papaw enclose-knit, and they cared about each other. couraged him. In the ensuing years, Papaw His grandmother, Mamaw, married often helped him with his homework while Papaw, his granddad, when she was 14 Mamaw always made sure he got it done. and the couple moved from Kentucky to Mamaw continually told him that, in her
words, he was not like the other “losers” around them. Eventually, life with his mother became so unstable that Mamaw took him in. This was when his scholastic turnaround began. However, despite Mamaw’s constant affirmation, the can’t-makeit attitude that permeating his community still lingered in the back of his mind, and unsure that he could handle college, he joined the Marines. The Corp had a profoundly positive affect. His drill instructors pushed him past what he thought were his limits which gave him confidence, finding he could do things he didn’t think possible. The Marines taught him discipline, planning, and even money management, traits which helped him graduate from Ohio State in just three semesters before finishing Yale law school. Everyone who reads this book gets something from it. I was influenced by his Marine Corps experience to make a reso-
lution to, every few months, find a challenge that I can push myself to complete. And while his story is inspiring, I also came to understand the hopelessness that permeates impoverished communities. People who grow up in an environment riddled with drugs, crime, abuse, failure and no positive role models have very little chance of escaping this life. This, of course, is obvious to all of us but when I experienced that world through Vance, it all became real. Ultimately, this book shines a powerful light on the cultural and familial conditions that contribute to the persistence of poverty, and while it is difficult to find answers, J. D. Vance’s life is an inspiring testament to what is possible. Steve Spencer is the owner of the Birmingham Medical News.
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Emerging and Reemerging Pediatric Infectious Diseases, continued from page 5 Kimberlin said. Another emerging disease that became an issue a few years ago was EV-68, an enterovirus that may mimic a common cold at onset, but can quickly become a respiratory crisis, especially in small children. In a small percentage of patients, a polio-like muscle weakness can develop. “Fortunately, we only saw a few cases compared to the numbers in states at the epicenter of the outbreak,” Kimberlin said. “It gradually faded, but the virus is still out there. We need to learn more about it so we can be better prepared to deal with it in the future.” Fears of an influenza pandemic affecting both adults and children have also been a concern in recent years. “Right now, we’re following the H7N9 avian virus in southeast Asia. So far, it doesn’t spread as easily as some strains, but if it mutates to become more transmissible, it could become an issue” Kimberlin said. Reemerging Tuberculosis is another story that has been making news in Alabama. “We had an outbreak in one of our southern counties where the infection rate for tuberculosis was higher than in many third world countries,” Kimberlin said. “We were fortunate that this strain responded to medications and we were able to treat patients and stop the spread of the disease. However, resistant strains in other countries are a concern that reminds us what a lethal killer tuberculosis was not so long ago. Resistant TB has come as close to us as Atlanta, where a passenger on a landing flight was infected. “What happens in other countries
should matter to us. We need to help people in other parts of the world stop diseases - first because it’s the right thing to do, and second because if we don’t stop them there, we could quickly find ourselves struggling to stop them here. In the age of air travel, the world is a small place as far as bacteria and viruses are concerned.” Resistant bacteria also brings up the issue of the overuse of antibiotics, which in years past were prescribed perhaps too often, particularly in children. “Not long ago, parents would feel cheated if they brought their child to the doctor for a cold and didn’t leave the office with a prescription for antibiotics, even though antibiotics do nothing for a viral infection,” Kimberlin said. “Now parents are becoming more savvy. We should continue to educate them. When needed, antibiotics can work wonders. But we have to be selective in when we use them and make sure they are used correctly to avoid teaching bacteria how to outsmart the antibiotic. “There are also growing concerns about the body’s microbiome and how antibiotics may have negative effects by killing off helpful microbes the body needs to stay healthy. Whether the effects on young immune systems that are just now forming have a greater or long term impact are questions that will take much more research to answer.” In the meantime, what are the best ways to protect our children from infectious diseases? “Immunize for the preventable diseases where vaccines are available—and teach our children how to avoid infections,” Kimberlin said. “Germs spread
through groups of children quickly. Young immune systems don’t have antibodies to as many infections, and the way children play and touch and interact tends to spread germs quickly. They can bring germs home from school and daycare and infect the entire family.
“We need to have infection deterrent measures in place wherever children gather. Most of all, we need to teach our children about hand washing, using hand cleaners and coughing into their arm. We need to model healthy habits for them until they become second nature.”
Reverse Total Shoulder Replacement, continued from page 9 dence of rotator cuff tears in the elderly population, this surgery gives patients an ability to stay active whereas they may previously have had to give up their recreational activities because of a lack of a good surgical option. Generally, people aren’t willing to try a newer procedure, but as patients’ reported outcomes improve I believe that word-of-mouth discussions are leading to an increase in volume for this procedure.” McGough says that like any surgery, the reverse total shoulder replacement comes with unique risks. “Nerve injury is possible but not common, and because of the lack of a rotator cuff, dislocation can occur in some cases,” he says. “Also, the ball could come loose or the shoulder blade could fracture. It has a higher complication rate than the anatomic procedure, but it doesn’t mean it isn’t a good surgery.” Dot Ray is a believer in the reverse total shoulder procedure. She injured her shoulder during a landscape project in her yard. Her doctor diagnosed her with arthritis in the shoulder and gave her a cortisone injection. However, the pain
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worsened, and she started to lose function in her left shoulder and arm so she went to an orthopedist. “He confirmed that the cartilage was gone in my left shoulder and that it was bone on bone. He recommended a cortisone injection for short-term relief and a total shoulder replacement as my only long-term option,” Ray says. “I decided I needed a second opinion. Some of our friends recommended Dr. Sam Goldstein. When I called Dr. Goldstein›s office at Andrews Sports Medicine, they told me that Dr. Wayne McGough performs most of the total shoulder replacements at Andrews.” After reviewing her medical records, McGough recommended a reverse total shoulder replacement because she had severe osteoarthritis and rotator cuff disease. “Dr. McGough performed my surgery on May 2nd. Three months later, I am totally surprised with how well I am recovering,” Ray says. “I appreciate Dr. McGough for helping give me back my quality of life.” MGough is happy to be able to offer this surgical option to his patients. “I think this is game-changing surgery, because there is a unique population with rotator cuff tear arthropathy who have significant pain and ‘pseudo paralysis’ and can’t lift their arm. If someone has a problem that sounds like rotator cuff tear arthropathy, they should contact a surgeon who has experience with this procedure,” he says. “I do a lot of different types of surgeries in my practice, and I can tell you that these are some of my happiest patients.”
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BE WELL AND VITAL
Body’s MiniMovements are Important for Health and Energy Editor’s Note: This is part three of our fourpart “Be Well and Vital” series with Micah Howard, MD. Dr. Howard practices family medicine in Decatur, Alabama. By Dale Short
Picture the term “exercise,” and chances are that some typical images come to mind: a runner pounding the track or the sidewalk, a lifter at the gym counting reps. But there’s a related, if lesser-known, type of exercise that can be just as significant for our health, according to Micah Micah Howard, MD Howard, MD. Think of them as “micro-movements,” the dozens of tasks our body performs each day without a second thought: standing, bending, lifting, stretching. “It’s the times when you’re moving your body but not for exercise,” Howard says. “And by the end of the day all those small tasks can consume more energy than a 30-minute exercise routine. If you can start being consistent with a small level of movement, you will see benefits without the stresses of the high-end intensity workouts we traditionally think of as exercise.” One of the most important aspects of these casual micro-movements is the simple battle against gravity. “Our fight against gravity is one of the major factors that keep our body moving the way it’s supposed to move,” Howard says. “That’s why astronauts who come back from space have lost muscle mass. Whenever you don’t have that pressure pulling you downward, many of these systems that keep our bodies healthy and protected start to fray at the ends.” Howard cites a study by NASA scientist Joan Vernikos, from her book Sitting Kills, Moving Heals, in which she finds that today many of us have “active-sedentary lifestyles”: exercise in the morning, sitting at a desk all day, maybe an evening walk, then sitting on the couch until bedtime. For what comes in between, Vernikos coins the acronym “non-exercise activity thermogenesis,” or NEAT. “You might have met your required minutes of healthy exercise,” Howard says. “But when you look at the whole scope of your week, the comparable micro-movement is lacking.” That balance can be evened out by purposely taking time for brief motions when you’d otherwise be stationary: squatting, standing, raising your arms into the air, crossing
and uncrossing your legs, and so on. Besides contributing to physical fitness, NEAT movements, like regular exercise, contribute to mental health, such as alertness, memory, and problem-solving skills. One landmark study that shows the impact of movement on academic abilities took place at Naperville Central High School, west of Chicago, where movement is integrated seamlessly with student’s studies. Not surprisingly, the first class of the day is physical education. But focused movement isn’t limited to the gym. Balls and bikes are built into the classroom. 30 minutes on the treadmill, the data found, leads to a 10 percent increase in problemsolving ability. More impressively, reading scores improved by a factor of 10 and math scores by a factor of 20. One of the study’s directors, Dr. Charles Hillman of the University of Illinois says “It’s good for attention; it’s good for how fast individuals process information; and how they perform on cognitive tasks.” Naperville recently gained headlines on an international level where some commentators touted it as a “super school.” U.S. schools generally rank poorly in science and math when compared to their counterparts around the world (half of Asian students, for example, rank in the top tier, compared to only seven percent of Americans). But students at Naperville took a quantum leap in the Trends in International Mathematics and Science Study (TIMSS). Naperville eighth graders who took the test scored number one in the world, finishing just ahead of formerly internationally leading Singapore. And on the math section, they ranked number six in the world. The research might be new, but the principles are ancient. “How many times a day does a doctor hear a patient say the word ‘fatigue?’” Howard says. “But the book Art of the Samurai tells us ‘Energy comes from expending energy.’ The more you use, the more you have. Energy is the only resource like that. “Find opportunities to move and you’ll be surprised at how quickly you become aware of clutter that limits your ability to do all those things. I invite people just to get up and move and see what your body does. “If there were a pill that made you both smarter and less depressed, wouldn’t you take it every day? This approach doesn’t take much time, and it gives so much in return.”
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Voluntary Benefits: Time For An Erisa Checkup by
Debra Lee Mackey
Multiple benefit consultants report that participation by employees in voluntary benefits is on the rise, in part due to increases in cost sharing under group major medical plans as a result of healthcare reform. Both employees and employers see voluntary benefits as a way to fill the gap on medical costs. In addition to voluntary medical-type benefits, traditional voluntary benefits such as supplemental life insurance and long term disability continue to be popular. What are voluntary benefits? Simply put, they are any benefit for which the employee pays 100% of the cost, but the
focus of this article is on fully insured welfare benefits. Voluntary benefits are found in the smallest medical practice to the largest hospital system. If employee-pay-all insurance is offered at your workplace, read on. Because employers do not contribute to the cost of voluntary benefits, there is a misconception by most that the employer has no responsibilities beyond collecting and remitting premium payments. While this may be true in some cases, in many cases it is not. What is involved in the ERISA checkup? First, identify all benefits for which employees pay 100% of the cost. Second, identify which are provided by insurance (both group and individual
policies). Third, identify which provide welfare benefits. Fourth, for those that are insured welfare benefits, carefully review your role under the ERISA “safe harbor.” Fifth, for those that fail to meet the safe harbor, take steps to comply with ERISA. The first two steps are self-explanatory. Let’s review the others. What are welfare benefits? ERISA defines welfare benefits by the type of benefit provided: medical, surgical, or hospital care or benefits; benefits in the event of sickness, accident, disability, death or unemployment; vacation benefits; apprenticeship or other training programs; day care centers, scholarship funds or prepaid legal services; and holiday or severance
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benefits. This is a broad, inclusive definition. This inclusiveness is ameliorated by several exclusions: payroll practices (e.g., shift premiums and payment of compensation while on jury duty); on-premises facilities (e.g., recreation and dining facilities); holiday gifts (e.g., turkeys); sales to employees (e.g., discount on employer’s products); hiring halls; remembrance and strike funds; unfunded scholarships; and certain group or group-type insurance programs (discussed in detail below). The exclusion frequently relied upon with voluntary benefits is the exclusion for certain group or group-type insurance programs. This exclusion applies only if all of the following requirements are met: (1) no contributions are made by the employer; (2) participation by employees is completely voluntary; (3) without endorsing the program, the sole functions of the employer are to permit the insurer to publicize the program to employees, collect premiums through payroll deduction and remit premiums to the insurer; and (4) the employer must not receive any consideration in connection with the program other than reasonable compensation for administrative services actually provided in connection with the payroll deductions. It is generally evident whether most of these requirements are met. The third requirement is the one that causes most voluntary benefits to fail the safe harbor because the employer has gone too far and endorsed the benefit. Case law and Department of Labor opinions find the presence of the following factors to be indicative of endorsement (and their absence indicative of no endorsement): selecting the insurance carrier; negotiating the terms of the insurance contract; tying eligibility for participation to employee status; using the employer’s name in communications and materials; recommending that employees participate; saying that ERISA applies; allowing premiums to be paid through the employer’s cafeteria plan; assisting employees with issues that arise with respect to the benefits offered; and doing more than processing payroll deductions. The specific facts are very important. The more factors found, the more likely is the benefit to be outside of the safe harbor. In a few cases, the presence of a single factor took the benefit outside of the safe harbor. Typical litigation facts involve a benefit that the employer treats as falling within the ERISA safe harbor, but when sued in state court by a participant, the insurer invokes ERISA as a defense. The insurer claims that the safe harbor does not apply, and as an ERISA covered benefit the participant’s state law claims are preempted by ERISA. (There is a good chance the insurer took the opposite position when setting up the benefit with the employer). Note: failing to meet the safe harbor should not automatically mean that the plan is subject to ERISA. Technically, it simply means that the em(CONTINUED ON PAGE 16)
Who’s Ready for MACRA? Hint: Not the Target Audience By CINDY SANDERS
In late June, the American Medical Association commended the Centers for Medicare & Medicaid Services for proposing several new policies to allow added flexibility in Medicare Access and CHIP Reauthorization Act (MACRA) implementation. Just over a week later, results from a survey conducted by the AMA and KPMG LLP made it clear why that flexibility was so desperately needed: fewer than one in four physicians in a decision-making role felt ‘well prepared’ to meet the new quality reporting requirements in 2017. MACRA, which was signed into law April 2015, makes fundamental changes to the way Medicare Part B will pay physicians and other clinicians under the Quality Payment Program (QPP) beginning in 2019 but based off of performance in 2017. The new payment methodology replaced the universally hated SGR formula with a system that links payments … and penalties … to performance under one of two tracks: Merit-Based Incentive Payment System (MIPS), which increases or decreases physician fees based on whether or not certain quality and efficiency benchmarks are met across four domains: quality, cost, advancing care information, and improvement activities; and
Advanced Alternative Payment Model (APM), which offers a more stable and favorable fee schedule and bonus but also requires physicians to take on more risk. Since many physicians and practices do not meet the initial qualifying criteria for APM participation, the majority will be paid under the MIPS track. While the overarching MACRA concept is generally well received, the devil for most clinicians is in the details. Responses to the AMA/KPMG survey of 1,000 active physicians who have been
involved in decision-making roles related to QPP for their practice raised a number of red flags. The survey found: • 56 percent of respondents plan to participate in MIPS in 2017 & 18 percent are expecting to qualify for the higher, more stable payment from APM. • 51 percent of decision-makers felt ‘somewhat knowledgeable’ about MACRA or QPP, 41 percent had heard of MACRA or QPP but didn’t consider themselves knowledgeable, and only 8 percent described themselves as ‘deeply knowledgeable’ on the subject.
• 70 percent have begun the process to meet QPP requirements in 2017, but only 23 percent of that group feels ‘well prepared’ to do so. • 90 percent felt the reporting requirements were ‘slightly’ (37 percent) or ‘very’ (53 percent) burdensome. AMA President David O. Barbe, MD, MHA, said the organization had conducted a previous survey within a general physician population that showed a very low percentage having an awareness of MACRA. However, he added, the hope was that the disconnect among ‘rank and file’ physicians wouldn’t be there when speaking directly to physicians in a leadership caDr. David O. Barbe pacity. “That was equally dispiriting,” Barbe said. “Fewer than 25 percent in physician decision-making roles have what they would consider adequate knowledge of MACRA … and we’re halfway into this first reporting year. These are scary statistics.” Larry Kocot, JD, national leader of the Center for Healthcare Regulatory Insight at KPMG, said although there was some good news to share from the survey, “83 percent said they needed more help and (CONTINUED ON PAGE 16)
Weily Soong, MD Maxcie Sikora, MD John Anderson, MD Sunena Argo, MD William Massey, MD Carolyn Comer, MD
Tree Nut and Peanut Oral Immunotherapy Now Available We are pleased to offer oral immunotherapy for both peanuts and tree nuts (almond, pistachio, pecan, walnut, and hazelnut) to adults and children as young as four years of age. Oral immunotherapy, or oral desensitization, is a treatment that retrains the immune system to tolerate a food allergen. Under the strict supervision of our allergist/ immunologist, Dr. Carolyn Comer, small, gradually increasing doses of peanuts are orally introduced each day. Dosing is increased under one-on-one monitoring in the office every one to two weeks for six to seven months on average, and can be individualized as needed. An at-home maintenance dose is continued indefinitely to protect patients from accidental ingestion or cross contamination, and many patients can freely add tree nuts and peanuts back into their diet. As the leading caregiver in the state for allergies, asthma, and immunology, Alabama Allergy & Asthma Center is committed to patient safety and offering quality care to all of our patients. Oral immunotherapy (OIT) has been extensively researched in an academic setting for over a decade with proven success. Studies show OIT can be 85 to 90 percent effective for both peanut and tree nut desensitization. Our goal of treatment is to improve our patients’ overall quality of life and help them obtain a lifetime of freedom from food allergy fear and stress. For questions or more information, contact our Physician Liaison directly at 205-218-4764.
To refer a patient for an OIT consultation with Dr. Carolyn Comer, our easy-to-use fax referral form can be found at alabamaallergy.com
6 Convenient Locations, One Number Homewood • Hoover • Chelsea • Cullman • Alabaster • Trussville
205-871-9661 Birmingham Medical News
AUGUST 2017 • 15
Who’s Ready for MACRA? continued from page 15 understanding. That’s one of my bottom line takeaways.” He added that 66 percent said their biggest challenge was the time required to report. The survey also indicated phyLarry Kocot sicians don’t expect the time burden to lessen in subsequent reporting years. Kocot said other concerns were the need for better understanding of the scoring (57 percent), cost of reporting (53 percent), and the need for improved organizational infrastructure to meet reporting requirements (49 percent). “We found the problems were pretty consistent across practice sizes so these aren’t unique,” he said. Barbe noted the AMA has advocated for more exclusions and flexibility for physicians in this first year. ‘Pick Your Pace,’ for example, gives physicians the option to not participate at all and receive a negative 4 percent adjustment; submit something … even just one improvement activity … and avoid a penalty; submit 90 days of data to potentially receive a small positive payment adjustment; or submit all of 2017 data for a moderate positive payment adjustment. Similarly, feedback about the burden on small practices led CMS to increase exclusionary low-volume thresholds from less than $10,000 in Medicare charges and seeing fewer than 100 Medicare patients to less than $30,000 in charges or seeing fewer than 100 Medicare patients. Additionally, clinicians in their first year of Medicare participation are exempted from reporting requirements. Kocot added CMS has invested substantial resources to help physicians get prepared and have seemed willing to work with
providers as evidenced by the enhanced flexibility in this first year. He also noted the work has continued smoothly despite staff changes in the wake of the presidential election. “Both administrations deserve credit for not missing a beat,” Kocot said. “The want to bring physicians to a point where they can operate comfortably in a new payment environment that ultimately will be more beneficial to patients and bring some sustainability to the healthcare system’s financial landscape.” He added, “Aligning physician incentives with quality and other performance targets will lead to greater rewards for physicians and better healthcare for patients.” While supportive of a payment system that rewards high-quality, evidence-based care, Barbe said moving to MACRA has been a two-edged sword. “On the one hand, it does actually represent an improvement. We do have reduced reporting requirements than before.” However, he continued, “It’s still a significant burden for practicing physicians to figure out what measures to report.” Adding to that burden are different reporting requirements across all payers. “Why can’t we all agree here are the three measures important for diabetes? Here are the four for hypertension. Let’s all work together toward the same measures,” he said of the bigger quality picture across public and private payer sources. Barbe noted some practices have had to hire extra staff to gather data and pull reports. “There are many practices who have found it costs more to comply than to pay the penalty. Rewards should be commensurate with the amount of effort to comply and report.” It’s frustrating, Barbe said, for phy-
sicians who feel like they learned the requirements for PQRS or Meaningful Use to switch gears once again. “Just about the time they figure out the game, the rules change,” he pointed out. That said, Barbe noted prior experience with reporting programs might have helped physicians with QPP preparation. The survey showed past participation appears to have positively impacted physician readiness for MACRA. “While progress has been made in preparing physicians for the move from volume in the fee-for-service payment model to value in alternative payment models, it is important that we do even more to assist physicians with the transition,” agreed Kocot. He also said the shifting payment model is inevitable. “CMS is not going to walk away from this transition from volume to value,” said Kocot. “We could do a better job of bringing people along, but we’re not going to turn back.” Although the survey confirmed worries that physicians aren’t confidently prepared for MACRA, Barbe said it also helped AMA in their quest to continue assessing readiness gaps and focus educational efforts. One such resource is AMA’s “Do One Thing Now for QPP” page located at ama-assn/qpp-reporting. The page walks physicians through the steps to successfully avoid a penalty in 2019 for the 2017 reporting year. Despite current concerns and ongoing tweaks to the process, Barbe said physicians do want to see a transition to value-based practice. “I am optimistic that we can improve not only the quality of care for patients but the practice environment for physicians so the frustration level begins to come down,” he concluded.
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Birmingham Medical News
Voluntary Benefits, continued from page 14
ployer is unable to rely on the safe harbor to remove the plan from ERISA. If you want to offer voluntary benefits and have them fall outside of ERISA, it is very important to strictly limit your role as the employer to those clearly permitted by the safe harbor, and avoid any action that could be construed as endorsement. As a practical matter, many employers find it difficult or undesirable to offer a voluntary benefit in the manner necessary to fall within the ERISA safe harbor. In that case, it will be necessary to comply with ERISA. What are the ERISA obligations? File an annual form 5500 (for smaller employers an exemption may apply); follow the DOL claims procedure; timely respond to participant requests for documents; prepare and distribute a summary plan description and a summary of material modification for amendments to the SPD; and generally carry out administrative obligations as a fiduciary (unless the insurer has taken on the fiduciary role of plan administrator). If the benefit is also a health plan, additional obligations are present, such as COBRA, HIPAA, and healthcare reform compliance. Voluntary benefits are valued by employees, not only for the gaps they fill but the ability to obtain them at better rates than the employee could get individually. As the employer, a little due diligence on new benefits and a checkup on existing benefits can minimize headaches and complications down the road. Debra Mackey is an attorney with Burr & Forman LLP practicing in the Employee Benefits & Executive Compensation Group.
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BBH Service Center Improves Transitions of Care, continued from page 1 “Our team found that very few primary care physicians were billing for this service because they were unclear about the requirements,” said John Gardner, Executive Director of Operations at Hoover BBH. “Many of them were providing the care management service but not meeting the specific time frames required for billing. The common challenge we found was the ability to know a patient was discharged within the required time frame for implementing TCM services.” Recognizing this need, Gardner and his staff developed a program wherein the Hoover BBH Service Center team pulls a list of discharged patients belonging to the BBH primary care physicians from all five BBH hospitals, and then calls all Medicare and Medicare Advantage patients within two business days of discharge. After asking a series of medical questions, the service team member schedules an appointment with the patient’s primary care physician. The service center later checks to make sure the patient showed up for the appointment. One of the requirements to bill the TCM codes is that an interactive contact must be made with the beneficiary and/ or caregiver, as appropriate, within two business days following the beneficiary’s discharge to the community setting. The contact may be via telephone, email, or face-to-face. This interactive contact must address the patient’s status and their needs. So the medical questions go beyond a simple how-are-you-feeling approach. “We have a different series of questions depending on the reason they were admitted to the hospital,” said Summer Rahman, clinical office manager for Hoover BBH Service Center. “For congestive heart failure, we’ll ask about worsening symptoms, but we will also ask if they have gained weight, because we are looking for fluid retention. We ask about chest pain and whether they are compliant with medications. We even have them get their medicine bottles and go over what the hospital might have taken them off of or added upon discharge. It can be very confusing to a Medicare patient who has been sick.” The goal is to catch those patients who are at risk of returning to the hospital. Sometimes they may be experiencing symptoms that need to be checked by their PCP sooner than the hospital suggested or
Pictured left to right, Service Center team: Karrie Sawyers; Lakita Barron; Summer Rahman; Donna Clay; Kimberly Arrington
they may be at risk of being readmitted because they were unable to afford their medications or did not understand their discharge instructions. On several occasions, Rahman has ascertained during the phone call that the patient needed to go back to the hospital. “It’s like a telephone triage,” she said. “Just like when we see a patient in person, we can hear if they are short of breath or disoriented and confused, and we can respond.” Those kinds of calls are not the norm, however. Most are straightforward follow-
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up calls. In addition to assessing the status of the patient, the service team member will review any discharge instructions and answer questions. Before hanging up, they make an appointment with the primary care physician. Later they check to see how the follow-up appointment went and make sure the doctor has billed appropriately. “We started doing this as a pilot project over a year ago,” Rahman said. “Baptist Health had received a Practice Transformation Network grant prior to the joint venture with Brookwood. While
the medical community has known that follow-up appointments play an important role in quality of care, the grant helped BBH implement a more effective plan.” “Timely notification of primary care physicians when a patient has been discharged from the hospital has always been a challenge,” said Theresa Keller, Administrator for the Practice Transformation Network team. “In order to improve patient outcomes and decrease unnecessary readmissions, we had to not only notify the physicians of the discharges timely, but also ensure the patients had access to their primary care provider within seven to 14 days, and that they kept their appointments. Our Practice Transformation Network team worked with several departments including admitting, case management, nursing staff and hospitalists to determine the best process to improve coordination of care. “The team developed this program, and now we are rolling it out system-wide to over 200 BBH primary care physicians.” If patients are discharged to a rehab or skilled nursing facility, the center contacts the physician’s office with that information. When the facility notifies the center that a patient has been released from rehab, the center provides the same follow-up service. The program is successful from a patient standpoint, with high compliance for follow-up appointments and a reduced readmission rate, but it benefits doctors as well. They can now get reimbursed for the care management services they were already performing as well as improve their patient outcomes and MIPS score.
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AUGUST 2017 • 17
McBride Joins Cullman Regional Stephen McBride, MD has joined the Cullman Regional Medical Staff where he will practice with Surgical Arts. McBride is a boardcertified general surgeon who graduated from Samford University and comStephen pleted Medical School at McBride, MD UAB. McBride provides a variety of surgical procedures including, but not limited, to: appendectomy; breast cancer surgery; colon surgery; gall bladder removal; lung surgery; thyroid surgery; and vascular surgery.
Jacobs Elected President of AAFP Tracy Jacobs, MD, has been elected president of the Alabama Academy of Family Physicians (AAFP). She has served on the AAFP board since 2012. Jacobs has been in private practice in Birmingham for five years. She joined the Grandview Tracy Jacobs, MD Medical Group physician network in 2014. Jacobs received her medical degree from the University of South Ala-
bama in Mobile where she also completed her residency in Family Medicine. Prior to attending medical school, Jacobs worked as a project coordinator for Research Genetics in Huntsville and then as a pharmaceutical representative for Eli Lilly. In addition to AAFP, Jacobs is member of the National Lipid Association, a fellow if the American Academy of Family Medicine and a member of the Obesity Medicine Association.
Landefeld Appointed to American Board of Internal Medicine C. Seth Landefeld, MD, professor and chair of the Department of Medicine in the UAB School of Medicine, has been named to the American Board of Internal Medicine. Landefeld is an internationally known clinician C. Seth and researcher in geriatLandefeld rics, epidemiology and biostatistics. He serves on the Boards of Directors of the UAB Health System and the University of Alabama Health Services Foundation and is a member of the U.S. Preventive Services Task Force. He completed his undergraduate work at Harvard and New College, Ox-
ford, where he was a Rhodes Scholar. He received his medical degree from Yale and trained in internal medicine at University of California-San Francisco and in clinical epidemiology at Harvard. Landefeld is a past president of the Society of General Internal Medicine and serves on the boards of the American Geriatrics Society, Association of Directors of Geriatric Academic Programs and San Francisco’s Institute on Aging. In 2011, he received the Robert J. Glaser Award “For Exceptional Contributions to Education and Research,” the highest award of the Society of General Internal Medicine.
Children’s of Alabama Specialties Recognized Among Nation’s Best For the eighth consecutive year, Children’s of Alabama is ranked among the nation’s best children’s hospitals by U.S. News & World Report. Seven of Children’s pediatric specialty services – Cancer, Diabetes and Endocrinology, Gas- Mike Warren troenterology/GI Surgery, Nephrology, Neurology/Neurosurgery, Orthopedics and Pulmonology – were placed among the top 50 in the United States in the magazine’s 2017-18 Best
Children’s Hospital rankings. Currently, U.S. News & World Report ranks 10 specialties. “We are happy that for the eighth year we are ranked among the nation’s best pediatric hospitals,” said Children’s CEO and president Mike Warren. “Year in and year out, our goal is to provide exceptional care, service and comfort to the patients who are entrusted to us for medical care.” Children’s and the University of Alabama at Birmingham Departments of Pediatrics and Surgery collaborated to submit the requested information. Children’s is the primary site for pediatric clinical and educational programs for the UAB School of Medicine.
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Alabama • Florida • Mississippi • Tennessee
Birmingham Medical News
AUGUST 2017 â€¢ 19
Alabama Hospital Association Elects Board Members and Ofﬁcers Several health care leaders from across the state were elected to serve on the Alabama Hospital Association (AlaHA) Board of Trustees during the Association’s recent meeting. Board of Trustee officers elected and installed include: • Will Ferniany – Chairman of the Board Ferniany serves as CEO of the UAB Health System.
Zero Prostate Cancer Run/Walk More than 220,000 men will face a prostate cancer diagnosis this year. We invite you to join ZERO - The End of Prostate Cancer and Urology Centers of Alabama to help end prostate cancer at this year’s ZERO Prostate Cancer Run/Walk Birmingham. As part of the nation’s largest Men’s Health event series, The ZERO Prostate Cancer Run/Walk occurs in more than 40 markets across the country and raises more than $3,000,000 towards the fight against prostate cancer each year. September 9th at 8:00 a.m. at Homewood Central Park
• Owen Bailey – Chairman-elect Bailey is CEO of the University of South Alabama Health System in Mobile. • Luke Standeffer – Secretary/Treasurer
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20 • AUGUST 2017
Birmingham Medical News
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Standeffer is senior vice president of the DCH Health System in Tuscaloosa. Andy Davis, COO of St. Vincent’s Health System in Birmingham, was elected to serve as an AlaHA board member. Peter Selman, CEO of Baptist Medical Center South in Montgomery, and Suzanne Woods, CEO of Medical Center Enterprise, were re-elected to serve as AlaHA board members through 2020.
UAB School of Nursing Earns National Honor The University of Alabama at Birmingham School of Nursing has been designated as a National League for Nursing Center of Excellence, which recognizes schools that have demonstrated a commitment to excellence and invested resources to distinguish themselves an area of nursing education. The school was cited for its sustained efforts to “Enhance Student Learning and Professional Development.” “This designation is a confirmation of the UAB School of Nursing’s commitment to preparing future nursing leaders, and aligns with our goals of maintaining excellence in teaching and learning,” said Doreen C. Harper, PhD, dean of the UAB School of Nursing. The UAB School of Nursing is ranked 13th in overall graduate programs, among the top five public schools of nursing in the country by U.S. News & World Report, and offers innovative bachelor’s, master’s and doctoral programs, including the state’s only PhD in Nursing degree and a DNP degree offering BSN, MSN and Nurse Anesthesia Pathways; more than 10 specialty nurse practitioner tracks, advanced nursing executive majors in administration and informatics, and an Accelerated Master’s in Nursing Pathway for students who already have one degree.
Dodd Joins Alabama Pain Erin Dodd, MD has joined Alabama Pain Physicians. After receiving her B.S. from the University of Alabama, Dodd continued her education at the University of Alabama School of Medicine where Erin Dodd, MD she earned her Medical Degree. She completed her residency in anesthesiology at the University of Mississippi Medical Center followed by a chronic pain management fellowship at the same institution. Dodd believes in treating the whole patient rather than just a specific pain generator. She implements targeted interventional techniques that allow the patient to improve overall health through physical therapy and improved nutrition. Therapies she may utilize include epidurals, major joint injections, medial branch blocks, radiofrequency ablations, and others.
DCH CFO Nina Dusang Elected President of Alabama Chapter of HFMA Nina Dusang, senior vice president and chief financial officer of DCH Health System, has been elected president of the Alabama Chapter of the Healthcare Financial Management Association. The Alabama Chapter of HFMA serves more Nina Dusang than 480 members and volunteers across the state providing healthcare finance education through multi-day events, webinars and newsletters. Dusang also represents mid-size hospitals on a national panel of CFOs.
Hoover Selected as Health Care Section Chair of the FDCC Jim Hoover, a partner in the Burr & Forman Birmingham office, has been elected to serve as chair of the Health Care Section for the Federation of Defense and Corporate Counsel (FDCC) for the 2017-2018 term. Hoover will serve one year in the Jim Hoover position and preside over the 94 members in the FDCC’s Health Care Section. Hoover is a member of the firm’s
health care practice group where he focuses on representing all types of companies and individuals in the health care industry including hospitals, physician practices, pharmacies, pharmaceutical manufacturers, nutraceutical manufacturers and medical device manufacturers throughout Alabama and the Southeast. FDCC Membership is limited and by nomination only. Election is by the Board of Directors upon recommendation of an independent Admissions Committee charged with the responsibility of making an investigation into the qualifications of each nominee to insure that those selected have distinguished themselves professionally.
Aspire Now Offers Virtual Reality Rehabilitation Aspire Physical Recovery Center at Cahaba River now offers the OMNIVR system, a virtual reality augmented rehabilitation system that allows clinicians to work with guests in novel, yet functional ways. The system can be utilized by physical, oc- Stirling Shirah, MD medical cupational, and speech director at therapists with a variety Aspire Recovery Center at of tasks available for each Cahaba River discipline. For example, physical and occupational therapy can design tasks that
incorporate components of upper and lower extremity strengthening along with balance training; speech therapy can use the system to focus on sequencing and higher level executive functioning tasks. The OMNIVR can customize a given task to a specific guest’s needs, altering the intensity, range, etc. This not only allows participation by a variety of guests of variable presentations, but also provides an objective means of tracking progress over time. Guests who have utilized the system not only show objective gains, but they also report increased levels of confidence with functional tasks.
St. Vincent’s Opens New Education Center at Samford St. Vincent’s Health System held an open house and blessing in July for its new nursing education training center on the Samford University Campus. The Ascension St. Vincent’s Education Center will serve as an advanced training site for new nursing hires. The Training Center includes a skills lab, medication room, and classroom, as well as two simulation and debriefing rooms for nurses to receive hands-on training in real-life scenarios. In addition to training new St. Vincent’s nurses, Samford College of Health Sciences students will also have access to the center, as well as the latest Electronic Health Record system technology. This is Ascension’s third nursing onboarding center to go live across the country. The Ascension St. Vincent’s Education Center includes a classroom to train new nursing hires.
Structural Heart & Valve Center Princeton Baptist Medical Center has an experienced structural heart program servicing the southeastern United States. The team of specialty physicians and practitioners at the Structural Heart and Valve Center offers advanced diagnostic testing and endovascular therapies such as transcatheter heart valves (TAVR), transcatheter mitral valve repair (Mitraclip®) and left atrial appendage percutaneous closure (Watchman™ device). The physicians of the Structural Heart and Valve Center partner with clinicians and patients to deliver individualized care plans. Through this focus, the interdisciplinary team is able to offer timely diagnosis, conservative treatment options, and innovative surgical techniques.
Mustafa Ahmed, MD
Ibrahim Hanna, MD
Interventional Cardiologist Director, Structural Heart Program
Cardiac Electrophysiology Medical Director
Clifton Lewis, MD
Kyle Eudailey, MD
To refer a patient, call (205) 783-3320.
Birmingham Medical News
AUGUST 2017 • 21
Cowell Joins Southern Research Rita Cowell, PhD has joined Southern Research as Chair of the Neuroscience Department. Cowell is examining the mechanistic underpinnings of why people develop neurodegenerative diseases. “Some of these disorders actually converge Rita Cowell, PhD on similar pathways in the brain. Even though they look different on the outside, if you look at one region of the brain, the process at the cell level is very similar,” Cowell said. “If we
could understand what that process is, we could use one drug to target one set of symptoms that is common to these diseases.” Neurodegenerative diseases affect millions of people worldwide. Alzheimer’s and Parkinson’s are the most common types in the U.S., with Alzheimer’s affecting more than five million people while Parkinson’s affects at least 500,000, according to the NIH. These diseases occur when nerve cells in the brain lose function and eventually die. Other disorders in this group include Huntington’s and amyotrophic lateral sclerosis (ALS). In addition, schizophre-
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nia is a disorder with some similar characteristics that have been examined in Cowell-led targeted investigations. Cowell’s research has focused on how cellular pathways in the brain are disrupted in these diseases. “All these diseases have characteristic symptoms. Someone will go into a clinic with a memory problem or they have a problem with uncontrolled movements,” she said. “What distinguishes these diseases and their symptoms from each other is the cell types in the brain that are dying.” In Parkinson’s, for instance, the neurons in the brain producing dopamine are dying, whereas the neurons producing acetylcholineare are dying with Alzheimer’s. “We’re trying to use our understanding of the basic biology of how neurons work to understand how they’re aging and how they’re dying in people who have these disorders,” Cowell said. Cowell joins Southern Research after 10 years at UAB, where she last served as associate professor in the Department of Psychiatry and Behavioral Neurobiology. Southern Research and UAB are close collaborators and joined together to form the Alabama Drug Discovery Alliance, which is currently funding three neuroscience projects. Cowell said Southern Research’s extensive drug discovery capabilities allow her to pursue her goal of developing a small-molecule drug that could prove useful against a number of neurological diseases. Her laboratory has identified a target that could play a role in the development of these disorders – a protein named PGC-1 alpha.
Samford’s Nursing School Receives National Honor
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Samford University’s Ida Moffett School of Nursing has been named a Center of Excellence for Nursing Education by the National League for Nursing. Samford received this designation in recognition of excellence in the category of “Promoting the Pedagogical Expertise of Faculty.” “The success of our school has been possible through the continuation of the legacy of its namesake, Ida Vines Moffett, and her belief in academic excellence, compassion and service,” said Nena Sanders, vice provost of Samford’s Col- Nena Sanders lege of Health Sciences and nursing school dean. “Today, more than 6,000 nurses who have graduated from our programs are impacting lives throughout the world.” REPRINTS: If you would like to order a reprint of a Birmingham Medical News article in a PDF format or request an additional copy of an issue, please email: steve@ birminghammedicalnews.com.
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Birmingham Medical News
A committee of six Samford nursing faculty members worked to complete the 100-page document that outlined the school’s unique initiatives and outcomes. Examples of the school’s accomplishments are its outstanding first-time licensure and certification pass rates, leadership and participation in interprofessional education and multiple opportunities for service learning including international missions. The maxims espoused by Moffett served as the theme for the document. Testimonies from College of Health Sciences faculty, nursing students, alumni and community representatives were included as supporting evidence of the faculty’s expertise and commitment to excellence. The honor comes as the school celebrates 95 years of nursing excellence.
EDITOR & PUBLISHER Steve Spencer VICE PRESIDENT OF OPERATIONS Jason Irvin CREATIVE DIRECTOR Susan Graham STAFF PHOTOGRAPHER April May CONTRIBUTING WRITERS Ann DeBellis, Jane Ehrhardt, Laura Freeman, Lynne Jeter, June Mathews, Cindy Sanders GRAND ROUNDS CORRESPONDENT Frank Sinatra Birmingham Medical News 270 Doug Baker Boulevard, Suite 700-400, 35242 205.215.7110 • FAX 205.437.1193 Ad Sales: 205.978.5127 All editorial submissions should be mailed to: Birmingham Medical News 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242 or e-mailed to: firstname.lastname@example.org —————————————————— All Subscription requests or address changes should be mailed to: Birmingham Medical News Attn: Subscription Department 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242 or e-mailed to: email@example.com Birmingham Medical News is published monthly by Steve Spencer ©2017 Birmingham Medical News, all rights reserved. Reproduction in whole or in part without written permission is prohibited. Birmingham Medial News will assume no reponsibilities for unsolicited materials. All letters sent to Medical News will be considered Medical News property and therefore unconditionally assigned to Medical News for publication and copyright purposes. ——————————————————
Daniel Avery, MD Joins Princeton Daniel Avery III, MD joins Princeton Baptist Medical Center this month where he will practice orthopedics. After earning a BA in business at the University of Alabama in 2002, Avery attended Auburn University where he graduated Daniel Avery III, MD Magna Cum Laude with a BS Biomedical Sciences. He went on to earn his Doctor of Medicine at UAB Medical School in 2010. Avery completed his Orthopaedic Surgery residency at St. Luke’s University Hospital and Health Network in Bethlehem, Pennsylvania where he served as Chief Resident and he received his fellowship in Orthopedic Sports Medicine at the University of Connecticut. He was the Undergraduate Teaching Assistant of the Year at Auburn in 2003 and he received the Heroes Award for excellence in trauma care at St. Luke’s University Hospital.
New President of Huntsville Hospital Heart Center Joshua Hewiett has been named President of Huntsville Hospital Heart Center and Vice President of Cardiovascular Services at Huntsville Hospital. The Heart Center includes 50 physicians
and is the largest cardiology practice in North Alabama. Heart Center is a part of the Huntsville Hospital Health System and has offices in Huntsville, Athens, Boaz, De- Joshua Hewlett catur, Madison and Sheffield. Hewiett joined Heart Center in 2012 and has served as Director of Cardiology Services since 2013. He graduated from the University of Florida with a bachelor’s degree in finance and earned a master’s of business administration degree and a master’s of science in health administration degree from UAB.
no and his sports medicine fellowship at the American Sports Medicine Institute in Birmingham. Agee has served in clinical leadership roles as Chief of Primary Care Sports Medicine, Medical Director, and Fellowship Director. He has over 10 years of experience caring for elite
athletes from the NFL, MLB, NBA, and NHL. He has particular interests in sports-related trauma, concussion management, non-surgical orthopedic care, sideline care, regenerative medicine, sports and work-related musculoskeletal injuries, and acute or chronic tendon injuries.
BBH New Sports Medicine Practice Brookwood Baptist Health’s Specialty Care Network has opened a new sports medicine practice at Princeton BapAgee, tist Medical Center with Robert Jr., MD Robert Agee, Jr., MD as the principal provider. Agee is a board-certified sports medicine physician who focuses in primary care sports medicine. He earned his bachelor’s degree from Morehouse College and his medical degree at Meharry Medical College. He finished his family practice residency at UCSF Fres-
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Fair Haven’s Renovation Opens in fall 2017 Over the last 18 months, the team at Fair Haven has been working to complete a $42M renovation and construction project. Fair Haven has opened new assisted living, rehabilitation, and long-term care accommodations, renovated existing units, and transitioned to the Household Model. Construction has now moved to the center section of the community to add 15 new independent living and 23 new assisted living apartment homes.
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