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New Device May Improve Function for Heart Failure Patients By Ann B. DeBellis

Pooling Helps Track COVID Testing for Returning College Students Before Alabama college students could return to campuses this fall, officials decided that the 200,000 students in the state would need to be tested within weeks of the start of the school year. ... 3

The Challenges of a Rural Paramedic Serving 30 years as a paramedic in rural Alabama has left John Reed, MPH, BSN, RN, with hardearned insights concerning the difficulties faced in rural emergency medical service (EMS). “Even though we’re all paramedics, being a rudral paramedic is a different animal,” says the Professional Nurse Development Specialist at UAB Center for Nursing Excellence ... 9 FOLLOW US

Heart failure affects six million adults and represents one of the most common cases of cardiac hospital admissions in the United States. The condition can range from mild heart failure to more advanced disease where patients are almost bedridden. Despite advances in treatments, millions of people with systolic heart failure still have problems. Because the heart can’t pump enough blood to sustain the body’s needs, patients experience fatigue, shortness of breath, and swelling in the legs and ankles, among other symptoms. Many are even at risk of early death. “Many of these patients can only walk a city block before having to rest and are limited in their ability to carry out daily activities. There aren’t a lot of treatment options for them,” says Anil Rajendra, MD, a cardiac electrophysiologist at Grandview Medical Center. “However, we have a new device that may bring relief for some patients. The Barostim NEO can improve quality of life, increase mobil(CONTINUED ON PAGE 16)

Drs. Anil Rajendra and John Casterline.

RURAL HEALTH

Citizens Baptist Celebrates 50 Years By JAne ehrhArDt

including forming a partnership with Baptist Health SysAt a time when Alabama tem in 1991, which assured has seen six rural hospitals the continued operation of close in nine years, Citizens the hospital as a not-forBaptist Medical Center has profit medical center. remained a solid bastion When Tenet Health of healthcare in Talladega. merged with Baptist in 2015, Now celebrating 50 years Citizens became for-profit since the current location for the first time. They reopened back in March 1970, tained the citizens comthe hospital was originally mittee, though, in a role of Citizens Baptist current location opened 50 years ago. founded nearly 100 years ago oversight for agreements by a group of local doctors. made as part of the partnership, such as maintaining a surgical The name derives from the citizens committee formed at the department. request of those physicians to direct the institution. That commitWith a population of only 15,000 in the city and 79,978 in the tee remains active today even as the hospital has changed hands, (CONTINUED ON PAGE 8)

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Birmingham Medical News


Pooling Helps Track COVID Testing for Returning College Students Before Alabama college students could return to campuses this fall, officials decided that the 200,000 students in the state would need to be tested within weeks of the start of the school year. The University of Alabama at Birmingham (UAB) Department of Pathology and several other agencies partnered and found a way to accomplish this daunting task. With the leadership of the UAB Department of Pathology – Chairman George Netto, MD, and Assistant Professor Sixto Leal, Jr., MD, PhD – and the help of the Alabama Department of Public Health, the University of Alabama System, and UAB Medicine, the team launched the GuideSafe™ initiative, which was funded through the Sixto Leal, Jr., MD, PhD CARES Act. GuideSafe™ is a multi-tool platform application that performs testing, tracing and symptom reporting. The platform and tools were developed by leaders in the University of Alabama system through an effort led by Sue Feldman, RN, MEd, and Mohanraj Thirumalai, MSEE, PhD. To help set up testing sites throughout the Alabama, the Bruno Event Team joined the initiative to sign up students for drive-through testing near their hometowns. Each student got a nasal swap, and those samples were delivered to UAB for processing and testing. Each result was sent to the student’s school and emailed to the student. “The process was new to everyone, and my main focus in the laboratory was to figure out how to provide all of these tests,” Leal says. “We brought in a lot of new equipment and reagents and recruited about 20 individuals with molecular biology skill sets to help us with the initiative. But that was just the laboratory component. There is an information technology component that had to be built from scratch. We worked with computer programmers to build lab information systems that enabled us to process and deliver data. A process like this usually takes six months, but we completed it a month and a half, thanks to great efforts from a lot of people.” To speed up the testing, Leal and the team uses a pooling method with a real-time reverse transcription polymerase chain reaction (rRT-PCR) test for detection of nucleic acid from SARs-CoV-2 in clinical specimens. This process has been used before in other

PHOTO: UAB PHOTOGRAPHER STEVE WOOD

By Ann B. DeBellis

UAB Pathology and other agencies work hard to meet testing deadline

contexts such as HIV population screening of donated blood products, but this is the first time it has been used for this purpose and on such a large scale. “The test we developed at UAB is the most sensitive FDA Emergency Use Authorization test in the country. Normally, we test one sample at a time which consumes one set of limited reagents per test,” Leal says. “The pooling innovation we developed enables us to use this sensitive test on eight people at a time. If the test on the pooled sample

came back negative, we knew with high confidence that those eight people did not have the virus. We were able to report all individuals in the pool as negative. In contrast, if the pooled sample tested positive, each sample was tested individually to identify the infected individual. When the positivity rate in the population is low enough, samples can be pooled with a high level of efficiency.” During the surge of back-to-school testing, the lab was conducting up to

11,000 tests per day, seven days a week. “That surge was when all of the students were coming back, so we obviously had a timeline to meet,” Leal says. “Now, we are doing 1,500 to 2,500 tests per day in the sentinel testing phase, and the slowdown is nice. “I appreciate our leadership – the pathology chairman, Dr. Netto; Selwyn Vickers, MD, Dean of the UAB School of Medicine; and UAB President Ray Watts who pushed for this effort. Also, thanks to Sherry Polhill and Diane Hendricks from the UAB Hospital labs, Fungal Reference Lab members, and the skilled molecular biologists from the UAB community who stepped up and contributed to this initiative.” Can this process be used for other efforts? Leal says it depends on the positivity rate in a given population. “We thought testing for returning students would result in about one percent positive tests, and it did. That is an efficient process, but if positivity is greater than five or 10 percent, the pooling process becomes inefficient,” he says. “However, there are populations in the hospital such as pre-surgery testing where the positivity rate is about 0.5 percent. We can and will be pooling for that particular population, and we believe this process will be a good tool for other uses in the future.”

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Birmingham Medical News

NOVEMBER 2020 • 3


Is It Time for Healthcare Professionals to Rate Insurance Companies? By Jane Ehrhardt

“Most people know more about their car insurance than their health insurance,” says Jerry Golden, and he wants to change that. Golden oversees five medical practices in Alabama as CEO of Forefront Medical Management and serves as administraJerry Golden tor for Coastal Neurological Institute in Mobile with 10 neurologists and neurosurgeons. “I think a group of medical admin-

ll a F

istrators could provide a rating system of payers in Alabama to the general public,” Golden says. “It would give them a rating from people who deal with the insurance companies.” He has already presented the concept to the Medical Group Management Association of Alabama (MGMA), a trade organization with 765 members throughout the state. Though not yet determined, the ratings would cover categories that influence the care of the patient, such as the length of time to achieve prior authorizations for procedures, the ease of renewing prescriptions, the likelihood of gaining approval for the medication

preferred by the physician, and the difficulty of attaining diagnostic testing. “With that kind of insight, the public could become aware of an insurer’s poor rating and that would make it more difficult from them to sell policies,” Golden says. This should spur improvements in the insurers’ protocols. The knowledge could be especially useful for Medicare Advantage or Medigap plan buyers, where the choice of insurance is in the hands of individuals who generally need the most medical care. Employees could also utilize the rating to influence their companies’ choice of coverage.

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Currently, people unknowingly choose policies from insurance companies whose protocols can inhibit their care. For instance, some payers regularly take weeks to grant authorization for MRIs and other diagnostic testing. “And they may still come back and deny it, and then you have to appeal it,” Golden says, meaning a month may pass before being able to be diagnosed. The process at various insurers for approving prescriptions can also have an unexpected and detrimental impact on patients, especially for those with chronic conditions. Most insurers require physicians to regularly request approvals on renewals of prescriptions. “Even for generic medicines that have been on the market for some time,” Golden says, speaking about patients with MS and Parkinson’s disease at the neurological practice. “They’ve been on the medicine for years or it’s a maintenance drug for a chronic condition. They should not have to go through all this nonsense.” A sampling of 13 medication requests to three different insurers this year at the neurological practice Golden manages showed a time investment of the staff and physicians of at least 30 minutes up to four hours every year or six months per prescription. One insurer in September required a separate prior approval to include alcohol pads with the injectable prescription. Gaining approval to perform procedures can be worse. “The prior authorization process has been a pain point for physicians and practices for years,” says Mark Jackson, executive director of the Medical Association of the State of Alabama. “What I hear from my members is that Mark Jackson the process seems to be worsening.” Insurance companies usually require a physician to call for a peer-topeer conversation to justify a procedure if the initial paperwork request is denied. “Insurance companies want to talk directly to the physician, and the process of making that connection is often cumbersome,” Jackson says. Generally, the specialist ends up in phone tag with the insurer. “And when they finally do talk to somebody, it’s not a peer. The physician is trying to explain something to someone who may not be another physician.” “That’s a waste of time,” says Lisa Warren, CEO at Andrews Sports Medicine and Orthopaedic Center. “Nine (CONTINUED ON PAGE 12)

4 • NOVEMBER 2020

Birmingham Medical News


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NOVEMBER 2020 • 5


Fagan Wants to Prevent Health Problems Before They Become an Issue By Marti Webb Slay

isn’t what it used to be. Or I have patients who come to All medical practices have me after they have seen their been affected in some way by doctor and are told they don’t COVID-19, and Fagan Sports have an illness, but they know and Lifestyle Medicine practhey don’t feel as good as they tice is no exception. used to. They want to investi“Diet was an issue inigate further.” tially, when everyone was stayFagan gives them time ing in,” Kimberly Fagan, MD to dig into the details. First said. “A lot of patients were appointments can last a half concerned about weight gain hour and start with an exduring the early times.” tensive medical history. “We “We also saw an uptick in take time to listen,” she said. nutrition consults by phone,” “When did you first notice a said Michael Brown, office problem? What might you manager. “Some folks had to feel is off? I want to know if learn how to cook for the first there are gut issues. Thyroid, time because restaurants were stress hormones, and adreclosed. They came face to face nal glands all work together. with the reality that they didn’t We do a vitamin and minreally know how to care for eral evaluation. Correcting First appointments with Kimberly Fagan, MD can last an hour and half while she themselves.” deficits can make a big differexplores a medical history. Helping people learn to ence.” care for themselves is one of the goals of Fagan works closely with a patient’s fruition about six years ago. I’ve always lifestyle management, and it is an aspect of primary care physician and often gets rebeen interested in finding ways to prevent practicing medicine that Fagan dreamed ferrals from other doctors. But she’s clear health issues and injuries before they beof pursuing for years. “It had been on my about her role. “I’m not a primary care come a real problem for people. mind for a long time to combine my inphysician and I’m not trying to replace “Our patients come from a variety ternal medicine skills and my sports medithat doctor,” she said. “Many physicians of sources. My sports medicine patients cine skills,” she said. “Finally that came to will refer patients to me who are experimay recognize that their performance

6 • NOVEMBER 2020

Birmingham Medical News

encing fatigue, weight gain, or they just feel like their hormones are off. For a lot of doctors, that just isn’t in their wheelhouse. “I try not to prescribe medications. I try to do everything a natural way, usually with supplements or lifestyle changes that can complement what their physician has prescribed.” When the tests do indicate a need to prescribe hormones, Fagan prefers pellets, creams, or injections for men. “Pellets are well received,” she said. “Forty percent of people don’t absorb hormone cream very well, or they get erratic absorption.” The pellets are put in under the skin and last three to four months for women and up to six months for men. A large part of lifestyle medicine consists of teaching, but Fagan is also open to learning and adapting herself. She now offers CoolSculpt, a service she didn’t think she’d ever include in her practice. “The people who encouraged me to get it were my athletes,” she said. “It’s about getting rid of pockets of exercise-resistant fat.” The non-invasive procedure freezes fat cells in the area that’s treated. “Fat freezes at a higher temperature than (CONTINUED ON PAGE 8)


HIPAA Patient Rights By Beth Pitman and Nathan Kottkamp

Although HIPAA is probably best known for its privacy and security provisions, it also affords certain essential rights to ensure that individuals have access to their medical records. Since 2019, the HHS Office for Civil Rights (OCR) has stated its intent to increase enforcement of this specific right in response to a directive from HHS. There has been a gradual increase in this targeted enforcement activity until recently. Enforcement of these rights drove nine settlement agreements  in September and October. These are in addition to three breach-related settlement agreements in the same period. Obviously, the OCR has ramped up its enforcement efforts recently, and all covered entities and business associates should beware. The first of the settlements involved  St. Joseph’s Hospital and Medical Center  (“St. Joseph’s”), which entered a corrective action plan and paid $160,000 to settle potential violations of HIPAA’s right to access provision. In this case, a mother requested a copy of her son’s medical records. Despite an initial production of some of the records, St. Joseph’s only produced the complete records 22 months later. Another settlement involved  NY Spine Medicine (“NY Spine”), which also entered a corrective action plan and paid $100,000 to settle a potential violation of HIPAA’s right to access provision. Similar to the St. Joseph’s situation, a patient requested a copy of her medical records, but NY Spine initially provided her with only a portion of her record. Significantly, NY Spine did not produce the remaining records—including the portions of her record that the patient specifically requested in the first place—until over a year later.   “No  one  should have  to wait over a year to get copies of their medical records.  HIPAA entitles patients to timely access to their records and we will continue our stepped-up enforcement of the right of access until covered entities get the message,”  said Roger Severino, OCR Director. This flurry of HIPAA enforcement action confirms that the OCR is as busy as ever in its efforts to ensure compliance. All covered entities and business associates are encouraged specifically to review their access policies—and ensure that staff are implementing them appropriately. Additionally, as more and more care is provided electronically, entities need to revisit their Security Rule Risk assessments to ensure that they reflect the current state

of operations. Patient rights to access are not limited to HIPAA. In May, the HHS Office of National Coordinator for Health IT (ONC) and the Centers for Medicare and Medicaid (CMS) released final rules and regulations related to the 21st Century Cures Act (Cures Act) Interoperability and Information Blocking Rules  and the Office of Inspector General (OIG) released its proposed enforcement Rule. Under these Rules, a patient’s request for records (as well as others) must be provided in compliance with the Information Blocking Rule requirements or the Health IT developer and healthcare providers risk enforcement. Under the proposed enforcement rule, Health IT developers regulated by the Cures Act are subject to civil money penalties of up to $1 million per violation, and the OIG will refer healthcare providers to “the appropriate agency to be subject to appropriate disincentives using authorities under applicable Federal law, as the Secretary sets forth through notice and comment rulemaking.” CMS also has a specific enforcement blueprint with regard to managed care plans and certain enrolled facilities. At this time, however, the potential enforcement structure for healthcare providers has not been determined. The compliance deadline for Information Blocking compliance is November 2 with a COVID-related enforcement discretion waiver of three months. With time running out, it is imperative that health IT developers, managed care plans and healthcare providers assess their abilities to meet the Information Blocking requirements. Beth Pitman and Nathan Kottkamp are partners at Waller Lansden Dortch & Davis LLP.

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NOVEMBER 2020 • 7


RURAL HEALTH

Citizens Baptist Celebrates 50 Years, continued from page 1 county, the hospital continues to deliver a full complement of specialties not often found in rural areas, such as neurology, nephrology, orthopedics, and cardiology. Citizens also offers advanced diagnostic technology, including MRI, CAT scan, nuclear medicine, and mammography. “We’ve had struggles along the way just like other rural hospitals,” says CEO Frank Thomas, who took the position two years ago, but had served as director of operations for about five years in the early 2000s. “Rural hospitals have to look for ways to maximize what they have to offer and adapt over Frank Thomas time.” For example, in 2018, Citizens shut down their maternity ward and OB/GYN department. “We cut that service to help us financially,” Thomas says. The department was a money drag. Rural patients commonly rely on Medicaid and, without a balance of higher payments from commercial insurers to support the service, gynecological non-timely services are vulnerable. However, Anniston hosts three hospitals and is only 26 miles from Talladega. The necessity of the emergency

8 • NOVEMBER 2020

room to the area, however, continues to be apparent, handling around 20,000 visits each year and providing, on average, about $4.5 million in uncompensated care to the community. “Time is critical for people who need an ER,” Thomas says. “It’s probably the biggest need for any rural community. If you’re in Talladega and have chest pains, you want to go 10 minutes up the street as opposed to 25 to 45 minutes to Pell City or Anniston. “Our strong suit is our ability to handle a broad range of emergencies. With 122 patient beds, a staff of hospitalists, and a six-bed ICU, Citizens can handle a lot for a rural market. We get them good treatment, stabilize them, and if they need more sophisticated care, we have the ability to get them quickly to one of our sister hospitals in Birmingham—Brookwood or Princeton.” The hospital also caters to a unique population of disabled patients stemming from the nearby state-run Alabama Institute for Deaf and Blind. “We have a large population of deaf and blind individuals in Talladega, and we’ve learned to adapt and care for those who need us,” Thomas says. The hospital contracts with personnel who know the system, and staff can dial up interpreters on a large monitor that rolls into the patient’s room. The staff of 90 physicians, 250 em-

Birmingham Medical News

ployees and nearly 50 indirect workers tend to be natives and stick around, adding a loyalty and family feel to Citizens. “That’s a strength for us. So many employees have been here for 10, 20, 30 years. We have a gentleman in radiology who can remember when the old hospital was torn down in 1968 and the replacement was built next to it,” Thomas says, adding that he was born in this facility. “So was my chief nursing officer, Van McGrue. There’s probably no other hospital where the CNO and CEO were both born there.” In 2017, Citizens completely remodeled all the patient rooms. “New wallpa-

per, new furniture. They were refreshed. It was needed,” Thomas says. They hope to add physician office space through remodeling or new construction. “It would help us attract additional physicians.” Right now, a state-of-the-art telemetry system is currently being installed to provide advance patient monitoring. For the long-term future, Thomas would like Alabama to expand Medicaid. “It would help us deliver care to those without the ability to get that care now,” he says. “We spend so much in our country on healthcare. We have to think of how we can offer these things in rural communities and do it economically.”

Fagan Wants to Prevent, continued from page 6 other cells, so you don’t damage anything around it. The cells die off slowly in about 12 weeks. Once those fat cells are killed off, they never come back,” she said. While she has a Physician Assistant to help in the sports medicine side of her practice, Fagan sees all the lifestyle patients herself. Those patients come from all over the state and she sees teens up to people in their 70s and 80s. “When it comes to aging, we want to see a plateau rather than a bell curve. We focus on preventative medicine,” she said.

Unlike many lifestyle management practices, Fagan Sports Medicine does take insurance and Medicare, and the practice is not affiliated with any particular hospital system. “Cash pay practices can become very expensive for patients,” said Fagan. “We wanted to make this accessible.” COVID-19 has heightened the concerns of some patients and made access to gyms and sports activities more difficult, but it hasn’t changed the ability of Fagan to listen and be accessible to her patients.


RURAL HEALTH

The Challenges of a Rural Paramedic By Jane Ehrhardt

Serving 30 years as a paramedic in rural Alabama has left John Reed, MPH, BSN, RN, with hard-earned insights concerning the difficulties faced in rural emergency medical service (EMS). “Even though we’re all paramedics, being a rudral paramedic is a different animal,” John Reed, MPH, BSN, RN says the Professional Nurse Development Specialist at UAB Center for Nursing Excellence. Distance and call volume make the difference. “We deal with the same medical conditions as urban paramedics—a heart attack is still a heart attack— but sometimes our patients are sicker because they may not have a community hospital in the county,” Reed says. “Or they may only have one ambulance.” So not only does it take more time for rural paramedics to reach the patient, but the lack of access to healthcare means paramedics often face sicker patients with more untreated comorbidities.

One way to mitigate both these challenges would be to establish morefreestanding emergency clinics in rural areas. “There are whole counties that don’t even have a hospital or a single physician,” Reed says. As of 2017, seven Alabama counties were without a hospital according to the Alabama Rural Health Association: Cleburne, Coosa, Henry, Lamar, Lowndes, Macon, and Perry. And 81 percent of the state’s counties are designated as rural. In Blount County, where Reed has served as a volunteer paramedic for decades, it can take up to 30 minutes to reach the emergency scene and sometimes another hour to drive to the hospital. By comparison, Birmingham patients will usually arrive at the hospital in 10 to 15 minutes. “The lengthy transports mean that rural EMTs have to be better at the job, but although they are trained, they don’t get the real life exposure that urban paramedics get,” Reed says. “A rural paramedic may only treat three heart attacks in a year versus a paramedic stationed in a city who might respond to 25 of those calls a month.” Most trauma calls in a city center around car wrecks and gunshot wounds,

but in the country, trauma usually means something farming related and not always accessible. “You go to a grain mill, and someone’s 100 feet up in the air who needs help,” Reed says. “Once, we had a deer hunter who had an accident on an ATV a mile away from any roads. We had to get creative. We transported him out of the fields on a wagon pulled by a farmer’s tractor. That kind of thing doesn’t happen every day, but occasionally it’s what we’re up against.” That creativity must compensate for the lack of resources, from jaws of life and long truck ladders—which most every city fire department carries—to something as simple as a tow truck. “One time we sent someone to the farm down the road to get the tractor because a vehicle in a ditch had fallen on the man working on it,” Reed says. The wrecker would have taken 45 minutes to reach the scene. The neighbor got there in minutes. “To lift that car in the city, they would have used a wrecker or specialized air bags. For us, the biggest resource is the farmer next door.” Rural paramedics are more likely to have to deal with an emergency alone, unlike urban areas where multiple paramedics staff each ambulance. Many

rural areas have just one paramedic serving 20,000 to 40,000 people because most paramedics want the higher pay and benefits offered in cities. With paramedics now scarce nationwide, especially since COVID-19 hit, a few Alabama cities have found a way to improve the efficiency of their emergency staff by initiating a concept called community paramedicine which engages the paramedics in resolving medically-related situations. For instance, a woman in Birmingham had been sent to the ER as a result of not taking her medications correctly. “The paramedic visited her in her home as part of the program and realized that she was illiterate and unable to read the pharmacy label,” Reed says. “With this program, we can see the patient in their home environment which makes a difference. This kind of untraditional role for paramedics as problem solvers could help draw some paramedics out of the cities and into rural communities. The bottom line there is so many challenges to rural healthcare, and hopefully we can find creative ways to improve things.”

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Birmingham Medical News

NOVEMBER 2020 • 9


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tapped to host the event to facilitate the ongoing discussion on ways to break down silos between chronic kidney disease, kidney failure and treatment protocols including transplantation. Last year, HCA led the nation in performing 418 live donor kidney transplants. Additionally, the health system was responsible for 652 deceased donor transplants, which is more than 7 percent of the kidneys recovered nationwide. While there have been advances in care and expansion of organs deemed acceptable for transplantation, Perlin said clinicians and organizations across the country that work with patients with end-stage renal disease (ESRD) know more can and should be done. “There are too many at-risk patients who progress to late-stage kidney failure; mortality rate is too high; treatment options are expensive, and the quality of life is simply too low,” he stated, adding there are not enough kidneys donated to meet the need. “Kidney disease is a major, prominent, prevalent condition,” Perlin continued. “It’s the ninth leading cause of death in the United States.” He added 37 million American live with kidney disease and more than 726,000 progress to ESRD. Each year, more than 100,000 Americans begin dialysis with 20 percent dying within a year and 50 percent dying within five years. Currently, nearly 100,000 Americans are awaiting transplant. Unfortunately, on average, 13 people a day die before a kidney becomes available. In introducing the new model of care, Verma said the focus across the federal government has been on finding ways to make healthcare more affordable and more accessible. However, she continued, the way government programs are structured can sometimes create misaligned incentives. “In Medicare, in particular with our ESRD program, that’s exactly what we’ve seen,” Verma continued. “And so, we’ve been really focused over the last year – based on the president’s executive order – to try to specifically improve the lives of people with kidney disease.” As a result, CMS announced finalization of the End-Stage Renal Disease Treatment Choices (ETC) Model on Sept. 18 to transform chronic kidney care for Medicare beneficiaries. Building off President Donald Trump’s Advancing Kidney Health Executive Order, the ETC model encourages increased use of home dialysis and kidney transplants. Verma noted traveling to a hemodialysis center not only eats up a large portion of the day but also potentially exposes ESRD patients to other health threats, including COVID-19. Verma

noted Medicare beneficiaries with ESRD who contract the coronavirus have higher rates of hospitalization. With home dialysis, patients are able to shelter in place during the public health crisis while still receiving the care they need. “The model today is part of a larger effort to improve the health, in general, of people living with kidney disease,” Verma said. While the ETC program creates a new payment model, she said the agency has also been focused on improving organ procurement. “The idea is to make sure that we’re doing everything we can to increase the transplantation rate,” she said. Brad Smith, who was tapped to lead the CMS Innovation Center at the beginning of 2020, drilled down on the ETC model. Smith noted the work was very personal for him, as he had a cousin who had been on dialysis for several years before passing away at the age of 28. “And so, this is an issue I’ve always been really interested in and really passionate about,” he noted. Smith said CMS has been looking at the way kidney care is delivered in the United States and working to transform the model over several years. The focus, he added, has been on three big areas: in-home dialysis, transplant rate, and the impact of the pandemic on ESRD patients. In thinking about how the U.S. compares to other countries, Smith pointed to in-home dialysis rates. He said the latest statistics show about 12 percent of patients in the U.S. get inhome dialysis. “But when you compare that across the world, that’s a pretty low rate – so in the U.K., it’s about 18 percent, and Canada is about 25 percent,” he said. Smith added that although only 12 percent nationally are doing dialysis at home, 85 percent of individuals are actually eligible for that treatment option. “The second piece is when you look at our transplant rate,” Smith continued. “Of the 61 more developed countries, we’re actually 39th in terms of transplant rate. Only 2.9 percent of patients actually are able to receive a transplant before they go on dialysis and only about 30 percent of those with ESRD actually have had a transplant, so we feel like there’s a tremendous opportunity to change how we deliver care in this country around end-stage renal disease.” When it comes to COVID, Smith said, “Our ESRD patients are one of our highest risk groups across the entire country. If you get COVID and you have ESRD, you’re eight times more (CONTINUED ON PAGE 12)


CARES Act Provider Relief Funds Reporting Requirements By MArGAret h. CooK, MBA, CMPe

Since early April 2020, the CARES Act Provider Relief Fund (PRF) has distributed $175 billion to healthcare entities impacted by the coronavirus. The eligibility and allocation parameters have evolved throughout the public health emergency, as federal agencies have had to quickly adapt to the legislation and its requirements. There have been numerous rounds, phases, and targeted distributions rolled out including the most recent Phase 3 General Distribution set to close on November 6, 2020. Each designated distribution requires the applicant and recipient to attest to the Terms and Conditions for the specific funding. Terms and Conditions are detailed documents that stipulate the eligibility requirements, outline the permissible and impermissible uses of the funds, and define obligations for the recipient to participate in required reporting and recordkeeping as defined by the Secretary of Health and Human Services (HHS). The central purpose for the PRF funds is that recipients use the funds to cover expenses attributable to coronavirus and supplement lost revenues. Recipients of PRF payments have 90 days to attest to the Terms and Conditions or return the funds. If the recipients fail to log in to the portal and attest and has not returned the monies, they are deemed to have accepted the Terms and Conditions by default. Numerous PRF recipients are receiving correspondence from Health Resources and Service Administration (HRSA) alerting them when there is not a confirmed attestation on record. The recordkeeping and reporting obligations have evolved since the initiation of the CARES Act PRF. The attestation Terms and Conditions stipulate quarterly reporting and established

the reporting threshold to be $150,000 in federal funds related to coronavirus, with the initial report due July 10, 2020. In mid-June, the FAQs on the CARES Act Provider Relief Fund website were updated to indicate healthcare entities did not need to prepare and submit a separate report by July 10th; rather HHS would develop a report to comply with the requirements. Publicly posting the recipient names and corresponding payment amounts on the Tracking Accountability in Government Grants System (TAGGS) and USASpending.gov websites fulfilled the immediate CARES Act reporting requirements. In July 2020, HHS lowered the reporting threshold for all recipients who receive more than $10,000 in aggregate from the CARES Act PRF. HHS has also outlined a plan that included a template and detailed instructions which were due in mid-August, anticipating an October 1 reporting system. However, as the most recent September 19, 2020 guidance specifies, with the exception of specific nursing home and testing programs, the revised deadlines for PRF recipients are as follows: • January 15, 2021: first day for reporting portal to be available • February 15, 2021: first reporting deadline for providers on the use of PRF funds in 2020 • July 31, 2021: final reporting deadline for PRF funds expended after January 1, 2021 The purpose of the reporting is to assess if recipients properly use PRF proceeds in compliance with the agreed upon Terms and Conditions. The reporting requirements progressively increase with the aggregate of PRF funds: 1) $10,000 to $499,999; 2) > $500,000; 3) >$750,000. HHS has not elaborated on the process recipients with less than $10,000 will be expected to document to substantiate compliance with the Terms

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and Conditions. A primary restriction on the PRF monies is the prohibition to pay expenses that have been reimbursed from other sources such as insurance payers, patients, grants, or similar proceeds. A reporting template has not yet been made available; however, reporting is expected to focus on net patient revenues, allowable expenses, and estimated lost revenues between 2019 and 2020. Revenue derived from patient care will include 340B pharmacy revenues. Allowable expenses will be attributable to coronavirus and include general and administrative expenses as well as healthcare–related expenses. Data elements that are anticipated in the report include standard organizational demographics as well as specifics on other assistance received in 2020 such as Paycheck Protection Program, Alabama CARES Relief Fund grants, Small Business Administration – Economic Injury Disaster Loans, CARES Act Testing, business insurance proceeds and similar funds. The reporting requirements will also obtain non-financial information such as employee counts, patient encounters, and bed counts for facilities.

Based on the rapid deployment of the CARES Act PRF funds throughout public health emergency, the reporting requirements to assess compliant use of the funds have been in continual development. They will continue to be refined and defined throughout this last quarter of 2020. It is imperative for recipients to monitor changes in the reporting elements and requirements to utilize the funds permissibly and maintain proper recordkeeping. HRSA is expected to host webinars and provide further clarification on the reporting requirements. Please consistently reference the CARES Act Provider Relief website: https://www.hhs.gov/ coronavirus/cares-act-provider-relieffund/index.html Margaret H. Cook, MBA, CMPE is a Healthcare Advisor with Kassouf & Co.

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Is It Time for Healthcare Professionals, continued from page 4 times out of 10, it is not a specialist and not in the state where we are located,” she says, explaining that the standards of care can deviate within regions or states. Recently, one of their patients was losing feeling in her foot and her ability to walk. She needed spine surgery. When the payer denied it, the neurosurgeon appealed and made the required call to the insurer’s medical professional to justify the procedure. “He talked to a family practice doctor. She has zero experience and zero anatomical knowledge to deal with this conversation and the medical necessity of it,” Warren says. The neurosurgeon had to explain neuromonitoring, a common piece of equipment in neurosurgery to continuously track the integrity of the neural structures to prevent permanent or long-term nerve damage. The payer denied the surgery and denied the neuromonitoring. “Our doctor said no spine surgeon would do this surgery without neuromonitoring, and she didn’t even know what it was,” Warren says. “This is the person making the judgment on whether to authorize your surgery.” The only option was to write a letter and appeal again. “We were about to submit the appeal when her husband changed jobs, so she had

a different insurance. Within 48 hours, we got her on the schedule.” Warren estimates that 99 percent percent of the time, her physicians seek approvals from someone not in their specialty. “Last week, we had a peer-topeer call for a hip scope with an OB/

GYN and a spine surgery with a family practice doctor. Our physician had to explain basic anatomy and the surgical procedure to him, and then it was still denied,” she says. The rating system would expose these areas of difficulty that patients

would face under each insurer in the state. “I think the general public wants to know this. Because patients feel the practice or physician is the road block to their care, and we’re not,” Golden says. “It’s the payers.”

Addressing a Chronic Killer, continued from page 10 likely to pass away than the average American.” To address these issues, the Center for Medicare and Medicaid Innovation has been working on payment transformation over the past five years, staring in 2015 with the comprehensive End-Stage Renal Disease Model with 37 groups taking full capitated risk for their dialysis beneficiaries. “We’ve seen really good results in that model. Hospitalizations have come down; emergency dialysis treatments have gone down; readmissions have gone down,” he said. While the quality of care increased, Smith said CMS didn’t really see the anticipated savings from the program. “Part of the reason for that is really we were starting too late, and we were only starting with patients once they reached dialysis.” New models being rolled out in 2021 focus on patients in stage 4 and 5

of chronic disease before they advance to ESRD. “That’s a time when we believe we can have the biggest impact,” he said. A second lesson from the earlier model was the needle didn’t move on in-home dialysis or kidney transplant, which is why the new ETC model increases reimbursement for in-home dialysis claims. “In the first year, we’ll increase them by 3 percent, then 2 percent, then 1 percent in the third year,” Smith said. “In addition, and probably even more importantly, we’re putting in place an incentive structure for nephrologists and for ESRD facilities around in-home dialysis and transplants,” he continued. Smith explained each year the percentage of patients for each practice or clinician will be calculated who either get in-home dialysis, are on the wait list for transplant or who receive living-donor

transplant. “And then based on that, it will make an adjustment to their Medicare claims. In the first year that could be as much as +4 or -5, and in the last year, year five, that could be as much as +8 or -10,” he said. This demonstration model will roll out to about 30 percent of the country this coming January. The hope is to improve quality, give providers and centers more flexibility and save an estimated $23 million through the program. However, Smith stressed the savings component isn’t the main driver. “The main goal of the model is to make sure that folks can have the choices that they want and hopefully that we can altogether increase … along with all the other rules that we’re reviewing and regulations we’re rolling out … increase the number of transplants that are happening across the country.”

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CMS Revises Repayment Terms For Loans Issued Pursuant To The Accelerated And Advance Payment Program By: Anthony Romano

On October 8, 2020, the Centers for Medicare & Medicaid Services (“CMS”) announced amended repayment terms for loans (“AAP Loans”) issued under the Accelerated and Advance Payment Program (the “AAP Program”), to help ease the terms of repayment and recoupment. Originally, repayments by providers and suppliers were required to start 120 days after the AAP Loan was issued, which in some instances could be as early as August of this year, and recipients could face recoupment up to 100 percent of Medicare payments during the repayment phase. However, as a result of congressional and CMS action, repayment for each AAP Loan will now begin one year from the issuance date of such AAP Loan, and recoupment percentages are now reduced, as further detailed below. As you are probably aware, CMS expanded the existing AAP Program in March of this year and issued AAP Loans to healthcare providers and suppliers in order to assist with the financial

burden of the COVID-19 pandemic. CMS paid a total of more than $98 billion in accelerated payments to more than 22,000 Part A providers. In addition, more than 28,000 Part B suppliers, including doctors, non-physician practitioners, and durable medical equipment suppliers, received advance payments totaling more than $8.5 billion. The Continuing Appropriations Act, 2021 and Other Extensions Act (P.L. 116-159) (the “Continuing Appropriations Act”), enacted on October 1, 2020, amended the repayment terms for all providers and suppliers who requested and received AAP Loans during the COVID-19 Public Health Emergency. “In the throes of an unprecedented pandemic, providers and suppliers on the frontlines needed a lifeline to help keep them afloat,” stated CMS Administrator Seema Verma. “CMS’ advanced payments were loans given to providers and suppliers to avoid having to close their doors and potentially causing a disruption in service for seniors. While we are seeing patients return to hospitals and doctors providing care we

She’s taking on

are not yet back to normal,” she added. Using CMS’ revised repayment guidelines, below is an overview of the repayment requirements and milestones with respect to an AAP Loan: 1. Day 1 – Provider or supplier receives the AAP Loan. 2. Day 1 through Month 12 of the AAP Loan – No AAP Loan repayments are required, and CMS does not recoup any amounts to apply to the AAP Loan. 3. Month 13 through Month 23 of the AAP Loan – Repayment begins through offset of Medicare payments. Medicare will automatically recoup 25 percent of the Medicare payments otherwise owed to the provider or supplier and apply such recoupment to the outstanding AAP Loan balance. Note, CMS will not reduce the repayment percentage or defer recoupment at the request of a provider or supplier, as these terms are specified by Congress in the Continuing Appropriations Act. 4. Month 24 through Month 29 of the AAP Loan - Medicare will automatically recoup 50 percent of the

life

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Medicare payments otherwise owed to the provider or supplier and apply such recoupment to the outstanding AAP Loan balance. Again, CMS will not reduce the repayment percentage or defer recoupment at the request of a provider or supplier, as these terms are specified by Congress in the Continuing Appropriations Act. 5. After Month 29 of the AAP Loan - If the AAPC Loan isn’t paid off after the 29th month after the AAP Loan is issued, the Medicare Administrative Contractor (“MAC”) in the provider or supplier’s geographic area will issue a letter (the “MAC Demand Letter”) to the applicable provider or supplier requesting payment of the remaining balance. If payment is not received in full within thirty (30) days from the date of the MAC Demand Letter, interest will accrue on the outstanding balance at the rate of four percent from the date of the MAC Demand Letter, and such interest will be assessed for each full 30-day period that the balance remains unpaid. The FAQ to this CMS announcement (CONTINUED ON PAGE 16)

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UAB’s New Center for Addiction and Pain Prevention and Intervention By Laura Freeman

Think back to the time before Covid19. Another epidemic was ravaging America, leaving thousands of grieving families to mourn the loss of loved ones to opioids, pain killers and other addictions. As we’ve lost hundreds of thousands of Americans to the virus, deaths from overdoses and addiction haven’t slowed down. If anything, the stress of the pandemic has made it worse. Last year, almost 72,000 people died from overdoses—more than died from HIV, gun violence or traffic accidents. Early numbers for 2020 suggest that these deaths are trending up an additional 13 percent. The Center for Addiction and Pain Prevention and Intervention (CAPPI) at UAB is launching an all-out fight to save lives and improve outcomes. “The center isn’t a place. It’s a resource,” Karen Cropsey, PsyD, co-director of CAPPI and professor in the Department of Psychia- Karen Cropsey, PsyD try and Behavioral Neurobiology said. “We’re creating a synergy of expertise to make information more accessible, to facilitate the conversations that lead to innovative research, and to provide outreach to help more people who are dealing with addiction and pain find effective treatment sooner.” Cropsey, along with 10 other clinical experts from three different schools and more than eight specialties, make up the initial core of investigators, educators and clinicians specializing in addiction and pain. “Through the center, we are creating a collaborative environment that should attract more investigators conducting cutting-edge research that should complement the work our research team is already doing,” she said. “This will also connect philanthropists with opportunities to have an impact on moving knowledge and treatment forward to help free people from addiction and improve quality of life for those suffering with chronic pain.” Co-director Burel Goodin, PhD is a clinical health psychologist who specializes in pain-related behavioral medicine. “We also want to develop better interventions to prevent addiction and to erase the stigma that delays many people from getting the help they need. You can’t necessarily see how much a person is suffering. We need to debunk the myth

that it’s a character issue. Addiction and pain are disease processes and they need real, evidence-based treatment,” Goodin said. In addition to supporting the School Burel Goodin, PhD of Medicine as well as research and clinical programs across the UAB campus, CAPPI will also be a resource for health care providers throughout the region. “Physicians can check our website to learn about new treatment options and we can connect them with someone who has expertise in their area of interest,” Goodin said. “We’re also doing outreach through our website with zoom lectures and topics in our CAPPI chat feature,” Cropsey said. “Patients, family and anyone who is interested can access the information. Recent topics have included the current status of the legal use of cannabis in health, and updates on opioids. “Another interesting project CAPPI is facilitating relates to the training of professionals preparing to work in the fields of addiction and pain. In addition to fostering mentorship, we’re matching up those in training with people who have lived the reality of addiction or chronic pain. One of our fellows was paired with a mother who had lost one son to an opioid death and had another in prison. Another was matched with someone who had been addicted to heroin and recovered. This gives our future professionals the direct perspective of real life rather than reading about it second hand.” Part of the center’s educational mission also includes improving the understanding of how substance use and pain intersect. The monthly CAPPI Journal Club and the Pain and Addiction Special Interest Group are aimed at growing the breadth of expertise among UAB clinicians and researchers. Alabama has higher than average levels of addiction, drug use and chronic pain. One factor may be the role of poverty and the number of people doing physically demanding work that takes a toll on the body. Our people need better treatment and more effective interventions to prevent addiction. Those are two of the top goals CAPPI hopes to achieve as it grows into the future. To learn more about resources and outreach programs, go to the center’s website, www.uab.edu/cappi.

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New Device May Improve Function for Heart Failure Patients, continued from page 1 ity and potentially improve heart performance and reduce hospital admissions.” Drs. Rajendra and John Casterline, a cardiac surgeon at Grandview, became the first in Alabama and third in the Southeast to implant the device designed to use the body’s natural receptors and nervous system to lessen the impact of heart failure. Advanced heart failure patients’ bodies release hormones that adversely affect their heart function. “This new neuromodulation therapy, approved by the FDA about a year ago, is designed to trick the body into thinking it is functioning better than it does and by doing so, it decreases the hormones that are adversely affecting the heart,” Rajendra says. The main study of the Barostim NEO device showed that most patients were more active and felt better. The heart failure patients completed the Minnesota Living with Heart Failure questionnaire to evaluate their idea of quality of life. “Their quality of life was much better when they received the Barostim device. It also showed they were able to walk further after receiving the device versus patients who remained on medical therapy alone,” Rajendra says. The implant procedure is performed by an electrophysiologist and a cardiovascular surgeon. It requires an

incision in the neck down to the carotid artery. Then, an electrode is sutured to the carotid artery where receptors in the body measure blood pressure and heart rate, and send information to the brain to monitor heart function. Another incision near the clavicle allows the insertion of a generator. “When the device is turned on, it sends impulses through the electrode to the receptors in the carotid artery,” Rajendra says. “That stimulation tricks the body and brain to think the heart is functioning better than it is. There is a feedback loop to the brain that tells the body that the heart is doing well, so we can have fewer hormones circulating. That will cut down on the release of those hormones over time and can help the heart function better.” Rajendra has performed one implant so far. “It takes some time after an implant to see improvement,” he says. “We have to keep the implant turned off for a couple of weeks to allow the incisions to heal. After that, we slowly turn it on and the stimulation of those receptors in the body is increased over several months. It can take about two months to be fully functioning. “Once the device is activated, the patient generally feels better, but it usually takes several months to realize the maximum benefit of the therapy. Quality of life was shown to be better

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through this pivotal study. The study is not completed yet, but the device was approved by the FDA based on quality of life data.” The study is ongoing and researchers will continue to collect data from patients. “There is a possibility that patients could live longer with this therapy, but we just don’t know that yet,” Rajendra says. “We also hope to

see heart function improve. We saw a small improvement in heart function at six months, but we believe it will take longer to see significant improvement. “We want patients to live longer with this therapy, but often in medicine we may not affect the natural history of the disease process. However, if we are able to improve patients’ quality of life, I think that’s still a win.”

CMS Revises Repayment Terms, continued from page 14

indicates that the above mentioned automatic recoupment of Medicare payments (25 percent and 50 percent respectively) cannot be extended after the 29th month of the AAPC Loan in order to avoid receiving the MAC Demand Letter. After the MAC Demand Letter is issued, providers and suppliers may submit a request for an Extended Repayment Schedule (“ERS”) to attempt to obtain a statutorily authorized debt installment payment schedule by meeting specified criteria related to financial “hardship” or “extreme hardship.” If met, the ERS would allow repayment over the course of three years, which may be extended to as many as five years where certain extreme hardship criteria are met. Also worth noting with respect to

AAP Loans: (i) providers and suppliers may contact their assigned MAC to confirm the outstanding balance of their AAPC Loan, and may prepay their AAPC Loan in one or more lump sum payments (but should contact their MAC for pre-payment instructions); and (ii) any payments made to CMS for outstanding overpayments will be applied to any outstanding interest on the oldest debt first, followed by the principal on the oldest debt. Any other existing Medicare debt owed by a provider or supplier will not be subject to the special repayment terms for AAP Loans. Anthony Romano is a Partner at Burr & Forman LLP practicing in the firm’s Health Care Industry Group.


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NOVEMBER 2020 • 17


RESERACH NOTES

Pro-inflammatory Lipids Precede Type 1 Diabetes Onset in Mouse Model and Children Type 1 diabetes (T1D) results when the body’s immune cells attack and destroy the beta cells of the pancreas that produce insulin. Researchers have long tried to unravel the signaling that provokes this attack. Sasanka In a study pubRamanadham, lished in JCI Insight, PhD Sasanka Ramanadham, PhD and colleagues at the University of Alabama at Birmingham have identified a proinflammatory lipid profile that precedes development of T1D in a mouse model and in children under the age 15 who are at high risk for T1D. This finding may identify candidate lipid therapeutic targets to prevent T1D. Phospholipase A2 (PLA2) enzymes can release a free fatty acid from glycerophospholipids. When the free fatty acid is arachidonic acid, it can be metabolized by several other enzyme classes to produce oxidized bioactive lipids, including some potent inflammatory eicosanoids. One of the phospholipase A2 enzymes is a calcium-independent phos-

pholipase A2, designated iPLA2-beta. Its activation promotes poor outcomes in experimental and clinical diabetes. Ramanadham and others have shown that iPLA2-beta participates in apoptosis of beta cells, modulating inflammatory polarization of macrophages, and promoting T-cell immune responses. “In light of these observations,” said Ramanadham, a professor in the UAB Department of Cell, Developmental and Integrative Biology, “we used lipidomics to gain insight into the lipidome associated with T1D development in spontaneous-T1D-prone nonobese diabetic mice (NOD mice) and in humans at high risk for developing T1D.” Female NOD mice show a progression of T1D, and an inhibitor can show the importance of iPLA2-beta on T1D development. About 80 to 90 percent of NOD mice become diabetic by 25 to 30 weeks of age; but if the iPLA2-beta inhibitor FKGK18 is given to the mice, starting at 10 days, only 10 to 15 percent of the NOD mice develop diabetes. But if the inhibitor was started later, at four or eight weeks, the researchers saw that about 60 or 80 percent, respectively, of the mice developed diabetes. “These findings,” Ramanadham said, “suggest that iPLA2-beta-derived

lipids contribute to T1D onset, and they identify select lipids that could be targeted for therapeutics and — in conjunction with autoantibodies — serve as early biomarkers of pre-T1D.”

Frequent Soft Drink Consumption May Increase Aggressive Behavior in Adolescents A UAB study, led by Sylvie Mrug, PhD and published in the Journal of Adolescent Health, has identified soft drink consumption as a likely predictor of aggressive behavior. Interviews with 5,147 children and their caregivers were conducted from three sites, at child ages 11, 13 and 16. At each time, the children reported on their frequency of consuming soft drinks, aggressive behavior and depressive symptoms. The study showed that soft drink consumption at ages 11 and 13 predicted more aggressive behavior at the next time point. Aggressive behavior at age 13 also predicted more soft drink consumption at age 16. Soft drink consumption at age 13 predicted fewer depressive symptoms, but depressive symptoms did not predict soft drink consumption. Findings from this study suggest that reducing adolescents’ intake of soft drinks may reduce

aggressive behavior, but not depressive symptoms. A number of studies have found that more frequent consumption of soft drinks has been associated with more aggression, other behavior problems such as hyperactivity and oppositional behavior, and depression and suicidal behavior in adolescents from the United States, Norway, Slovakia, Iran and China. Another recent crossnational study found a consistent association between adolescents’ high sugar consumption and fighting, bullying and substance use in 24 of the studied 26 countries. All of these studies have included statistical adjustments for a variety of potential confounders such as child age, gender, BMI, physical activity, diet, substance use and family factors. Although the results are typically interpreted in terms of soft drinks’ contributing to behavioral problems, it is equally likely that mental health problems may be driving the consumption of sugar-sweetened soft drinks, Mrug says. Studies show that some individuals consume more sugary foods in response to negative emotions.

BROCKS GAP HEALTH CENTER Medical West is thrilled to expand our services to the residents

Medical West’s newest Health Center is opening this November in the Brocks Gap community.

of West Jefferson County. Our brand new Brocks Gap Health Center is set to open this November, providing care for the entire family. With many years of family medicine experience in the Birmingham area, we are proud to welcome Dr. Jody Gilstrap and Dr. Allyson Gilstrap to our team of Medical West physicians. Schedule your appointment today by calling (205) 481-7263. For more information about Medical West, our health centers, and our physicians, visit us online at www.medicalwesthospital.org.

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Birmingham Medical News


GRAND ROUNDS

Physicians Join University Medical Center Two new physicians have joined the University Medical Center at The University of Alabama in Tuscaloosa. Shawnna Ogden, MD will practice at the UMC Family Medicine Clinic and Betty Shirley Psychiatry Clinic. She received a bachelor’s degree in kinesiology from LSU and a master’s degree in biomedical science from Barry University in Miami before earning her Shawnna Ogden, MD medical degree from St. George’s University in Grenada, West Indies. After her residency at LSU Health Sciences Center’s Family Medicine Residency, she completed a behavioral health fellowship at The University of Alabama College of Community Health Sciences. Russ Guin, MD will care for patients in UMC’s Family Medicine Clinic and Sports Medicine Clinic. He received a bachelor’s degree in health sciences from The University of Alabama and earned his medical degree from the University of Alabama School of Medicine Russ Guin, MD before completing his residency training at The University of Alabama Tuscaloosa Family Medicine Residency Program. After residency, Guin completed a sports medicine fellowship at the UA College of Community Health Sciences.

Thomas Dukovac, MD Joins Cullman Regional Medical Group Urologist Thomas Dukovac, MD has joined the Cullman Regional Medical Group and is practicing with the Cullman Regional Urology Clinic at 1800 AL Hwy 157. Dukovac is a graduate of Middle Tennessee State University and completed Medical Thomas Dukovac, MD School at the University of Tennessee College of Medicine. He completed his post-doctoral training at the Ochsner Clinic Foundation in New Orleans.

Study Finds Link between Depression and Stoke Risk A collaborative study led by investigators at the University of Alabama at Birmingham and the University of Alabama showed that individuals who scored higher on a test designed to measure depressive symptoms had a higher stroke risk than those with lower scores. The study involved 9,529 black and 14,516 white strokefree participants, age 45 and older, enrolled in the UAB-led REGARDS study which is a national longitudinal study designed to examine risk factors associated with racial and regional disparities in stroke incidence and mortality. Depressive symptoms were assessed using the four-item version of the Center for Epidemiologic Studies Depression Scale (CES-D-4), administered during a baseline evaluation of each participant. There were 1,262 strokes over an average follow-up of nine years among the study cohort. Compared to participants with no depressive symptoms, participants with CES-D-4 scores of one to three had a 39 percent increased stroke risk after demographic adjustment. Participants with CES-D-4 scores of more than four experienced a 54 percent higher risk of stroke after demographic adjustment. There was no evidence of a differential effect by race. “There are a number of well-known risk factors for stroke, such as high blood pressure, diabetes and heart disease, but we are beginning to understand that there are nontraditional risk factors as well, and depressive symptoms looms high on that list,” said Virginia Howard, PhD, professor in the Department of Epidemiology in the UAB

School of Public Health and senior author of the paper. One goal of the study was to see if depressive symptoms might help explain the increased risk that black populations have for stroke, especially in the southern United States. “The results have been mixed among the few studies that enrolled Black participants and examined race and depressive symptoms in relation to stroke,” said Cassandra Ford, PhD, RN, Capstone College of Nursing at the

University of Alabama and the study’s first author. “Depression often goes undetected and undiagnosed in black patients, who are frequently less likely to receive effective care and management. These findings suggest that further research needs to be conducted to explore nontraditional risk factors for stroke. The implications of our findings underscore the importance of assessing for this risk factor in both populations.” The takeaway, according to Howard, is that medical professionals need to recognize that stroke risk from depressive factors is high. “As nurses, we care for the entire person,” Ford said. “When a patient has a particular condition, such as diabetes, hypertension or stroke, that is the focus of diagnosis and care. Our study provides support for considering nontraditional risk factors during patient assessment, particularly conducting some mental health screenings.”

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Birmingham Medical News

NOVEMBER 2020 • 19


GRAND ROUNDS

Cullman Regional Holds Ground Breaking On October 20, Cullman Regional Medical Center held a ground breaking ceremony for the new Cullman Regional Hartselle Health Center. The center, which will open in the fall of 2021, will be approximately 17,990 square feet with an additional 4000 square feet of unfinished space for future growth. It will have nine exam rooms; two main waiting rooms, one for urgent care and one for the imaging/ specialty clinic; separate MRI, CT and X-Ray rooms; lab area; physician and nurse practitioner offices, Rendering of the new Cullman Regional Hartselle Health Center. along with nurses stations. Cullman Regional will hire about 25 new employees to staff the facility fully.

J. Lynn Cochran, M.D. P. David Miller, M.D. J. Cotton Shallcross Jr., M.D. Charles S. Bluhm, M.D. Owen R. McLean, M.D. David Landy, M.D. Christopher Shaver, M.D. Rajat N. Parikh, M.D. Rishi K. Agarwal, MD Charles A. Dasher, Jr., MD Donny D. Kakati, MD Michael T. Phillips, MD

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UAB and St. Vincent’s Hospitals Named to Hospital rankings for Exceptional Consumer Loyalty The UAB Health System/Ascension St. Vincent’s Alliance has seen both organizations named to the third-annual NRC Health Top 100 Consumer Loyalty list, which recognizes the top U.S. health care organizations for earning exceptional loyalty ratings from their patient populations. Both St. Vincent’s Birmingham and UAB Hospital were named Best in Class, and designated as two of the top 10 hospitals in the country on the Consumer Loyalty list, based on results from NRC Health’s Market Insights survey, the largest database of health care consumer responses in the country. From April 2019 to March 2020, NRC Health surveyed more than 310,000 households in the United States to measure consumer engagement with community health care brands. The winning organizations on the 2020 Consumer Loyalty list achieved remarkably high scores on NRC Health’s Loyalty Index, a composite of seven different critical aspects of consumer loyalty, including access, engagement, experience and net promoter score.

Adamsville Family Medicine Joins Complete Health Adamsville Family Medicine has joined the Complete Health family of primary care practices, making it the second Complete Health practice in the Birmingham area, along with Birmingham Internal Medicine Associates. Adamsville Family Medicine, founded by Drs. Albert Smith and Mark Richman in 2001, will continue in the same location with its current name, while benefiting from additional resources that Complete Health provides, including dedicated care coordinators and member support representatives who educate and address concerns of patients, and help them access benefits and health services. Adamsville Family Medicine provides same-day visits, convenient hours and special programs for seniors.

Beau Grantier, MD Joins Southlake Orthopaedics Beau Grantier, MD has joined Southlake Orthopaedics and is seeing patients at the Grandview office. Grantier specializes in Sports Medicine non-surgical and is a member of the American Medical Society for Sports Medicine. He completed medical Beau Grantler, MD school at the University of Mississippi Medical Center in Jackson, where is also obtained an Emergency Medicine Residency at UMMC and then went on to complete his Primary Care Sports Medicine Fellowship at Vanderbilt Medical Center, Nashville.


GRAND ROUNDS

Parker Elected President of the Alabama Chapter of the American College of Surgeons Mark Parker, MD, FACS has been elected to serve as President of the Alabama Chapter of the American College of Surgeons. Parker, who practices with Alabama Colon & Rectal Institute, received his undergraduate degree in 1994 from Mark Parker, MD Samford University and earned his medical degree from the University of Alabama School of Medicine. He is a member of the American College of Surgeons; the Medical Association for the State of Alabama; the Jefferson County Medical Society; and the American Society of Colon and Rectal Surgeons. The Mission of the Alabama Chapter of the American College of Surgeons is to be an effective voice for surgeons and to advance the highest standards of ethical patient care through education, mentorship, fellowship, and advocacy.

Jason Biddy Elected President of Alabama MGMA Jason Biddy, MBA, CMPE, the CEO of Urology Centers of Alabama, has been elected to serve as President of Alabama Medical Group Management Association (MGMA). Before joining Urology Centers in 2016, Biddy served as CEO of Jason Biddy Alabama Allergy & Asthma Center. He has been on the board of the Birmingham MGMA since 2009. The Alabama MGMA was founded in 1976 and currently has over 750 members.

Shaughnessy Named Director of Pediatric Hospital Medicine Erin Shaughnessy, MD has been named director of the division of Pediatric Hospital Medicine at the University of Alabama at Birmingham and Children’s of Alabama where she succeeds former division director Robert Pass, Erin Shaughnessy, MD MD. Shaughnessy joins UAB and Children’s from Phoenix Children’s Hospital and the University of Arizona College of Medicine-Phoenix. “Joining UAB and Children’s of Alabama is an exciting opportunity,” Shaughnessy said. “I hope to continue to build upon the unmatched care we provide our patients and the contributions to research that have been the hallmark of the division for years

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Birmingham Medical News

NOVEMBER 2020 • 21


GRAND ROUNDS

Leadership Changes at Grandview

Your health & safety are our

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SERVE OUR PATIENTS All of us at ENT Associates of Alabama, P.C. are extremely grateful to our patients for their loyalty and patience during this crisis, and we are working hard to be available to you. As always, the health and safety of our staff, our patients and their families are our top priority. During these difficult times, it is even more critical that those in need of healthcare services have access to treatment, while practicing social distancing and exposing them as little as possible to any potential infections. In order to continue to serve our patients and be considerate of their safety, we have temporarily limited appointment times during this crisis.

Call our office or visit our website for specific office hours at each location.

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Birmingham Medical News

Keith Granger has announced his retirement from his role as CHSPSC President of Region 1, which includes hospitals in Alabama, Georgia and the Florida panhandle, at the end of 2020. Prior to this position, Granger served as CEO of Flowers Hospital in Dothan and Grandview Medical Center in Birmingham. Drew Mason, who was promoted to CEO of Grandview Medical Center in 2017 after serving the hospital as Chief Operating Officer since 2014, will succeed Granger as the new CHSPSC President of Region 1. Mason has been a part of the CHS organization since 2006, workDrew Mason ing in a number of CHS affiliated hospitals and in the corporate office as part of a Division supporting multiple facilities. Daniel McKinney has been appointed to the CEO position at Grandview, beginning on January 1. Over the past decade, McKinney has held leadership roles at hospitals in Alabama and South Carolina. For the past two years, he has served as Chief Executive Offi- Daniel McKinney cer of South Baldwin Regional Medical Center in Foley, Alabama.

Hindman Joins Brookwood as Chief Nursing Officer Robbie Hindman has joined Brookwood Baptist Medical Center as chief nursing officer (CNO) while continuing her role as CNO of the Brookwood Baptist Health System. Most recently, Hindman served as CNO of Princeton Baptist Medi- Robbie Hindman cal Center, a role she held since May 2018 in tandem with her duties as CNO for the Brookwood Baptist Health System. Hindman joined the Baptist Health family in 2000 as executive director of operations of Walker Baptist Medical Center and was named CNO in 2011. Prior to joining the Baptist Health family, Hindman was part of DCH System in Tuscaloosa. During her tenure with DCH, she launched the Fayette Medical Center Home Health Agency where she served as administrator for 10 years. Additionally, she started the Fayette Medical Center Hospice Agency and DME Company, as well as the Maternity Medicaid Steps Ahead Program. Hindman obtained her bachelor’s degree in nursing from Mississippi University for Women and master’s degree from Faulkner University. She previously served on the Nursing Board Selection Committee of Bevill State Community College and the Birmingham Regional Emergency Medical Services System Board.

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1 in 9 men will be diagnosed with prostate cancer this year. Utilizing the most advanced technology available, the urologists at UCA lead the way in prostate cancer diagnosis and treatment. Our team of urologists, medical and radiation oncologists and pathologists work together to create an individualized plan for each patient.

To refer a patient, our easy-to-use Referral Form can be found at UrologyCentersAlabama.com/referral.

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24 • NOVEMBER 2020

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November 2020 Birmingham Medical News  

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November 2020 Birmingham Medical News  

Your primary source for professional healthcare news