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Brookwood Baptist to Spend $12 Million on Cardiac Unit By JaNe

Military Veteran receives Pro Bono Surgery to Repair Nasal Injury When military veteran Don Austin, who received trauma to his nose during Desert Storm, needed a revision of his septorhinoplasty surgery in order to breathe adequately, he contacted the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) and their Faces of Honor Program. ... 3

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“In Alabama, we have what I like to call Alabama Barbecue Disease. We have a lot of folks with calcified, challenging arteries,” says Dave A. Cox, MD, interventional cardiologist and director of the Cardiac Catheterization Laboratory at Brookwood Baptist Medical Center. “You need the equipment to tackle those kind of cases.” To achieve that vision, the medical center has made a $12 million capital investment to Dave A. Cox, MD upgrade and expand their cardiac offerings, in addition to the $10 million hybrid operating room that opened just over a year ago. In April, Brookwood Baptist opened the next phase with a new $2 million electrophysiology lab. (CONTINUED ON PAGE 10)

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Karen Landers, M.D., F.A.A.P., examines a young patient.

Since the middle of the twentieth century, vaccines have prevented countless cases of disease and have saved millions of lives. The Centers for Disease Control and Prevention (CDC) estimates that vaccination of children born in the United States between 1994 and 2018 will prevent 419 million illnesses, help avoid 936,000 deaths, and save almost $1.9 trillion in total societal costs. Karen Landers, MD, FAAP, District Medical Officer and Medical Consultant for Tuberculosis and Immunization for the Alabama Department of Public Health (ADPH), has been a physician for 42 years, and has seen diseases eradicated as a result of vaccinations. “In the 20th century, vaccinations resulted in a big reduction in diseases like measles,” (CONTINUED ON PAGE 10)

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Military Veteran receives Pro Bono Surgery to Repair Nasal Injury By Marti Webb Slay

aware of it so they can give back to those who need it.” The AAFPRS web site When military veteran Don (www.aafprs.org/face-to-face/ Austin, who received trauma to faces-of-honor/) offers details his nose during Desert Storm, about the program: “We want needed a revision of his septoto provide a ‘thank you’ to the rhinoplasty surgery in order to brave men and women who have breathe adequately, he contacted served our country. Some may the American Academy of Facial have already received treatment Plastic and Reconstructive Surin a military hospital while on gery (AAFPRS) and their Faces active duty and may have been of Honor Program. Because discharged. Others may have rehe was about to relocate from located to their home base and Kansas to Birmingham, he was remain on active duty, being referred to Daniel Rousso, MD cared for by a DOD or VA medof Rousso Facial Plastic Surgery ical facility. Some veterans may Clinic and Aesthetic Medical be from the National Guard or Spa. Under the Faces of Honor reserve, some may be geographiProgram, Rousso performed the cally separated from a VA facilsurgery free of charge. ity, and some may just want an The program, started in additional caregiver consultation. 2009, offers pro bono medical “Our volunteer surgeons are and surgical expertise to veteroffering to help complement the ans who received face, head, or care that these facilities provide, neck injuries while serving our From left to right: Daniel Rousso, MD; Nancy Higginbotham; Vera Johnston, RN; Don Austin, the patient; Angela Carlisle, RN; but we are not trying to comcountry. Cam Johnson (Digital Imager); Johnna Prince (Surgery Scheduler); Vikki Little (Patient Liaison). pete with them. We want to help “I’ve been involved in the eligible veterans find a qualified AAFPRS for over 30 years,” clinic comes by to check on his patients patient was tickled because he was breathsurgeon with the best matched skills, and Rousso said. “We have a number of prothat evening as well. ing so much better.” hopefully in a convenient location. grams to help people. One helps victims Embassy Suites donated the room Higginbotham said they hope more “If you are a military service member of domestic violence and this one is for for the recovery, and many of the staff at vets and facial plastic surgeons will learn or veteran who was injured while serving veterans. This is a way for us to give back Rousso’s clinic donated their time. Rousso about the program when they hear about our country and have facial, head or neck to vets who have given up so much. The absorbed all other costs. this case. “Vets don’t use this program very injuries sustained either in combat or nonprogram has a lot of merit.” “The surgery was very successful,” often, because they don’t know it exists,” combat/support activities, you may be eliAustin’s surgery is the first Rousso Rousso said. “At his one-week visit, the she said. “We want to make other doctors gible for these services.” has done under this program, although he once, for another organization, repaired a scalp defect for a young boy whose father was killed in Iraq. Austin’s nose was injured in 1991 and then again in 2003. He originally had his nose rebuilt using a rib cartilage graft, but the cartilage had warped and shifted, causing a 60 percent obstruction which made breathing difficult. “When he came to Dr. Rousso, in addition to the breathing obstruction, he had external dorsal deviation, a widen dorsum, a dorsal hump and a ptotic/ asymmetric tip. He needed a revision rhinoplasty to help him breathe and feel better about himself, and to get him back to square one,” Nancy Higginbotham, practice administrator, said. Rousso removed the original graft and after reshaping it, put it back in to rebuild the bridge of the nose. He then rebuilt the tip of Austin’s nose using cartilage from his septum, and straightened the septum as well. “We use special stitches so we don’t have to pack the nose for this surgery,” Rousso said. “Typically, patients are feeling good and looking good, with little bruising, within a week. We get them back in the swing of things quickly.” To schedule, call 205-802-6900 The surgery was performed at the Rousso Facial Plastic Surgery Clinic. Fax orders to Rousso has his patients spend their first 205-802-6901 night at Embassy Suites with a sitter who brookwooddiagnostic.com provides cold compresses and changes the gauze bandages. A physician from the

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Rethinking the Approach to Acne

Putting the Evidence to Work for Patients By CINDY SANDERS

New evidence and agents have clinicians rethinking traditional approaches to treating acne, the most common skin condition in the United States affecting an estimated 40-50 million Americans at any given time. While the occasional pimple or breakout might not warrant a doctor’s appointment, dealing with moderate to severe acne takes an evidence-based approach and the recognition that acne often takes a serious toll on self-esteem, as well as the skin. “It can be devastating for anyone,” said Linda F. Stein Gold, MD, FAAD, a board-certified dermatologist with Henry Ford Health System in Michigan and member of the American Academy of Dermatology (AAD) Board of Directors and Executive Committee. For teens and young adults, Linda F. Stein Gold, MD, FAAD dealing with persistent acne can contribute to isolation, a decreased quality of life, anxiety, isolation and a poor self-image … particularly when surrounded by picture perfect images of peers on social media. Stein Gold said the emotional impact is very real for older acne sufferers, as well. “Don’t underestimate the effect on adults with acne,” she noted. “For a teenager or a 20-year-old, it’s acceptable to have some acne lesions. For adults, it’s not socially acceptable.” It is, however, a growing problem. Although dermatologists are unsure why, an increasing number of women in their 30s, 40s and beyond are dealing with acne. The AAD estimates adult acne now affects up to 15 percent of women. While some providers might still subscribe to the theory of just letting acne ‘run its course,’ dermatologists are quick to note that isn’t necessarily the best advice. A growing number of options are available

to effectively treat the condition, lessening both the emotional and physical scarring.

Treating Acne “Our thought process on acne has changed over the past few years,” said Stein Gold. Today, she explained, dermatologists are using oral antibiotics in combination with a potent topical treatment for a shorter course of time. “Before, we might have kept patients on antibiotics much longer … maybe a year or two. Now, we understand (antibiotic) resistance is a real problem.” Additionally, she said, dermatologists are increasingly considering other hormonal therapies. “For women, we think of spironolactone or birth control pills; and for all patients, we think about going more quickly to isotretinoin.” Spironolactone is an androgen blocker used to treat hormonal acne. Isotretinoin is typically a second line treatment for cystic acne when other options have failed to yield the desired clearing. When evidence of scarring is present, Stein Gold suggests isotretinoin be started more promptly. “We have a number of agents in the pipeline,” Stein Gold added. “For the first time, we have a topical agent that looks like it can reduce excess sebum production. They’ve just finished Phase III trials on clascoterone. It blocks the androgen receptor; it decreases sebum production and decreases inflammation.” This first-in-class androgen receptor inhibitor by specialty pharmaceutical company Cassiopea SpA penetrates the skin to reach androgen receptors in the sebaceous glands. The 1 percent cream quickly metabolizes to cortexolone, which is found throughout human tissue, thereby minimizing any systemic side effects. In the completed Phase III clinical trials of more than 1,400 patients with moderate-tosevere acne across 112 clinical sites in the U.S. and Europe, 17.5 percent of patients assigned to clascoterone and 5.8 percent receiving vehicle cream achieved treatment success at week 12 (P<0.0001). (CONTINUED ON PAGE 6)


Low Dose Naltrexone Easing Pain from Fibromyalgia and Other Painful Conditions By Laura Freeman

When researchers began to look at how low the dosage of naltrexone could be and still be effective in helping patients overcome addiction, unexpected things began to happen. A low dose of the drug had a paradoxical effect. Given an hour before bedtime, it lowered endorphins as expected for a few hours. Then, in the early hours of the morning when the body manufactures endorphins, there was a rebound effect, increasing endorphins up to triple the previous day’s level. That in itself has implications for many physical and mental health conditions. Researcher Jarrod Younger, PhD, director of UAB’s Neuroinflammation, Pain and Fatigue Laboratory, has been studying another way low dose naltrexone (LDN) seems to be easing pain and fatigue from conditions such as fibromyalgia, chronic fatigue syndrome and Jarrod Younger, PhD Gulf War syndrome. “Low dose naltrexone crosses the blood brain barrier and has a novel antiinflammatory effect that modulates in-

flammation in microglia,” Younger said. “Current thinking is that it goes beyond endorphins to directly act on the receptor that activates the inflammatory process in microglia. In reducing the inflammation, it also reduces the cascade of cytokines and toxins assaulting neurons. More than half of the participants in the study reported a meaningful improvement in symptoms after taking a nightly 4.5 mg dose of LDN for 90 days. Although this was a small study, results were promising enough to warrant further investigation. On the other side of the blood brain barrier, a similar calming of immune cells in the body has been reported in a number of other small studies looking at the use of LDN in a wide range of autoimmune conditions, with a corresponding improvement in symptoms. As naltrexone is a low cost generic drug, there are no financial incentives for funding large studies to get separate FDA approval for low dose use. So funded by foundations and small government grants, studies around the world, particularly in the UK, have been investigating the effects of LDN on autoimmune conditions like Crohn’s and MS, depression, and even looking at possible effects on tumors with opioid receptors. The studies are small, but the number is adding up to an impressive

volume of positive results. Health care providers who have been following the studies are taking notice and beginning to use LDN off label. This is especially true for patients who have experienced side effects with other medications or who haven’t been able to achieve adequate relief from the usual therapies. One of those providers is UAB rheumatology nurse practitioner Vanessa Hill, CRNP. “I was intrigued by the results Dr. Younger was seeing, especially when I saw the data and understood how LDN modulates inflammation in microglia,” she said. “I see so many patients with fibromyalgia and a whole range of arthritic conditions who are hurting in spite of treatment. So I started to discuss LDN with some of them. Naltrexone has a good history of being generally well tolerated at a much higher dose of 50 mg. or more for addiction and alcoholism. Low dose for pain usually starts at around 2.5 mg. and steps up to 4.5 mg. depending on how the patient is doing. “When I saw how my patients responded, I could hardly believe it. I have never seen so many patients respond so well to any one medication. Several have told me it has changed their lives. Some merely say they are feeling better, but then they start talking about all the new things

they are doing and realize what a difference it has made in more energy and less pain. One of those patients was Karen, a UAB research nurse who was experiencing chronic, widespread tendonitis, muscle pain, poor sleep and fatigue. “I constantly had to get injections just to make it through the day,” she said. “The steroids didn’t do enough or last long enough, and there are limits to how often you can have them without health consequences. Since I work in clinical research, I saw how well people in Dr. Younger’s study were doing, and realized LDN might be the answer for me. I asked my rheumatology nurse practitioner at my next visit and she had heard Dr. Younger’s lecture and was beginning to prescribe it. “I was her third patient using it, but I would have been first in line if I had known sooner. I have seen 80 percent improvement for a year and a half now. The pain is so much less. I’m sleeping better and have less fatigue. I was worried that I was going to have to give up nursing, but now I’m doing so much better.” Hill often gets calls from other physicians around UAB and even out of state. “I tell them about it and refer them to the research data,” she said. “Since it is low dose, prescriptions have to be filled at a (CONTINUED ON PAGE 6)

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Diet & Acne “The role of diet in acne has been really controversial for decades,” said Stein Gold. In the 1960s, she continued, many clinicians and researchers believed diet definitely influenced sebum production. However, diet as a contributing factor fell out of favor in the ensuing decades. “Today, we’re coming back to understand diet probably does have an impact on acne,” she said. “We don’t have any really, really good evidence that proves diet directly influences acne, but a lot of small studies suggests that it does.” Most notably, several studies have pointed to a high glycemic diet – which includes foods like white bread, potatoes, sugar and white rice – as a potential trigger. Hyperglycemic diets increase insulinlike growth factor 1 (IGF-1) that has been shown to increase sebum production. Stein Gold pointed to an Australian study where two groups of participants consumed the same number of calories, but one group ate a high glycemic diet while the other consumed foods with a low glycemic load. “By eating a low glycemic diet … and changing nothing else … they actually had a significant decrease in their acne lesions,” she said of participants in the second group. “There have been some studies that suggest dairy products, especially skim milk, might also be associated with acne,” said Stein Gold, adding yogurt and cheese

do not seem to have the same associative relationship to excess sebum production. While the jury is still out on cause and effect of diet on acne, there is significant research touting the overall benefits of consuming foods with a lower glycemic load including whole grains and lentils. “You can never go wrong telling someone to eat more brown, whole grain foods,” Stein Gold pointed out.

When to Refer “Early acne can certainly be handled by a primary care provider,” said Stein Gold. “If you start to see scarring develop – and scarring can occur even in mild acne – it’s time to refer.” She added, “Also, take a pulse of the patient’s emotional state. The most important thing is to be empathetic with patients and listen for a few minutes.” However, Stein Gold noted primary care providers have to cover a lot of ground, and acne can tumble down the priority list when there are other pressing topics to address. If over-the-counter and first line prescription options don’t seem to work, or if a patient is exhibiting emotional distress over their acne, a dermatologist can explore other tailored therapies. “With today’s treatment armamentarium, there’s no reason we can’t get our patients clear or almost clear,” Stein Gold concluded.

2019 AAD Summer Meeting Linda Stein Gold, MD, is one of many presenters and panelists at the upcoming 2019 Summer Meeting for the American Academy of Dermatology. Set for July 25-28 in New York, the meeting’s agenda covers a range of clinical and practice management topics. For more information or to register, go online to aad.org/meetings.

Low Dose Naltrexone, continued from page 5 compounding pharmacy and I always prescribe a 90-day supply. It isn’t covered by insurance, but it is a low cost generic drug. Compounding costs vary widely, but most of my patients have found sources that charge between $35 and $45 for a 90-day supply. “Patients should take it every night about an hour before bedtime. It takes a while for such a small dose to turn around so much inflammation. They need to take LDN consistently for 90 days to get a clear sense of how well it will work for them. “You may find additional benefits. One of my patients was prescribed opioids by a pain clinic. A while after she started LDN, a doctor at the pain clinic called to ask how on earth I got her down from several opioid pills a day to using just 45 pills over 90 days. I told him about LDN, and now he is prescribing it. Dr. Younger is also studying other well-tolerated medications and readily available substances to find more alternatives that can pass through the blood brain barrier and calm inflamed microglia. “We may one day have drugs with the financial incentives to fund large studies, but discovery, development, clinical testing

and FDA approval could take years,” he said. “Meanwhile, people are suffering. We need more research to find options that are available now to relieve symptoms. “For the next few weeks, we will be continuing to recruit fibromyalgia patients for an ongoing pilot study using low dose dextromethorphan, the cough suppressant in cold medicines, which seems to have a similar effect on microglia inflammation, but doesn’t block opioid receptors. This would offer another alternative for people who need the pain relief of opioids for other conditions, or need the usual higher dose of naltrexone to fight addiction or alcoholism.” Toward the end of the year, Younger hopes to be evaluating preliminary findings on this study and another that evaluates the effectiveness of commonly available substances with anti-inflammatory properties such as curcumin and resveratrol. To refer fibromyalgia patients who may be candidates for the low dose dextromethorphan trial, contact UAB’s Neuroinflammation, Pain and Fatigue laboratory, youngerlab@uab.edu or call 205 9755907.


Protecting Patients from Surprise Medical Bills By Howard Bogard

Lawmakers in both the United States House and Senate are considering two proposals to address unexpected, patient medical bills from out-of-network providers. Often referred to as “surprise medical bills” or “balance billing,” the situation arises when a patient inadvertently receives care from an out-of-network provider. Often, the patient is not aware that an out-of-network provider has rendered services until receiving the bill. According to a 2018 study by the Kaiser Family Foundation, about 18 percent of inpatient admissions result in charges by out-ofnetwork providers. For emergency room services, out-of-network services occur 24 percent of the time. Surprise medical bills can occur when a patient receives planned care from an in-network facility, such as a hospital, but other out-of-network providers also provide professional services, such as an anesthesiologist, radiologist or pathologist. It can also arise when a patient is in need of emergency care and has no ability to select the hospital emergency room, treating physicians or ambulance provider. If any of the emergency providers are out-of-network, the patient can receive a bill reflecting the full charge for the pro-

fessional service rendered. For example, a patient inadvertently receives care from an out-of-network provider and the provider submits a charge of $1,000 to the patient’s insurance company. The insurance company pays 10 percent of the charge, rather than the fee schedule amount that applies to in-network providers. After receiving the insurance payment, the provider balance bills the patient the remaining $900. This type of arrangement is generally prohibited when a provider has a contract with the patient’s insurer, including Medicare or Medicaid. Absent applicable

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state law, it is, however, permissible for an out-of-network provider to bill a patient the remainder of the full charge amount. On May 16, 2019, the “STOP Surprise Medical Bills Act of 2019” was introduced in the Senate. The House has proposed similar legislation called the “No Surprise Act.” Both the Senate and the House measures would prohibit balance billing for all emergency services and require that providers bill the patient the in-network rate. In addition, hospitals and physicians would be required to provide patients scheduling non-emergency treatment written and verbal notice of out-ofnetwork and in-network provider status and whether balance billing charges might occur. Patients who do not consent in writing to the additional charges could not be balanced billed. Finally, both measures would prohibit balance billing when a patient is not able to choose the provider, including where a patient receives care from an out-of-network physician during an in-network hospital stay. The Senate bill also protects patients from surprise medical bills from an out-of-network clinical lab or diagnostic imaging center when the services are ordered by the patient’s in-network physician. Under both proposals, the insurer would be required to reimburse the out-of-network provider the

median in-network rate in the applicable geographic market. The Senate version also gives the insurer and provider the option to request an arbitrator to determine the appropriate rate of reimbursement. Twenty-one states have adopted laws to protect patients from surprise medical bills, but according to the Commonwealth Fund only six states provide a comprehensive approach to safeguard patients. Alabama does not have any laws specifically addressing surprise medical billing. Existing state laws would not be superseded by any federal legislation. In February of this year, a coalition of groups representing hospitals and health systems sent a letter to Congress in support for legislation to protect patients from surprise medical bills for emergency care from an out-of-network provider. The letter was signed by the American Hospital Association, America’s Essential Hospitals, Association of American Medical Colleges, Catholic Health Association of the United States, Children’s Hospital Association, and Federation of American Hospitals. Howard Bogard is a Partner at Burr & Forman LLP and chairs the firm’s Health Care Practice Group.

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Important Issues for 2019 Tax Planning By Jonathan G. Kassouf, CPA, PFS

As the tax filing season under the Tax Cuts and Jobs Act (TCJA) comes to a close and extensions are being addressed, many tax advisors and financial planners have had the opportunity to address common concerns with their clients over the last six months. The information contained in this article brings to the forefront issues that many taxpayers deemed to be the most important to them. Consider how filing your income tax return can impact public service loan forgiveness (PSLF). If you are employed by a tax-exempt organization and you have a qualified loan, it is possible for your student loan to be forgiven after 10 years of employment. The loan repayments are calculated every year and are based on

your adjusted gross income (AGI) from the previous year. The more you make, the higher your loan payment is for the next year, which increases the likelihood of paying off your debt before the 10-year period lapses. It is good to determine what your tax differential is between married filing jointly and married filing separately, and whether the potential savings justify giving up the ability to have your loan forgiven. Take advantage of the qualified business income deduction (QBID). The TCJA lowered the C-corporation tax rate to 21 percent. In order to give non-Ccorporation businesses some similar benefit, the TCJA created a qualified business income deduction to reduce the effective tax rate. Many physicians receive pay for depositions and locum tenens work,

which could be reported as sole proprietor income on the personal income tax return. That income could be eligible for the QBID if certain parameters are met and AGI is under a certain threshold. Speaking of sole proprietor income, consider how you are currently substantiating the deductions you are claiming to offset that income. In a recent article published by Accounting Today, the tax gap – the difference between taxes owed and actually paid – is around $460 billion, $390 billion of which is attributable to underreporting, which includes taxpayers who understate their income or overstate their deductions. There are no tax forms that the IRS receives for deductions claimed. Always keep underlying receipts (credit card statements are not enough), and make sure the expenses are ordinary

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and necessary and that the documentation is contemporaneous (originating as the expense is incurred). These qualifications are also important for the more generous vehicle deductions afforded under the TCJA, especially when determining business versus personal use of vehicles with a gross vehicle weight rating of over 6,000 pounds. Depending on your unique circumstance, consider opening a donor advised fund (DAV) for charitable contributions. A DAV allows you to contribute cash or securities to a charitable investment account that can be used to support your desired charities. The funds can be invested for tax-free growth, and you could recommend gifts to almost any IRS public charity. You would receive the deduction in the year you contribute the assets to the account rather than when they are disbursed. This vehicle helps support a technique known as “stacking”- allowing you to bundle, or “stack,” multiple years of charitable deductions into one year to exceed the standard deduction threshold when you would otherwise benefit from the standard deduction. The DAV allows you to stack those contributions for income tax purposes while allowing you to fulfill your philanthropic goals over multiple years. For the long-term, it may be worth considering deferring into your employer’s Roth 403(b) or Roth 401(k) plan. In making post-tax contributions today, you are saving yourself from tax at retirement. The deferrals (not any match nor profit sharing contributions made to your account by your employer), grow tax free and are distributed tax free at the time of retirement. In 2019, let’s assume you defer the maximum amount allowed by the IRS of $19,000 as Roth contributions at age 35. Let’s also assume you are in the 35 percent tax bracket (30 percent% federal and five percent state). You would pay tax today of $6,650 that you would otherwise save if these were traditional deferrals. But if that $19,000 grows tax free and is distributed tax free and doubles every 10 years, it grows to just under $230,000 – and that is only on one year’s deferrals. Paying 35 percent tax today for that money to grow to $230,000 yields an effective tax rate of just under three percent. With the first filing season under the TCJA behind us, this time of the year provides many opportunities to plan for 2019 and beyond. These considerations, among others, should be part of your total tax plan. It is never too early to be proactive. Jonathan G. Kassouf, CPA, PFS is a Director, Kassouf & Co, where he specializes in accounting, tax and consulting services to small businesses with an emphasis on physician practices.


HEALTHCARE REAL ESTATE

Lease, Build, Buy, Sell: Finding the Best Fit for Each Medical Practice By CiNDy SaNDerS

Best practices augmented by analytical evidence drive the decision-making process behind clinical care delivery. That same informed approach should apply to the complex decisions surrounding healthcare real estate. For physicians, the decision to build, buy, lease or sell their practice space should only be made after carefully weighing long-term goals, needs, market forces and economic realities. What makes perfect sense for one group might be the wrong solution for another practice. Turning to medical real estate experts with their specialized knowledge helps physicians sort out the available options to make the best decision to meet a practice’s unique needs.

Lease or Own “There are so many physicians who subconsciously believe owning a building is the next evolution in their practice. Sometimes they are absolutely right – it’s Rich Campbell, CCIM a fantastic opportunity – but sometimes it’s not,” said Rich

Campbell, CCIM, principal with Birmingham-based Veritas Medical Real Estate Advisors. “Our physician clients hire us to offer clean, unbiased advice,” he continued. Campbell said the decision to lease vs. own comes with many considerations from location concerns to operational structuring. One of the most important factors, he noted, is to consider total occupancy cost. “The practice always needs to be considered as an occupancy cost,” he explained. “Even if you buy a building, the practice is always going to be a tenant.” To get a true picture of financial obligation, Campbell said that occupancy cost should be factored into each scenario being considered – lease, purchase, build or buy. “The cost can vary drastically … not only city-to-city and market-to-market but also street-to-street,” he pointed out. “You have to know how the total occupancy cost in any location affects the operations of the practice.” One factor that shouldn’t play into the decision of whether or not to pursue ownership is emotion. “It’s just another investment opportunity that needs to be looked at completely separately from your practice,” Campbell counseled. That investment, he continued, doesn’t happen in

a vacuum so other financial options also should be vetted to decide the best use of each physician dollars – whether that means investing those dollars in a building, technology or equipment upgrades or the stock market.

Buying & Selling “For a variety of reasons, including low interest rates, medical office building transactions have more than tripled during this decade,” said Chip Conk, CEO of Montecito Medical Real Estate, which is headquartered in Nashville. He added that his company anticipated this trend, and it has fueled Chip Conk Montecito Medical’s growth into the nation’s largest privately held acquirer of medical office real estate. “In addition, we pioneered a model that enables sellers to reinvest in the property – getting a second bite of the apple, if you will – and also to co-invest with Montecito in additional properties we acquire. The attractiveness of that model has played a big role in our growth.” Conk noted an office building is typi-

Michael Solomon, M.D. Phlebologist

cally the most valuable asset a physician practice owns. “Individual physician partners within the practice often have invested a meaningful amount of their net worth in the property,” he continued. “Selling the property and then leasing it back unlocks capital that the practice can invest to meet a variety of needs – from staying abreast of medical technology, expanding their services or operations, implementing electronic medical records, recruiting new physicians or covering rising salary and insurance costs – all of which ultimately can contribute to improved patient care and satisfaction and the sustained health of the practice group.” Montecito Medical’s investment vehicle, dubbed the Provider Real Estate Partnership (PREP) program, offers physicians in a practice group the opportunity to reinvest a portion of the proceeds from the sale back into the medical office building. Conk said the investment is typically 10 to 15 percent. “As investors, they enjoy significant tax advantages for the duration of time we maintain ownership of the property,” he explained. “They also receive quarterly distributions from the partnership based on the amount they invest. Then, when Montecito sells the property, (CONTINUED ON PAGE 14)

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Brookwood Baptist to Spend $12 Million on Cardiac Unit, continued from page 1 Renovating about 1,050 square feet, this Atrial Fibrillation (AFib) Center now utilizes the latest in Siemens equipment, including the C-arm mounted Artis zee with Pure x-imaging system. “The technology for and the treatment of AFib has accelerated in recent years,” Russ Ronson, MD says Russ Ronson, MD, chief of staff and director of cardiothoracic surgery at Brookwood Baptist. “AFib affects millions of Americans. With the substantial improvement in the technology, we felt that to be in the forefront of this disease, we needed the latest technology that has proven to be successful.” These advances have led to greater certainty in accessing parts of the heart, notably the left atrium. “It used to be difficult to reach the left atrium and when you got there, there was no way to find where the AFib was coming from,” Ronson says. Now the newer tech lends greater definition, along with color, to the blood vessels and walls, making it safe to work in that afflicted area.” Ronson estimates that initial success rates in procedures—depending on the location of the AFib—have shot up from 40 to 60 percent to around 80 percent in certain types of AFib. “In the past, a lot of patients would need to come back for

a second and third procedure,” he says. “But now that is much rarer due to the technology and what we’ve learned about who the tech will benefit.” Next spring, Brookwood Baptist plans to unveil the final part of their major investment. Three cardiac catheterization labs will replace older ones, and include six adjacent patient prep and seven patient recovery bays, along with a registration area. “It’s been a busy cath lab, and they have served our purposes well. But with three newer labs, we can take on more challenging cases in a safer fashion— blockages that we otherwise might have shied away from because we didn’t have the visualization capabilities,” Cox says. To understand the improvement in monitors in the last few years, Cox says to think of your flat-screen TV five years ago. “You can be blown away by the quality now,” he says, adding that the more vibrant color on the new equipment will also up the cardiac options. “You’ll be able to see the colors of the valve and what the valve is doing when you’re working on it. It will be markedly improved.” Procedures, like implanting a Watchman Device to avoid clots in those diagnosed with AFib or implanting the MitraClip, a device to treat mitral valve regurgitation in patients not eligible for open-heart surgery, have become a safer option, especially for elderly patients, who Cox says will benefit the most from these advancements.

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“It used to be that you would do a cath on someone at 86 in all sorts of chest pain,” Cox says, because of not wanting to perform open surgery at that age. “Now we have more advanced surgeries to open up their coronary occluded vessels. We’re getting more aggressive in elderly patients, that’s one of the drivers for this investment.” Additional advantages of the new tech include lowering the x-ray dose needed in procedures. “That’s a tremendous accomplishment,” Cox says. “Any time you can do more complex cases and use a lower dose, that’s safer for the patient.” So is the relocation of the new cath

labs. “All of interventional cardio in our cath lab is one focused unit and will be right next to the ER,” Cox says. “Heart attack patients will not have to take a long elevator ride to the cath lab. They’ll go right across the hall from the ER to the cath lab. I don’t think there’s a hospital in Birmingham that has that.” For Ronson, the most impressive outcome of this major investment is the complete comprehensiveness for cardiac diagnosis and treatment. “From the minute you walk in, you can get everything done here,” he says. “And with the availability of the newest technology, it’s safer than ever before.”

Safe and Effective Vaccines, continued from page 1 she says. “Vaccinations have prevented people from developing illnesses and the complications from those diseases, which can include death. Vaccines are a preventive measure, and we all know that prevention of any disease is superior to treatment.” There are many vaccine-preventable diseases. The common ones include diphtheria, pertussis, tetanus, hepatitis A and B, measles, mumps, rubella, chicken pox, rotovirus, Hemophilus influenza type B, pneumococcal, HPV, meningococcal, and polio. Other vaccines for international travel include yellow fever and typhoid. Too often, professionals in the CDC learn of people who suffer from illness and disability from infectious, yet preventable, diseases. They also see families who mourn the loss of a loved one from an illness that could have been prevented through vaccination. Healthcare professionals who work in Disease Control are concerned about the anti-vaccine movement because vaccines save lives. Anti-vaccine proponents are concerned that the MMR (mumps, measles, rubella) vaccine is linked to autism. That fear originated with a 1997 study published by Andrew Wakefield, a British surgeon, who suggested that the MMR vaccine was causing autism in British children. His paper has since been discredited by a number of sources. “More recent scientific evidence has proven that that MMR is not linked to autism and that claim has been retracted, yet this information still persists in the understanding of some people,” Landers says. “It is important that we continue to look at the science on that.” She adds that there also are worries about certain products contained in some vaccines. “There are concerns related to

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thimerosal, a mercury-based preservative,” Landers says. “The fact is that there hasn’t been any thimerosal in vaccines in many years. The benefit of vaccines far outweigh the negligible risks.” Anti-vaccine proponents also believe that infant immune systems can’t handle all the vaccines that are administered during early life. Paul Offit, MD, Director of the Vaccine Education Center at Children’s Hospital of Philadelphia says that 20 years ago children received seven vaccines routinely and up to five shots by two years of age. “Today, children receive 11 vaccines routinely and as many as 20 shots by age two,” he says. “The infant immune system has an enormous capacity to respond safely to immune system changes from vaccines. We can offer reassurance to parents that far from weakening an infant’s immune system, vaccines actually strengthen an infant’s defenses against serious and potentially fatal infections.” ADPH works diligently to combat erroneous information about vaccines. It provides scientific information to the lay public related to their safety and effectiveness. “If you look at our data, Alabama is still a highly vaccinated state which is good. It means that parents and guardians are taking advantage of educational information and are making good decisions for our children,” Landers says. “I’m concerned that if health care providers whether it be physicians, nurses, pharmacists or others - don’t continue to provide educational material and scientific information, people are going to continue to withhold vaccines from children.” Both Landers and Offit worry that children may not get protection from vaccine-preventable diseases because of erroneous information. They state, unequivocally, that vaccinations work. “Immunizations are extremely safe and highly effective at preventing disease and death. Vaccination is one of the most important steps parents can take to protect their children,” Offit says. “We can reassure parents that by immunizing their infants, they are affording them maximum protection against serious infectious diseases with minimum risk, helping their immune systems to become stronger and giving them the healthiest possible start in life.”


HEALTHCARE REAL ESTATE

Are You Paying Too LITTLE in Rent? By Richard Tidwell

Conventional wisdom says that spending less money is the most effective way to save money. After all, a penny saved is a penny earned. That logic is hard to argue with, but it is not always foolproof. Saving money for your practice the wrong way can lead to diminished patient care, outdated equipment, the wrong location for your practice and additional negative results. There are several factors often overlooked when a healthcare practice’s primary focus is paying the lowest rent instead of achieving the best combination of overall terms. Let’s look at three factors in which paying higher rent could actually increase your profitability.

themselves into trouble when they only focus on the lowest lease rate. The reason this can be such a costly mistake is because landlords often care the most about maximizing the property’s income, which is primarily driven by the lease rate. The Net Operating Income, which is a function of the lease rate, is the main number an appraiser looks at when valuing an investment property. Savvy landlords recognize this and would often rather invest more money into their space while providing other concessions such as free rent, lower annual escalations and tenant improvement allowance as opposed to lowering their lease rates. To a landlord, lower lease rates devalue capitalization potential should they decide to sell the property.

The Cost to Build Healthcare buildouts often cost two to three times more than a typical commercial real estate space. This is attributed to many factors that are unique to healthcare, including: • More durable finishes • Millwork and cabinetry • Plumbing and sinks in exam rooms, sterilization centers and laboratories • Increased electrical and HVAC requirements With buildout being such a costly expense, many healthcare professionals get

For example: A Landlord has a 2,000 SF vacant space listed for lease at $4,000 per month on a 10-year lease term. A doctor wants to lease the space for the lowest lease rate possible. The doctor offers the landlord $3,250 per month to get the lowest monthly rent. The landlord proposes keeping the rent at $4,000/month but is willing to give the tenant $100,000 and five months of free rent to buildout the space plus three months of free rent upon opening for business.

In this instance, the Doctor would be spending $90,000 more in rent over the 10-year lease term (assuming the landlord would agree to the lower proposed monthly rent). However, the doctor would be better taking the landlord’s higher-rent offer because they would be saving $100,000 on the buildout loan, receiving $12,000 in free rent (plus a free build out period) and saving an additional $27,000 on loan interest expense (assuming a 10- year loan term at a five percent interest). In this instance, the lower rent would have cost the doctor almost $50,000 more in total expenses. Additionally, with the higher lease rate, the doctor would receive a higher level of tax deductions as rent is 100 percent deductible. Conversely, some of the additional loan costs are not deductible and a portion of what the loan was spent on would need to be depreciated over a longer period of time to account for the build out. From the landlord’s perspective, this deal is more appealing with the higher lease rate and more concessions because the $112,000 tenant improvement and free rent allowance today will be primarily recaptured through rental income over the lease term. More importantly, it saves the Landlord from devaluing the property by over $128,000 when compared to lowering the lease rate. This same approach carried

over the entire property could save the landlord $500,0000 to $1,000,000 on an average sized property at the time of sale. In this scenario, the landlord is more likely to perform the transaction while the doctor would save well over $50,000 compared to seeking only the lowest monthly rent. Both the landlord and doctor win.

Location Another overlooked factor that could make paying a higher lease rate a better financial decision is a property’s location. Location is one of the most important factors in a healthcare practice’s success. There are two factors regarding your location that need to be considered: the first involves demographics, visibility, access, signage, etc. and the second is the quality of neighboring or anchor tenants. Having a strong anchor tenant can significantly impact the rate you pay. However, higher rent premiums can be worth the increased expense when you consider the number of potential new patients a strong anchor tenant can attract. A space with a better location and higher rent has the potential to increase the number of new patients per month to the point where the increased profit would be greater than the cost of the higher rent. (CONTINUED ON PAGE 12)

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Birmingham Medical News

JUNE 2019 • 11


HIPAA Myths and Misconceptions By Loretta Duncan, FACMPE

Trying to comply with HIPAA can be a challenge for healthcare providers, especially when there is so much confusion about specific aspects of the rules. Policyholders contact SVMIC almost every day for assistance with HIPAA-related issues. In fielding those calls and emails, we have identified some commonalities. Some of the most commonly asked questions with answers backed by the Department of Health and Human Services (HHS), are: When a patient requests a copy of their medical record, may a practice release records that were received from another healthcare provider? Yes. Excluding records with special protections by state or other federal law, such as psychotherapy notes and notes related to substance abuse treatment, practices are permitted to release other healthcare providers’ records. For example, a primary care practice receives a request from a patient for copies of all of their medical records. The PCP has records from the patient’s cardiologist and gastroenterologist included in their medical record. The PCP may release all of this information to the patient. The following information is from the guidance provided by HHS on the topic of patient access to their protected health

information:   The Privacy Rule generally requires HIPAA covered entities (health plans and most health care providers) to provide individuals, upon request, with access to the protected health information (PHI) about them in one or more “designated record sets” maintained by or for the covered entity. Individuals have a right to access this PHI for as long as the information is maintained by a covered entity…regardless of the date the information was created; whether the information is maintained in paper or electronic systems onsite, remotely, or is archived; or where the PHI originated (e.g., whether the covered entity, another provider, the patient, etc.).https:// www.hhs.gov/hipaa/for-professionals/ privacy/guidance/access/index.html Does HIPAA require the patient to sign an authorization or consent when releasing information to another healthcare provider for the purpose of treatment, payment or healthcare operations? No. HIPAA does not require anything in writing from the patient when disclosing PHI for treatment, payment or healthcare operations. HIPAA does require that the patient’s identity be verified to ensure that the correct individual receives the information. This can be done in a number of ways such as verifying the patient’s date of birth, last four digits of their social security number and/or current mailing address. This process may be done over the phone,

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Birmingham Medical News

in person or electronically through secure email or the patient portal. https://www.hhs.gov/hipaa/ for-professionals/faq/271/does-aphysician-need-written-authorizationto-send-medical-records-to-a-specialist/ index.html Is using a sign-in sheet or calling a patient by their first and last name a HIPAA violation? No. Using a sign-in sheet is not a HIPAA violation as long as the information on the sign-in sheet is kept to the minimum necessary. For example, a sign-in sheet with the patient’s name, appointment time and the physician being seen would meet the minimum necessary standard. Practices should avoid asking the patient to put their reason for visit or contact information on the sign-in sheet, since this information can be captured in another, more confidential manner. Keep in mind that certain specialties may choose not to have a sign-in sheet simply due to the sensitive nature of their practice. Calling patients by their first and last name is sometimes necessary due to patients having the same first or last name or similar names. https://www.hhs.gov/hipaa/forprofessionals/faq/199/may-health-careproviders-use-sign-in-sheets/index.html May a practice communicate with individuals involved in the patient’s care or payment for their care? Yes. Communicating with individuals involved in a patient’s care or payment for care is permitted under HIPAA if the patient agrees, or when given the opportunity, does not object. The HIPAA Privacy Rule at 45 CFR 164.510(b) specifically permits covered entities to share information that is directly relevant to the involvement of a spouse, family members, friends, or other persons identified by a patient, in the patient’s care or payment for health care. If the patient is present, or is otherwise available prior to the disclosure, and has the capacity to make health care decisions, the covered entity

may discuss this information with the family and these other persons if the patient agrees or, when given the opportunity, does not object. The covered entity may also share relevant information with the family and these other persons if it can reasonably infer, based on professional judgment, that the patient does not object. https://www.hhs.gov/ hipaa/for-professionals/faq/488/ does-hipaa-permit-a-doctor-todiscuss-a-patients-health-status-with-thepatients-family-and-friends/index.html Is an authorization form required to disclose protected health information to another treating provider? No. HIPAA permits healthcare providers to share information with other treating providers, without the patient’s written authorization, even in situations when the provider releasing the information did not refer the patient. Here is the HHS FAQ that addresses this type of disclosure: The HIPAA Privacy Rule permits a health care provider to disclose protected health information about an individual, without the individual’s authorization, to another health care provider for that provider’s treatment of the individual. See 45 CFR 164.506 and the definition of “treatment” at 45 CFR 164.501. https://www.hhs.gov/hipaa/ for-professionals/faq/271/does-aphysician-need-written-authorizationto-send-medical-records-to-a-specialist/ index.html Navigating HIPAA Privacy, Security and Breach Notification Rules can be difficult. HHS has provided a multitude of resources on their website at www.hhs.gov/ HIPAA. SVMIC provides answers to HIPAArelated questions. The Education Center on the SVMIC website has on demand self-studies, including HIPAA Training for the Medical Office, along with sample forms. For more information about HIPAA compliance or to ask a general HIPAA question, contact Loretta Duncan at LorettaD@svmic.com.

Are You Paying, continued from page 11 Condition of the Space The condition of a space makes a large impact on the overall cost of a deal and is often overlooked when the primary focus is on achieving the lowest rent. When was the building built or remodeled? When was the HVAC last replaced? Is there sufficient electrical service for your equipment and technology? What type of deferred maintenance is present? And the list goes on. Any of these items could cost you thousands of dollars to remedy over the term of your tenancy. Whether the issue needs to be fixed on the front end, like installing new HVAC, or something else that adds up over time, like poor-energy efficiency, the

extra costs of leasing an older space needs to be considered. There is a significant amount of money on the line when it comes to your healthcare practice real estate, and most of it is negotiable. It is important to consider more than just lease rate and length of the term when evaluating your real estate options. While landlords are often reticent to move off the lease rate, they can be willing to give significantly more concessions in other areas. Richard Tidwell is an agent with CARR Healthcare Realty, a provider of commercial real estate services for healthcare tenants and buyers. He can be reached at richard.tidwell@carr.us


The Literary Examiner BY TERRI SCHLICHENMEYER

Bitten: The Secret History of Lyme Disease and Biological Weapons by Kris Newby c.2019, HarperWave; $28.99; 319 pages You get so much from being outdoors One year in, she was healthy enough in nature. to begin asking questions, which spurred Ahhhhh, the fresh air, the sunshine, her to co-produce a documentary about the birds singing. You might Lyme disease. Government exsee wildlife or find berries or perts were unwilling to appear nuts to snack on. Touch the on-camera, so she and her cograss. Look up at the trees. producer began to look for a Think about how relaxed retired NIH Lyme expert who you’ll feel. As in the new book would talk. Bitten by Kris Newby, imagine That led her to Montana, what you might bring home. Willy Burgdorfer, and an exploOn a wonderful, idyllic sive story. Martha’s Vineyard family vaBecause of a literal flip of a cation in 2003, Kris Newby coin, Burgdorfer arrived from and her husband were both Switzerland to Montana in late Kris Newby bitten by ticks. 1951, having been hired by the They didn’t know it then. Rocky Mountain Laboratory They didn’t have an inkling to study tick-borne diseases. He settled until two weeks later when, back home, in, married a local woman, and dived they came down with “an intense, flulike into what apparently fascinated him. But illness” that wouldn’t go away. Newby’s as the Cold War heated up, Burgdorfer husband eventually got better but for began to see that his role in research had Newby, tests offered no answers until she changed. He was no longer looking for found a doctor who diagnosed Lyme disa cure for tick-borne illnesses. He was ease, and set her on a five-year treatment instead force-feeding ticks with diseases, regimen. and he had become the go-to person for

special tick requests for bioweapons projects. But what did he know? In subsequent interviews, Burgdorfer admitted to Newby that he hadn’t told her everything, so Newby requested information through the Freedom of Information Act, to see what Burgdorfer kept mum. What she found, she believes, is “straight out of some B-movie script.” Absolutely, you could be forgiven if, in the first 75 pages of Bitten, your thoughts start drifting along the “are-you-KIDDING-me?” side. What’s claimed here is, indeed, right out of a black-and-white 1950s flick. But then, as author and science writer Kris Newby continues to reveal information, name sources, and explain why her life may have been in danger during her

research, well, that chill you feel isn’t the air conditioning. Her research is documented. Her sources are all educated, well-known individuals. What she claims is plausible – isn’t it? Any conspiracy theorist or reader of thrillers may believe so, but there are still an awful lot of questions left to be answered. Even Newby admits that she edged uncomfortably too close to her subject. In her closing, which is wistful, readers are left longing for answers that may never come. You’ll also be scratching but don’t let a little squeamishness stop you if you’re a fan of thrillers or medical stories. For you, Bitten may just tick all the boxes. Terri Schlichenmeyer is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.

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JUNE 2019 • 13


Lease, Build, Buy, Sell: Finding the Best Fit, continued from page 9 they receive a return on their investment.” Conk added many of the same dynamics and principles also apply to hospitals and health systems. “Hospitals in the U.S. collectively own more than $1 trillion in real estate,” he pointed out. “The economic power of those assets is greatly underutilized. Selling office properties that they own enables them to redirect capital for new technologies, improvements in care delivery and even new outpatient facilities such as ambulatory surgery centers.” When deciding what direction to take when it comes to owning, selling and leasing, Conk said it was important to start with an accurate picture of what the real estate is worth and then look at the strategy for addressing important needs … whether that is paying down debt or expanding technology or services. He noted the model used by Montecito helps address the individual needs and interests of physicians, allowing younger providers who might not be able to afford an ownership stake or those simply not interested in the investment to continue practicing without being required to put up personal funds. “Reinvesting in the property is a decision for individual physicians in the group.” Campbell said when purchasing or divesting real estate as a group, it’s critically important to have addressed buy/ sell provisions on the front end. What happens to a physician partner’s shares of the facility when he or she retires or dies?

There is no one-size-fits-all solution when it comes to owning a facility. Firms specializing in healthcare real estate can help with the lease, buy, build or sell decision.

Do they pass to a spouse or children? If so, do those non-physician owners have input on facility decisions? “It gets really convoluted so you have to be really careful with your operational policies, as well,” he said of thinking about the longterm investment.

Reaching Out to a Specialist Campbell and Conk said partnering with a healthcare real estate specialist is important when considering facility needs. Campbell laughingly noted he recently had to re-read a particular lease amendment “about 17 times” to fully

understand what was being required. “There’s no way a client could understand it,” he said. Campbell added, “Never hesitate to make a call and ask for help.” Because the process is complex and often takes time, he encouraged physicians to reach out well before a lease is up to begin considering other options. “If it’s too early, folks will tell you,” Campbell said. More often, he added, physicians wait too long to reach out, which crunches the timeline on an important decision. “Physicians oftentimes have needs that don’t necessarily require a real estate transaction,” said Campbell, noting it’s one of

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the reasons Veritas offers advisory services. Campbell said a general commercial real estate broker without medical real estate experience is always happy to help close a transaction, which is their job. However, he continued, “The broker is not trained, nor is he motivated, to step back and ask if this is right for your practice.” Campbell added it’s important to find someone who understands the intricacies of medical practices and the total cost of occupancy. Sometimes, he pointed out, “You need someone willing to say, ‘You don’t need to do this deal.’” Conk noted the same principles apply to physicians considering selling the properties they own. “For some physician groups, it might make more sense to refinance their property rather than sell,” he noted. “But we can help them get a clearer picture of their options so they can come to the decision they think is best for them.” He added that practices mulling over the possibility of a sale should consider timing and the state of today’s market. “Right now, values for medical office real estate are at historic highs, and interest rates remain low … it won’t always be that way,” Conk pointed out. Buy, sell, build or lease – the decision always stays with the practice but having all the facts enables providers to make an informed decision that is best for individual physicians, the practice and patients. “Go in with eyes wide open,” Campbell concluded.

Natalie George, PA-C


Plenty of Questions with False Claim Act’s New Cooperation Credit Guidelines By J. D. Thomas

The Department of Justice (DOJ) recently provided a long-awaited update on how it will assign “cooperation credit” in civil False Claims Act (FCA) cases, but the new guidelines have left defendants with as many questions as answers. Defendants have wondered for some time whether and how the government gave credit for cooperation in civil FCA cases and section 4-4.112 of the Justice Manual clarifies some of those points. The new policy, intended to “incentivize companies to voluntarily disclose misconduct

and cooperate with investigations,” according to the DOJ, establishes guidelines for companies to: 1. Voluntarily disclose FCA violations uncovered internally 2 Cooperate with investigators related to the case 3. Undertake remedial steps towards compliance While these guidelines build off of previous DOJ initiatives to encourage cooperation, the new guidelines prescribe more specifics to what will, and will not, garner a defendant credit. The DOJ states that “proactive, timely, and volun-

Food Allergy Oral Immunotherapy: What is the benefit? By Erin Cuzzort, MSN, RN, FNP-C

What if a microscopic amount of food protein you accidentally ingested quickly resulted in life threatening symptoms such as hives, swelling, vomiting, diarrhea, coughing, wheezing, or difficulty breathing? This is a serious reality for patients with food allergies and results in a constant anxiety and fear of accidental ingestion. Many are never able to eat out at restaurants, go to baseball games, fly on planes, attend movies, or simply have the option to eat at any table in a cafeteria without fear. This not only affects the patients, but their families as well. Recent statistics from Food Allergy Research and Education revealed that approximately 32 million Americans have food allergies, one for every 10 adults and one for every 13 children, or roughly two children in every classroom. This number is staggering and reinforces food allergy as a continuously rising problem of epidemic proportions. More than 50 percent of adults and 40 percent of children have experienced a severe reaction. 25 percent of children with food allergies will experience their first reaction at school and about one-third have experienced bullying, and many parents report feeling isolated. So, with food allergies on the rise and food allergy oral immunotherapy (OIT) as a proven effective treatment option, what is the benefit? By allowing patients to slowly orally introduce their food allergen daily in weekly increasing amounts in office over a period of five to seven months, 85 to 90 percent of patients will reach a daily maintenance dose of their food allergen that provides them with protection against accidental ingestion. As long as they continue this treatment indefinitely, this built-up immunity to their food allergen will remain, allowing patients to experience a life free of

constant worry. For many, this treatment option provides hope in gaining autonomy over their food allergies. Nelson Mandela said it best: may your choices reflect your hopes, not your fears. Erin Cuzzort, MSN, RN, FNP-C practices with Alabama Allergy & Asthma Center.

tary self-disclosure” of misconduct, even if it is misconduct unrelated to an ongoing investigation, is one of the ways in which a company may earn credit. Those companies that cooperate with an ongoing investigation, such as by providing access to data and information that may be difficult for the DOJ to otherwise obtain, and identifying culpable individuals will receive credit. Likewise, a company that preserves relevant documents and information beyond the scope of the initial investigation and beyond legal and business requirements may earn credit. Corrective actions undertaken could also earn a company credit. The DOJ illustrated such remedial measures with examples including analysis of the root cause and remediation to correct it; disciplining and replacing individuals responsible; implementing or improving an effective compliance program. This is where it gets hazy, however. Outside of the DOJ’s examples of remedial measures and voluntary cooperation there is little clarification on what may and may not qualify a company for credit and that means a defendant will need to weigh the risks of further litigation exposure. There is ambiguity built right into the language of the policy as well, with emphasis on “effective” compliance. While more clarity on how to earn credit in a civil FCA case, is welcome, healthcare organizations will need to consider all the factors of their individual situation. Choosing to voluntarily disclose misconduct or provide access to materials that could expose misconduct

has potential consequences for a company. Without firm guidance outside of the handful of examples provided by the department, companies will have to parse this new guidance and make a decision of whether the information or assistance they may be able to provide will garner them some benefit. That is not the only question that providers and other targets of FCA investigations will be left asking. While the DOJ states that “credit will take the form of a reduction in the damages multiplier and civil penalties,” and could potentially result in the DOJ informing other agencies or the public about a company’s voluntary cooperation in the matter, the latest policy does not outline any standardized benefit a defendant can expect to receive in exchange for credit. While it may advantage a defendant for DOJ to put other agencies on notice of willing corporation, the real hammer of the FCA is monitory. Only time will tell what’s specific reductions DOJ is willing to make to multipliers or damages models for specific actions of an entity under investigation. As it stands, the language of this guidance rightfully begets further questions about whether defendants will be able to count on monetary exposure being reduced by an expected amount. J. D. Thomas is a partner with Waller where he serves as a member of Waller’s Government Investigations, Healthcare and Litigation groups.

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Grandview Medical Center in Top 10 Percent of Inpatient Rehabilitations Facilities in US For the third year in a row, Grandview Medical Center’s Inpatient Rehabilitation Center, known as Easy Street, has been ranked in the top 10 percent of 868 inpatient rehabilitation facilities (IRFs) that qualified to be ranked in the IRF database of Uniform Data System for Medical Rehabilitation (UDSMR) in 2018. The rankings were determined by using UDSMR’s program evaluation model (PEM), a case mix-adjusted and severity-adjusted tool that provides facilities with a composite performance score and percentile ranking drawn from nearly three-quarters of all IRFs in the country. UDSMR’s PEM Report Card uses the indicators of efficiency and effectiveness contained in the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), the CMS reporting tool for the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS).

Southeast Gastro is Acquired Gastro Health, a Miami-based gastrointestinal practice, has acquired Southeast Gastro of Birmingham. Founded in 1976, Southeast Gastro is comprised of 20 board-certified gastroenterologists and 17 advanced practitioners. Southeast Gastro operates four main clinic locations, four satellite

locations, and provides diagnostic and preventive procedures at three surgery centers throughout Birmingham.

Nearly $50 Million NIH grant for UAB Translational Science The UAB Center for Clinical and Translational Science (CCTS) has been renewed for another five years with grants from the National Center for Advancing Translational Science, part of the National Institutes of Health. The three linked grants, totaling nearly $50 million over five years, will support clinical and translational research, mentored career development, and pre-doctoral training. UAB’s CCTS, established in 2008, nurtures research through partnerships with academic health centers, research institutes and universities. It also accelerates the process of translating laboratory discoveries into treatments, facilitates training of researchers, and engages communities in research efforts. “As the sole Alabama-based hub in the NCATS-funded CTSA program, the CCTS has been a driving force for scientific innovation for the past decade,” said Robert Kimberly, MD, senior associate dean for Clinical Robert and Translational Re- Kimberly, MD search in the School of Medicine. “The

CCTS is transforming the biomedical research environment at UAB.” The CCTS has secured more than $123 million in competitive federal funding, including 14 supplemental awards, and has leveraged multiple multi-institutional grants across the network. It has granted 62 pilot awards, producing nearly 1,500 publications and an overall return on investment of 49:1 since 2008. Kimberly is the principal investigator on the core CCTS grant, totaling more than $38 million. The additional two linked grants — $5.2 million for the Deep South Translational Research Mentored Career Development Program and $3.7 million for a National Research Service Award training core — are led by Kenneth Saag, MD, the vice chair for Outcomes Research of the Department of Medicine. The CCTS partner network — which comprises 11 academic and scientific research institutions in Alabama, Louisiana and Mississippi — is the foundation of the center’s regional collaborative efforts. Launched in 2015, the network’s purpose is to reduce the burden of cardiometabolic, vascular and cancer-related diseases and health disparities that disproportionately affect the minority populations in the south. To prepare researchers for the collaborative projects, the CCTS Training Academy, under the leadership of Michael Mugavero, MD and David D.

Chaplin, MD, PhD, offers learning opportunities that create “translational thinkers” who are multilingual — that is, they are familiar with the basic principles and terminologies of key fields in translation, from informatics, biostatistics and study design to team science, ethics and community engagement. The CCTS Clinical and Translational Science Training Program, a six-month experience that has introduced hundreds of investigators to the language of translation, graduated nearly 50 trainees in 2018.

DCH Health System Raises Wages DCH Health System has made a major investment in its employees The wages for many positions at DCH were adjusted in April to make them more competitive. DCH studied wages for health care professionals and for individuals who work in scores of positions ranging from information technology to food service, according to DCH CEO Bryan Kindred. The adjustments will add about $11 million to DCH’s operating costs, according to Kindred. Positions whose wages were below the market rate were adjusted to position them in the marketplace. Employees whose rate was within the market salary range received a raise based on their annual evaluation.

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Birmingham Medical News


GRAND ROUNDS

UAB Huntsville Opens New Psychiatric Clinic In a state with a pronounced need for mental health services, the Huntsville Regional Medical Campus of the University of Alabama at Birmingham School of Medicine has opened a new psychiatric clinic to serve both adult and pediatric patients, located on the first floor of the Huntsville Medical Campus building. “There is a critical need for additional mental health services in North Alabama, especially for traditionally underserved populations,” said Roger Smalligan, M.D., the dean of the Huntsville campus. The clinic will be staffed by Clinton Martin, MD, associate professor and regional chair of Psychiatry, and Janaki Nimmagadda, MD, associate professor. Both physicians are board-certified in child and adolescent psychiatry and general adult psychiatry. Martin focuses primarily on psychosis in adolescents, adult ADHD and major depression in adults. Nimmagadda focuses on childhood ADHD, adolescent mental health and mood disorders in transitional age youth between the ages of 16 and 24. Nimmagadda and Martin came to UAB in 2011 to pursue their child psychiatry fellowship training following adult residency training at St. Elizabeths

Hospital, Washington, D.C. They joined the faculty in 2013 and 2014, respectively, jointly running the child and family assessment clinic. In addition, Martin was the co-director of the First Episode Psychosis Clinic at Birmingham. “Early identification and treatment are the keys to management of any psychiatric illness,” Martin said. “There is an average of eight to 10 years’ delay between the onset of symptoms and the beginning of treatment during these critical developmental years in the life of a child. Nearly two-thirds of children in need of mental health services receive very little or no treatment. Therefore, collaborating with community and school leaders who often serve as gate keepers to children’s mental health is one of our first agendas.” “The teenage years are critical for mental, social and emotional well-being,” Nimmagadda said. “Many psychiatric illnesses begin in adolescence and young adulthood, with almost half of all lifetime mental disorders starting by age 14. These psychiatric disorders could lead to considerable difficulty in a child’s ability to perform daily roles. The unique thing about our clinic is that we do not discharge a patient from our clinic at age 18 to adult services, but will continue to provide support during their early adulthood years.”

Brookwood Welcomes New Linear Accelerator & 3T MRI The TrueBeam® radiotherapy system is an advanced medical linear accelerator—fully-integrated for image-guided radiotherapy and radiosurgery and designed from the ground up to treat targets with enhanced speed and accuracy. TrueBeam treats cancer anywhere in the body where radiation treatment is indicated, including lung, breast, prostate and head and neck. Having the power to not only treat quickly, but also deliver highly precise dose rates are hallmarks of the TrueBeam system. TrueBeam offers clinicians intelligent tools for a wide spectrum of advanced treatment modalities including intensity modulated radiation therapy (IMRT), stereotactic body radiotherapy (SBRT), and RapidArc® radiotherapy, a form of volumetric modulated arc therapy (VMAT). New capabilities for TrueBeam feature highprecision Stereotactic Radiosurgery with HyperArc™, improved soft-tissue visualization via iterative Cone-Beam CT (iCBCT), and enhancements to intrafraction motion management techniques—giving clinicians the confidence to know treatments are delivered exactly as planned.

Brookwood Sandra Tincher, MD The Brookwood Baptist Medical Center has named Sandra Tincher, MD as Physician of the Month for the difference she makes in the lives of her patients. Tincher, a radiation oncologist who has been in practice over 20 years, received her medical degree from Mercer University School of Medicine in 1994 and performed her residency at UAB Hospital. The Brookwood Baptist Medical Center Physician of the Month program is designed to recognize physicians who emulate our values of integrity, service, quality, transparency and innovation in their everyday work.

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CMS Rule Change will Benefit Alabama Hospitals Fix to Wage Index Formula With 75 percent of Alabama’s hospitals operating in the red, the recent news of a proposed federal rule change to make hospital Medicare payments more equitable is a huge boost for the state. According to information released by the Centers for Medicare & Medicaid Services (CMS) in its proposed payment rule for fiscal year 2020, Alabama would receive a projected increase in Medicare payments based on a change to the wage index formula. “Our preliminary estimates predict an increase of more than $34 million for Alabama’s hospitals for the next fiscal year,” said Danne Howard, executive vice president and chief policy officer for the Alabama Hospital Association. In the proposed rule, all hospitals in the bottom quartile (almost all Alabama hospitals) would experience an increase in Medicare payments starting October 1st of this year. “The wage index factor has a floor and a ceiling, and Alabama hospitals have consistently been at the bottom of the range for years, with the lowest rural payments in the country. Raising the floor brings Alabama payments more in line with hospitals across the country,” Howard said.

UAB Hospital Lauded for Seventh Year in a Row as one of America’s Great Hospitals UAB Hospital has been listed on Becker’s Hospital Review’s 2019 list of 100 Great Hospitals in America. UAB has earned this distinction every year since

2013 and is the only hospital in Alabama to make the annual list published by Becker’s Healthcare, a leading source of business and legal information for health care industry leaders. Becker’s 100 Great Hospitals website describes UAB Hospital as a 1,157bed institution. The health system’s UAB Callahan Eye Hospital was one of the first level 1 ocular trauma centers in the country, and is the only level 1 ocular trauma hospital in Alabama.

Cindy Key Named Chief Nursing Officer of Walker Baptist Medical Center Cindy Key, a nurse executive with over 35 years’ experience, has been named chief nursing officer at Walker Baptist Medical Center. Key joined Walker Baptist Medical Center in 2011 following the acquisition of the Alabama Cindy Key Outpatient Surgery Center where she served as manager. She was promoted to Director of Procedural Services, which included the Inpatient OR, Ambulatory Surgery Center, Surgery, Outpatient Procedures and Sterile Processing. Key has also held roles as nurse manager of Orthopedics and Director of Maternal/Infant Services. Key earned an associate degree in nursing and later a bachelor’s degree in Health Administration from UAB. She will complete her master’s degree this summer.

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RESEARCH NOTES

New Trial of Long-Acting HIV Medication A new clinical trial led by the National Institutes of Health will evaluate the effectiveness of a long-acting antiretroviral therapy, or ART, combined with conditional economic incentives for patients living with HIV who have had a history of non-adherence to daily oral medication and treatment. The Long-Acting Therapy to Improve Treatment SUccess in Daily LifE — or LATITUDE — study will determine whether monthly ART injectables can help manage HIV in this population as compared to traditional ART treatments, which are often not taken as prescribed, thus continuing transmission to others and not providing suppression for those infected. According to the Centers for Disease Control and Prevention, it is estimated that up to a quarter of people prescribed ART stop taking the medication at some point, often due to factors like stigmas associated with the disease or socioeconomic status. “Regular adherence to ART can enable those living with HIV to lead healthier and longer lives and minimize transmission of the virus, but consistency in taking medication — especially on a daily level — is difficult,” said Aadia Rana, MD, associate professor in the

UAB Center for AIDS Research and national co-chair of the LATITUDE study. “Determining whether monthly injectables can provide a level of convenience for Aadia Rana, MD patients will be key in potentially changing how HIV is treated in the future.” The study will enroll 350 at-risk participants at sites across the country, including UAB, where two experimental ART injections — rilpivirine and cabetegravir — will be given to different groups. The participants will begin a daily oral ART regimen supported with conditional economic incentives. Once they are virally suppressed at 24 weeks, patients will be randomized either to use the injectable for one year or to continue their existing ART. After the 52-week trial has concluded, findings will be measured to determine efficacy and next steps for ART. To learn more about the LATITUDE study or to enroll, please contact the Alabama-Clinical Trials Unit at the UAB Center for AIDS Research.

Using Bag-Mask Ventilation During Intubation Improves Outcomes New research published in the New

England Journal of Medicine shows that using bag-mask ventilation during intubation improves outcomes and could potentially change the standard of care. Intubation is a dangerous, but necessary procedure for many critically ill patients, and thousands of Americans die each year during the process. More than 1.5 million patients undergo tracheal intubation each year in the United States. Up to 40 percent of tracheal intubations in the intensive care unit are complicated by hypoxemia, which may cause damage to the brain and heart, and two percent of people suffer cardiac arrest, a sudden failure of heart function that is frequently fatal. Some doctors are hesitant to use bag-mask ventilation during tracheal intubation due to fears of causing aspiration, but co-author and UAB Division of Pulmonary, Allergy and Critical Care Medicine Assistant Professor Derek Russell, MD says that, through the Preventing Hypoxemia with Manual Ventilation During Endotracheal Intubation (PreVent) trial, he and his colleagues Derek Russell, MD found bag-mask ventilation was effective in preventing low oxygen levels without any evidence that it increases aspiration risk.

In this multicenter randomized controlled trial conducted in seven intensive care units in the United States, PreVent investigators randomly assigned adults undergoing tracheal intubation to receive either ventilation with a bag-mask device at the time of induction or no ventilation until oxygen levels fell. Among the 401 patients enrolled, 113 at UAB, the lowest median oxygen saturation was 96 percent in the bagmask ventilation group as compared to 93 percent in the no-ventilation group, which was statistically significant. A total of 21 patients in the bag-mask ventilation group had severely low oxygen levels, as compared with 45 patients in the no-ventilation group. “These findings will change the way we train people to perform this procedure given the solid evidence provided by this randomized clinical trial,” Russell said. Patients enrolled in the trial suffered from an array of critical illnesses, including sepsis, COPD and acute respiratory distress syndrome.

To us, every baby is a special delivery. A COMMUNITY BUILT ON WARMTH We never forget that there’s more to care than medicine. There’s compassion. Attentiveness. And a healthy dose of kindness. Which is why when it comes to your care, all of us are here to treat you well. Find a physician at BrookwoodBaptistHealth.com Brookwood Baptist Medical Center | Citizens Baptist Medical Center | Princeton Baptist Medical Center | Shelby Baptist Medical Center | Walker Baptist Medical Center

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JUNE 2019 • 19


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