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Steven Stokes, MD


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New Linear Accelerator Streamlines Radiation Treatment for Cancer By DAle short

UAB Special Care Unit Improves Outcomes for Ventilator Patients In October 2016, UAB Hospital established a new Special Care Unit (SCU) designed to improve care for patients on a ventilator with a goal of weaning them off the machine sooner ... 6

Today’s radiation therapy for the treatment of cancer was a high-tech advance when it was introduced decades ago. But now there’s a brand-new generation of the machines, the Halcyon Linear Accelerator, that its user, Urology Centers of Alabama (UCA), calls transformative. “This new linear accelerator delivers radiation treatment with an innovative design that has several advantages,” says radiation oncologist Brian Larson, MD of UCA. Their machine is the first in the Southeast and one of only 20 around the country. “The typical linear accelerator has a large head that moves around the patient,” Larson says. “But with this design, the moving parts are enclosed in a gantry so that it runs like a CT scan, allowing the gantry to move much quicker. It rotates around the patient four times as fast as the typical linear accelerator. The high dose rate delivers radiation faster and controls the shape of the radiation faster so the treatments take far less time. The beam time is two minutes, so the patient can be in and out of the treatment room in five minutes whereas it used to (CONTINUED ON PAGE 8)

Brian Larson, MD with the Halcyon Linear Accelerator


Finding Effective Staff Incentives U.S. businesses spent $90 billion on non-cash incentives for staff in 2015. Only 26 percent of businesses offered any non-cash options ... 9 FOLLOW US

The Art of Collecting Procedure Payments By JAne ehrhArDt

“People don’t think about their deductible and when the time comes, we have to educate them about their insurance,” says Lisa Warren, CEO at Andrews Sports Medicine. “They’re unpleasantly surprised when they find out they’re responsible for their surgery.” With higher deductibles and out-of-pocket maximums reaching $5,000 or more, physicians and hospitals now find collecting payment from patients for procedures an ongoing predicament. “Many policies are high deductible, including through an employer, so

Lisa Warren

their $5,000 deductible is their entire case in most of the physician components,” Warren says. “Basically, they’re paying for their entire surgery.” Patients with higher deductibles are twice as likely not to pay outstanding balances. According to an analysis of 400,000 claims by the healthcare research firm, The Advisory Board, more than two-thirds of patients with deductibles under $1,000 were likely to pay at least some portion of what they owe. Only 36 percent of those with deductibles over $5,000 made payments. Maddox Casey, a CPA with Warren Averett, says (CONTINUED ON PAGE 12)

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Everybody’s Got a Story By Lori Quiller Steven Stokes, MD grew up on a small farm in rural Alabama, which means he has lots of stories to tell about life in the country with cows, the 4-H Club and football, all woven together with a closely knit family that seemed to get the better of him whether he liked it or not. Stokes put pen to paper and wrote about his life on the farm, his time serving as a Marine in Vietnam, the misadventure of nearly missing his trip to the altar to wed his sweetheart, to the world’s worst medical school admission interview. His book, Everybody’s Got a Story, is available on Amazon, and all proceeds go to charity, which is something Stokes is also very serious about. “I don’t really remember how I got so involved with Love In Action,” Stokes said. “I’ve been doing this for about five years now, and I remember it started with a phone call asking for help. That’s all it took.” Although Love In Action Ministries is headquartered in Dothan, volunteers help residents in the Philippines, Myanmar, Haiti, and Pakistan. Stokes and three other physicians from the Houston County Medical Society signed on to help

render aid every Thursday evening during the medical clinic hours. “We’re all volunteers,” Stokes said. “I tell people that it’s a low return on investment. People get burned out when they volunteer. They want to change the world which, of course, won’t happen. But occasionally you have some people who will turn their lives around. So then, you’re changing the world for those that you can help. You have to start somewhere.” The largest population Love In Ac-

tion aims to help are the homeless individuals that tend to get lost in the shuffle. “The people we help are the homeless people who live under a bridge that barely have clothing and don’t have access to the health care,” Stokes said. “We have a lot of migratory people here who will come through this area going south in the fall because winter is coming, and in the spring they head back north. This is a high-transit area, so we do what we can at Love In Action.”. One saving grace for the charity has been the giving spirit of area nursing homes and physician practices and their willingness to donate supplies to further Love In Action’s mission, which extends beyond medical care. Area churches contribute to the charity for nondenominational services on the weekends and during the week the doors open for an opportunity to shower, change clothes and get a hot meal. Stokes knows the community rather well. But it was his interest in solving the community’s problems that called him to serve on the city commission for two terms and one term as chair of the school board. “You never know what the longterm change is going to be,” Stokes said. “Change takes a while. I like solving prob-

lems, and that’s how I got involved with government. Keeping our constituents happy wasn’t as easy. I’m glad doctors are serving more in their communities because they need to be involved in what happens around them.” Gov. Kay Ivey recently reappointed Dr. Stokes to the Board of Trustees at the University of South Alabama College of Medicine, his alma mater, but he insists this will be his last term after serving for 24 years. Stokes wrote in his book that “Many people pass through life and leave no tracks – nothing to bear witness to their passing. At best, they have a stone marker on their graves, or maybe a few kids who remember their names for one or two generations before oblivion.” Stokes continues to make his mark on plenty of lives through his work with Love In Action in Dothan. If you would like to make a donation or to learn more, go to and click on “Dothan” in the top navigation menu.His book has a five-star rating on Amazon. Visit Amazon and type in “Everybody’s Got a Story: Short Stories from South Alabama.”

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Cullman Regional Medical Center Focuses on Patients’ Total Health By Ann B. DeBellis

Cullman Regional is differentiating itself from the current trend facing many community hospitals that are closing or being sold to larger healthcare systems. With teamwork and the leadership of Chief Executive Officer James Clements and the board of directors, Cullman Regional has reversed a $13 million deficit into a 23 percent increase in volume along with new projects for hospital expansion and upgraded facilities. Clements says smaller hospitals often face a complex management environment and a level of unpredictability that generally doesn’t affect other businesses. “We all are experiencing an increase in uninsured patients probably caused by a reaction to the Affordable Care Act, cost or factors such as unemployment. We have unpredictable payment streams from payors such as Medicare and Medicaid,” he says. “In addition, larger urban hospitals are marketing aggressively in our areas to pull patients into their profitable service lines.” When Clements joined Cullman Regional in 2014, he was determined to challenge those issues and find ways to increase the hospital’s patient services and profitability. The first, and maybe the biggest, change was a shift from a political culture

Cullman Regional CEO James Clements, right, confers with Chief Medical Officer William Smith, MD

to one of accountability. “We ask our team to focus on quality and efficiency when they make changes, and we want them to be adaptable,” Clements says. “Change management is hard, particularly in a small or medium-sized hospital that is not accus-


tomed to a rapidly changing environment, so we hired new team members who are experienced in health care accountability. Finally, we have an engaged and informed board of directors. That is critical to our success.”

Next, Clements and the board built a leadership team with two goals: to put patients’ needs first and to grow volume so they can devote resources to the best quality care. “We educated our doctors and nurses about what ‘patient first’ means,” Clements says. “It means that we don’t put the doctor, nurse or hospital first in the equation. We expect that of every person in the organization. Because we have to rely on 1,100 people to make these decisions in a tense environment, we had to give them a framework to do so. We tell them that we will support every employee who has to make an independent decision as long as the patient comes first.” Clements is pleased with the progress of Cullman Regional’s patient services and its current financial health. “We are definitely improving,” he says. “We are in the top five percent in Alabama on all financial metrics. In the last three years, there has been a 15 percent increase of Cullman County residents selecting Cullman Regional as their provider, a 22 percent increase in patient volume, and a five percent increase in outpatient volume.” A self-funded expansion at the hospital and urgent care center will help with current volume issues. The primary purpose of the urgent care center expansion is to assist (CONTINUED ON PAGE 8)


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Birmingham Medical News

MARCH 2018 • 5

UAB Special Care Unit Improves Outcomes for Ventilator Patients By Ann B. DeBellis

In October 2016, UAB Hospital established a new Special Care Unit (SCU) designed to improve care for patients on a ventilator with a goal of weaning them off the machine sooner. In the first 12 months, ventilator wean rates exceeded the national average and hospital readmissions, along with ventilator length of stay, have dropped significantly with these types of patients. The UAB Hospital SCU is the first unit of its kind to open in Alabama. Since opening, more than ALS patient returns to SCU for visit after being home for four months 125 patients have been transferred to the unit. says Phillip Morris, RN BSN, Chief CliniThe hospital partnered with Special cal Officer for Special Care Providers of Care Providers of America which has America and a UAB alumnus. “We partbeen operating these care units for 27 ner with acute care hospitals and operate years. “Unlike Long Term Acute Care these specialized units within the host hosHospitals (LTACHs), our company does pital. That allows the hospital to maintain not build hospitals, nor do we rent beds control over quality and outcomes.” and renovate wings in existing facilities,”

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For acute care hospitals, management of these critically ill patients can pose challenges in the areas of throughput, increased length of stay, and readmissions. Their multiple co-morbidities can make these patients prone to hospital-acquired conditions. With the growing importance

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DOJ Formalizes New Approach to Frivolous Qui Tam Actions By J. Matthew Kroplin and Adam W. Overstreet

We recently reported that Michael Granston, Director of the Civil Fraud Section of the Department of Justice (DOJ), made comments during a November 2017 healthcare compliance conference suggesting that in cases where the DOJ has determined allegations in a qui tam (or “whistleblower”) lawsuit lack merit, the government may more aggressively exercise its statutory authority – rarely used in the past – to dismiss such cases. In a formal memorandum released on January 10, 2018, Director Granston put those words to action. In his memo, Director Granston acknowledges that although the DOJ has seen “record increases” over the last few years in qui tam actions filed under the False Claims Act, it has “sparingly” utilized its authority to dismiss those lawsuits following its decision not to intervene. As a result, the government has “expend[ed] significant resources” in continuing to monitor these cases. In light of that,

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the memo encourages prosecutors to more carefully consider the prospect of dismissing qui tam lawsuits in which the government opts not to intervene (which occurs in approximately 75 percent of these cases). The memo then identifies seven factors that prosecutors should consider when evaluating whether to seek dismissal: • Curbing meritless qui tam lawsuits – where the complaint is “facially lacking in merit” because of a defective legal theory or frivolous factual allegations; • Preventing parasitic or opportunistic qui tam lawsuits – where the lawsuit duplicates a pre-existing investigation and adds no useful information to the investigation; • Preventing interference with agency policies and programs – where an agency has determined that a qui tam lawsuit threatens to interfere with the agency’s policies or the administration of its program and has recommended dismissal to avoid these effects; • Controlling litigation brought on behalf of the government – when necessary to protect the DOJ’s litigation prerogatives;

• Safeguarding classified information and national security interests – particularly in cases involving intelligence agencies or military procurement contracts; • Preserving government resources – when the government’s costs are likely to exceed any expected gain, such as when the estimated government losses are less than the anticipated burden imposed on taxpayers by continued governmental participation even when the relator advances the litigation; and • Addressing egregious procedural errors – where there are problems with the relator’s lawsuit that frustrate the government’s efforts to conduct a proper investigation, such as when the relator fails to serve the qui tam complaint or disclose material facts to the government. The memo goes on to provide other practical guidance to prosecutors and, among other things, advises that the seven factors are not exhaustive, and there may be other factors that can be considered in determining whether to dismiss a case. The memo reminds prosecutors that they can seek partial – as opposed to wholesale – dismissal of qui tam complaints and also instructs prosecutors to “consider advising relators of perceived deficiencies in their cases as well as the prospect of dismissal” so that relators can consider dismissing the lawsuit on their own. According to the memo, since January 2012, relators have dismissed over 700 qui tam lawsuits voluntarily after learning that the DOJ was de-

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clining to intervene. The Granston memo is significant because it marks the first time in the DOJ’s history that it has issued written guidance on this matter. As a result, healthcare providers who find themselves defending a meritless qui tam action now have a blueprint – through the DOJ’s seven guideposts – in arguing for its dismissal. Although the practical impact of the memo remains to be seen, at the very least it reflects the DOJ’s willingness to dismiss burdensome and frivolous whistleblower lawsuits. In the end, it may turn out that the memo will not result in many more dismissals by the DOJ itself, but rather in more voluntary dismissals by relators who learn of the “perceived deficiencies in their cases” and the “prospect of dismissal.” Either scenario would be welcome news to health care companies that spend millions of dollars every year defending meritless whistleblower lawsuits.

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be 15. It’s easier for the patients because they don’t have to lie there as long, and it gives the therapist more treatment options to schedule appointments when it’s convenient for patients.” Other patient enhancements include a lower couch for easier access when entering the machine and soft ambient light inside the enclosure. The machine is more than twice as quiet as other systems, and includes a couch-mounted camera so the physician can watch over the patient, and a sound system making it easier for the patient to communicate with the therapist. Besides the improved speed and comfort for patients, the machine offers many improvements for the physician. “It’s a more precise treatment that delivers radiation much more accurately and the results have been even better than I expected,” Larson says. One advancement is a greater streamlining of preparation time. Lason says: “The handling of the radiation beam data is a very complicated process, because you have to know how much radiation the beam puts out at every single treatment field so the computer can calculate an exact dose. “Traditionally that’s a long, tedious process that involves a physicist going in and measuring every one of these. It can take weeks to prepare to calculate the radiation dose. The designers of this machine have figured out a way for all of this to come pre-packaged. And because it’s able to give the radiation in a different way, the dosimetrist can really innovate with the planning.

Cullman Regional, continued from page 4 with emergency room overcrowding. “We are treating approximately 50,000 people a year in our existing ER. About 20 percent of those people could be treated more efficiently in an urgent care environment,” Clements says. A 30 bed expansion, set to open this fall, will be a surgery floor designed to improve quality of care along with features specific to family members. The nursing station will be moved to the middle of the unit to allow nurses quicker access to patients. “Amenities are being upgraded in each patient room to provide better access for family members,” Clements says. CRMC recently added tele-neurology coverage in the area and has purchased a controlling interest in a local surgery cen-

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“Just looking at the plans and seeing the therapist interact with the machine, the ease of use and simplicity make it very ergonometric, both for the therapist doing the treatment and for the patient.” Health experts say this technology is the new standard for linear accelerators of the future because its features help simplify the increasing need for cancer treatments worldwide. In the U.S. alone, cancer diagnoses for 2017 numbered more than 1.7 million. Still, says UCA president Taylor Bragg, MD: “Every day we seem to be gaining ground in the fight against cancer. The Halcyon system presents our team with the ideal platform to treat patients using best practice delivery of radiation oncology. This allows increased efficiency while delivering high-quality treatments. “It’s an amazing piece of equipment, and we’re excited for Dr. Larson and his team because they’ve done a great job for so long, but now have the newest equipment that allows for even better quality, safety, and accuracy. We’re in a unique situation now, where we can offer our patients with prostate cancer the robotic surgery, the highest quality radiation, and chemotherapy without them ever having to leave our office. “We hear a lot about patient-centered care, which is so important with patients living longer and having multiple different medical issues. We’re able to individualize that treatment. They can come to one location and know they’re going to be treated professionally and that’s exciting to us.”

Fifth-floor expansion close to completion

ter. “This will be important going forward as we want to add more high-quality, lowcost options for our patients. Anything that increases quality and efficiency is a top priority for us,” Clements says. Having numerous projects in the works does not stop Clements from looking several years into the future of CRMC. “The biggest change I see in the next few years is a move from being an inpatient hospital to being a health system. We will have continuum of care that will include an inpatient hospital, outpatient urgent care center, emergency room, ambulatory surgery center, home health, and hospice,” he says. “It is about the total health of the consumer, not just one point in their lives.”


Finding Effective Staff Incentives By Jane Ehrhardt

U.S. businesses spent $90 billion on non-cash incentives for staff in 2015. Only 26 percent of businesses offered any non-cash options. “The biggest obstacle to finding incentives is just that everyone’s motivator is different. Some people are more motivated by money, others by praise, others by time off,” says Jennifer Perry, chief administrative officer at Norwood Clinic. “Trying to make it an incentive everyone wants is difficult.”

Jennifer Perry

For their 90th anniversary, Norwood Clinic gave employees t-shirts and bags and took them and their families to a Barons baseball game. “Some people were stoked to bring their family, and it was a great motivator,” Perry says. “Others didn’t want to participate. They thought of it as just one more work thing to do.” Even incentives that work on the majority of employees seem to lose their impact over time. “Typically every year we do Christmas bonuses. Unfortunately they’re no longer a surprise, so they don’t feel like a bonus,” Perry says. Perry found the same problem with goal-based bonuses for higher level employees. “The problem with those type of bonuses is they did these three things to achieve the bonus, but these other ten things that they’ve always done well are now suffering,” she says. If the bonus is quarterly, the employee may have gone a couple of quarters meeting those criteria before they start showing the lag. “Now that person has started thinking of them not as bonuses, but as part of their pay,” she says. It loses

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its drive factor and can cause more problems than it solves. “Some people do really well in that system, but it’s not for all employees.” Robby Carruba, administrative director at Neurosurgical Robby Carruba Associates, says the ceaseless changes in initiatives from programs like Meaningful Use have drained staff tremendously. But it formed an opportunity for incentives. “If we met certain goals that resulted in increased revenue, we committed to sharing a piece of the pie with staff,” he says. “I don’t think you can teach motivation,” Carruba says. “You can create it if you need to, but it’s only temporary. Motivation comes from within. But loyalty can feed motivation. And the way you keep an employee loyal is to be appreciative and include them in the decision-making processes.” For Carruba and his coordinators of the 17 employees at the practice, one form of appreciation takes the form of openly complimenting individuals. “Verbal commendation goes a long way, especially in front of their peers,” he says. Joseph Bolen IV, chief operating officer at the fertility clinic AIRM– Alabama, prefers handwritten thank-you notes sent to the employee’s home. “It seems personal, thought-out, and they’re surprised,” he says. Plus opening the note among their family that night feels more like a special commendation. Perry sees another advantage to send-

ing incentives to the home. “If an employee is disgruntled, they take that home with them, and their family can make it better or worse depending on how they react to those comments,” she says. So on each staffer’s birthday, the clinic sends a tin of homemade cookies to their home. “They’re customized with ‘Norwood Clinic,’ and cost around $25,” she says. “This way, the family gets to participate in the treat.” When the next bad day rolls around, the goodwill generated with the family may temper their reaction and lessen the employee’s bad feelings. Bolen agrees that the participation of family and friends can boost the impact of an incentive. When he worked at a large hospital, ten employees would be chosen each month to be honored at a special 30-minute Joseph Bolen IV presentation. “The CEO would talk about these people and

provide examples throughout the month of why they won,” Bolen says. The family and friends of each award winner would also attend the ceremony. “That inclusion of family can make a difference. And seeing your peers getting such attention motivates coworkers to want to win.” Time-off can also be a powerful motivator, says Perry. To spur the front desk to be more vigorous about collections, Perry offered the department four hours off with pay if they met a certain goal. “We’ve seen behavior changes in people from that,” she says. “It’s hard to say I need this additional $35 from your last visit. But now they’re more forceful when someone says they can’t pay.” The perfect incentive for an entire staff remains elusive. “You put time into an event and want everyone to enjoy it and, for a majority, they do. But there are some people that are just not going to be happy with whatever you give them,” Perry says. “And you have to look past that and take pride in the ones that did appreciate it.”


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Password Protected Simple Steps to Enhance Cybersecurity By CINDY SANDERS

From U.S. elections to national healthcare providers and payers, the news is filled with examples of massive organizations with massive IT departments that still got hacked. So how do much smaller healthcare companies and medical practices avoid the same fate? Scott Augenbaum, who recently retired after 29 years with the Federal Bureau of Investigation, said there is any number of best practices … most of which cost little or nothing … that healthcare practices should put in place to maximize protection. “I’ve dealt with thousands of cybercrimes in my career,” noted Augenbaum, who spent the last 14 years working exclusively in this arena. “When a large healthcare organization has an issue, they are able to throw a lot of money at the problem … but not the smaller companies, and when the smaller companies have a breach, it can be devastating.”

First, the Bad News He added most healthcare practices that are victims of cybercrime have five points in common: They believe they are too small to

attract the attention of cyberthieves. Augenbaum noted, “Nobody ever expects to be a victim.” He added that many healthcare providers believe larger health systems or insurers are at greater risk than a small practice or payer … but security is often easier to breach at smaller organizations. They don’t think they have anything of value to hackers. “I don’t hear this as much in the practices but do from insurers and consultants. Even without patient records, they have financial records and emails,” he noted. A mistaken belief that law enforcement can fix it. “When the bad guys steal your stuff and you call law enforcement, law enforcement doesn’t get your stuff back,” he said of the impossibility of recovering data after it’s gone. “The chances of us putting the bad guys in jail are tougher than getting your stuff back,” he said, adding that most bad actors are overseas.

While points one through four are depressing, Augenbaum said the last common trait is the hardest for him. “Why does it make me depressed? Because 90-95 percent of what I have dealt with could have been prevented without spending money on technical solutions.”

Some (Slightly) Better News While companies buy a lot of tech products that are supposed to keep them safe, there is no real silver bullet, cautioned Augenbaum. “People are now HIPAA compliant, HITRUST compliant, PCI compliant … but being compliant is completely different than being secure.” He continued, “Most organizations are not doing the basic things … they’re not doing the fundamentals. All the bad guys need to do today is steal your password – that’s it. It really comes down to securing that password.” The ways to steal passwords vary and are becoming more sophisticated. A prac-

tice administrator might receive an email that appears to be from someone they know and trust that has a document, usually in a PDF format, to be accessed. To look at it, the person must log in with their Microsoft 365 credential. “They enter it and nothing happens,” said Augenbaum. Instead, a popup appears saying that didn’t work so please enter Gmail credentials to access. “Now a bad guy sitting in Africa has both your Microsoft 365 and your Gmail credentials.” Since most people use the same password or slight variation of a password for everything, having that information realistically opens the entire organization to the hackers. But … here’s the good news … it’s relatively easy to avoid catastrophe. First, said Augenbaum, “You need to be your own human firewall. Think before you click.” Second, he continued, “Have separate passwords for mission critical platforms – anything bad guys can use to weaponize against you.” Create a strong password (see below), use two-factor authentication, and back up the most important information you have so that if ransomware is deployed, you have a copy of your critical information. Those five steps, he continued, cost almost nothing but go a (CONTINUED ON PAGE 12)

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The Art of Collecting Procedure Payments, continued from page 1 the motto for getting paid for procedures is ask early and ask often. “The process starts at pre-visits when talking to the patient to schedule the appointment. Get the patient ready to pay in full before the procedure is done,” he says. Hospitals and practices must tell the patient they will not book the room, the time, or the staff for the Maddox Casey procedure until they have paid 100 percent. “Now you’ve got to collect it,” Casey says. Before the patient shows up, get half of what is owed. Collect the remainder the day before or day of the procedure. “If they don’t have it, know whether you have the flexibility to reschedule.” Some procedures, like emergencies or cancer treatments, may need to proceed. In other situations, collecting at least some monies on the day may make it worth proceeding. “A patient is rarely going to pay the first time you ask,” says Jim Stroud, a CPA also with Warren Averett, adding there is an art of knowing how to collect, such as word choices. “It’s not will you pay today, but how will you pay.” Train staff to ask a second time. “And be sure to smile while saying you understand but you must collect something today,” Stroud says. “If the patient again says they cannot pay, compliment their new phone or manicure or coat, saying you hope you can get a phone like that someday, but you must collect something. Never break eye contact.” Anything going home with the patient, like samples or paperwork, should be handed out by the check-out person who needs to start off by asking for payment. “The implication is that I will give you everything you need when I get payment,” Stroud says. “Otherwise, if you give them everything in the exam room, their next goal is the exit door.” Doctors also need to be coached to

stay out of the payment conversation. If the patient begins talking about payments, physicians should state they do not deal with handling payments and to talk with whoever is designated on staff for handling payment plans. “When doctors make exceptions for friends, it’s discouraging to the staff,” Stroud says. One of Warren Averett’s physician clients found success with a full-payment deadline set a month in advance of the procedure. “Then he moved it to 45 days before, and that extra 15 days helped to postpone fewer procedures,” Stroud says. Warren says the majority of their orthopedic patients will reschedule until they can pay. Their practice of 19 physicians and surgeons also employs a dedicated financial counselor who calls patients in ad-

vance to talk payments. For greater security, holding a patient’s credit card on file for the procedure balance offers a back-up for payment. “Then it shifts from you being the bank to the credit card company being the bank,” Casey says, warning to store the card number using a third-party encrypted software. With the card on file, any balance due on the day of the procedure is charged to that account or according to a pre-set payment plan. “They sign a credit-on-file agreement, same as in a hotel,” Casey says. “The agreement stipulates the payment plan and the maximum to be charged. A credit card-on-file system does increase your collection percentage. It’s impossible not to.” CareCredit offers another option for

Password Protected, continued from page 10

long way in protecting a medical practice or healthcare company.

Password Protected So what does a strong password look like? Augenbaum said, for starters, it isn’t a common word. “A good password is 12 characters, upper/lowercase, has a special symbol and number with no dictionary words,” he explained. To come up with a great, seemingly random password, think in terms of ‘pass phrases’ with a hint that can be written down without tipping off the password to a random viewer. For example, your hint might be ‘my child’s latest accolade.’ The actual phrase from which the password is derived is: ‘Tommy came in first at the state swim meet in backstroke.’ And, the actual password is: Tci1@Tssmib! Another option is to pick a special number and character that you use at the beginning and end of most passwords and just change the center part. Perhaps you always use the number four and the # sym-

bol. Your hint is how you feel about your patients. Your actual pass phrase is ‘We love helping our patients feel great,’ and your password is #4wLhopfG4#. The idea, he continued, is to create hints and phrases that mean something to you but would be difficult for anyone else to decipher. Taking a few simple, inexpensive steps, Augenbaum concluded, can certainly avoid a lot of time, effort, heartache and money by making it much harder for cyberthieves.

More Simple Steps to Improve Security With March Madness in the air, retired FBI agent Scott Augenbaum shared his own ‘Sweet 16’ when it comes to a winning cybersecurity strategy. • Think before you click on a link or open an attachment, become a human firewall and question every email. • Intrusion Detection Systems are a must but they will not stop everything as virus writers write in excess of 50,000 new

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patients. A credit card only for medical expenses, it offers a set line of credit interestfree for the first six months. “Some patients are already set up with CareCredit, but it can be hard to qualify for,” Warren says. Other medical credit lines exist with easier qualifications, but without the interest-free period. “The farther into the collection process you go, the less likely you are in collecting it all. Like paying for a meal billed 15 days later, you’ve forgotten it by then,” Casey says. “The good news is it gets easier every time,” Stroud says. “The process takes over and the money comes in. The other side of that is you have to be respectful of patients in return—don’t make them wait an hour, and don’t cancel.”

viruses a day. • Separate passwords for mission critical accounts. • Strong passwords need to be longer than twelve characters in length with capital and lower case letters, numbers and a special symbol and NO dictionary words. Think passphrase instead of password.  • Updated operating systems are a must, as Microsoft doesn’t support XP anymore. • Patch your system, Microsoft updates, java and adobe. • Multifactor authentication is a must on Facebook, LinkedIn, Outlook 365, Gmail, LogMeIn, VPNs and financial accounts when offered. • Consider a separate computer for critical business functions. If you can access your client records on a computer that is used for Facebook and personal web surfing you are putting yourself at risk. If you are gaining remote access to your company and you are using a home computer that you share with your kids, you are putting your organization at great risk. • Do not surf the Internet as the Administrator on a computer. If you purchase a computer and you are the only user, chances are you are the administrator. Go to the control panel and create a new profile and give it administrator access and change your profile to regular user. • Back up your mission critical files on a daily basis. There have been numerous cases of ransomware that turns a company’s critical data into useless information unless you send $500 in bitcoin to a bad guy in Eastern Europe. • Have a plan for your organization, • Practice smart online banking http:// • Don’t store your password in the browser; it’s the same as leaving your keys in the car for ease and convenience.   • If you can access your information in the cloud and all you have is a password, be prepared for the info to be stolen. Use multifactor. • Once the bad guys get your stuff … it’s usually too late. • You need to have a strong password for your smart phone and if you are using an Android, consider an intrusion security suite.

Personalized, Less-Invasive Repair for Thoracoabdominal Aneurysm By Marti Webb Slay

Traditional treatment for thoracoabdominal aneurysm requires a large incision and clamping of the aorta, which can lead to significant complications and often eliminates surgical repair options for patients due to their age or overall health. But Adam Beck, MD, director of the Division of Vascular Surgery and Endovascular Therapy at UAB, is conducting a study of devices customized to individual patient anatomy and inserted in a less invasive procedure. “The traditional open surgery is a huge operation with high morbidity, and depending on the extent of it and the health of the patient, the mortality can be high too,” Beck said. “With this device, we can do repair through incisions that are about one centimeter in each groin. Sometimes we have to put a little incision in the arm too. It’s a big operation through small incisions. We are working through the inside of the blood vessel over wires on x-ray, and we never stop blood flow around and through the graft, which decreases risks.” Beck holds a physican-sponsored investigational device exemption (IDE) from the FDA for this clinical trial. “It allows me to design custom devices created to match a patient’s anatomy to fix an aortic aneurysm that involves the portion of the aorta that has branches to the intestines and kidneys,” he said. Beck uses 3-D imaging to construct the customized grafts. In cases where the surgery is elective, Beck constructs a three dimensional model of the aorta and uses it to determine if the anatomy meets the criteria for this procedure. If the patient chooses to enroll in the trial, Beck designs the device and sends the plans to Cook Medical in Australia, where the device is manufactured by hand. Patients who are symptomatic and don’t have two months to wait on a device to be manufactured are often still eligible for the procedure, but Beck will develop the device himself. “I can take a device meant for a simpler repair, a straight tube, and take the device out of its packaging, modify it, and essentially create the same thing they


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Adam Beck, MD confers with a patient.

would in Australia. This is done at the time of surgery while the patient is being put to sleep under anesthesia,” he said. Beck completed a mini-fellowship on this procedure in Holland while in training at Dartmouth 10 years ago. His current study has been ongoing for over three years, and he has completed 100 surgeries so far. He recently received approval from the FDA to implant another 100 devices. “You are supposed to monitor for five years after you implant the devices, but

clinically we follow these patients for the rest of their lives, which we hope is longer than five years,” Beck said. Beck explained that the FDA will not approve customized devices that aren’t intended to be brought to market, but the surgeons who are performing this procedure are collaborating and sharing data, and there are now companies working to develop similar standard devices for more widespread use. “They try to make a couple of con-

figurations that will fit most patients’ anatomy. Those are probably five years off,” he said. “It would be ideal to have devices on the shelf, and you just pick the one that fits your patient and put it in. But there will probably always be a role for custom devices.” Although Beck has performed 100 of these surgeries under the current study, he has, over his career, performed nearly 450, and in over 300 cases he has created the device himself. “It takes a tremendous amount of experience and skills to do this,” Beck said. “And you have to have specialized imaging in the operating room. We use interoperative three-dimensional overlay imaging. In the operating room we take the same CT scan we designed the device off of, and we fuse it with their bony landmarks. It’s almost like you are looking inside the patient’s body and seeing the aneurysm itself on the screen. When you deliver the device, you know where the branches are, but you have to know how to use the 3-D overlay. It’s complicated.” Because of the complication, there are few facilities in the U.S. performing this procedure. UAB is the only hospital in Alabama that offers this customized option. Patients in the Southeast would otherwise be referred to Florida, Texas, or North Carolina. For physicians interested in the surgery, Beck has a 13-minute video describing the procedure at https://www.

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The Practical Potential for Low Cost Genetic Testing By Laura Freeman

In narrowing a difficult diagnosis while choosing medications and advising the patient, an accurate family history can offer valuable insights. However, getting one isn’t always simple. At a time when contact with one parent or extended family may be limited, and adoptions and fading memories make reliable information scarce, putting together an accurate family history from patient interviews can be difficult. Fortunately, as genomic medicine becomes integrated into medical practice, physicians will have evidence-based data to evaluate genetic predispositions. The sticking point is that although the cost of genomic sequencing has come down, insurance often doesn’t cover its use for preventive medicine. For many patients, the out-of-pocket cost for medical genomic testing can still be a bit steep for routine use. Enter FDA approval for direct to consumer genetic health reports provided by services like 23AndMe. People can upgrade their $99 ancestry reports to include a wide range of genetic health information for $199. For $10 more, they can upload that data to Promethease for a more detailed report comparing their data to a large SNP database. Physicians will likely soon will be seeing more printouts from direct to con-

Bruce Korf, MD, PhD

sumer genetic testing. Well managed, they can be a helpful resource. Poorly managed, the volume of information can be overwhelming. On the plus side, low cost direct to consumer health reports can alert patients and their physicians to higher risks for gastric complications from NSAIDs; myopathy associated with statins; poor response to warfarin; lactose intolerance; celiac

disease; macular degeneration and a long list of other markers including the APOE4 variant linked to late onset Alzheimer’s and coronary artery disease, and variants in LRRK2 and GBA linked to Parkinson’s Disease. Reports also include carrier status for a range of inheritable diseases to help couples planning to have children who have concerns about conditions that run in their families. The reports include carrier status for Cystic Fibrosis, Sickle Cell, Tay Sachs, Sjogren’s syndrome and a number of other disorders. Other reports physicians might find helpful include predispositions to more subtle health factors patients might not be inclined to self report, including an inclination to sleep disturbances. When combined with a Promethease upload, the patient’s individual data can be compared to a large SNP database for correlations to several types of cancer, heart disease and a wide range of other disorders. The challenge lies in making sense of all this information and helping patients understand what to do with it. “First, it’s important to verify the reliability of the data and the source. We may also need to protect patients from opportunists who try to sell them supplements and remedies that haven’t been proven effective,” UAB Chief Genomics Officer Bruce Korf, MD, PhD, said.


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The physician’s role in managing the big picture of the patient’s health and genetic risk is vital. There are so many different genes that what might help reduce risks for one variant could be exactly the wrong thing for another. “The integration of genomics and medical practice offers a tremendous potential for improving outcomes with more precise, personalized treatment. It’s a rapidly emerging field, and those of us in genomics are working with physicians to help them make effective use of this new information,” Korf said. Even better than low cost testing, Alabama residents can get free testing through the Alabama Genomic Health Initiative. “UAB and HudsonAlpha Institute for Biotechnology are gathering a genomic database of 1,000 volunteers from all 67 counties in Alabama,” Korf said. “Though their physicians, those who participate will receive reports on 59 genetic markers for diseases with actionable treatment options. If a patient is positive for one of these markers, our genomics specialists and genetic counselors are available to assist physicians and patients in making the most effective use of this information.” For details about the initiative and how to participate, go to UABMedicine. org/AGHI. Both 23AndMe and Promethease have extensive cautions about interpreting data and accessing genetic counseling when needed. Those who order the tests can choose whether or not they want to know about their status for APOE4 and Parkinson’s Disease markers. So what does a patient and physician do when they receive a report showing APOE 4/4 alleles? There are treatments to reduce the risk of coronary artery disease, but treatments to address the high risk of late onset Alzheimer’s are still elusive. Hopefully soon, new treatments will be on their way. The Titanic could have missed the iceberg if they had changed course in time. Knowing the iceberg is there can help patients begin to make small changes early to reduce risks. An active area of research is studying how carbohydrates and different types of fats are handled differently in the brain depending on which alleles are in the patient’s genome. Antioxidants and omega 3s seem to show benefits in some studies, and there are reports that some types of exercise influence epigenetic changes that can modify risks. Studies of brain trauma and neurodegenerative disorders also suggest that reducing the risk of concussions and other brain injuries could be particularly important. The more we know about the genes that spell out human life, the more we learn about how to correct misspellings and the best individual treatments for the most effective outcomes.


Building Better Vaccines By Laura Freeman

A hundred years ago, the influenza pandemic of 1918 swept the globe, killing between fifty and a hundred million people--between three and five percent of the world’s population. Although this year’s difficult flu season was only a pale echo of that epidemic, it was deadly enough to remind us what could happen if a strain as lethal as 1918 emerges again in today’s global travel environment, especially if the effectiveness of flu vaccines are as disappointing as we have seen this season. The need to find more effective ways to protect our population from flu and other infectious diseases is obvious. The clock is ticking, and researchers around the world and here in Birmingham are working to develop new and better vaccines. “Based on the available evidence, a mutation occurred this season when the vaccine was developing in eggs,” Landon Westfall, PhD, of Southern Research Institute, said. “In the past, eggs Landon Westfall, PhD worked fine for many

types of vaccines. However, strains like the H3N2 we saw this year are very adaptive and tend to mutate. The mutation that occurred in eggs created a different antigen, which produced an antibody that had a difficult time recognizing the pathogen. The circulating strain and the mutated strain in the vaccine were different. That is one reason there has been so much interest in developing different platforms for producing vaccines. “New platforms are moving toward cell based Paul Goepfert, MD, director of UAB's Alabama Vaccine Research Clinic vaccines since the flu virus have been very positive. doesn’t seem to change as much in these “The cell platforms generate recomsystems. Our Southern Research Institute binant vaccines targeting proteins rather teams are providing preclinical testing than the virus,” he said. “They offer a very support for several new vaccine initiatives clean background without other compousing mammalian and plant cells, and for nents from fractionation that can create those that prove promising we will also debris that might cause problems. offer safety testing and support to help “Some of the plant platforms could move them toward clinical testing for FDA also be multipurpose. In theory they could approval.” almost be plug and play to develop vacGrowing flu vaccines in plant cells cines targeting other diseases. may seem unusual, but Westfall says the “We are also working with platresults he is seeing in a plant cell platform


An Ounce of Prevention forms using recombinant mRNA. These are still in the earlier stages with more layers of work to be done, but this approach has a great deal of potential.” Another area of flu vaccine research that Westfall finds exciting is the idea of a universal flu vaccine. “Most vaccines are aimed at a very specific strain of pathogen,” he said. “A universal vaccine would target proteins common to several strains at a more basic level. The vaccines might be given like a tetanus shot that creates immunity for several years. If you have built an immunity to one strain, you would also be likely to be immune to a similar strain that might develop. There are several types of flu viruses, so you would likely need a set of vaccines rather than one, but wouldn’t need a vaccination every year to get broad protection.” The movement toward more effec(CONTINUED ON PAGE 16)

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UAB Special Care Unit Improves Outcomes, continued from page 6 stead of treating them in various units,” Morris says. “Our SCU patients come from the trauma and burn unit, medical intensive care, neuro intensive care, and surgical intensive care. Prior to opening the SCU, each unit would be responsible for weaning their own patients.” Special Care Providers manages these units with a multidisciplinary approach. “Once embedded in a partner hospital, each of these patients is transferred from a unit within the hospital to the SCU allowing all consulting physicians to follow their care,” Morris says. “We provide the nec-

essary staff – acute care nursing personnel, respiratory therapists, physical therapists, speech therapists and occupational therapists – with low patient-to-clinician ratios that are not common to LTACHs. This concentrated multidisciplinary unit enables us to deliver better outcomes for the hospital.” “With UAB, we have been able to wean 81 percent of the very complex patients, which is phenomenal based on the national average of around 60 percent. We are decannulating – removing the tracheostomy completely – in about 64

percent of patients. That means we are decannulating a higher percent than the national average is for weaning them. We are keeping hospital-acquired infections to a minimum and are reducing readmissions to less than six percent. A lot of hospitals are looking at 30 to 60 percent.” In another effort to maximize patient care, Special Care Providers has employed Bluetooth technology to track dwell time with the patient, by discipline. “Each patient bed has a Bluetooth beacon that interfaces with each caregiver’s special badge to record how many sec-

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onds a healthcare professional was with a patient,” Morris says. “There is an interactive dashboard that illustrates how recently a patient has been seen. The next step in this research is measuring the impact of dwell time by discipline on patient outcomes. We have seen research on patient outcomes related to nurse shift times, ratios and nursing education, but we haven’t found any research related to the amount of patient care by discipline and how that affects outcomes. We are working with UAB on this effort and look forward to presenting our findings.” According to Special Care Providers, this complex patient population is growing in the Medicare and commercial insurance markets,  due to the  aging U.S. population, an increasing prevalence of chronic illnesses, and advances in critical care medicine. “While we are ecstatic about the results we see at UAB Hospital, we also recognize the growing need throughout our country,” Morris says. “We are prepared to support our acute hospitals in improving outcomes for this patient population.”

An Ounce, continued from page 15

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tive vaccines against a broader range of illnesses is picking up speed. A vaccine for malaria has been launched in east Africa, a vaccine against Ebola was developed after the most recent outbreak, and results from an HIV vaccine have been encouraging. The search for a more effective tuberculosis vaccine to counter resistant strains is ongoing, a herpes vaccine is making progress, and clinical trials using an old tuberculosis vaccines in type one diabetics to slow progression and in some cases reverse damage is showing exciting results. A clinical trial of a vaccine against solid tumors in humans has just been launched at Stanford, and a new, more effective vaccine against shingles just came on the market this year. Paul Goepfert, MD, director of the Alabama Vaccine Research Clinic at UAB, said, “Shingrix is a remarkable achievement and improvement from the older shingles vaccine (Zostavax). Not only is it safe to give to immunocompromised individuals, it also has higher rates of efficacy. The main weakness compared to the old vaccine is that it must be given twice.” The second dose of the new vaccine must be given between two and six months after the first. The new vaccine tends to be more reactive, with possible soreness, fever and other symptoms in some people for up to three days. However, it is showing much higher rates of effectiveness especially in older individuals who tend to have a less robust immune system. The effectiveness also seems to be sustained over a longer period of several years. As exciting as advances in curing diseases can be, progress toward preventing them is perhaps even more encouraging. The recent surge in new vaccines is making a contribution in protecting health, preventing suffering, and helping people live longer lives.


YOU’RE SKILLED ON KEEPING YOUR PATIENTS HEALTHY...BUT WHAT ABOUT THEIR DATA? In today’s online world, cybersecurity is a non-negotiable for anyone dealing with data in the cloud. The amount of sensitive information that healthcare organizations store makes cybersecurity of the utmost importance. Cloud solutions from TekLinks and Microsoft can transform the care continuum for your organization without compromising security. Contact TekLinks today to find out how to improve the health of your security practice. Alabama • Florida • Mississippi • Tennessee


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MARCH 2018 • 17

New Tools for Providers in False Claims Actions By Bill Athanas

A pair of Justice Department memos have made waves in the past month and have the potential to significantly impact the way the federal government prosecutes civil enforcement cases, particularly those brought under the False Claims Act. In the broader of the two memos, released Jan. 24 by Associate Attorney General Rachel Brand (and hence referred to as the “Brand Memo” (found at https:// , the Department of Justice seeks to rein in the use of so-called “guidance documents” issued by regulatory agencies to establish violations in affirmative civil enforcement cases. In the past, the DOJ has occasionally used non-compliance with certain guidance documents in an attempt to establish non-compliance with specific regulations.

Those days are gone. The Brand Memo is a clear extension of the Trump administration’s desire to reduce regulation at the federal level, and expands on prior DOJ guidance prohibiting the Department itself from issuing such guidance documents. While it will take time to see the exact impact of the Brand Memo, it is clear that it will narrow the scope of regulatory guidance that will give rise to False Claims Act prosecutions. What documents will fall under this restriction? The Brand Memo is silent on that point. As the Brand Memo makes clear, the “Department should not treat a party’s noncompliance with an agency guidance document as presumptively or conclusively establishing that the party violated the applicable statute or regulation. That a party fails to comply with agency guidance ex-


panding upon statutory or regulatory requirements does not mean that the party violated those underlying legal requirements; agency guidance documents cannot create any additional legal obligations.” While defendants will work to expand this new requirement as much as possible, there are two important caveats to keep in mind. First, the Brand Memo may have limited application to currently pending FCA actions. Indeed, the “wherever practicable” language suggests that the further along a particular matter, the less impact it may have. Second, and perhaps more importantly, awareness of a guidance document can still be used to prove scienter — or knowledge — under the FCA. As such, the Brand Memo is not a license to ignore agency guidance, but rather a guidepost to its application as evidence of violations in affirmative civil matters brought by the DOJ.

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The second memo, dated Jan. 10 (found at https://assets.documentcloud. org/documents/4358602/Memo-forEvaluating-Dismissal-Pursuant-to-31-U-S. pdf), is in many ways more interesting and with a much more unknown impact. This memo, authored by Michael Granston, head of the Commercial Litigation Branch’s fraud section — which is charged with enforcing the False Claims Act — was never intended for public release. Rather, the leaked memo sets forth a detailed analysis of what situations the Department should consider dismissing qui tam actions brought under the FCA pursuant to 31 USC 3730(c)(2)(A). For the uninitiated, this provision allows the department to dismiss — sua sponte — actions brought by a relator. Until now, it has been rarely exercised. As the Granston Memo suggests, that may be about to change, and cites this thus-far little used provision of the FCA as an “important tool to advance the government’s interest, preserve limited resources, and avoid adverse precedent.” The Granston Memo lays out a series of situations in which the department may consider dismissing what it deems “meritless” qui tam actions, along with detailed examples of each situation. These include: • Curbing meritless qui tams • Preventing “parasitic” or “opportunistic” qui tam actions • Preventing interference with agency policies and programs • Controlling litigation brought on behalf of the United States • Safeguarding classified information and national security interests • Preserving government resources • Addressing egregious procedural errors. Obviously the memo would only apply in situations where the federal government has already made the decision to not intervene in a particular action. Nonetheless, the memo could be a powerful tool for defendants faced with non-intervened qui tams litigated by relators. This has been a much more common trend in recent years as the number of qui tam filings — and the variety of relators’ counsel bringing them — have continued to expand. As evident from the chart below, settlements and judgments in FCA actions have topped $35 billion over the last decade, with a large chunk of that coming from the health care industry — at least $2 billion from the healthcare industry in each of the last eight years. With the arrival of the Granston Memo, defendants faced with a qui tam where the United States chooses not to intervene would be well advised to carefully analyze the factors in this memo and consider whether or not to urge the government to take the additional step of dismissing the case pursuant to 31 USC 3730(c)(2)(A). Bill Athanas is a partner with Waller law, practicing in the Birmingham office. He is a former federal prosecutor.


The Group: Seven Widowed Fathers Reimagine Life by Donald L. Rosenstein, MD and Justin M. Yopp, PhD; c.2018, Oxford University Press; $24.95; 175 pages ‘Til death do you part. Did those words give you pause when you said them in front of an officiate and a handful of friends and family? Did you even hear them, in your nervousness and joy? Or, as in the new book The Group by Donald L. Rosenstein and Justin M. Yopp, were they things you put aside, hoping they’d never come true? As far as they could tell, it had never been done before. In their work at the Lineberger Comprehensive Cancer Center at the University of North Carolina, Rosenstein (a psychiatrist) and Yopp (a clinical psychologist) often consult with patients nearing the end of their lives. Their work sometimes includes patients’ families, but Rosenstein and Yopp noticed something missing: there were few support systems specifically for widowed fathers. To fix the issue, the doctors organized their ideas, created a format, decided on topics for discussion, and hung a sign-up sheet. Five men joined (Joe, Karl, Bruce, Neill, and Dan), and two came in later

(Steve and Russ). Single Fathers Due to Cancer began with the original intent to meet once a month for six months. At first, the sessions included lectures followed by open talk, but the format was altered immediately. Instead of lectures, the men needed to examine thoughts and ask questions. They talked about their own grief and that of their children, while learning to overcome societal expectations of stoicism. They discussed experiences of being alone

early in a marriage, and they tackled the subject of cluelessbut-well-meaning friends and relatives. Through the realities and situations they shared, the seven men changed – and they changed Rosenstein and Yopp’s way of looking at patients with terminal illness and the spouses they leave behind. They were only supposed to meet six times. More than three years later, they were still meeting. While this may seem like a book for clinicians and hospice workers, I saw it differently. As much as it is about dying, The Group is also about friendship and finding the people we need to lean on. Yes, there are things here that grief professionals will appreciate, including new studies on loss and a deep look at how

Elizabeth Kübler Ross’s five stages of grief has expanded and altered with better understanding. That’s information that layreaders can surely appreciate, but they’ll be just as fascinated by the journeys that authors Rosenstein and Yopp shared with the seven men who taught the doctors so much. There’s sadness inside this book but, moreover, there’s hope and healing; resolution and honesty; eye-opening observations that may surprise you; some unexpected chuckles; and tales of ultimate peace with a situation that nobody ever wants to think about. Also, be sure you read all the way to the end, to catch the sweetest closure you’ll ever find. For men who are facing the unthinkable, this book will ultimately be a valuable resource. For professionals, absolutely, The Group is a book to read. And if slice-of-life stories enhance your days, be sure to make this one a part. 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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Birmingham Medical News

MARCH 2018 • 19

Kirklin Clinic Looks to Industrial Engineers to Improve Patient Access to Care By Marti Webb Slay

The best medical care in the world is only as good as the access a patient has to that care. At Kirklin Clinic, industrial engineers in the Performance Engineering department seek to improve patient access by focusing on better ways to increase efficiency, reduce healthcare costs and improve the overall patient experience. “A lot of our projects are aimed at improving access: how do we get patients in to see the doctor in a more timely manner? Once they are in clinic, how can we get them through the clinic quicker, so they aren’t waiting three hours and it’s not an all-day visit,” said Deborah Flint, senior director of Performance Engineering at The Kirklin Clinic of UAB Hospital. One of the tools Flint and her colleagues use to improve the patient experience is a process improvement technique known as Lean Six Sigma (LSS). “LSS is used in all sorts of industries. It has been adapted and is very popular in healthcare now,” said J.M. “Mickey” Trimm, PhD, associate professor and director for the Center for Healthcare Management and Leadership at the UAB School of Health Professions. “Healthcare is moving from pay for procedure to pay for performance or pay for quality. In order for hospitals to be reimbursed at the highest level, they are going to have to prove and improve their existing quality levels. Healthcare organizations now need to look at what they do and how they do it,

Deborah Flint (left) and Mickey Trimm, PhD at The Kirklin Clinic.

in order to do better.” When a hospital or clinic decides to employ LSS to improve one or more processes, a process improvement team is assigned. “The techniques take some time,” Trimm said. “There is a lot of work that goes into analyzing, collecting information, studying, comparing processes and more. The processes that need to be improved are usually identified by the customers. A good example is doctor’s offices where patients have to wait two to four hours before they get to see the doctor.

That is a waste for the customer. It costs them money and creates a lack of satisfaction. Good physician practice groups will try to eliminate as much of that waiting time as possible.” In one project, Flint and her colleagues sought to reduce waiting time at Kirklin and tracked the results for a year. The team assigned to the project successfully streamlined the front desk checkin process, reducing process time by 26 percent and patient waiting time by 61 percent. The average time for patients

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waiting in the lobby before being placed in an exam room dropped from seven and a half minutes to two minutes, and total patient time in the clinic from arrival to departure dropped from 70 minutes to just under 55 minutes. Flint said having the right people on the team was critical to the success of that project. “Having that group together really helped us drive change,” she said. “We had senior leadership on board, which helped us remove barriers so we could move forward with the recommendations.” LSS is born out of Japanese process improvement ideas devised following World War II, so many of the terms used are Japanese in origin. People highly trained in LSS for over a year who learn to apply the concepts and demonstrate their ability can achieve black belt status in the field. Content experts in the medical field who are called upon to serve as team members can complete a five-day training experience and achieve a green belt. “These are people who are knowledgeable enough about process improvement techniques that they can use their content expert capabilities to apply with the LSS process,” Trimm said. Together, black belts and green belts can achieve needed change and improvements. The Performance Engineering Department consists of industrial engineers who don’t interact directly with the patients, but Flint believes they play a key role at the clinic. ”Healthcare has gotten very expensive, and we’re trying to do our part,” she said. “We may not be the one touching the patient, but if we can help that cancer patient not have to wait all day for something and make their time here more pleasant, we feel like we’ve done something to help.”


Six Sigma phases 1. Define 2. Measure 3. Analyze 4. Improve 5. Control

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Birmingham Medical News

MARCH 2018 • 21


Christopher S. Carter, MD

Emily Bell Casey, MD

Ricardo E. Colberg, MD

Cherie B. Miner, MD

José O. Ortega, MD

Jay S. Umarvadia, MD


James R. Andrews, MD

E. Lyle Cain, Jr., MD

Andrew M. Cordover, MD

Jeffrey C. Davis, MD

Jeffrey R. Dugas, MD

Benton A. Emblom, MD

James A. Flanagan, Jr., MD

Samuel R. Goldstein, MD

Wayne McGough, Jr., MD

Kathleen E. McKeon, MD

Welcome, Dr. Ryan!

Steven R. Nichols, MD

Michael K. Ryan, MD

K. David Moore, MD


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St. Vincent’s Birmingham 805 St. Vincent’s Dr, Ste 100 Birmingham AL 35205


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By Janet Cox

Physicians serve on the frontlines of our healthcare system, and by extension the many social programs guaranteed by the Social Security Administration. It’s a large responsibility and we owe them a debt of gratitude. These dedicated care providers, across many areas of practice and at varied levels within our medical system, help more than 57 million children and adults who live with disabilities across the United States. Not only are physicians relied upon to provide sound medical advice and treatment options for patients with significant disabilities, the Social Security Administration also relies on care providers to furnish “objective” medical evidence to help decide whether someone qualifies for disability benefits. That’s no small task given that more than one million Americans are currently waiting, often desperately, to see whether they qualify for assistance. What would one million people look like if we lined them up shoulder to shoulder? How many states would they cross? Would they reach the moon? And back? What’s more, for those who qualify there’s an average wait of nearly two years before they receive benefits; many die before the process is completed. Policy makers and administrators know all too well that disability and poverty are closely related. Along with the physical and emotional limitations imposed by severe disabilities, most people living with disabilities face significant financial pressures, having extremely limited savings and other assets needed to survive. What’s more, the costs directly associated with having a disability such as out-of-pocket medical expenses, can be overwhelming. Physicians do play a vital role in the health of the disability benefits process but are routinely asked to balance that need with the rigorous daily demands of the healthcare system. So how can physicians support the needs of disabled patients

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Birmingham Medical News

within the confines of an already busy schedule? What strategies are available for care providers to help reduce the burden of paperwork, yet still provide accurate information to the Social Security Administration so their patients can receive a fair evaluation? Here are some tips: • Take a few moments to become familiar with the basic tenets of the Social Security disability programs. This will help you have a rough, working knowledge of what is available for your patients and the general process for obtaining disability benefits. • Make sure your patient understands your role in the disability process. It is a complex system, and your role is to provide accurate information to support a fair evaluation. Patients need to understand that while physicians want to help, they cannot be held responsible for the disability approval process. • If you are aware that your patient is considering an application for disability benefits, ask them to provide you with a short and concise list of limitations in advance of their visit. The list should include specific ways the disability limits their daily life, including real-life examples. • Discuss the list of limitations honestly with your patient, providing up-front feedback for areas of disagreement or confusion. This will provide your patient with a realistic expectation of what you consider to be “objective” medical evidence that would be included in a report to the Social Security Administration. • Take a moment to reference the Social Security Administrations Physical Residual Functional Capacity Assessment form. This will help you understand the types of information gathered by the Social Security Administration to evaluate disability claims. The Social Security Act is very complex and there are many exceptions to almost every rule. For help with the legal process, always recommend a qualified disability attorney for guidance. The advice is particularly important before a patient files their initial application. Social Security has a very helpful website with a wealth of general information and downloadable PDFs on a multitude of subjects. The website also publishes a toll-free number for those who wish to speak with a live representative. I am personally aware that the wait times to get a live person on the phone can be very long and that the quality and accuracy of the information varies from one representative to another. Janet Cox practices at Cox Disability Law where she specializes in social security disability benefits. She can be reached at the website or via email to


Scott Harris, MD Appointed State Health Officer The State Committee of Public Health has appointed Scott Harris, MD as Alabama’s 12th state health officer. Harris, who has over 19 years in private practice, graduated from Harding University in Arkansas and attended medical school at the UAB School of Medicine. He served his resi- Scott Harris, MD dency and internship at Carraway Methodist Medical Center before returning to UAB to complete a fellowship in infectious diseases. In 2017, he was awarded a master’s degree in public health from the UAB School of Public Health. Harris practiced infectious disease medicine at Decatur General Hospital and Parkway Medical Center. He served on the Medical Executive Committee, medicine department chairman and director of multiple committees including infection control, pharmacy and therapeutics, and the surgical care improvement project. He is past chairman and current member of the Decatur Morgan Hospital Foundation. In 2005, Harris became medical director at the Decatur-Morgan Community Free Clinic. He has also served on many international medical missions to Central America, South America and Africa. In 2015, Harris joined the Alabama Department of Public Health as area health officer for seven North Alabama counties. For the past six months, he has served as acting state health officer and currently co-chairs the Alabama Opioid Overdose and Addiction Council. He is a fellow of the American College of Physicians (FACP), Infectious Disease Society of America (FIDSA), and a credentialed HIV specialist, American Academy of HIV Medicine.

Malensek Joins Grandview Frank Malensek, MD, MBA, has joined the medical staff of Grandview Medical Center. Malensek is board certified in Internal Medicine and has a certificate of additional qualifications in Geriatric Medicine. He is in practice with GrandFrank Malensek, view Medical Group. MD, MBA Malensek received his medical degree from Creighton University School of Medicine in Omaha, Nebraska. He completed his internship and residency at Medical College of Wisconsin Affiliated Hospitals in Milwaukee, Wisconsin. In 2003, Malensek moved to Birmingham where he has been in private practice. In 2004, he earned a Physician Executive MBA from Auburn University. Malensek has practiced traditional internal medicine, as well as hospitalist medicine, for 27 years.

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Birmingham Medical News

MARCH 2018 • 23


John Paul Jones Hospital Joins the UAB Health System Paul Jones Hospital in Camden, Alabama, has entered into a management agreement with UAB Medicine to become a member of the UAB Health System. The hospital joins two other rural Alabama hospitals with management agreements with UAB: Bryan W. Whitfield

Memorial Hospital in Demopolis and LV Stabler Memorial Hospital in Greenville. This past August, the 30-bed hospital, located in one of Alabama’s poorest counties, announced that the hospital, which has been in operation for 60 years, would soon be forced to close due to the difficult financial environment facing small, local hospitals.

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“We believe it is part of the UAB Medicine mission to help provide assistance to hospitals throughout the state and to do what we can to ensure the survival of these rural hospitals,” said Will Ferniany, PhD, CEO of the UAB Health System. “Joining hands with UAB can be the key strategic relationship that keeps John Paul Jones Hospital open and able to continue to serve this community,” said George Alford, chair of the hospital board. Under the new relationship, UAB Medicine will provide managerial expertise and assist in supply chain logistics, revenue cycle management and compliance issues. UAB will also help with clinical resources such as assistance in physician recruiting and staffing. The UAB Health System now includes UAB Hospital, UAB Highlands Hospital, UAB Callahan Eye Hospital and management relationships at Medical West, Baptist Health Montgomery and Whitfield, Stabler and Jones Hospitals. Affiliation relationships exist with Eliza Coffee Memorial Hospital in Florence, Northeast Regional Medical Center in Anniston, Infirmary Health in Mobile and Russell Medical Center in Alexander City.

Alabama’s Physicians Contribute Billions to State Financial Health Alabama’s more than 8,700 patient care physicians fulfill a vital role in the state’s economy by supporting 101,770 jobs and generating $16.7 billion in economic activity, according to a new report

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released by the Medical Association of the State of Alabama and the American Medical Association. “Urban or rural, large group or solo practitioner, Alabama’s physicians are major economic engines,” Medical Association President Jerry Harrison, MD of Haleyville said. “While we are healers first, this study shows physicians help improve the health of our state as much as the health of our patients.” The report measured the economic impact of Alabama’s physicians according to four key economic barometers: • Jobs: Each physician supported an average of 11.7 jobs, including his/ her own, and contributed to a total of 101,770 jobs statewide. • Output: Each physician supported an average of $1.9 million in economic output and contributed to a total of $16.7 billion in economic output statewide. • Wages and Benefits: Each physician supported an average of $839,103 in total wages and benefits and contributed to a total of $7.3 billion in wages and benefits statewide. • Tax Revenues: Each physician supported $64,816 in local and state tax revenues and contributed to a total of $565.4 million in local and state tax revenues statewide. The study also noted that in comparison to other industries, patient care physicians contribute as much or more to Alabama’s economy than higher education, nursing and community care facilities, legal services and home health care. View the full report and an interactive map of the United States here: www.

Michael K. Ryan, MD Joins Andrews Sports Medicine Michael K. Ryan, MD has joined Andrews Sports Medicine & Orthopaedic Center. Ryan is an orthopaedic surgeon, specializing in sports medicine surgery, hip preservation surgery, and knee and anterior hip replacements. Michael K. Ryan, MD He focuses the hip preservation portion of his specialty towards treating non-arthritic hip disorders. He treats hip conditions such as hip impingement, labral tears, and hip dysplasia through hip arthroscopy and other joint preserving surgeries. Additionally, Ryan is the only physician in the state of Alabama trained to perform periacetabular osteotomy, a surgical procedure to treat hip impingement (FAI) and hip dysplasia —congenital disorders that often go undiagnosed in adolescents and young adults. Ryan developed an expertise in sports medicine and hip preservation surgery during his fellowship at Birmingham’s American Sports Medicine Institute (ASMI). He then completed a fellowship in Bern, Switzerland, training alongside the world’s top innovators in (continued on page 25)

GRAND ROUNDS hip preservation and surgical treatment of hip pathology in adolescents and young adults. “We are excited to welcome Dr. Ryan to our practice,” said Lyle Cain, Jr., MD, the managing partner at Andrews Sports Medicine. “He was a valuable asset to our team during his ASMI sports medicine fellowship.” Ryan’s previous sports medicine

experience includes working alongside various organizations as part of their medical team, including the University of Alabama football team and University of Alabama athletics, SEC Baseball, the Birmingham Barons, the Birmingham Ballet, Cordova High School, Athletes Without Limits, New York Public School football, and New York University and Long Island University athletics.

NPAA Awards Representative April Weaver The Nurse Practitioner Alliance of Alabama (NPAA) awarded the NPAA Power of One Award to Representative April Weaver at the 11th Annual NPAA Conference. The award honors Weaver for having distinguished herself as an outstanding healthcare professional serving in the Alabama State Legislature. Weaver was first elected to the House of Representatives in 2010 and re-elected in 2014. She is the first female ever appointed as Chair of the House Health Committee. In addition to chairing the Health Susan Alexander, NPAA Immediate Past President (left) Committee, she is currently a memand Representative April Weaver (right). ber of the State Government and Internal Affairs Committees. She also serves as Vice Chair of the National Conference of State Legislatures’ Health and Human Services Committee and is an Executive Committee member of the Energy Council. Governor Kay Ivey recently appointed Weaver to the Alabama Opioid Overdose and Addiction Council and to her fifth term as a member of the Statewide Healthcare Coordinating Council, where she serves as Chair of the Hospital Committee.

Birmingham MGMA Donates to Amelia Center in Honor of Michael Bonner Birmingham MGMA featured guest speaker Robert Smith from the Amelia Center at the February luncheon. Smith spoke on grief in the workplace. Birmingham MGMA donated $1000 to the Amelia Center on behalf of Jeff and Cathie Bonner in honor of their son Michael Bonner. Jeff is a Past President of the Birmingham MGMA Chapter. To learn more about the Amelia Center and the services they offer to grieving parents and children, please visit their website at

Larry Dye, MD Receives John Burrett, MD Award The CVA Medical Education Foundation held its 11th annual Cardiovascular Update Conference at the Hyatt Regency Birmingham Hotel in Birmingham in February. Each year at the conference a physician receives the John Burrett, MD award. This award is given to an individual who has contributed significantly to the advancement of cardiovascular healthcare in Alabama The award is named for John Burrett, MD who was the first cardiologist to practice in the state of Alabama and the founder of Cardiovascular Associates. The year, the award went to Larry Dye, MD. Dye, who practiced for over 40 years with CVA, earned his medical degree from UniverLarry Dye, MD (left) receives the John Burrett, sity of Louisville School of Medicine in 1972 MD award from Andrew Miller, MD. and went on to do his residency, followed by a fellowship in cardiovascular disease at the University of Alabama Medical Center.

Birmingham Medical News

MARCH 2018 • 25



The 30th anniversary meeting of the International Symposium on Endovascula Therapy (ISET) was held in February at The Diplomat hotel in Hollywood, Florida. At the conference, Gary S. Roubin, MD, FACC received the Career Achievement Award. Roubin, who serves as Medical Director of Cardiovascular Associates (CVA), is an internationally renowned interventional cardiologist. He performed the groundbreaking work in the development of the first FDA approved coronary stent, Gianturco-Roubin Flex Stent. He has edited 20 major textbooks on Interventional Cardiology and has published more than 240 papers and 225 abstracts in peer review journals. Roubin earned his medical degree at the University of Queensland, Australia. He completed his residency at the Royal Prince Alfred Hospital and his fellowship at Hallstrom Institute of Cardiology in Sydney. He holds a PhD in cardiovascular physiology at Sydney University Hospital. Roubin has served in numerous leadership roles throughout his career including Chair of Interventional Cardiac & Vascular Services at Lenox Hill in New York City for nearly a decade. He also served on faculty at Emory University School of Medicine and the UAB School of Medicine.

STAFF PHOTOGRAPHER April May CONTRIBUTING WRITERS Cara Clark, Ann DeBellis, Jane Ehrhardt, Laura Freeman, Cindy Sanders, Marty Slay

Gary Roubin, MD (right) receives Career Achievement Award.

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Lake Joins Pearce, Bevill, Leesburg, Moore Karen Lake, CMIS has joined Pearce, Bevill, Leesburg, Moore P.C. as a Healthcare Advisor. Lake has over 20 years of experience in revenue cycle management services and medical practice administration. She most recently worked as Director Business Services and Accounts Receivable for a healthcare solutions organization. She earned the professional designation of Certified Medical Insurance Specialist in 2009. As a PBLM Healthcare Advisor, Karen will be responsible for: • Complete Medical Practice Consulting • Practice Start-ups • Business Office Accounting Assistance and Training • Revenue Cycle Optimization • Staffing and Human Resources Assistance “We are pleased with the addition of Karen to our healthcare team,” said Hal (Buzz) Coons III CPA, Pearce Bevill Shareholder and Director of Healthcare Services. “She brings very strong credentials that will add significant value to our physician practice clientele.”

Barmore Joins Grandview Medical Staff LaShelle Barmore, DO has joined the medical staff of Grandview Medical Center. Barmore is board certified in Family Medicine and has a special interest in diabetes management. She is in practice with Grandview Medical Group TrussLaShelle Barmore, ville. DO Barmore received her undergraduate degree from Miles College in Fairfield, AL. She received her Doctorate of Osteopathic Medicine degree from Kansas City University of Medicine and Bioscience. Barmore completed her residency with St. Vincent’s East Family Residency Program. She has been in private practice in the Birmingham area since 2012. Barmore serves on the Junior Board of the Birmingham Chapter of the American Diabetes Association as well as the Juvenile Diabetes Research Foundation. She is a member of the Alabama Medical Education Consortium, Alabama Osteopathic Medical Association, American Academy of Family Physicians, American Osteopathic Association, Alabama College of Osteopathic Medicine Preceptorship, American College of Osteopathic Family Physicians, Mineral District of Medical Society Medical Association of the State of Alabama (MASA), and the Impact Mentoring Executive Board.

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