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Howard Rubenstein, MD ON ROUNDS

Inflammation is the Common Denominator in Chronic Diseases Lupus and asthma, COPD and diabetes, Crohn’s disease and Alzheimer’s—what do all these and so many other chronic diseases have in common? Inflammation is a characteristic part of the body environment as these disease processes develop ... 5

NOVEMBER 2017 / $5

Rural Healthcare Presents Unique Challenges and Rewards By marti WeBB SLay

With all the problems facing healthcare professionals today, perhaps the most challenging arena of all is providing primary care in rural areas. Despite those challenges, however, several Alabama physicians also tout the advantages of choosing a rural setting. “There’s a lot of personal satisfaction in practicing medicine in rural Alabama,” said John F. Simmons, Sr., MD, who practices in Geneva. “We get to practice the whole gamut of medicine. Here, if you see a rash, it’s not easy to send the patient to a dermatologist, or to send someone who’s wheezing to a lung specialist. You get to make the decisions, which is both challenging and rewarding.” Despite the rewards, Simmons said it is still difficult to recruit new physicians to rural areas, where restaurants, shopping and cultural activities are more limited. “But the biggest challenge is time,” he said. “There are great opportunities in urban areas for family doctors to work 38 hours a week on salary with no call and no weekends. I probably average 80 hours a week.”

John Simmons, Sr., MD checks on a patient.



The State of Senior Health

Urology Clinics Focus on Men’s Hormonal and Sexual Health

2017 Rankings Show Progress, Challenges

With the holidays just around the corner, many families will enjoy multigenerational gatherings. Not nearly as many will take the opportunity to discuss expectations ... 11

By ann B. deBeLLiS


Brian Christine performs a penile implant.

For the past 11 years, Brian Christine, MD has focused his Urology Centers of Alabama practice on men’s sexual health with the Men’s Sexual Health Clinic which provides treatment for patients with erectile dysfunction and other problems. This year, Christine established another clinic that treats patients with low testosterone. “We offer state-of-the-art treatments for couples with sexual dysfunction issues. We take care of patients with low testosterone, erectile dysfunction, premature ejaculation, pain with intercourse, and other conditions,” Christine says.


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2 • NOVEMBER 2017

Birmingham Medical News



The Doctor Mayor By Lori Quiller

Saraland, Alabama is a long way from Chicago, both geographically and culturally. However, that didn’t stop Chicago native Howard Rubenstein, MD from diving right into civic activity when he moved to Saraland upon completing his residency. Since starting his family practice in 1985, Rubenstein has been involved in all aspects of community service, from working with volunteer groups and the Chamber of Commerce to politics where he served on the city council before he was elected mayor. “Part of the joy of living a small community is having patients ask me about city council business or folks approaching me after a council meeting and asking for medical advice,” Rubenstein said. “That’s just how things work.” He credits his love of public service to his residency director, who also served as mayor of his hometown. It was a philosophy of civic duty that resonated with the then-young physician. “During my residency, he hammered into us the idea that it’s not enough to hang out a shingle and practice medicine. You should get involved in your community and give back. It’s a great philosophy that I took to heart,” Rubenstein said.

Rubenstein worked with as many civic groups as he could until 1996 when a seat opened on the city council. “I told my wife I’d like to run for it, and she said I was crazy,” he said. “But after doing everything else, I realized I wanted a little more input on how things were done in the community. I was shocked to win. I think I won by just 72 votes.” According to Rubenstein, there is a big difference between practicing medicine and public service. “As a physician, you want to make every patient as happy as possible, he said. “You can’t always do that as an elected official. With every decision, you’re going to make someone happy and someone unhappy.”

Rubenstein is currently serving his second full term as mayor. “I’ve really enjoyed this opportunity to serve,” he said. “We’ve done a lot of great things in our community over the last 20 years,” he said. “We have our own city school system, which we started about 10 years ago; a brand new high school and elementary school, and we just built an early education center. There’s a lot of growth in the area now. I think my favorite part of this job is the enjoyment you get when a project that you’ve thought about and worked on is actually done. There’s such a sense of accomplishment in seeing a project from conception to completion.” Between the two jobs, Rubenstein has

many long days. He begins each day in his practice around 7:30 a.m. seeing patients and ends sometimes as late as 9 p.m. working on city council business. “I don’t enjoy sitting at home and watching television,” he said. “I love seeing my patients. And with the civic work, I’m helping my community grow. To me, every physician should be able to make time to do something they enjoy to prevent burnout. Being a physician is a challenging career that can take a toll, so this work with the city helps break up my day.” And yet, with all this activity, he has somehow found time for a hobby. For the past 12 years, Rubenstein and his family have visited the Cayman Islands for scuba diving. In the end, Rubenstein’s love affair with his community is a two-way street. After the sudden passing of his son, Rubenstein said the outpouring of compassion from the community was breathtaking. “My wonderful wife Tammy and I have been married for 34 years,” he said. “In 2012, our 28-year-old son went to bed one night and didn’t wake up the next morning. We discovered he had a rare congenital heart defect. Our community was extremely sympathetic. Without their support, I don’t think we would have made it through.”

Birmingham Medical News

NOVEMBER 2017 • 3


Living With Versus Living Better By Laura Freeman

Chronic disease doesn’t usually come with the drama of a new miracle drug. However, with good management, physicians can make a positive difference for these patients. Sooner or later, many of us will have to learn to deal with a chronic disease either in ourselves or in family members. Diabetes, arthritis, asthma, heart and kidney failure, fibromyalgia, Parkinson’s Disease, and COPD are only a short sampling of the chronic disorders humans are heir to. By detecting warning signs early, in some cases physicians may be able to help prevent or delay onset of these maladies. “With new management codes and a greater focus from insurers on helping patients stay out of the ER and avoid

bouncing back to hospitals, we’re putting structures in place so we can take the time to manage conditions proactively rather than reactively,” Norwood Clinic primary care physician Gilbert F. Douglas, MD, said. “We don’t have to spend all our time addressing only the immediate symptoms. Under Medicare guidelines, when patients have two or Gilbert F. Douglas, MD more chronic conditions with a potential for decline, they can qualify for twenty minutes or more a month of chronic care management services to establish, implement or review care and monitor the patient’s condition.”

To work effectively with this new care model, it helps to develop a plan to pinpoint patients who meet the criteria and could benefit from proactive management of chronic conditions. It is also important to have documentation systems in place to gather the data needed for reimbursement. “Other members of the care team can be helpful in managing chronic disease,” Douglas said. “I’ve been very impressed with our nurse practitioners. Before we even go into the exam room, they have reviewed medications and other details. It is surprising how often they find patients taking drugs prescribed by other doctors long ago that are no longer needed or may even duplicate or interact with their current medications. “Nurses also excel at teaching patients. Chronic conditions can be complex, and

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it’s important to help patients understand what they can do to take charge of their health. When patients understand what their prescriptions do and how to take them, they are more likely to comply with medications. And depending on the diagnosis, your patient may need a physical therapist, occupational therapist, diabetes educator, nutritionist and perhaps psychological counseling. You need access to a solid team of professionals who can help your patients achieve the best outcomes.” Another vital resource for primary physicians is a list of specialists they can call on when they need a consult or their patients need a referral. “I like working with specialists who will tell me straight up when unusual lab results are not significant and when patients need a more comprehensive evaluation,” Douglas said. “Primary care providers see the big picture with the patient’s health. We can manage many types of chronic diseases, but no one is a specialist in everything. Some conditions require more complex evaluation and specialized treatment. That’s when you need to be able to call on the expertise of someone you trust.” As a rheumatologist, Nop Unnoppet, DO, of Advanced Arthritis Care and Shelby Baptist Medical Center frequently receives calls from primary physicians. “Often it’s when labs come back with unusual results and they want an opinion on whether it is clinically significant,” Unnoppet said. “Sometimes an elevated ANA only means that patients have autoimmune disorders in their family tree. I ask about symptoms to determine whether what I’m seeNop Unnoppet, DO ing in labs is being expressed physically. “Rheumatologists by definition work with chronic disease patients. Many different disorders come under that heading, and the first thing I have to do when a patient comes in is determine whether their symptoms come from an autoimmune process or from years of use.” “Is it inflammatory or noninflammatory? Can a patient’s pain be cured with a knee replacement? Or is it a major flare of rheumatoid arthritis or lupus that warrants more aggressive treatment to calm the immune system before it does permanent tissue damage?” At this point in medical science, it’s fair to say that autoimmune diseases, like many chronic disorders, are generally treated rather than cured. New areas of research, particularly advances in gene therapies, may change what is a chronic disease and how we treat it in years to come. In the meantime, the best advice to help patients live better with chronic disease is to help them learn why and how to take their medications as prescribed, eat healthy, be as active as they can when possible, get plenty of restful sleep, avoid stressors, and take the time to savor what they love about life.


Inflammation is the Common Denominator in Chronic Diseases By Laura Freeman

Lupus and asthma, COPD and diabetes, Crohn’s disease and Alzheimer’s— what do all these and so many other chronic diseases have in common? Inflammation is a characteristic part of the body environment as these disease processes develop. In a world full of pathogens, inflammation is the immune system’s arsenal to fight invaders. But like a guided missile that loses its way, it can cause a tremendous amount of collateral damage, destroying the body’s own tissues with friendly fire. How do we intercept destructive inflammation in diseases without leaving the body defenseless against infection? Andrew West, PhD, is working to answer this. West, co-director of the UAB Center for Neurodegeneration and Experimental Therapeutics, serves as co-chair of the Parkinson’s Disease Biomarker Program for the National Institutes of Parkinson’s disease. A new biomarker that correlates with the presence and severity of Parkinson’s Disease now allows researchers to measure the activity of the LRRK2 (pronounced Lark two) protein in biofluids. “Our lab began working on Parkinson’s from a genetics perspective. We saw genes associated with small components of the disease beginning to align with those involved in the regulation of inflammation. That’s something that wasn’t on our radar before,” West said. “We don’t yet know the basic causes of Parkinson’s and Alzheimer’s, but we are learning a lot about the processes.” Mutations associated with LRRK2 are the most common known factor in familial Parkinson disease. Expression of LRRK2 is elevated in B cells, T cells and monocytes, which secrete more inflammatory cytokines. LRRK2 seems to be related to the aggregation and misfolding of alpha-synuclein, which contributes to neurodegeneration. “Developing a way to influence LRRK2 expression could help us block alpha-synuclein problems and prevent the death of dopamine producing cells in the substantia nigra,” West said. “This offers us a target for a potential treatment to prevent or slow down Parkinson’s Disease.” While investigating the problem of inflammation in the brain, UAB researchers have also come across parallels in other chronic diseases. “Rather than an inflammatory cascade, when we examined the brains of people with autism looking for synaptic changes, we found anti-inflammatory cascades,” West said. “This was a surprise. What it means is yet to be determined. Would it be beneficial to promote anti-inflammatory support, or is something else going on? Could pursing this finding lead

Andrew West, PhD, investigates the problem of inflammation of the brain.

to treatments? In mouse models, we are seeing that the plasticity of the brain may eventually allow us to help patients. It will take time, but the potential gives us hope.” The ability to detect markers of inflammation and targets for intervention in diseases like Parkinson’s is also a hopeful sign for millions of people suffering from other chronic diseases where inflammation plays a role. Francis Lund, PhD, is director of the working group for UAB’s research focus on inflammation, infection and immunity.

Her research is aimed at identifying the key players that suppress or exacerbate mucosal inflammatory responses with the long-term goal of developing therapeutics to treat immunopathology associated with chronic infectious, allergic and autoimmune disease. “Inflammation is a component of almost every chronic disease Frances Lund, PhD

from rheumatoid arthritis to COPD, most types of heart disease and many types of cancers,” Lund said. “Some of the drugs we use for one disease are used for others. For example, the cytokine inhibitors we use in arthritis may also be used in Crohn’s disease and the checkpoint inhibitors developed to treat cancer may be used to train the immune system to rerecognize other problems.” In treating many chronic diseases, the goal is to quiet the immune system. “Depending on the disorder, doctors may prescribe anti-inflammatories or steroids to calm down the immune system and manage the disease,” Lund said. “We’re working to learn more about inflammatory diseases and develop new drugs to treat them. “In the meantime, there are strategies doctors can encourage patients to use to help keep their immune systems healthier. Finding better ways to manage stress, sleeping and eating better are good for the immune system. A balanced diet with plenty of fruits and vegetables can give you antioxidants to help block inflammation. You may also want to look at foods that may increase the risk of a systemic immune system response. “Another consideration is obesity. There is a correlation with inflammation, and every excess pound patients manage to shed not only fights obesity—it could (CONTINUED ON PAGE 12)



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Northside Medical CARE Coordination Program

First in State Focuses on Medical Conditions and Barriers to Care A nurse practitioner usually makes the initial visit to a patient’s home Research shows that where she records the about 75 percent of healthpatient’s vital signs and care costs come from just 10 performs any needed dipercent of the population. agnostic work. Next, the And almost half the people NP accesses the patient’s in this small group suffer social situation, includsocial deficiencies that afing issues such as isolafect their health. How many tion; transportation; lack millions of dollars could be of adequate nutrition; fisaved if this was addressed? nancial barriers to mediAnd how much more procal care; or medication ductive and happy might compliance problems. these patients be? Based on the initial Northside Medical Asassessment, the CARE sociates of Pell City decided team develops a care to tackle this problem by plan and works with the launching its CARE Team patient to follow it. which is designed to link The CARE team patients to all the approworks with patients with priate resources in order to dementia or parkinson’s enhance their quality of life Rock Helms, MD and CARE Program Director Dianna McCain study notes from a CARE disease; patients with and reduce hospital read- patient’s case. complex issues such as missions. tor, it doesn’t matter.” So Northside has congestive heart failure or lung disease; “We want to connect the patient to enlisted community partners like St. Clair chronically ill patients, like those sufferall the applicable medical team memCounty that provides transportation; or ing from diabetes, high blood pressure, bers,” said Rock Helms, MD, CEO of churches and food banks for patients who depression, chronic obesity, renal disease Northside Medical. “And then we want to need nutrition. and COPD. focus on the social determinants. You can The CARE Team, which is the first Maybe the most important aspect of give someone the right medication and of its kind in Alabama, was launched in the program is the focus on the patient’s schedule them with the best doctors, but April and now serves over 200 patients. social determinants. Recently, for examif they don’t have a car to get to the docBy Steve Spencer

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ple, Northside saw an uninsured patient who had been in the emergency room approximately 25 times in the past year, mostly for chest pains. But there was nothing wrong with his coronary arteries. “He has mental health issues,” Helms said. “If a little money was invested to make sure he got the mental health services he needed, many hundreds of thousands spent in the ER would have been saved.” In some ways the program is reminiscent of healthcare in the early part of the past century when doctors knew the patient on a more personal level. When a recent patient was unable to walk after his last hospitalization, the CARE team found an agency that donated needed supplies, including a wheelchair, and helped build a ramp at his home. Then the CARE team, along with other members of the Northside practice, cleaned and painted the house themselves. Northside Medical Associates is not able to bill for much of the CARE team’s work. “Medicare is beginning to pay for it through their care coordination efforts. It’s not a lot,” Helms said. “But they will pay a per-member, per-month fee to provide these coordinations. And we have a small contract with an insurance company as a trial pilot program. “We’re having to take profits out of other areas and funnel it into this program. It’s still in its infancy but our goal is to have a robust team of case managers, social workers, dieticians, mental health workers, and medical coaches who can do the hard legwork required. “If you’re in primary care with specialists at your disposal and you’re working as a team, ideally, we should be able to coordinate services to lower the costs. And when we progress to a bundled payment system where we’re rewarded for saving money because we’re more efficient, then it all pays off. “That’s our strategy and it’s the right thing to do.”


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Birmingham Medical News

OUR BLOG Every Monday and Thursday, we’ll feature healthcare professionals discussing important medical topics. In right sidebar, click on blog

Respiratory Tract Medicine Oral Corticosteroids versus Vitamin D By Marti Webb Slay

Two studies about treatment for respiratory tract infections have been released recently. One finds no benefit to using oral steroids for non-asthmatic adults with acute lower respiratory tract infection, and the other finds that vitamin D may help reduce acute respiratory tract infection.

Oral Steroids A randomized, placebo-controlled study suggests that oral corticosteroids should not be used in adult patients without asthma or chronic obstructive pulmonary disease who do not require treatment with an antibiotic. This study confirms the results from other studies. “This is not really news,” said Michael Vaughn MD who practices internal medicine with MedHelp. “The use of steroids is not backed by Michael Vaughn MD evidence.” Nonetheless, many doctors still prescribe steroids for respiratory tract infections. “This is not a surprising piece of infor-

mation,” Micah Howard, MD said. “This is another example of the difference between a doctor’s information and a patient’s desire for treatment. Sometimes it’s hard to tell a patient to just wait; Micah Howard, MD that things will get better.” Vaughn agreed. “A lot of doctors do it to make ourselves feel better. It can also make the patient feel better, but it doesn’t change how long they are going to be sick,” he said. Howard, who practices in Decatur, cautions that physicians must also weigh the negative effects of prescribing steroids. “Even though they may have a mildly positive subjective effect, we know we are not making people better faster or decreasing the symptoms of the disease,” he said. “And, we need to consider the negative effects. The overuse of steroids leads to a lot of issues, including insulin resistance, weight gain and some electrolyte imbalances. It makes you feel better in the short term, but it adds to the stress in your system.”

Vitamin D A recent study that conducted analysis of the data on 10,933 participants found that vitamin D supplementation was associated with a 12 percent reduction in the proportion of patients who suffered at least one acute respiratory infection. These analyses showed a protective effect of vitamin D supplementation in participants who received daily or weekly vitamin D supplements without additional large bolus doses, but not in those who received one or more large bolus doses. Both Howard and Vaughn monitor vitamin D levels in their patients and advocate regular supplementation. “I recommend that everyone take 5,000 units of vitamin D whether they are sick or not,” Vaughn said. “Vitamin D is known to help your immune system. It affects nearly every aspect of your body, whether it’s your immune system, your bones or your mental state.” Both doctors tout the low cost and low risk of taking vitamin D as reasons to have patients use the supplement. “You can get a month’s worth of treatment for about three dollars, and you never have an overdose,” Vaughn said. “The risks associated with vitamin D only come at a very high level. This is a medication where the risk is low and the

benefit is possible, so we have a minimal benefit and minimal risk,” Howard said. “If you look at it from a non-maleficent point of view, it’s a really great medicine. It’s not going to be a medicine that cures cancer or creates health in an acutely ill individual, but we’re starting to crack open the box of these chronic illnesses.” Vaughn tells patients to look for D3 which is better absorbed than D2, and as when purchasing any supplements, to buy a brand that has ‘USP’ on the label, which shows it has been tested by an independent lab. “Vitamin D is a fat-soluble vitamin that is so closely related to hormones that it acts more like a hormone than a vitamin or mineral,” Howard said. “And we know that hormones have a varied effect throughout the body. Unless we have a definitive benefit, it’s not going to change the guidelines for practice, but we have to take into consideration those things that don’t have a significant deficit as well. We are realizing the benefits of a medicine with no side effects for chronic conditions.” “Too many doctors don’t have a clue about vitamins,” Vaughn said. “Here’s a study that emphasizes vitamin D is more than just a quack or passing fad. It’s my hope that more doctors will test for vitamin D and tell people to take it.”



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Alabama • Florida • Mississippi • Tennessee


Birmingham Medical News

NOVEMBER 2017 • 7

Rural Healthcare Presents Unique Challenges and Rewards, continued from page 1 “Students graduate with essentially a mortgage worth of school debt, and they are hesitant to go into rural practice where you might not make money for a couple of years,” said Julia Boothe, MD in Reform, Alabama. “Historically, rural hospitals would hire the providers, but their business plan is so unsteady now, they can’t recruit like they could 10 or 15 years ago.” General Shane Lee, MD of Marion, Alabama, in Perry County, has not been successful recruiting physicians to join his practice, and he uses nurse practitioners to help keep up with patient load. “Thank God for nurse practitioners,” he said. “I was one of the first guys on the block to partner with them. I was getting destroyed and it was the only way I could get help.” Transportation is an additional challenge for rural patients and caregivers. “People here have to use clandestine taxi service and pay someone $10 to get to the clinic,” Lee said. “I’ve had to give people gas money before.” The transportation issue creates problems with compliance on some tests such as mammograms and colonoscopies. “We see about a 20 percent compliance on colon cancer screenings,” Lee said. “You have to drive 30 miles on rural roads to see a surgeon. And you have to have someone drive back with you, usually at 5:30 in the morning. Nobody wants to do that.” Boothe said transportation is also a huge issue in Pickens County. “I’ve

Julia Boothe, MD

learned to ask if patients have someone to take them to the clinic or specialist, and if they can afford to pay whatever that person will charge. We were not trained to do this in medical school.” In some cases, even getting to a drug store can be a challenge. “Most of our local pharmacies are very good,” Boothe said. “But a lot of my patients have insurance plans that require them to use Walgreens. The nearest Walgreens is 45 miles away.”

Transportation is only one part of the problem when it comes to drug stores, where independent pharmacies, like rural hospitals, are closing their doors and insurance policies are dictating the use of chain stores. “It’s hard to call up the pharmacist and chat with them about patient compliance when it’s a 1-800 number,” Lee said. Electronic health records and internet connections are also challenges for the rural physician. “I’m on a first name basis with our local internet provider,” Boothe said. “We pay $1,000 a month for internet service, because we have to have a certain upload speed for EHR. That doesn’t include the cost for IT, and I have to pay for a tech to come from Birmingham.” “EHR is horrendously difficult,” Lee said. “My computer has been down all day, so I can’t do medical records. That means another evening at the clinic, because IT has to drive 30 miles to see what’s wrong with the computer. Electronic medical records have been a real coffin-nail for primary care. Specialists are able to template, but in primary care, we have to manage multicomplexity. You are not just managing diabetes but also depression and other diagnoses. I used to see 60 patients a day and walk out of the door at 5:00. I can now only see 25, and I’m at the clinic until 8:00 at night.” Simmons has opted not to use electronic health records and pay the financial penalty. “Patients like to look at me; they

don’t want to see me on a laptop,” he said. “When I’m in the room, I talk to them.” He quoted studies that show a decrease in productivity by between 10 and 50 percent after moving to electronic records. Despite the struggles, all three physicians agreed there are benefits. And two of the doctors have sons following in their footsteps. Lee has a son in residency who is planning to come back to Marion. “I’ve encouraged him to give it a shot,” he said. “It’s not all bad. I live on a farm and have a four-mile drive to work. My staff is superb and my patients are loyal. You never get bored professionally.” Boothe agreed. “I can do all the procedures I’ve been trained in and can apply those. You never know what’s coming in the door next,” she said. “It’s exciting.” Simmons’ son joined him in practice two years ago, a decision he made while still a senior in high school. He had seen the impact of the clinic on generations of families, and he told his dad, “I want to do what you do.” “As a rural physician you are part of a community and you can make a difference,” Simmons said. “I’ve never missed one of my kid’s ball games or programs or graduations. I feel blessed and would choose the same path again.”

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Stark Still Requires an Executed Written Agreement Between a Hospital and a Physician By Patricia Powers Alexander Mills


Recently, in United States ex rel. Emanuele v. Medicor Assocs., 242 F. Supp. 3d 409, 431 (W.D. Pa. 2017), reconsideration denied, No. CV 10-245, 2017 WL 3675921, the U.S. District Court for the Western District of Pennsylvania issued an opinion clarifying that the Stark law still requires executed written agreements to meet safe harbor requirements. Applying the materiality standard from Universal Health Services v. United States ex rel. Escobar to the “writing requirement” utilized throughout various exceptions to the Stark Law, the District Court found that this requirement, and the signature requirement specifically, represents a material component of the Stark Law for purposes of establishing liability under the federal False Claims Act (FCA). The Stark Law exists for the purpose of prohibiting a physician (or an immediate family member of said physician) from making referrals for “designated health services” to an entity with which the referring physician (or immediate family member) has a financial relationship unless the parties comply with one of the exceptions

set forth in the federal regulations. Additionally, Stark prohibits entities like hospitals from submitting claims for payment to Medicare or Medicaid for items or services that result from the prohibited referrals. Although the concept of a “financial relationship” may seem simple, Stark defines the term broadly and includes both ownership and investment interests and compensation arrangements between physicians (and their immediate families) and entities. Violation of the Stark Law can incur significant civil liability under both the False Claims Act, civil monetary penalties, and exclusion from all federal healthcare programs. Included in the framework of the Stark Law are numerous exceptions to civil liability. One common theme among them is the requirement that any arrangement must be evidenced by a signed writing. In November 2016, the Centers for Medicare & Medicaid Services (“CMS”) codified amendments to the Stark Law to make it easier for healthcare providers to meet the writing requirement. Many of the Stark exceptions require a written agreement between a referring physician and an entity with whom he or she has a financial relationship. This requirement was originally interpreted to be a writing in the form of a single signed agreement, but CMS amended language across the statute to relax this exacting standard. The amendments instead allowed for the writ-

ing to be codified in an “arrangement” or various contemporaneous documents evidencing the conduct between the parties. CMS explained: In most instances, a single written document memorializing the key facts of an arrangement provides the surest and most straightforward means of establishing compliance with the applicable exception. However, there is no requirement under the physician self-referral law that an arrangement be documented in a single formal contract. Depending on the facts and circumstances of the arrangement and the available documentation, a collection of documents, including contemporaneous documents evidencing the course of conduct between the parties, may satisfy the writing requirement of the leasing exceptions and other exceptions that require that an arrangement be set out in writing. However, despite relaxing the standard for what constitutes a writing sufficient to meet a Stark exception, the Emanuele court illustrates that the writing requirement remains significant. The court initially noted that Stark expressly prohibits payment on Medicare claims that do not satisfy each element of an applicable exception. As such, all claims submitted by health care providers to CMS inherently imply compliance with the requirements of any relevant Stark exception. The court, quoting Escobar,

cautioned that although “statutory, regulatory, and contractual requirements are not automatically material, even if they are labeled conditions of payment,” they nevertheless represent “relevant” evidence in favor of materiality. Emanuele represents the first time that a federal court has had the opportunity to interpret and enforce CMS’s 2016 amendment as to the writing requirement. It cannot be overstated that the writing requirement is essential to ensure compliance with exceptions and avoid liability under Stark. Although the linguistic shift to an “arrangement” intended to relieve healthcare providers from the necessity of strictly maintaining and updating written agreements, the collection of contemporaneous writings still must contain the minimum requirements set forth in the regulations, notably a signature. Without meeting these requirements, healthcare providers may be exposed to liability under both Stark and the FCA, since federal courts will likely continue to interpret the writing requirement to go to the “basis of the bargain” between healthcare providers and CMS. Patricia Powers and Alexander Mills practice health law with Waller. Thank you to Chase Doscher and Emmie Futrell, Belmont University College of Law students, for their help in preparing this article.

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Birmingham Medical News

NOVEMBER 2017 • 9

The State of Senior Health 2017 Rankings Show Progress, Challenges By cindy SanderS

With the holidays just around the corner, many families will enjoy multigenerational gatherings. Not nearly as many will take the opportunity to discuss expectations and plans for the most senior members of the family … but perhaps they should. Earlier this year, UnitedHealth Foundation released “America’s Health Rankings Senior Report 2017: A Call to Action for Individuals and Their Communities.” The report provided a mixed bag of good news and concerns facing the nation’s fastest-growing population segment. “We continue to see improvements in clinical care,” said Rhonda Randall, DO, chief medical officer for UnitedHealthcare Retiree Solutions. Now in its fifth year, Randall said the annual ranking allows providers, researchers, insurers and population health managers to begin to see trends over time for Rhonda Randall, DO seniors. Since the first senior report was released in 2013, Randall said there have been decreases in hospital readmissions, deaths in the hospital, preventable hospitalizations, and less time in the intensive care unit during the last six months of life. Additionally, there has been an increase in the use of hospice care. Nationally, there was a 7 percent decrease in preventable hospitalizations (from 53.8 to 49.9 discharges per 1,000 Medicare enrollees) just in the past year. Since the first edition of the senior rankings in 2013, there has been a 7 percent decrease in hospital readmissions, a 30 percent decrease in hospital deaths, a 21 percent decline in hip fracture hospitalizations, and a 9 percent drop in ICU use at the end of life in the

Medicare population. However, Randall continued, “We continue to see challenges in our lifestyle – in the choices we make around our health.” Despite receiving good clinical care once the system is accessed, a growing issue is the volume of individuals who require that access. “Not only are we seeing a higher percentage of people turning 65 with a chronic condition, but we’re also seeing more people over age 65,” Randall said of the country’s demographic shift. In 2011, baby boomers began turning 65, and an average of 10,000 boomers celebrate the milestone birthday every day. By the time the last of the boomers hit retirement age in 2029, Pew Research Center projects 18 percent of the American population will be 65 or older. While the sheer volume of seniors could strain the delivery system, Randall said social determinants of health add to that burden. In creating the annual “America’s Health Rankings®” and subsequent senior report, UnitedHealth Foundation uses the World Health Organization definition of health: “Health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.” Therefore, the UnitedHealth reports consider 34 measures including the impact of behaviors, policy, and community and environment, in addition to clinical care, to assess health outcomes. “Obesity increased by 9 percent from the 2013 edition,” Randall said of the 27.6 percent of adults 65 and older who now fit the criteria. “Food insecurity increased by 16 percent over the last five years.” Additionally, she noted, data from the U.S. Department of Agriculture shows there has been a decrease in SNAP reach, which has gone down by 7 percent over the last two years for adults 60 and older living in poverty. Similar to other health rankings, the

Southeast was once again well represented at the bottom with Georgia (41), Alabama (43), Tennessee (44), Arkansas (46), Louisiana (47), Kentucky (49) and Mississippi (50) making up seven of the last 10. Higher rates of physical inactivity and smoking were a common thread among states at the bottom. On the other end of the scale, the five healthiest states for seniors were Minnesota, Utah, Hawaii, Colorado and New Hampshire. Randall was quick to say, “Every state, no matter where it’s ranked, has areas it should be proud of and areas where there is room for improvement.” She noted, “There’s no silver bullet to being ranked high on this list, but I can tell you the states that tend to rank highest on the list have a tendency to also rank very high in individual behaviors.” In addition to behavioral factors, environment and policy supports also have a major impact in how well seniors fare. Within the category of community and environment, the report looked at six key measures, including giving back. “We look at volunteerism,” Randall said. “It’s a proxy for purpose. We know that has a lot of positive effects on aging,” she continued of staying plugged into the community. Research has shown seniors with a reason to get up and do good typically have fewer depressive symptoms, better cognitive performance, higher activity levels and better mental wellbeing. Higher rates of volunteerism have also been associated with lower rates of mortality and heart disease. “Another call to action, I think, is around home-delivered meals,” Randall said of a measure where the large majority of states have room to improve. “That can be a significant benefit to the senior community,” she continued, adding a stable source of nutrition is a key factor in being able to age in place. The 2017 report stated

that increasing the number of seniors receiving home-delivered meals by 1 percent in each state has a projected cost savings of $109 million to Medicaid programs. Randall said the annual report is intended to be put to use by providers, policymakers and community representatives at a local, state and national level. “It’s definitely meant to be a call to action,” she said. Randall encouraged stakeholders to go online to and click on the 2017 senior report to take a deeper dive on specific measures to foster dialogue about what is working and where there is need to improve on behalf seniors.

Alabama by the Numbers

Overall Rank: 43 (up one slot from 2016) Determinants Rank: 36 Outcomes Rank: 47

The Good – National Rank Pain Management (% of adults 65+ with arthritis): 3 Excessive Drinking (% of adults 65+): 8 Community Support (dollars per adult 60+ in poverty): 15 Dedicated Health Provider (% of adults 65+): 7 Hospice Care (% of Medicare decedents 65+): 16

The “Needs Improvement” – National Rank Physical Inactivity (% of adults 65+ in fair or better health): 45 Geriatrician Shortfall (% of needed geriatricians): 43 Home Health Care (number of workers per 1,000 adults 75+): 48 Preventable Hospitalizations (discharges per 1,000 Medicare enrollees): 45 Able-bodied (% of adults 65+): 47 High Health Status (% of adults 65+): 49 Depression (% of adults 65+): 47 Multiple Chronic Conditions (% of Medicare enrollees 65+): 45 Premature Death (deaths per 100,000 adults 65-74): 45

Other Highlights

• In the past year, community support increased 94 percent from $344 to $666 per adult aged 60+ living in poverty. • In the past two years, low-care nursing home residents (those at the lower end of acuity) decreased 16 percent from 15.5 percent to 12.2 percent of residents. • Hospital readmissions have decreased 6 percent from 15.3 percent to 14.4 percent of hospitalized Medicare enrollees aged 65+ over the last three years. Since 2013, preventable hospitalizations have decreased 24 percent from 80.1 to 61.1 discharges per 1,000 Medicare enrollees. • On the flip side, obesity has increased 11 percent since 2013, rising from 27.1 percent to 30.2 percent among adults aged 65+.

10 • NOVEMBER 2017

Birmingham Medical News


Less Invasive New Therapies Are Restoring Hair By Ann B. DeBellis

the Southeast to use the stateof-the-art Healeon system for the stem cell therapy. T3 will be providing data to the FDA which will be regulating stem cell therapies. For complete hair loss and as a last resort treatment for some patients, Beckenstein uses the Neograft hair transplantation system. “It is the ultimate transplant for baldness that uses a technique called follicular unit extraction,” he says. “It allows us to move individual hair follicles from one part of the scalp to the thin or bald areas to restore more natural-looking hair. Small needle punctures create recipient sites for the hair follicles using follicular unit transplantation. This procedure eliminates the removal of large strips of scalp as was done in the past. It covers larger areas while using more grafts in a single session which reduces the number of procedures, the risk and the cost. There is no permanent surgical scar and minimal discomfort.” Neograft allows for natural restoration of the hairline as the T3 team carefully plans the location and orientation

Hair loss can be a sensitive issue for many men and women, but new treatments ranging from medications and lasers to a revolutionary hair transplantation procedure are offering hope for many. Michael Beckenstein, MD has made hair restoration a specialty and offers several options for re-growing hair. A board certified plastic surgeon, Beckenstein has developed treatments for a numerous hair loss causes. “People think hair loss results from hair that is falling out, but it is actually the hair shafts getting thinner. As they continue to thin, you start to see your scalp. After a while, those hair follicles will stop making hair and that’s when you have com- Michael Beckenstein, MD, performs a Neograft transplant. plete baldness,” he says. At Beckenstein’s hair again. We are seeing amazing results with restoration clinic T3, which stands for this therapy, averaging 99 percent viability ‘through thick and thin,’ he and his staff in the procedures we have done thus far,” evaluate patients and may use a variety Beckenstein says. T3 is the first clinic in of options to reach a positive outcome for each. “We offer several treatments for the early stages of thinning hair,” Beckenstein says. “We might recommend Propecia and Rogaine. Laser therapy is one of the better treatments for younger patients. A specialized laser penetrates the scalp and rejuvenates the hair follicles which will begin making thicker hair shafts.” For patients in early stages of hair loss, Beckenstein has introduced an approach to hair restoration known as platelet rich plasma (PRP) therapy. “We use the patient’s own blood products that contain platelets and activated growth products to stimulate the follicles to produce thicker, healthier hair shafts.” The blood is separated into concentrated PRP and the growth factors are inAt America Institute for Reproductive jected directly into the scalp at the follicle Medicine —Alabama, our new practice level. Beckenstein uses the Arteriocyte offers you not only exceptional clinical and PRP system which obtains the highest laboratory capabilities, but Dr. Long brings concentration of PRP. “The PRP growth you over three decades of helping couples factors mediate healing and restore the like you achieve that dream of a healthy baby. thicker hair shafts,” Beckenstein says. “We are seeing great responses to PRP therapy in a lot of patients.” The newest hair growth therapy at T3 uses true stem cells to restore hair. Board Certified in Stem cells live in bone marrow and fat, so Reproductive Endocrinology/Infertility they can transform into other cells to help with healing and regeneration. The stem DR. LONG IS ACCEPTING cells are injected into the scalp to stimulate NEW PATIENTS. the hair follicles to heal the hair shaft and Please call 205.307.0484 to stop the thinning process. “We have to schedule your appointment today. wake up the follicles so they will make hair

of each transplanted hair follicle. “We perform the procedure in the office with local anesthesia, and recovery is quick,” Beckenstein says. “Neograft is also ideal for eyebrow enhancement, scar reduction, and facial hair restoration.” Even with the variety of hair restoration therapies that are available, some patients are not candidates for the treatments. For these people, T3 offers scalp micropigmentation, a medical-grade tattooing practice to simulate the look of closely shaved hair. Beckenstein and surgical first assistant, Genger Ferrell, are the first practitioners in the United States to earn certification for this treatment developed by world renowned artist Andrea Darby. With any hair restoration therapy, Beckenstein’s primary goal for each patient is to stop the thinning process. People as young as 20 are visiting his practice for regular treatments to prevent significant hair loss as they age. “These new treatments are more of a continuum. We have changed a whole philosophy and that’s why we changed our practice name to Through Thick and Thin,” he says. “When you can stave off hair loss for several decades, that’s a big bonus. Eventually, hair transplantation will be obsolete.”

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Birmingham Medical News

NOVEMBER 2017 • 11

Urology Clinics Focus on Men’s Health, continued from page 1 Eric Westerlund, CRNP, Director of the Men’s Hormone Replacement Clinic, says they aim to address the full spectrum of patient issues. “We focus on low testosterone to help patients with low energy, fatigue, and weight loss, among other things,” he says. “We evaluate each patient and develop a specific plan for him.” While low testosterone doesn’t affect every man, many suffer the effects of a drop in the hormone level. “We start to see it in men in their 40s. It’s primarily a quality-oflife issue,” Christine says. “The symptoms often include a decrease in libido, decreasing energy levels, and difficulty in maintaining muscle mass. That’s when hormone replacement can be a big help.” Doctors commonly use testosterone injections once every other week to treat the problem. Other treatments that have been used in recent years include testosterone gels that are applied to the skin


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12 • NOVEMBER 2017

and testosterone pellets that are placed under the skin. Each of these treatments has pluses and minuses and should be discussed between patient and doctor. “We can’t stop father time, but a man with normal testosterone levels will feel better and have a higher quality of life than men of the same age who have low testosterone,” Christine says. Often, there is an overlap in the hormone clinic and the Men’s Sexual Health Clinic for erectile dysfunction issues. Laura Anderson, RN, is the senior nurse in the Men’s Sexual Health Clinic where the staff helps educate patients. “We develop a treatment plan based on the specific needs of each patient,” she says. “It’s not just men’s lives that we improve. Spouses and partners tell me how much they appreciate our help. We treat the couple as a whole and help them regain their intimacy.” Increasing age, medical conditions like diabetes and high blood pressure, pelvic surgery such as radical prostatectomy, and spinal cord injury all can lead to erectile dysfunction. “It is important for patients to know that regardless of the cause of erectile dysfunction, it can be treated,” Christine says. The treatment Christine uses most for these patients is implant surgery. “Most men who come to my office have already seen their primary care doctor or another urologist. They have tried treatments like Viagra or penile injections,” he says. “Many have such severe erectile dysfunction that none of those treatments are helping. That’s when I do a penile implant.” Christine says only about 10 urolo-

Birmingham Medical News

gists in the United States do the volume of penile implants that he does. “Few urologists do the surgery where an implant is placed into the penis completely,” he says. “A pump is placed in the scrotum with a saline sac located in the abdomen. The implant is self-contained in the body and will give a rigid erection. Of all the treatments we offer, penile implants have the highest patient satisfaction ratings, because they are natural and allow spontaneity. For 95 percent of men with severe erectile dysfunction, the implant surgery makes a tremendous difference in their sex lives.” Christine emphasizes that while his practice is centered around a man’s sexual problems, he would be remiss if he didn’t also treat the man’s spouse or partner. “Treating the man is only half of the issue. There is a couple involved, so we also treat any problem the partner may have,” he says. “If I don’t make it a point to ask both how they are doing, I may be missing a big part of the problem. I will never ignore the partner in that relationship.” Men’s sexual health is an important part of medicine, and Christine looks forward to new treatments that may be available soon. “There is a lot of research under way,” he says. “One day, for example, we may be able to inject testosterone directly into the penis to restore a man’s erectile function. In the next five years, I think the next generation of penile implants will use batteries like a pacemaker, and we may have an app on our phones where we can tap a button to inflate the implant. These new devices will be dramatically different, more sophisticated, and more patient friendly.”

Inflammation is the Common Denominator in Chronic Diseases,

continued from page 5 also fight inflammation.” Being able to measure inflammatory response has also become helpful in treating diseases like rheumatoid arthritis and lupus. “Rheumatologists can look at circulating levels of protein,” Lund said. “If there is a drug to block that protein, we can get a better sense of what drug is likely to work best. In lupus, doctors can look at inflammation to predict flares, which allows us to fine-tune medication to ease symptoms. “Transplantation research has also taught us a lot about the immune system. We have developed biologics to block proteins that cause inflammation. But we have to be careful about increasing susceptibility to other diseases. “We don’t want to block all immune response. We use vaccines to rev up the immune system to help it recognize diseases, and we’re creating adjuvants to increase response to make inflammation a more effective weapon against other diseases.” “The key is to better understand how the immune system works. When it detects a threat, proteins send immune cells to tissues. When they are activated, usually by a pathogen, they are supposed to kill it. But when tissue is damaged, the cells still go there and begin to kill that tissue. We’re trying to figure out how to teach the immune system not to attack what it shouldn’t. “With allergy shots and transplantation, we’ve been able to teach it not to pay attention so it doesn’t launch an immune attack. We’re working to develop similar treatments in other diseases with research such as that Dr. West is doing in Parkinson’s.” With so many chronic diseases, especially those that develop and progress as we age, there is a lot of work ahead. “When the immune system was evolving, it did a good job at learning to attack infections so humans could survive long enough to pass on their genes,” West said. “It didn’t do that much selecting to counter diseases that show up later in life, which is why so many chronic diseases become an issue as we get older. Now that we have a way to detect LRRK2, I’m hoping that will allow earlier detection in people at risk for developing Parkinson’s, particularly in those showing what could be early symptoms such as sleep disruptions and psychiatric changes. “We’re working to develop funding support for what would be the first Parkinson’s center focused on inflammation research. We need a weapon with laserguided precision to defeat Parkinson’s. We want to make the immune system smarter.”

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6/22/17 4:54 PM

NOVEMBER 2017 • 13

The Opioid Epidemic: Are We Headed Toward a Tipping Point? By Chris Thompson


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14 • NOVEMBER 2017

Birmingham Medical News

Health care law and policy occupy a prime place in the current news cycle. Much of the attention revolves around the actions or inactions of Congress and the White House, particularly with regard to their impact on the future form and function of the Affordable Care Act. Some significant health care issues can become overshadowed in the sometimes-tumultuous debates surrounding hot button pieces of national legislation. One of these national and seemingly growing issues is the problem of opioid abuse. This nation’s opioid problem has been labeled by many as an epidemic. It has played out across local, state, and national scales. Opioid abuse affects Alabama more than it does most other states, and the City of Birmingham itself has taken action in the fight against the problem. President Trump has, like others, labeled the problem a “national emergency.� His Administration has not escaped its touch: the President’s pick for “drug czar� withdrew from consideration on October 17th after allegations that he sought to shield big drug distributors—in particular, distributors of opioids—from some of the Drug Enforcement Administration’s powers. It is easy to lose sight of opioid-related developments in light of also important news about cost-sharing reduction subsidies, block grants, and changes to MIPS and the insurance market, but the present and ongoing impact of the opioid epidemic are undeniable. Opioids are often the default treatment for pain in America, but they do not come without risks. Prescribing physicians may find themselves in the trenches in the battle to help prevent opioid abuse, and arming themselves with information on the problem and possible solutions can help them help their patients. The Centers for Disease Control and Prevention (CDC) reports that the number of overdose deaths involving prescription opioids such as oxycodone, hydrocodone, and methadone have more than quadrupled since 1999. The CDC also noted that 91 Americans die each day from opioid overdose. Close to home, the Alabama Department of Public Health’s Center for Health Statistics reports a 13 percent increase in opioid deaths since 2011; more pain pills are prescribed per person in Alabama than in any other state. This epidemic appears to be gaining ground, but its damage has not gone unnoticed or unopposed. It’s worth paying attention to the many efforts, in our state in particular, that have been brought to bear on the crisis. The responses to the

crisis have been varied, ranging from policy approaches to education, from legislation to litigation. In August of 2017, Governor of Alabama Kay Ivey created the Alabama Opioid Overdose and Addiction Council to study opioid addiction. The Council will report to the Governor by December 31, 2017 on strategies to address Alabama’s ongoing opioid crisis. Such strategies are already being advanced, such as the distribution in September of 600 opioid overdose kits to Alabama rapid responders Also in August of 2017, the City of Birmingham filed a suit in the Northern District of Alabama against three major national drug distributors, alleging that the distributors sent millions of dollars’ worth of opioids into Birmingham while failing in their obligation to report suspicious drug shipments. As will be discussed further below, this case is one among many several cases. Then, in September, Alabama Attorney General Steve Marshall announced that he would be joining with the Attorneys General of 40 other states in order to address the opioid crisis. In particular, the bipartisan group of State AGs will investigate whether drug manufacturers and distributers are violating any laws as they market and distribute opioids. The group has issued subpoenas and demanded information from several manufacturers and distributors—including the three distributors which are the focus of the City of Birmingham’s lawsuit. Even commercial insurers have gotten in on initiatives to address the opioid crisis. Blue Cross Blue Shield of Alabama (BCBSAL) is partnering with local and state agencies to increase public awareness of opioid risk; supporting proper prescribing of opioids by educating primary care physicians; offering medication-assisted treatment for BCBSAL members; and supporting public outreach efforts to prevent opioid use and abuse. The history of the opioid epidemic suggests that the most effective responses will come from various categories of actors (distributors, prescribers, and patients) working together towards the same ends. Multi-focused approaches like those of BCBSAL recognize that no one solution will fix this problem. As noted above, the City of Birmingham’s lawsuit is not alone. Counties and cities across the country have been filing suits against drug companies involved in the opioid supply chain, and this trend shows no sign of ceasing. One law firm recently moved to transfer 66 lawsuits, filed in various federal courts around the nation, leading to expectations that consoli(CONTINUED ON PAGE 17)


Who Will Take Care of Me When I’m Old? by Joy Loverde; 2017, Da Capo Livelong Books; $17.99; 313 pages “I do it myself!� Those are words you’ve been saying practically since you were able to speak. You can get your own drink, button your shirt, pull on your pants, walk yourself downtown, drive yourself around, and figure out life. You’re independent, but in the new book Who Will Take Care of Me When I’m Old? by Joy Loverde, you might want to re-rethink the future. As the author of three books meant for seniors, Joy Loverde knows a few things about being that Age. One of the first, biggest truths is that one in three baby boomers is “separated, divorced, widowed, or never married� – in other words, alone. What happens, then, when solo living isn’t an option anymore? You can prepare for that near-inevitability, says Loverde, but you have to promise to be “completely honest with yourself about the fact that you are getting older.� Stop spouting cutesy things and remember that “Sixty is not the new thirty.� Think about where you are now, and imagine what life will realistically be like a decade hence. Know your sociability: do

Joy Loverde

you like people? Can family be counted on to help? Are you frozen in fear? (Hint on the latter: you’ve been through changes before, you know). Remember that money is key to surviving old age. You’ll need to be financially savvy, and that includes knowing absolutely everything about your household situation. Talk with your spouse and take notes. Hire a lawyer or advisor to help; it’s imperative that you’re protected, smart, and you know where you stand.

Think about the obstacles you’ll encounter should you need to relinquish independence. Make a detailed list of your life: online presences, passwords, bank accounts, and the location of personal papers. Know what you face if you fall ill. Consider finding an age-friendly community in which to grow old, and remember: “family� isn’t necessarily biological. It doesn’t even have to be human. There’s a lot of help inside Who Will Take Care of Me When I’m Old? And there’s a lot of fluffy-work. Initially, you’ll want to know that this book doesn’t stay exactly true to its title. Author Joy Loverde encourages readers to do a lot of prep-work, including a good amount of self-examination, well before getting to the information for which this book was likely sought. Impatient readers should be forgiven for chafing. Once you’re past that, the tasks get hard-boiled and there’s a lot to think

about. Loverde asks you to consider the thorniest questions about leaving home or staying, asking for help or stoicism, severe illness, death, and facing the truth about any other new situation you’ll encounter. There’s where the worksheets are extremely helpful; so are the websites and checklists. Another thing: this book has a wide audience. Loverde touches upon concerns for LGBT and straight readers , as well as for families and those who are superearly-bird planners. And that, overall, makes Who Will Take Care of Me When I’m Old? a great resource because you can’t always do it yourself. 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

NOVEMBER 2017 • 15

A Plan to Address COPD find solutions to support the community.”


Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of death and fourth leading cause of disability in America, according to the National Institutes of Health. The umbrella term encompasses a number of progressive lung diseases including emphysema, chronic bronchitis and refractory asthma. While the National Heart, Lung, and Blood Institute (NHLBI) identifies 16 million Americans as being diagnosed with COPD, that figure only tells part of the story. The American Lung Association and COPD Foundation both estimate closer to 25-30 million Americans are impacted by COPD … but millions are unaware they have the disease.

The Diagnosis Issue Jamie Sullivan, MPH, vice president of Public Policy and Advocacy for the COPD Foundation, said one reason people go undiagnosed is because symptoms often aren’t noticeable in the earliest stages. Even when individuals begin to experience increased breathlessness and coughing, it’s easy to pass it off as a cold, allergies or simply part Jamie Sullivan, MPH of the aging process and to change behaviors, like avoiding stairs, to mask the problem. Another issue, she added, is that phy-

sicians aren’t necessarily asking the right questions during routine visits when the disease might be caught in the early stages. Sullivan noted most diagnoses occur when symptoms have become so severe patients can no longer ignore them. The CAPTURE Study, she added, found most people aren’t diagnosed with COPD until they have already lost half their lung function. Primarily seen as a smoker’s disease, Sullivan said there is also a “shame and blame” element surrounding COPD. However, she noted, there is an increasing understanding that other factors including environment, prematurity, and genetics also add to the burden of the disease. “Our founder John Walsh, who unfortunately passed away earlier this year, saw there was this huge hole in support for COPD patients,” said Sullivan. “He really put out a call to action to the patient and scientific community to come together and

Mounting a National Response It has only been since 2013 that COPD rates across all 50 states have been available with the data put forth from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance Survey (BRFSS). Further complicating the issue, there haven’t been national screening parameters, a coordinated action plan, or funding for COPD research at the level of other diseases. However, the hope is all of that might be about to change with the release of the COPD National Action Plan earlier this year. “Prior to the release of the federal action plan in May, there hadn’t been a coordinated federal response,” said Sullivan. Now, she continued, “Here’s a blueprint of how we, as a country, can tackle COPD.” Sullivan said the COPD community had advocated for this type of coordinated response for years. She noted many stakeholders, including the COPD Foundation, had a voice in creating the collaborative plan. Following interagency work groups at the federal level in 2014 and 2015 and a letter from Congress urging next steps in late 2015, Sullivan said NHLBI hosted a town hall meeting in February 2016 open to physicians, patients, researchers and COPD organizations. “That was a great chance for the community to come together to talk about what are the major issues the plan should address and to prioritize goals,” Sullivan noted. Following the town hall meeting and

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Birmingham Medical News


period for public comment, the finalized COPD National Action Plan outlines five key goals: • Empower people with COPD, their families, and caregivers to recognize and reduce the burden of COPD. • Improve the diagnosis, prevention, treatment and management of COPD by improving the quality of care delivered across the healthcare continuum. • Collect, analyze, report and disseminate COPD-related public health data that drive change and track progress. • Increase and sustain research to better understand the prevention, pathogenesis, diagnosis, treatment and management of COPD. • Translate national policy, educational, and program recommendations into research and public health actions. The next steps, Sullivan said, are to move forward with implementation of the plan.

What’s Happening Now In the meantime, Sullivan said there are a number of immediate steps to improve care including an emphasis on ensuring everyone is diagnosed properly and on time, enhancing patient education efforts, instituting a personalized treatment regimen to meet a patient’s specific needs, and where appropriate, utilizing pulmonary rehab. “These are all things we don’t need new treatments to do,” she said of deploying an evidence-based approach. Sullivan added the COPD Foundation and others have long advocated for broader use of primary pulmonary rehab, a non-pharmacologic management option. “Think of it as physical therapy for your lungs with the added benefit of education and support,” she said. Reimbursable at low levels that Sullivan said aren’t sustainable, pulmonary rehab therapy is typically offered only though hospital-based programs. Without enough programs, Sullivan said it’s been hard to gain traction among patients and physicians. Another issue is the time commitment, which entails two hours of education and exercise plus travel time. “To get adherence and compliance with someone, that takes a major commitment,” she noted. “But for the people who do, nearly everyone you talk to will say it changes their life.” While the therapy is evidence-based, Sullivan said more research is needed to grow awareness and improve reimbursement rates. However, she noted, research funding has been another ongoing issue. “It goes back to the federal response to COPD, which is around $100 million per year gets spent on federal research … which is pennies compared to the impact of the disease,” she said. Sullivan added that while a great deal of progress has been made in understanding COPD and its genetic basis, additional research funding could really accelerate that work. “This coordinated action plan could be the tipping point,” she said. “It has the potential to be if the community rallies around it,” she concluded.

The Opioid Epidemic, continued from page 14 dation into multi-district litigation (MDL) may be around the corner. As many of the suits involve the same defendants and the same allegations (generally, that the drug companies have understated the addictive nature of the drugs for the sake of profit, and/or that they have failed in reporting obligations), consolidation of at least some of the suits may make sense. Regardless, staying abreast of the proliferation of such cases on the national scene is valuable, as the resolution of these cases may shift the opioid-prescription landscape. The approaches to confronting the opioid epidemic discussed above are only a selection of the many steps taken at both the state and federal levels. The opioid crisis shows little sign of receding, while at the same time efforts addressing the problem have ramped up. It may be that we are nearing the point of critical mass at which some of these efforts gain significant traction. Whether the problem at large is solved, however, health care professionals’ awareness of this crisis and of the resources and initiatives available to address it can only help their patients. Chris Thompson practices at Burr & Forman LLP in the Health Care Industry Group.

Billing Under Another’s Provider Number can Cause Trouble By Emma Cecil, JD

An Oklahoma physician recently agreed to pay the government $580,000 to resolve allegations that he violated the False Claims Act by submitting claims to the Medicare program for services he did not provide or supervise. According to the government, the physician allowed a company that employed him and in which he had an ownership interest to use his NPI numbers to bill Medicare for physical therapy services that he did not provide or supervise. The government further alleged that after he left the company and deactivated his NPIs associated with the company, he reactivated those NPIs so that the company could use them to bill Medicare for services he neither performed nor supervised. This case is another example of the risk involved in billing services provided to federal health program beneficiaries under another provider’s name and national provider identification (NPI) number. In 2011, the University of North Texas Health Science Center agreed to pay $859,500 for allegedly violating the Civil Monetary Penalties Law (CMPL) by submitting claims for physicians’ services provided to Medicare and Medicaid beneficiaries using the NPI numbers of 103 physicians who neither provided nor supervised the services rendered. Other examples include a family practice physician who paid $133,880.50 under the

CMPL for submitting claims to Medicare for nurse practitioner services as if he had personally performed the services; and a hospital that paid $706,090.46 for violating the CMPL by submitting claims for physicians’ services provided by a doctor to Medicare beneficiaries using the provider identification numbers of another doctor, who did not further the services. Although these cases involve relatively small penalties under the CMPL, the Oklahoma physician’s settlement makes clear that more significant False Claims Act liability is a real risk for providers who bill under the incorrect provider identification number. As a reminder, services provided to Medicare beneficiaries should always be billed under the name and NPI of the provider who actually performed the services, and billing under one physician’s NPI for services that are in fact provided by another physician or non-physician provider may be viewed as fraudulent since there is little doubt that the identity of the person performing the service would be material to the government’s decision to pay the claim. The most common exception to this general rule is when services provided by non-physician practitioners to Medicare beneficiaries are billed “incident-to” a physician’s services. While CMS has acknowledged in informal guidance that a physician’s services may be billed incident to another physician’s services so long as all

of the incident-to requirements, including direct supervision, are satisfied, this practice is not favored and should be used sparingly. CMS has observed that billing a physician incident to another physician is warranted only in rare circumstances. Importantly, the incident-to rules are a Medicare invention and may not apply outside the context of Medicare billing. Many commercial plans prohibit the practice of billing the services of one provider under the name and NPI of another provider and explicitly require that all services be billed under the name of the rendering provider. Providers billing private payors must therefore review their provider contracts to determine whether billing the services of one provider under the name and NPI of another provider is allowed – and if so, under what circumstances – or whether it’s forbidden. If prohibited, billing under another provider’s name and NPI could result in criminal liability under the federal health care fraud statute, which makes it a crime to knowingly execute, or attempt to execute, a scheme or artifice to obtain, by means of false or fraudulent pretenses, representations, or promises, money or property owned by any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services. Practices under pressure to pay non(CONTINUED ON PAGE 18)

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Study Shows Brain Structures Make Some Resilient to Alzheimer’s The size, shape and number of dendritic spines in the brain may play a major role in whether someone gets Alzheimer’s disease, according to new research from UAB. Dendritic spines are sub-units of neurons that act as the connector to other neurons. In findings published October 24th in the Annals of Neurology, the research team showed, for the first time, that the presence of healthy dendritic spines conveyed a protective effect against Alzheimer’s in people whose brains had proteins associated with the disease. “One of the precursors of Alzheimer’s is the development in the brain of proteins called amyloid and tau, which we refer to as the pathology of Alzheimer’s,” said Jeremy Herskowitz, PhD, assistant professor in the Department of Neurology, School of Medicine and lead author of the study. Jeremy Herskowitz, “However, about 30 PhD percent of the aging population have amyloid and tau buildup but never develop dementia. Our study showed that these individuals had larger, more numerous dendritic spines than those with dementia, indicating that spine health plays a major role in the onset of disease.” Neurons are constantly sending out long, thin dendritic spines in search of other neurons. When they connect, a synapse, or exchange of information between neurons, occurs. This is the basis for memory and learning. “One obvious culprit in Alzheimer’s disease is the loss of dendritic spines and thus the loss of synapses,” Herskowitz said. “This would impair the ability to think, so the assumption has been that those without dementia had healthy spines and those with dementia did not. But no one had gone in to see if that was true.” Herskowitz’s team studied brain samples from patients at memory clinics at Emory University. The control group did not have the Alzheimer’s pathology of amyloid plaques and tau tangles and never developed dementia. A second group had the Alzheimer’s pathology and progressed to the disease. The third group had the pathology, but no disease. The researchers took thousands of microscopy images of the subjects’ brains which they then turned into 3-D images using novel software. This allowed the team to look more fully at the shape and dimensions of each image. “We first noted that the control group had more dendritic spines than the group with Alzheimer’s, which matched beautifully with existing historical data,” Herskowitz said. “But we also saw that the group with Alzheimer’s pathology but no disease also had more spines than the Alzheimer’s group. In fact, they had roughly the same spine density as the control group. What is even more exciting is that the ‘pa-

thology but no disease’ group had very long spines, longer than both the control group and the disease group.” Herskowitz said the longer spines demonstrated great plasticity. This indicates that they could navigate around or through amyloid plaques or tau tangles in their efforts to connect with other neurons. “This provides an explanation of why some people are resilient to Alzheimer’s, even if they possess the typical Alzheimer’s pathology,” he said. Herskowitz says that the high plasticity and density of dendritic spines in this population could be genetic. Another theory suggests that it could be the result of healthy lifestyle behaviors, such as good diet and exercise, which are known to be protective against dementia. It may be that the reason these behaviors are protective is that they help maintain spine health, plasticity and density. The findings also offer a new target for slowing or preventing Alzheimer’s. “This provides a target for drugs that would be designed to support dendritic spine health in an effort to rebuild neurons or prevent their loss,” Herskowitz said. “This data suggests that rebuilding neurons is possible. And as we are better able to identify the increase of amyloid and tau early in the progression of the disease, even before symptoms arise, we might be able to one day offer a medication that can contribute to maintaining healthy dendritic spines in those with the Alzheimer’s pathology.” Herskowitz credits the innovative 3-D imaging system used in the study to groundbreaking work done by UAB science and technology honors student Benjamin Boros. Funding for the study was provided by the National Institute on Aging, part of the National Institutes of Health, and the Alzheimer’s Association.

Billing Under Another’s Provider, continued from page 17 credentialed physicians should think long and hard about billing the non-credentialed physician’s services under a credentialed physician’s NPI. Doing so without strictly complying with all of CMS’s stringent incident-to requirements, or in violation of private payor contracts, can spell big trouble, including penalties under the CMPL, treble damages under False Claims Act liability, and even criminal liability under the federal health care fraud statute. If you have questions about Medicare incident-to billing requirements or billing for non-credentialed providers, please call MagMutual’s Senior Regulatory Attorney, Emma Cecil, at (404) 842-4670. Emma Cecil, JD is the Senior Regulatory Attorney & PolicyHolder Advisor with MagMutual.

Birmingham Medical News

NOVEMBER 2017 • 19


UAB Listed in 100 hospitals with Great Heart Programs Becker’s Healthcare has named UAB Hospital to the 2017 edition of its list of “100 hospitals and health systems with great heart programs.” UAB is the only hospital in Alabama to be named to the list. UAB Hospital houses a 21-bed cardiac care unit specializing in procedures such as heart transplants and cardiopulmonary rehabilitation. To develop this list, the Becker’s Healthcare editorial team examined several reputable rankings and award agencies, including U.S. News & World Report rankings for cardiology and heart surgery; Truven Health Analytics cardiovascular hospital rankings; CareChex rankings for cardiac care; Blue Distinction Centers for cardiac care; and Society of Thoracic Surgeons star rankings.

St. Vincent’s Health System to Adopt Ascension as Part of its Name St. Vincent’s Health System (STVHS) will add Ascension to its name as part of a national effort to make it clearer for patients to access care. In moving toward a unified name, St. Vincent’s will change its name to Ascension St. Vincent’s and adopt the Ascension logo. By creating more consistent names for its facilities across the country, Ascension will better connect every aspect of care across its hospitals. STVHS has been part of Ascension since its founding in 1999. Ascension is the nation’s leading nonprofit health system, with 2,500 sites of care and 36,000 provid-

ers in 22 states and Washington, D.C. STVHS joins Ascension systems in five other states in beginning the move to a unified name, which will take place within the next year.

UAB physician named to 2017 National Academy of Medicine Fellows Ellen Eaton, MD, assistant professor in the UAB Division of Infectious Diseases, was selected for the 2017 National Academy of Medicine Fellows. Eaton is one of five outstanding health professionals chosen based on her qualifications and accomplishments, reputation as a scholar, and relevance of current field expertise to the work of the NAM and the Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine. As a fellow, she will collaborate with eminent researchers, policy experts and clinicians from across the country during her two-year fellowship. She will help facilitate initiatives convened by the National Academies to provide evidencebased guidance to national, state and local policymakers, academic leaders, health care administrators and the public.

Blue Cross and Blue Shield of Alabama Partners With axialHealthcare Blue Cross and Blue Shield of Alabama is partnering with axialHealthcare, a national leader in pain management, to collaborate with Alabama physicians to help curb the opioid epidemic. In 2015, Alabama ranked first in the nation in number of opioid scripts per

capita. The recent Blue Cross and Blue Shield Association’s report on the opioid epidemic showed over 26 percent of its commercial members in Alabama filled at least one opioid prescription in 2015, and 16 per 1,000 members were diagnosed with opioid use disorder in 2016. “By working in conjunction with our physicians and axialHealthcare, Blue Cross intends to reduce opioid misuse by giving our physicians resources and tools that encourage appropriate prescribing protocols,” said Anne Schmidt, MD, Medical Director for Blue Cross and Blue Shield of Alabama. This new program aims to support Blue Cross and Blue Shield of Alabama providers by giving a more comprehensive view of a patient’s medical history, providing ongoing consultation with axial’s team of pharmacists, increasing awareness of prescribing behaviors and the latest evidence-based guidelines, and sharing resources and educational tools to support appropriate prescribing protocols.

UAB Breaks Ground on New Facility UAB has broken ground for a new freestanding emergency department and adjacent medical office building in Gardendale. The two buildings, which will be connected to each other on a 6.2-acre site in the Gardendale city center, are scheduled for completion in spring 2019. Construction will cost $22 million, with a total project budget of $33.9 million. The site is at the intersection of Mount Olive Parkway and Flippo Road. Brasfield & Gorrie

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is the general contractor. Sims Architectural Studio is the architect for the emergency department, and Gresham Smith & Partners for the medical office building. The freestanding emergency department will have 26,700 square feet of space and provide a full range of emergency medicine services staffed around the clock by physicians who are boardcertified in emergency medicine. The facility will have an FAA-compliant heliport, advanced MRI/CT/X-ray imaging, 12 exam rooms, a bariatric lift, laboratory services, and a pharmacy. The emergency department will be capable of performing trauma care and will have facilities for isolation and decontamination. The 38,400-square-foot, two-story medical office building will offer primary care, obstetrics, gastrointestinal care, orthopedics, cardiology, neurology, neurosurgery, ophthalmology and specialty care programs. It will feature a diagnostic imaging suite, lab services, telemedicine and digital public interface kiosks. Together, the two medical facilities will employ more than 100 staff, including physicians, nurses, laboratory technicians, other medical professionals and office staff.

Biotech Veteran Jay Liu Joins Southern Research

Jay Liu, PhD has joined the Southern Research Drug Discovery division as director of technology development and innovation. Liu will seek to expand Southern Research’s drug discovery capabilities in areas that include biologics and monoclonal antibodies. He will also strive to advance projects already in Southern Research’s drug discovery pipeline. “I want to push these projects forward so that a pharmaceutical company or venture capitalist investors will want to work with us to deliver a commercial product,” Liu said. Before joining Southern Research, Liu served as CEO of China’s Nanjing Galaxy Biotech and Suzhou Galaxy Biopharma, where he directed a team of around 70 scientists. In 2010, he co-founded China’s Rugen Therapeutics where he formed alliances with research organizations around the world while building a drug discovery capability that targeted central nervous system diseases. During his tenure, the Rugen team developed several candidate drugs that were licensed for clinical evaluation as treatments for autism and bipolar disorders. In 1995, Liu started his career in the U.S. pharmaceutical industry, which included jobs at Merck and AstraZeneca. During this time, he led teams that delivered five investigational new drugs, two of which completed Phase II clinical studies. Liu holds a doctorate in pharmacology from the State University of New York at Buffalo and also studied at the Chinese Academy of Sciences and the University of California. He received postdoctoral training at the National Institutes of Health. He has published more than 30 research papers and has filed 10 patent applications.


Researchers Awarded $5.7 Million Researchers studying methods of exercise delivery and the effects on people living with multiple sclerosis have been awarded $5.7 million in funding by the PatientCentered Outcomes Research Institute (PCORI). The research represents a collaboration between Robert Motl, PhD, a professor at the UAB School of Health Professions and Deborah Backus, PT, PhD, director of Multiple Sclerosis Research at Shepherd Center. Gary Cutter, PhD, professor of biostatistics at UAB, will run the project’s data analysis core. The study will evaluate the effectiveness of different types of exercise programs for people with multiple sclerosis. The project will compare exercise programs provided at gyms or rehabilitation facilities with a telerehabilitation program available to patients at home. The goal is to increase the accessibility and sustainability of exercise options for people with MS. In addition to being co-principal investigator of the study, Motl developed the exercise program being implemented in the study. “The exercise program itself was developed based on 15 years of research on exercise in persons living with MS, and has been optimized for maximizing compliance and adaptations,” Motl said.

Charlie Braswell, MD with the da Vinci Xi System.

Shelby Baptist Obtains New Robotic System Shelby Baptist Medical Center has acquired the new da Vinci Xi Surgical System, further complementing the hospital’s minimally-invasive robotic surgery capabilities. The da Vinci Xi system is the next frontier for minimally invasive surgery, combining the latest assisted surgical technologies which allows for easier access to targeted areas. “As a surgeon, the da Vinci Xi system gives me greater flexibility and control over more areas of the body,” Charlie Braswell, MD said. “Patients appreciate the opportunity for less scarring, quicker recovery and going home faster.” While the da Vinci Xi robot was initially adopted for prostatectomies and gynecology, the technology is becoming more commonly utilized in general surgery. Today, the da Vinci Xi can be used in hernia repair, thoracic surgery, gynecological, pelvic floor and abdominal procedures including gallbladder, colorectal and a number of other procedures.

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Mona Fouad, MD is Honored Mona N. Fouad, MD, professor and director of the Division of Preventive Medicine in the UAB School of Medicine, has been elected as a member of the National Academy of Medicine — one of the highest honors given to a physician or scienMona N. tist in the United States. Fouad, MD This honor acknowledges a lifetime of exceptional work in health and medicine. Fouad is nationally recognized as a leader in health disparities research. Fouad has served in myriad local, national and international leadership positions for a variety of organizations. She has served as a member of the NIH National Advisory Council on Minority Health and Health Disparities and the American Cancer Society Mid-South Division Board of Directors. For six years, Fouad was commissioner of the Black

Belt Commission, appointed by former Alabama Governor Bob Riley. She is an external advisory board member of the Gulf South Minority/Underserved NCI Community Oncology Research Program, Louisiana State University, and the Centre for Health and Development, Staffordshire University, U.K. Her achievements have been recognized nationally as a recipient of the American Cancer Society St. George National Award in 2016, recognizing her distinguished service to achieving the ACS’ strategic goals and the 2016 President’s Council on Fitness, Sports and Nutrition Community Leadership Award for exemplary service and dedication to improving the lives of others by promoting and fostering opportunities for participation in fitness, sports and nutrition programs. Fouad was also named one of the 2016 “Women Who Shape the State” by the Alabama Media Group.

William McAlexander, MD Chosen for Fellowship The American Association for Thoracic Surgery has selected William McAlexander, MD as a recipient of the 2017 James L. Cox Fellowship in Atrial Fibrillation Surgery. McAlexander, who affiliates with Brookwood Baptist Medical Center, was chosen out of William 334 other surgeons. He is a McAlexander, MD Thoracic Surgery Specialist who graduated with honors from Tulane University School of Medicine in 1998. “I’m honored to have the opportunity to participate in this immersive learning experience with guidance from top experts in the atrial fibrillation field,” McAlexander said. The fellowship was set up to provide cardiothoracic surgeons with an engaging educational experience at leading surgical Afib centers across the United States. Eight experts in Afib surgery will act as host surgeons, providing one-onone mentoring and formalized training to award winners over the course of three months. The fellowship will also include a didactic training course led by Dr. James Cox, whose pioneering work established the field of Afib ablation.

Wilson Joins Alabama Allergy & Asthma

The Whitaker Clinic at UAB.

UAB Medicine Opens New Outpatient Clinics UAB has added 28,600 square feet of clinical space with expansion into the John N. Whitaker Building, which sits just east of the Kirklin Clinic parking deck. The new facility, called the Whitaker Clinic at UAB Hospital, houses primary care, dermatology, podiatry and rheumatology clinics. After the UAB Health System administrative group moved from the Whitaker Building to the new UAB Medicine Avondale Business Center, UAB undertook a $10.8 renovation to transform the building into an advanced clinical space. The renovation includes 80 exam rooms, waiting areas, a laboratory, digital Xray, and a convenient injection area for flu shots or other basic inoculations. The clinics employ the care team model, which includes a physician, physician assistant or nurse practitioner, nurses, and other medical staff who form groups of primary care staff members with collective responsibility for a set of patients. Renovations will begin in the Kirklin Clinic of UAB Hospital later this year to reconfigure space there for additional growth.

Lorena Wilson, MD has joined Alabama Allergy & Asthma Center, and is seeing patients at the Homewood, Hoover and Alabaster locations. Wilson received her medical degree from Drexel University College of Medicine and completLorena ed her Pediatric Residency Wilson, MD at St. Christopher’s Hospital for Children in Philadelphia. She completed her Allergy and Immunology Fellowship at Duke University Medical Center in Durham, North Carolina. After her fellowship, Wilson completed her Masters of Health Sciences in Clinical Research at Duke University. She is Board Certified in Pediatrics and Adult and Pediatric Allergy and Immunology, and is a member of the American Academy of Allergy, Asthma and Immunology and the American College of Asthma and Immunology.

Bryant Promoted to COO of Grandview


Rehearsal Dinners


Corporate Events



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Birmingham Medical News

Justin Bryant has been promoted to Chief Operating Officer of Grandview Medical Center. He succeeds Drew Mason who was recently promoted to CEO. Bryant was named Assistant Chief Executive Officer of the medical center Justin Bryant in 2015. In the new role, he will be responsible for procedural, ancillary and clinical support services and serve as the operations support link to nursing services.

Prior to joining Grandview, Bryant served as an Administrative Specialist at Flowers Hospital in Dothan. He also has five years of experience in a clinical setting as a staff nurse in CVR/CVSU. A native of Birmingham, Bryant graduated from Hoover High School. He received his bachelor’s degree from Auburn University in 2005. He holds three degrees from UAB - a Bachelor of Science degree in Nursing; a master’s degree in Business Administration; and a master’s degree in Health Administration. Bryant serves on the Alabama Hospital Association’s Telehealth Task Force and is on the Board of Directors for The Bell Center for Early Intervention Programs. He is a member of the American College of Healthcare Executives and the American Association of Critical Care Nurses.

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St. Vincent’s Primary Care Adds New Physicians St. Vincent’s Primary Care, a service of St. Vincent’s Health System, has recently added one existing practice and three new physicians to their network. Herbert Walker, Jr., MD, who has a longestablished primary Herbert care practice in Cahaba Walker, Jr., MD Heights, has added his practice to the St. Vincent’s Primary Care network. Walker, who is board certified in family medicine, received his medical degree from UAB and completed his family medicine residency at East End Memorial Hospital which is now St. Vincent’s East. Drew Smith, MD has joined Northside Medical Associates at the Trussville location. St. Vincent’s Health System and Northside Medical Associates have partnered to provide primary care services at this office. Smith is board certified in Family Medicine. He received his medical degree from the University of Alabama School of Medicine and completed his internship and residency at the Family Medicine Residency Program at the University of Alabama in Huntsville. Shanon Jernigan, MD has begun practice at the Patchwork Farms Vestavia location that is a partnership of St. Vincent’s Primary Care and Birmingham Internal Medicine Associates. Jernigan is board certified in family medicine. He received his medical degree from UAB and completed his residency at Tuscaloosa Family Practice Residency. Joseph Brewer, DO has joined the St. Vincent’s Primary Care in Gardendale. He received his medical degree from the DeBusk College of Osteopathic Medicine at Lincoln Memorial University and completed his family medicine residency at the University of Alabama.

Giammanco Joins Cullman Podiatry Natalie Giammanco, DPM has joined the Cullman Regional Medical Staff where she will practice with Cullman Podiatry. Giammanco is a board-certified podiatrist who has been in practice for 19 years. A native of Natalie Philadelphia, Pennsylva- Giammanco, DPM nia, she is a graduate of Temple University and completed Medical School at Temple University School of Podiatric Medicine.

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