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FOCUS TOPICS DENTISTRY • MEN’S HEALTH • DERMATOLOGY/AESTHETICS • MIPS

June 2018 >> $5 ON ROUNDS Daughter Follows Dad to Medicine, Then Takes a Turn Memphis physician Frances Kirkland Lawhead was drawn to medicine at an early age and followed her father’s example to become a doctor. But along the Frances Kirkland way, she Lawhead turns down a different path.

Profile on page 3.

Aesthetic Medicine’s Biggest Challenge: Patient Expectations A nationally recognized plastic surgeon said the biggest fear patients have with cosmetic procedures is they’ll wind up looking like they’ve had a cosmetic proSteven Dayan cedure. “It’s our number one barrier to getting patients in the office.”

Strengthening the Connection Between Teeth and Heart                                 

Study: Periodontal Disease Connected to Risk of Heart Attack, Stroke By MADELINE PATTERSON SMITH

Those who argue that dentists could save their patients from a heart attack or stroke now can point to research that supports the claim. A new study is strengthening the link between periodontal disease and increased risk of heart attack and stroke. David R. Cagna, DDS, MS, is Associate Dean at the University of Tennessee College of Dentistry. “A lot of diseases that are in the mouth,” he said, “can have a global effect on the body.” He sees a future where “dentists and physicians will have to interact more frequently than they used to” as we continue to learn more about the links between diseases in the mouth and the rest of the body.  The University of South Carolina School of Medicine’s Souvik Sen, MD, conducted one of the largest U.S.-based studies of periodontal disease, dental care and ischemic stroke. The results were (CONTINUED ON PAGE 6)

HealthcareLeader

President of Medical Society, Dr. Parker Tracks Opioid War 

Story on page 4.

Task Force Reveals Recommendation On PSA Screening

By JUDY OTTO  

Memphis Medical Society President and Memphis native Autry Parker Jr., MD, seems as proud to be a former Wooddale High School Cardinal as he is of his medical degree from Yale University – and the distinguished recognition that has followed him during his 30 years in practice as a pioneering anesthesiologist. Currently accepted views on a multidis-

The final recommendation by the U.S. Preventive Services Task Force concerning PSA-based screening for men 55-69 and those 70 and up: Where the evidence led them.

Report on page 5.

ONLINE: MEMPHIS MEDICAL NEWS.COM

ciplinary approach to pain management were groundbreaking in 1988, when Dr. Parker focused on this approach during his residency and fellowship at Johns Hopkins Hospital. He served there as the first Blaustein Pain Fellow, following a graduate thesis that introduced early protocols for patient-controlled analgesia (PCA) that are still widely used today.            His early lectures and papers on opiate therapy – regarded by some as heretical at the (CONTINUED ON PAGE 8)

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PhysicianSpotlight

Father Set the Example for Dermatologist Frances Lawhead Followed Him Into Medicine, Then Chose a Different Path By LAWRENCE BUSER

Perhaps like many other physicians, Frances Kirkland Lawhead found herself drawn toward medicine at an early age. She enjoyed accompanying her father, otolaryngologist Dr. Ron Kirkland of Jackson, Tennessee, on hospital rounds, often spinning around in the chairs at the nurses’ station. “The medical staff was always kind to me, and dad knew everyone and spoke jovially as we walked through the halls,” Dr. Lawhead recalled. “It was neat watching him as I was growing up not only as my father but as a great doctor. I was drawn to science and math, and I ended up following his footsteps, going to med school and loved it. It was a great fit.” As if hospital rounds and a friendly staff weren’t enough, there was her father’s unique homework project. “We still laugh about his preserving ears – yes, human ears – in our refrigerator at home for a research project he was conducting,” she said. “We’ve enjoyed discussing medicine over the years and even sharing a few patients prior to his retirement.” Today, Dr. Lawhead is a dermatologist at the Memphis Dermatology Clinic on Union, where she specializes in Mohs surgery and cutaneous oncology. Mohs surgery, named for Wisconsin physician Dr. Frederich Mohs in the 1930s and since refined many times, is used to treat cancerous lesions, growths and tumors of the skin. The surgery also treats local skin cancers such as basal cell carcinoma and squamous cell carcinoma. The surgeon removes skin tissue one layer at a time, examines the tissue under a microscope and continues until the final layer is free of cancerous cells. The Mohs procedure minimizes damage to healthy skin and reduces the size of scarring, which is important when dealing with areas such as the face, ears and neck. “I thought OB-GYN would be my path in medical school but decided during the clerkship that it wasn’t for me,” Dr. Lawhead said. “Then I rotated with Dr. (Rex) Amonette at his office, where I now work, and fell in love with dermatology. I am truly grateful to practice at Memphis Dermatology Clinic alongside extremely bright, talented, caring physicians and a superb staff.” With all of its outdoor attractions, Memphis also has the accompanying downside: lots of sun. People don’t always wear a hat and protective clothing, don’t MEMPHISMEDICALNEWS

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avoid peak sunshine hours, or don’t coat themselves with sunscreen with at least a 45 SPF (skin protection factor). “We see so many patients who’ve been exposed to the sun for many, many years for work or pleasure, such as playing

tennis or running,” Dr. Lawhead said. “That’s one of the draws of Memphis. You want to live your life and enjoy yourself, but you’ve got to be smart about it.” Dr. Lawhead comes from a family that is loyal to the University of Tennessee and all of its institutions throughout the state, including Knoxville, Martin and Memphis. There have been nearly two dozen UT graduations involving her parents, her three brothers, herself and husband Jake, a Memphis realtor. She jokingly worried that she might be disowned when she accepted a fellowship in Mohs micrographic surgery and cutaneous oncology at the University of Florida in Gainesville, which she completed in 2011. “We love the University of Tennessee,” she said. “Medical school was a special time. Sometimes it was hard seeing my friends having a more enjoyable lifestyle, but the things we learned to do and opportunity to practice medicine is incredible. There are a lot of benefits to having worked hard.” She and other doctors at the clinic work with medical students and residents, and Dr. Lawhead currently is helping a

high school student with a dermatology project this summer. “Part of medicine, in my opinion, is giving back in some way, and that’s one way we do it,” she said. “My focus is mostly on detecting and treating skin cancer. Technology seems to change day by day, and we’ve got to use it to help patients as best we can. It’s really neat to have a patient come in with skin cancer and to leave without it.” Dr. Lawhead and her husband are the parents of two active daughters, Sadie, 6, and Iris, 5, but she still manages to work in some time for tennis and running. She has run the Boston Marathon twice – once in 2008 and again nine years later when, with a time of 3:35:38, she shaved nearly a half-hour off her previous finish. “I’ve yet to run a great Boston Marathon,” said Dr. Lawhead, a multi-sport high school athlete at the University School of Jackson. “My best marathon was in my hometown at 3:16:44. You have to manage multiple aspects during marathon preparation, including training schedules, hydration and nutrition. “We rarely sit down at our Mohs surgery practice during the day, and I think being physically fit helps with some of those challenges. Running also lowers my stress, and it’s a fun activity.” And she never forgets the sunscreen.

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Finding the Sweet Spot in Aesthetic Medicine By CINDY SANDERS

I want to look natural. Steven Dayan, MD, noted Chicago facial plastic surgeon and keynote speaker at the recent Symposium for Cosmetic Advancement & Laser Education (SCALE) conference held in Nashville, said the biggest fear patients have with cosmetic procedures is that they will wind up looking like they’ve had a cosmetic procedure. “It’s our number one barrier to getting patients in the office,” he said. “It’s the reason we don’t have more people getting aesthetic treatments … it’s because they’re afraid of looking unnatural.” Dayan pointed out, “Cosmetic treatments cannot equal natural results. It’s a flawed logic.” In fact, he added, when he was asked to write a paper defining ‘natural,’ he quickly recognized he couldn’t do it. The realization led Dayan to think about beauty in a different way. Based on the theory of relativity, he created a different platform to encapsulate what people mean when they strive for natural beauty. “It’s a four-dimensional model … not a two-dimensional model … to explain what is natural, which is really just an

Steven Dayan

interpretation because you can’t define it,” he said. A New York Times bestselling author, Dayan is a researcher who has published five books and more than 110 articles in medical journals, as well as an adjunct professor at the University of Illinois. He noted, “Beauty works at a sub-

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conscious level because we are pre-wired to know what beauty is whether it’s a peacock’s feathers, a flower or a human.” While naturalness cannot be defined, Dayan said the same isn’t true of beauty. “It’s mathematically definable,” he said, adding that he was taught the figures and formulas of what makes a face beautiful during his training as a plastic surgeon. “I believe now that beauty is not our aim. I think when we put beauty out there as our target, we fail,” Dayan continued. He pointed out there was a time when everyone believed the world was flat. That same fallacy comes, he said, from confusing beauty with the genuine attractiveness that most patients really desire. “Beauty is flat. Beauty is onedimensional,” he stated. “If we increase cosmetic interventions, yes, we can make someone more mathematically beautiful.” However, he continued, much like a bell curve, there is a peak after which more treatments actually diminish beauty rather than add to it. Dayan noted that a flat, one-dimensional scale is also how the FDA approves products and the field measures outcomes in the United States. “I need to show a two-point improvement in the crow’s feet or nasolabial folds,” he said of defining success. However, what hits the mark on paper doesn’t necessarily hold up in practical application. “Cosmetic treatments cannot make people more natural. It’s logically flawed,” he reiterated. “But the problem is when we teach beauty, what we teach is unnatural. We say, ‘Yes, we got a twopoint improvement.’ We think we’re making people more beautiful on a flat scale, but the reality is when they are in animation, they look less beautiful … and they look unnatural.” Instead of frozen perfection, Dayan called on clinicians to recognize that four dimensions are required to create the results patients want – beauty, genuineness, self-esteem/confidence, and attractiveness. He noted genuineness actually is definable and identifiable. Using pictures of two Hollywood stars smiling, one had mouth corners that slightly turned up and no other movement. The other had broader lip movement and crow’s feet around the eyes – the very definition of the Duchenne smile, which involves contraction of both the zygomaticus major muscle to raise the mouth corners and the orbicularis muscle to raise the cheeks and form the crow’s feet. “If someone smiles, and they have no crow’s feet, they don’t look genuine, and you don’t trust them,” said Dayan. Yet, he continued, physicians remove them with 12 units of FDA-approved neurotoxin all the time. While beauty can be improved to a point before there are diminishing

returns, he said the second dimension of genuineness begins to slip the minute any procedure is done. “We can’t make people more genuine. You’re born 100 percent genuine. All I can do is make you less genuine,” Dayan said. The goal, therefore, is to find the sweet spot where beauty and genuineness cross. Even then, sometimes people aren’t attractive. Why? “This is the third dimension – self-esteem and most importantly, confidence,” he stated. “Confidence is the most attractive feature on anyone.” While confidence often trumps physical beauty, studies have shown that 70 percent of self-esteem and confidence is wrapped up in beauty. Research has also found that after receiving fillers and neurotoxins people feel more confident, and a new study found an increase in actual happiness. “We know our products can improve the way people feel about themselves,” Dayan said. He added aesthetic medicine has the power to impact expression, emotions, selfesteem and confidence. “We’re doing so much more than just making people beautiful,” he said. “We’re making them more attractive.” Taking into consideration physical beauty, genuineness and confidence, he said, “Now I’m seeing that what we’re doing is creating attractiveness by bringing these three dimensions together.” So what does that mean? Dayan said it means a forehead that still moves when you cry. It means fine lines around the eyes that crinkle with laughter. It means maximizing the first three dimensions. “If I provide all of that, that to me is the interpretive point where natural falls in place. Everything comes to a max point. Too much cosmetic intervention – I reduce physical beauty; I reduce genuineness; I reduce selfesteem and confidence; and they look unnatural … and that’s where patients don’t want to be.” Dayan added the fourth dimension of attractiveness is variable. Different people find different things attractive, and it’s relative to time and space. He said it’s critical to understand the math and science behind beauty but also to recognize the need for genuineness so that procedures aren’t overdone and to recognize there is a psychological component to treatments. The most challenging factor is the fourth dimension, which he said isn’t intuitive, that calls upon physicians to try to understand where the patient is in space as it relates to others. “Our mission is so much deeper and more meaningful than just making people beautiful,” he concluded. “We’re evolving beyond beauty to form and function, beyond form and function to improving the mind, mood and attractiveness of our patients … and that, to me, is where the future lies.”

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USPSTF Issues Final Recommendation on PSA-Based Screening By CINDY SANDERS

U.S. Preventive Services Task Force last month published its final recommendation for screening men for prostate cancer. After reviewing the evidence, the task force issued a ‘C’ recommendation for men ages 55-69 with an emphasis on “informed, individual decision-making based on a man’s values and specific clinical circumstances.� For men aged 70 and older, the task force issued a ‘D’ recommendation, noting such screening would not routinely be advised as potential benefits do not outweigh harms. The recommendation applies to all adult men who have no signs or symptoms of prostate cancer and who have not previously been diagnosed with the disease – including men at increased risk for the cancer. However, the recommendation statement incorporates specific sections to address higher risk populations with additional information for these men and their clinicians to consider during the decision-making process. While the final recommendation letter grades didn’t change from the draft report issued last year, USPSTF Vice Chair Alex Krist, MD, MPH, said some of the wording was refined after reviewing the feedback submitted from various

stakeholders during the public comment period. “It’s a little bit clearer that we’re trying to cue patients and clinicians in the factors that might lead Dr. Alex Krist a man to be screened or not be screened,� he said, adding there is an increased focus on this being an individual decision.

“Prostate cancer is one of the most common cancers to affect men, and the decision whether to be screened is complex,� Krist noted. “Men should discuss the benefits and harms of screening with their doctor so they can make the best choice for themselves based on their values and individual circumstances.� While the routine use of prostate-specific antigen (PSA) screening elicits strong opinions both for and against, Krist

pointed out the evidence-based USPSTF recommendation aligns with a number of other organizations, including the American Urological Association (AUA). While specific screening recommendations from the AUA, American Cancer Society, National Comprehensive Cancer Network, and USPSTF are somewhat varied in the details, all stress a shared decisionmaking component between patient and clinician. Krist – who is a professor of Family Medicine and Population Health at Virginia Commonwealth University, an active clinician, and director of community-engaged research at the Center for Clinical and Translational Research – said it is important for a physician and patient to talk about the clinical implications of screening in the context of that patient’s particular circumstances. “For some men, it may not even need a discussion,� he noted of patients facing competing health concerns that would significantly reduce or eliminate the need to worry about prostate cancer, which is typically slow growing. For others, who are at higher risk for the disease and expected to live more than 10 years, the decision should be weighed in terms of benefits versus harms. (CONTINUED ON PAGE 8)

  

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Strengthening the Connection, continued from page 1 published in the January issue of the journal Stroke, showing that patients with regular dental care had half the stroke risk of those who fail to see their dentist regularly. However, researchers hesitate to draw a causal link because periodontal disease, strokes and heart disease are complex health conditions with multiple causes and are all exacerbated by smoking. The European Journal of Preventive Cardiology published a study early this year showing a connection between periodontal disease and heart disease, especially in men who smoke. “In men, tooth loss was associated with an elevated risk of coronary heart disease,” the report stated. “The magnitude of these relationships was, however, modest such that the greatest increased risk associated with tooth loss was around 10 percent.” When studying the female subgroup, the researchers found “the general pattern of an increased risk of coronary heart disease with a greater degree of tooth loss remained, even in ‘never-smokers.’” In summary, although the study was large in scope, including a sizable number of “never-smokers,” researchers proved a “modest” tooth loss-coronary heart disease link in men that was explained by the presence of cigarette smoking in patient

THANKS FOR READING

Memphis Medical News! JULY FOCUS TOPICS:

Gastroenterology • Pain Management CFO Roundtable • Stand-Alone ERs

Alan O. Blanton

history but not in other subgroups. Memphis private practitioner Gregg Kemp, DDS, said he was “shocked” by the strong correlation between periodontal disease and heart blockage. He has observed that some patients often put off going to see a doctor, so dentists must help catch warning signs of more serious conditions during routine teeth cleanings. “We take your blood pressure when you get your teeth cleaned and refer patients to their doctor if it’s high. It’s comprehensive care. . . . We’re the first ones to catch a lot of things,” Kemp said. Other things are changing in dental care. For example, implants. According to the American Academy of Implant Dentistry’s latest figures, 3 million people in the U.S. have implants, and that number is growing by 500,000 per year. Implants have become big business. Researchers at Million Insights said the dental implants market was valued at more than $3.56 billion in 2015. Dr. Cagna noted the change in general dentistry curriculum at schools such as the University of Tennessee Health Science Center now include implant restoration for all students. Previously, implants and implant restoration were only part of spe-

cialty dental programs. Dr. Kemp notes that physicians, dentists and dental specialists have collaborated for years, especially regarding patients with recent surgery, or those undergoing cancer treatment, and patients with heart conditions. Sleep apnea recently has been added to that list, as UTHSC opened the Center for Dental Sleep Medicine and Orofacial Pain in the College of Dentistry. Treatment options for those with sleep apnea include the CPAP (continuous positive airway pressure) machine, surgery on the palate or base of the tongue and oral appliance therapy. Alan O. Blanton, DDS, MS, Diplomate, American Board of Dental Sleep Medicine, believes oral appliance therapy is the least invasive treatment option for patients, and is personally invested in continuing research. Dr. Blanton was diagnosed with sleep apnea and decided to join the UTHSC faculty in January. The oral appliance is fitted to the patient and is similar to a mouth guard worn during sports. It holds the lower jaw forward, adds stability and lifts tissue to prevent the airway from collapsing during sleep. The treatment is generally only for those without severe sleep apnea. The Center hopes to develop a graduate program for residents to learn about sleep disorders and orofacial pain. “I want Tennessee to be positioned to be a major player in that inter-professional education initiative,” Dr. Blanton said. “Patients are less likely to see their primary care physician for regular check-ups and physicals. However, many patients will see their dentists regularly, once or twice a year. “That puts us in the position of being able to screen for many conditions like hypertension, skin disorders, oral cancers, sleep-disordered breathing problems, just to name a few,” Dr. Blanton said. “We will continue to see more research on mouth and body links, and dentists and physicians collaborating in the future.”

AUGUST FOCUS TOPICS:

Ortho/Sports Medicine • Physical Therapy Health Law II • Medical Devices

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President of Medical Society, Dr. Parker Tracks Opioid War, continued from page 1 time – continue to serve as study guides and support continuing medical education in opiate therapy. His input as a member of the Tennessee Medical Advisory Board has aided development of today’s state guidelines for pain management.  After initially developing an East Tennessee pain clinic for the Anesthesia Partners group, Dr. Parker brought his family home to Memphis, where he established and operated the Parker Pain and Rehab Center for nearly 20 years before aligning his practice with Semmes-Murphey in 2010.  “Up until very recently Shelby County was the one county in the state of Tennessee that had not been overly affected by the opiate epidemic,” Dr. Parker said. “I like to think that’s partly because of the standard of care that we expected here in Shelby County. Since there were only two or three other pain specialists here when I arrived, I’d like to think we had something to do with that.” It is the dosages, rather than the opiates themselves, that led to the current epidemic, he explained. “The drugs that cause addiction behavior are all rapidrelease,” he said. “You want something that dissolves quickly into the bloodstream; all the addictive medications are that way.” Where the previously used MS Contin, a long-acting morphine, had no immediate release and was less addictive, OxyContin (a brand name derived from “oxycodone continuous”) had 30 percent immediate release and provided a potentially addictive “rush.” So OxyContin “became a catalyst for the problem.”  The medical profession didn’t light

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the fuse, however, Dr. Parker believes. Illicit opiates like fentanyl are a greater threat than prescription overdoses in many places, where single kilos of fentanyl — the size of a loaf of bread — arrive from foreign countries and can be obtained for $5,000.  “If cut correctly, a person can make $1.5 million from it. That’s a lot of incentive to not behave correctly,” he said. He is optimistic about Shelby County’s future in the opioid war, however. “The community is very aggressive with awareness; everybody’s got their eyes open, vigilance is up, and that’s going to help a lot as we catch people before they’re out of control.” In his role as president of the Memphis Medical Society, Dr. Parker admits that its mission of advocacy for the physician community is handicapped by the misperception of its relevance among younger physicians, who “just don’t join.” That’s a problem, because “without a collective voice we are on the menu rather than at the table,” he said. “The greatest challenge that faces our society faces all physicians: Decisions that affect physicians are being made by people who don’t understand the unique role that physicians have. With so many people pulling in different directions, trying to get their agendas through, there’s no other organization right now that really speaks for medicine. We have the AMA, but all politics starts local. We need the Society to protect our interests and the lives in our community.” He points to a movement toward allowing nurse practitioners to practice independently. “I’ll go on record that I don’t think that is a very good idea because it’s impossible for nurse practitioners, with the limited amount of training they have in comparison to a physician, to be on par with that kind of training.” The current team-based model works, he said, “because many nurse practitioners are extremely well-trained and work in an environment where a physician knows their skill sets completely. So patients are directed in an appropriate environment and are seen with the level of expertise that’s necessary.”

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But when a patient with no records and new complaints needs a diagnosis and treatment plan, and physician backup or oversight is not available — as in the proposed non-team-based approach — “that’s something I’m not comfortable with.”  He also expresses concerns over the recently passed “Tennessee Together” law that goes into effect July 31, placing barriers to over-prescribing opiates and opioids. Unfortunately, it also creates barriers to prescribing appropriately, Dr. Parker noted. “It’s going to make fewer doctors write opiates, period. That’s their goal — but the unintended consequence of that is that these patients are just going to go to pain clinics for the medications that have kept them functional — and many of these pain clinics are more part of the problem than a solution.

“From a medical standpoint, I’m afraid that now the pendulum is going to swing too far in the other extreme,” he said.  “Insurance companies, too, are requiring prior authorizations even for acute pain — like a broken leg.” Despite his high-profile challenges and achievements, however, Dr. Parker’s feet are tapping. A dedicated bass guitarist, he admits that his first love was and is music. “I still play in several bands, and I’m still trying to make it and get my big break!” he joked. “But I’m lucky; my day job pays relatively well.”   He takes greatest pride in his three daughters who have just graduated: one from Howard Law School, one from Johns Hopkins Graduate School in education and one who is working for Amnesty International.

USPSTF Issues Final Recommendation on PSA-Based Screening, continued from page 5 There are three major concerns tied to PSA screening, said Krist. The first is the number of false positives as a result of testing. Krist noted, “240 men out of 1,000 will have a high PSA . . . and approximately 140 of those are false positives.” There are a number of reasons why a man’s PSA level might be elevated from cancer to an enlarged prostate or inflammation of the prostate. Krist said many of those with elevated PSA levels will go on to have a biopsy for a definitive diagnosis. In addition to stress, there are other potential side effects with biopsy including pain, bleeding and infection. The second concern, he continued, is over-diagnosis. “Of those screened, 100 out of 1,000 men will be diagnosed at some point in their lifetime (with prostate cancer), but 20 to 50 percent of them will be over-diagnosed,” Krist said. “That’s a really hard concept for people to grasp because there is fear with cancer, but it won’t cause any signs or even symptoms ever in their lifetime,” he explained of those in the over-diagnosed group who have prostate cancer that never grows, spreads or harms them. The third issue is that the majority of men, once they’ve received a prostate cancer diagnosis, will go on to have surgery or radiation treatment. Data cited by the USPSTF shows 80 of the 100 diagnosed undergo one of the two treatments initially or after a period of active surveillance. Yet, Krist said, there are harms that could result from either treatment option. Estimates based on observed benefits in the ERSPC trial for men 55 to 69 years of age and on harms derived from pooled absolute rates from three treatment trials found 50 of the 80 who choose surgery or radiation treatment will experience erectile dysfunction and 15 will have urinary incontinence. Further, the USPSTF

estimates three men will avoid cancer spreading to other organs, 1.3 will avoid death from prostate cancer, and five will die from the cancer even after surgery or treatment. Krist said the Task Force didn’t make any recommendation for men younger than 55 due to a lack of clinical data. “I certainly think we need more research on men under 55 at higher risk – African-American men and those with a family history,” he said. Krist added this call for additional research was part of the group’s report to Congress. On the other end of the age spectrum, he said there were quite a few comments about extending screening. “In the draft, many folks criticized us and said men are living longer so we should be screening longer,” Krist noted. However, he continued, “There is good data that there are more false positives, more overdiagnosed prostate cancers, and more harms for biopsies and treatments. We had good confidence that men over 70 are more likely to be harmed than would benefit from screening.” Krist pointed out these recommendations pertain to routine screenings across the broad population and reiterated individual circumstances at any age could influence screening decisions. At the heart of the recommendations, Krist concluded, “We want men and their doctors to talk about the benefits and the harms. We want men to make informed decisions about what’s right for them.” International Men’s health Week 2018 is June 11-17. For a list of global activities, visit Global Action on Men’s Health at gamh.org.

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2018 MIPS Update: 10 Changes You Should Know About                                  By JAYNE COLLARD

In the new 2018 Quality Payment Program (QPP) Final Rule, the Centers for Medicare and Medicaid Services (CMS) has outlined a wide range of changes to its value-based care programs. Are you and your EHR vendor prepared? 2018 marks the second year of the Merit-Based Incentive Payment System (MIPS), and the requirements are definitely ramping up and posing more of a challenge. However, CMS’ MIPS is nothing to be too scared of—as long as your practice has the right technology to streamline your MIPS data collection and submission. So what’s specifically changing? In case you don’t have time to read all 1,653 pages of the 2018 Quality Payment Program Final Rule yourself, here’s an overview:

1. Payment adjustment increases to +/-5 percent.

CMS is raising the stakes for 2018—if only by 1 percent. This past year, providers could earn up to a 4 percent positive or negative adjustment on their Medicare reimbursements (applied in 2019) depending on their MIPS performance, but that percentage increases to +/-5 percent for 2018 (applied in 2020). This means that if your practice bills $1,000,000 in Medicare per year, then your MIPS performance could earn you a $50,000 bonus or penalty in 2020. And since the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS’ MIPS program to be budget-neutral, that bonus could increase by an additional adjustment factor if more providers earn a negative adjustment than anticipated.

formance categories and meet the same MIPS requirements as non-virtual groups. Once MIPS reporting is complete, all group members will receive the same score and Medicare payment adjustment percentage. The idea is that by sharing the reporting burden and combining their strengths, providers may be able to earn higher MIPS scores together than individually. To learn more, download CMS’ MIPS Virtual Groups Toolkit.

7. Extreme and uncontrollable circumstances exemption added

For the 2018 performance period, you’ll need 15 points or more to avoid the negative adjustment in 2020. While this is a 400% increase, it could still be as simple as completing 2-3 Quality measures, four IAs or all PI base measures. For practices that are already strong MIPS performers, this minimum threshold change will have little impact. The exceptional performance threshold required for positive adjustments will remain at 70 points.

4. Cost category takes effect

In its first year, MIPS scored providers on three categories: Quality, PI and IA, with the Cost category weighted at 0%. Starting in 2018, MIPS adds a 10 percent weight for the Cost category, which is based on Medicare Part B claim submissions. Because eligible clinicians (ECs) already submit this claims data to

Cost category in an upcoming blog post, so stay tuned!

5. Category weights change

The Quality category was originally proposed to remain at 60 percent of the MIPS CPS in 2018, with Cost not factoring in until 2019. However, the 2018 QPP Final Rule introduced Cost this year at 10 percent, so CMS is decreasing Quality’s weight to 50% to compensate. The PI and IA categories will remain at 25 and 15 percent, respectively.

6. Virtual group participation option introduced

With many small practices concerned about their ability to succeed independently under MACRA and MIPS, CMS has introduced a virtual groups option that can allow ECs to benefit from group

2. Low-volume threshold goes up

In 2018, providers with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries will not be subject to MIPS. Compared to the 2017 MIPS threshold of ≤$30,000 in charges or ≤100 beneficiaries, this is a significant increase. The 2017 threshold already exempted a large proportion of Medicare Part B providers, and this 2018 change will exempt even more.

3. Performance threshold increases to 15

For the 2017 performance period, providers could avoid the negative Medicare payment adjustment in 2019 with a MIPS Composite Performance Score (CPS) of just three points. This could be easily achieved by submitting either one Quality measure, one Improvement Activity (IA) or all Promoting Interoperability (PI; formerly Advancing Care Information) base measures. 10

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In the wake of Hurricanes Harvey, Irma and Maria, CMS has added new hardship exemptions for physicians who cannot meet MIPS reporting requirements due to hurricanes, natural disasters or public health emergencies. These will apply to the 2017 Quality Payment Program performance year as well as 2018, and the application deadline for hardship exceptions will be December 31 each year. How does it work? If affected clinicians don’t submit any data, they will be exempt from penalties. Meanwhile, those who do submit data will be scored on the data they submit, but the categories will be reweighted. If you were impacted in 2017, you may submit an application for reweighting of the PI category. Even if you don’t submit a PI application, CMS will automatically exempt you from Quality, Cost and IA for 2017.

8. Small practice bonus instituted

In an effort to further reduce the MIPS reporting burden for small practices, CMS will automatically award qualifying practices a bonus of up to 5 points. Practices must have 15 or fewer ECs and submit data on at least one performance category to be eligible.

9. 2014 CEHRT permitted and 2015 CEHRT bonus created

CMS, they will not need to send any additional data to report the Cost category. More specifically, Cost scoring is based on the Medicare spending per beneficiary (MSPB) and the total per capita costs for all attributed beneficiaries measure. This could have an enormous impact on the scores of clinicians who frequently prescribe expensive Part B drugs, such as ophthalmologists, rheumatologists and oncologists. We’ll take a closer look at the

reporting without actually joining a group or selling their practice. To form a MIPS virtual group in the Quality Payment Program, a solo practitioner or group of 10 or fewer ECs must come together virtually with at least one other solo practitioner or group to participate in MIPS for a year. Group members do not need to be in the same specialty or location. CMS simply requires that they report as a group across all per-

Originally, CMS planned to allow 2018 MIPS data submission only from 2015 Certified Electronic Health Record Technology (CEHRT). Instead, it has now decided to continue allowing ECs to use 2014 CEHRT—a relief for both vendors and providers. However, CMS is offering a 10 percent bonus in the PI category to providers who report with 2015 CEHRT.

10. New ePrescribing and HIE exclusions established starting 2017

To allay concerns about the difficulty of meeting certain measures involv(CONTINUED ON PAGE 11)

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2018 MIPS Update: 10 Changes You Should Know About, continued from page 10                                  or reduce costs. However, for many physicians and industry associations, this relative leniency comes as a major relief. To learn more and view the full list of calendar year (CY) 2018 MIPS changes, check out CMS’ 2018 Quality Payment Program Final Rule fact sheet.

The Bottom Line

ing ePrescribing and health information exchange (HIE), CMS has introduced new exclusions that would allow ECs to claim the exclusion from one or both of those measures and still earn a base score. It’s important to note that these exclusions are being applied to the 2017 performance year as well as 2018. Who’s eligible? To claim the eRx exclusion, a provider or group must write fewer than 100 permissible prescriptions during the reporting period. For the HIE exclusion, they must refer or transition fewer than 100 times during the reporting period.

Analysis

With these new rules, CMS is continuing to ramp up the reporting requirements as planned, building up to full MIPS implementation in 2019. In response to concerns from the healthcare community about the burden of Quality Payment Program reporting, CMS is also focusing heavily on easing the transition and accommodating real clinical workflows. Especially for small practices, the new Quality Payment Program rules provide additional flexibility and incentives in a wide variety of areas. As a result, some organizations have actually criticized CMS for not challenging providers enough to substantially improve health outcomes

Value-based care is here to stay, but it’s reassuring to see that CMS continues to listen to feedback from the healthcare community. And ultimately, meeting these new MIPS requirements doesn’t require an enormous amount of time and resources – it just comes down to whether you have the right tools. With the performance periods for Quality and Cost beginning on January 1 for all MIPS-eligible clinicians, now is a good time to evaluate whether your current EHR system will be able to support your MIPS success in 2018. A robust MIPS solution should be able to collect

reportable MIPS data during the exam, track and benchmark your CPS in real time and submit your data directly to CMS. Plus, consider augmenting your technology with personal guidance from certified MIPS coaches who are also experts in your EHR system. When you’re equipped with comprehensive MIPS support tools from a proven MIPS performer, you can gain peace of mind while helping increase your Medicare income. Reprinted with permission from Modernizing Medicine. Modernizing Medicine and its affiliated companies empower physicians with suites of mobile, specialtyspecific solutions that transform how healthcare information is created, consumed and utilized to increase practice efficiency and improve patient outcomes. Built for value-based healthcare, Modernizing Medicine’s datadriven, touch- and cloud-based products and services are programmed by a team that includes practicing physicians to meet the unique needs of dermatology, gastroenterology, ophthalmology, orthopedics, otolaryngology, pain management, plastic surgery and urology practices, as well as ambulatory surgery centers. For more information, please visit www.modmed.com. 

About the Writer Jayne Collard is the Manager of Advisory Services at Modernizing Medicine and is a Certified MIPS Health Professional (CMHP). She leads an EMAzing team of MIPS Advisors for both EMA and gMed while living and working out of Colorado.

Do you have patients that are non-compliant with or intolerant of CPAP therapy? Studies show that about 50 percent of your patients diagnosed with Obstructive Sleep Apnea are either non-compliant with or intolerant of CPAP therapy. There is an alternative therapy, Oral Appliance Therapy. The American Academy of Sleep Medicine (AASM) recommends that a “qualified dentist” provide Oral Appliance Therapy to patients who prefer or are in need of an alternative treatment to CPAP. Dr. Blanton is the only dentist in the immediate Memphis and Shelby county area certified by the American Board of Dental Sleep Medicine. “We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827.

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St. Jude Expands International Reach with St. Jude Global

GrandRounds

Near the end of a news conference that ran about 90 minutes and included comments from prominent physicians from four different countries, James R. Downing, MD, concisely summed up the announcement. The president and chief executive officer of St. Jude Children’s Research Hospital said it was an “important day” for his hospital and for untold hundreds of children around the world. “We’re going to export our knowledge across the globe.” Specifically, during the media event last month St. Jude unveiled an initiative to invest more than $100 million aimed at accelerating efforts to improve childhood cancer survival rates worldwide. With the launch of “St. Jude Global” the hospital hopes to achieve an ambitious goal of influencing the care of 30 percent of children with cancer worldwide within the next decade. “St. Jude founder Danny Thomas dreamed of a world where ‘no child should die in the dawn of life,’” Dr. Downing said. “While we have made great strides in achieving this dream in some parts of the world, the majority of children still die from cancers that can be effectively treated. With St. Jude Global, we are expanding the ways in which St. Jude reaches and impacts the quality of care provided to children around the world, closing the gap in survival that has persisted for too long.” According to St. Jude, global childhood cancer rates are on the rise as more children worldwide survive infancy. Today, more than 80 percent of children with cancer live in low- and middleincome countries, where they lack access to adequate diagnosis and treatment. The majority of those children will die from their disease. This is a sharp contrast to developed nations where survival rates for pediatric cancers exceed 80 percent. St. Jude began its first global outreach initiative in childhood cancer in 1993 when it established the International Outreach Program (IOP). This program used a twinning model that allowed St.

Evan Glazer, MD, a surgical oncologist with UT Methodist Physicians and West Cancer Center, spent 18 days in South Korea learning, sharing, and observing the most common types of cancers South Korean doctors see, the stages at which Evan Glazer cancer patients seek care, and the treatments South Korean physicians offer patients. Dr. Glazer also is an assistant professor in the Division of Surgical Oncology in the University of Tennessee Health Science Center Department of Surgery. He was selected through a competitive application process of the Society of Surgical Oncology (SSO) to visit South Korea and observe at Seoul National University Hospital (SNUH) and the Korean National Cancer Center (NCC). “Even after surgeons have completed formal training, we never stop learning,” Dr. Glazer said. “The experience I had to learn from other physicians on an international platform at the Korean Society of Surgical Oncology (KSSO) – the Seoul International Symposium of Surgical Oncology was extraordinary. To have this opportunity on an international level offered great insight into different approaches to complex surgical problems surgical oncologists routinely encounter.” Dr. Glazer noticed that the patients he sees in the Mid-South with gastric cancers seek medical attention when their cancers are much more advanced than in South Korea. The explanation he says is due to the screening programs that are offered in South Korea. In the United States, there are robust screenings in place for colon and breast cancer, but not for gastric cancers that are not as common in the U.S., but are common in South Korea. He said his experience in South Korea reinforced the value of multidisciplinary care. “Seeing how their surgical oncologists, gastroenterologists, medical oncologists, radiologists, and radiation oncologists all worked together to support the surgical oncologist validated the importance of teamwork.”

© 2018 ST. JUDE CHILDREN’S RESEARCH HOSPITAL; ALL RIGHTS RESERVED

Framed by media representatives and St. Jude employees below, and flags of many nations above, Carlos Rodriguez-Galindo, MD, director of St. Jude Global, addresses the news conference.

Jude to develop direct, one-on-one relationships with hospitals around the world to improve the delivery of care to children with cancer. In the last 25 years, the IOP has grown to encompass 24 hospitals in 17 low- and middle-income countries. By sharing knowledge, technology, organizational skills and resources through the IOP, St. Jude steadily improved outcomes in children with cancer in the regions in which it operated. In 2016, St. Jude formed the Depart-

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Methodist Physician Observes Medical Care in South Korea

ment of Global Pediatric Medicine to accelerate its work to ensure that children with cancer and other life-threatening diseases have access to quality care and treatment — no matter where they live. It set a goal of growing the number of children whose care it influenced from three to 30 percent within the next decade. Ultimately, its goal is for all children with cancer and blood disorders to have access to quality care. With these ambitious objectives in focus, the Department of Global Pediatric Medicine created St. Jude Global. “More than two decades of experience combating childhood cancer around the world has taught St. Jude powerful lessons about how we can improve care for children and save more lives,” said Carlos Rodriguez-Galindo, MD, executive vice president and chair, St. Jude Department of Global Pediatric Medicine, and director, St. Jude Global. “Through St. Jude Global, we are taking on the ultimate challenge of tackling childhood cancer at a global level. We are working to create a global health system that is driven and well prepared to confront this challenge.” Those who want more detailed information should visit www.stjude.org/ global.

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GrandRounds

CONSOLIDATED MEDICAL PRACTICES OF MEMPHIS salutes Dr. David H Iansmith, MD, PhD, of The Cardiology Group of CMPM who specializes in Cardiology, Clinical Pharmacology, and Electrophysiology. Dr. Iansmith attended Medical School at the University of Tennessee at Memphis where he received a Doctorate of Medicine degree. He completed his residency at Baptist Memorial Hospital in Memphis, specializing in Cardiovascular Disease and Internal Medicine, and completed his fellowship at Vanderbilt Hospital, specializing in Cardiovascular Disease, Clinical Pharmacology, and Electrophysiology.

An artist’s rendering of Campbell Clinic’s planned facility.

Campbell Clinic Breaks Ground for New Facility Campbell Clinic took a step closer to a new, four-story medical office building with a ground breaking celebration last month on a five-acre parcel adjacent to its current location at 1400 South Germantown Road. The clinic purchased the property in 1992 and has held it in reserve for future expansion. Campbell Clinic has retained Rendina Healthcare Real Estate to be its representative in connection with the design, development and construction of the facility, which will include outpatient orthopedic clinical space, expanded physical therapy and imaging suites, and an ambulatory surgery center with eight operating rooms, among other offerings. Last January, Campbell Clinic was awarded an eight-year retention PILOT (payment-in-lieu-of-taxes) from the Germantown Industrial Development Board to assist with the expansion plans, which include 120,000 square feet of new space at an approximate cost of $30 million. The City of Germantown Planning Commission has approved the final site plans. The project is expected to result in the retention of 280 jobs, and during the next three years, 185 new jobs with an average wage of more than $67,000. A practicing and teaching orthopedic center, Campbell Clinic has five facilities located in the Mid-South and After Hours urgent care clinics at its Germantown and Southaven locations.

UTHSC Professor Wins CORNET Award in Drug Discovery Sue Chin Lee, PhD, an assistant professor of Physiology in the College of Medicine at the University of Tennessee Health Science Center (UTHSC) has been awarded the UTHSC/Southern Research Collaborative Research Network (CORNET) Award in Drug Discovery and Development for studying treatments that target anti-tumor immunity. For her project, titled “Drug Discovery Targeting Lysophosphatidic Acid (LPA) GPCR Subtype 5 (LPA5),” Lee will receive combined funding from SR and UTHSC for up to two years to further develop her novel research project investigating the role of LPA5 in cancer metastasis and cancer immunosurveillance. Lee and her team have discovered that LPA5 plays a key role in cancer metastasis. Specifically, they found that LPA5 receptors knock-out mice were protected from developing melanoma-derived lung metastasis. Moreover, activation of the LPA5 receptor on Sue Chin Lee CD8 T-lymphocytes suppresses the immunosurveillance activities of CD8 T-lymphocytes against tumor cells. These findings led Dr. Lee and her team to believe that developing compounds that target the LPA5 receptor have potential therapeutic utility in cancer, especially in the area of cancer metastasis and anti-tumor immunity. Nearly two years since its inception, the CORNET Awards have been the seed of more than $1.4 million in funding to support new collaborative research teams and their groundbreaking drug discovery and development initiatives. memphismedicalnews

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Dr. Iansmith has been awarded with the American Heart Association’s teaching fellowship and the American Pharmaceutical Foundation fellowship for his MD and PhD. He has been honored by several organizations for his leadership and honorary citations. His office is located at 6799 Great Oaks Rd, Rd Ste 100, in Memphis and patient referrals may be sent to 901-747-3330.

We address the health care needs of those in the Shelby County region and surrounding areas by providing outstanding and compassionate care. Derene E Akins, MD Derene Reuben EW.Akins, Avila, MD MD Reuben W. Avila, Robert Burns, MDMD

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GrandRounds Wajih Istanbouli, MD, Joins Methodist Medical Group Wajih Istanbouli has joined Methodist Medical Group and will practice internal medicine at Methodist Medical Group, 6570 Summer Oaks Cove. He earned his medical license at Aleppo University, Aleppo, Syria. He continued his Wajih Istanbouli medical education with a residency at Techrin Military Hospital in Damascus, Syria; an internship PGY-1 at Lawrence Memorial Hospital at Medford, Massachusetts, and an internal medicine residency at Carney Hospital, Boston University Affiliated.

Mehul Patel, MD, Joins Sutherland Cardiology Clinic Mehul Patel, MD, a structural and adult congenital heart disease specialist, and an interventional cardiologist has joined Sutherland Cardiology Clinic. Dr. Patel earned his medical degree from K.J. Somaiya Medical College in Mumbai, India. After completing an internal Mehul Patel medicine residency and cardiology fellowship, he further trained in interventional cardiology at Mount Sinai Medical Center in New York City and adult congenital heart disease at Texas Children’s Hospital, Texas Heart Institute, Baylor College of Medicine in Houston.. He worked as Chief of Adult Congenital Heart Disease, Assistant Professor at Michigan State University where he not only expanded the program, performing complex interventions and device implantations, but also established the percutaneous pulmonary valve implantation (Melody Valve) program. Due to his passion to treat structurally abnormal hearts with transcatheter therapies, he focused on a Structural Heart Disease Fellowship at Henry Ford Hospital in Detroit where he worked with pioneers in this field.

BlueCross Launches Healthy Place Program in Memphis The BlueCross BlueShield of Tennessee Health Foundation announced the first project under its new strategic focus, the BlueCross Healthy Place program, will be a revitalized public space at David Carnes Park in Memphis. The Memphis site was selected in partnership with the city and in response to community residents who previously expressed interest in having more resources for the park. BlueCross BlueShield of Tennessee gathered feedback for the Memphis project during a community meeting held at Greater Faith Tabernacle Ministries in April. The project will be completed with PlayCore, a national play and recreation company. Efforts will be made to work

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with local and diverse suppliers. In total, the foundation is investing as much as $5.4 million in the Whitehaven neighborhood park. Up to $4.5 million will go toward construction of the park and its facilities, along with a $900,000 endowment earmarked for its maintenance and care. The BlueCross Healthy Place program provides neighborhoods with communal spaces for healthy activities, improving the overall wellbeing of Tennesseans.

Riders to Pedal for Organ Donation The 7th Annual ‘Ride for Life for Organ & Tissue Donation Awareness’ bicycle event will be held Sunday, June 24, at 7:00 am at Memorial Park, 5668 Poplar Ave. near Poplar Avenue and I-240. There will be a 25-mile ride and 1-mile kid’s fun ride. The event is a noncompetitive, family-friendly, bike tour through East Memphis and Midtown. It is designed to encourage health and wellness as well as organ and tissue donor registration. Event registration includes SAG support, breakfast by the Crepe Maker and Say Cheese, T-shirt, finisher medal and post-ride party. Those wanting more information should visit www.midsouthtransplant.org or www.MidsouthtransplantRFL.racesonline.com.

Derek Kelly Honored by Pediatric Orthopedic Society Derek M. Kelly, MD, a physician at Campbell Clinic Orthopaedics, received the Special Effort and Excellence Award from the Pediatric Orthopaedic Society of North America (POSNA) at the Society’s annual meeting last month. The Special Effort and Excellence Award is presented to physicians who have completed outstanding service in line with the mission of POSNA, along with their leadership within pediatric orthopedic research. The Society is a notfor-profit professional organization, with more than 1,400 physicians, devoted to advancing musculoskeletal care for children and adolescents through research and education. Dr. Kelly specializes in a variety of pediatric orthopedic conditions, such as hip dysplasia, fractures and limb deformities, sports injuries, scoliosis and foot deformities. He also treats Perthes disease, a childhood hip disorder that typically affects children from two to 15 years old.

Two Memphis Hospitals Honored for Excellence in Stroke Care Two Memphis hospitals – Saint Francis Hospital-Bartlett and Methodist University Hospital (MUH) – have received the American Heart Association/ American Stroke Association’s Get With The Guidelines- Stroke Gold Plus Quality Achievement Award. The award recognizes the hospital’s commitment to ensuring stroke patients receive the most appropriate

treatment according to nationally recognized research-based guidelines related to the latest scientific evidence. Additionally, MUH received the American Heart Association’s Target: Stroke Elite Honor Roll Quality Achievement Award. To qualify for this recognition, hospitals must meet quality measures developed to reduce the time between the patient’s arrival at the hospital and treatment with the clot-buster tissue plasminogen activator, or tPA.

Behavioral Healthcare Center at Memphis Changes Its Name The Behavioral Healthcare Center at Memphis has changed its name to Unity Psychiatric Care, however a spokesperson stressed that its mission remains the same: to provide acute inpatient psychiatric care for senior adults experiencing either a mental health crisis or behavioral disturbances related to dementia.   Michael Bailey, CEO of American Health Companies, the parent to Unity Psychiatric Care, said the new name is not due to changes in leadership or ownership, but is simply designed to clarify the company’s mission and services for patients, families and referral sources. “Our new name and logo help to more clearly convey our commitment to holistic treatment of the patient, which includes cognitive, emotional and behavioral care,” Bailey said. “This focus is illustrated in our logo as overlapping circles. We want to help as many people as possible by letting everyone know we are here and ensuring they are aware of what we do.” The facility accepts patients 55 or older who meet criteria for admission. Symptoms may include aggression, agitation with outbursts, impulsive behavior, confused thoughts, severe depression or excessive, unresolved grief, thoughts of self-harm, worrisome changes in eating or sleeping habits, extreme mood instability, paranoia, hallucinations, or delusions.   Patients may self-refer or be referred by family members, hospitals, home health agencies, skilled nursing facilities or physicians. If admitted, the patient’s treatment plan may include medical and therapeutic interventions. 

UTHSC’s Altha Stewart Installed as President of Psychiatric Organization Altha Stewart, MD, an associate professor of psychiatry at the University of Tennessee Health Science Center (UTHSC), is the new president of the American Psychiatric Association. Dr. Stewart is the first African-American to lead the more than Altha Stewart 37,000-member organization since its founding in 1844. The APA sets policy, establishes practice guidelines, and represents the field of

psychiatry nationally and internationally. She also serves as the director of the Center for Health in Justice Involved Youth at UTHSC as well chief of Social and Community Psychiatry at UTHSC. Dr. Stewart grew up in South Memphis, graduated from public and parochial schools in the city, and was among the first class of women admitted to what is now Christian Brothers University. She received her medical degree from Temple University Medical School in Philadelphia, and did her residency at Hahnemann University Hospital there. She is a nationally recognized expert in public sector and minority issues in mental health and in the effects of trauma and violence on children.

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translate research into revolutionary treatments. We can offer the most advanced therapies and drugs, even before they’re publicly available. We can research new techniques to create greater possibilities. We can create better outcomes – and better quality of life. Because here, you don’t just have cancer. You have West Cancer Center. And at West Cancer Center, we can.

901.683.0055 • westcancercenter.org

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June 2018 MMN  

Memphis Medical News June 2018

June 2018 MMN  

Memphis Medical News June 2018