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FOCUS TOPICS GERIATRICS • BEHAVIORAL HEALTH • KIDNEY HEALTH • COVID-19 UPDATE

November/December 2020 >> $5 ON ROUNDS

Geriatrician’s Personal-Touch Practice is ‘Old School in a Good Way’ For as long as he can remember, Nidal Rahal, MD, has been interested in caring for elderly people.

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Pandemic Pressures & Stress Takes Toll on Mental Health Psychiatric Nurse Practitioner, Anna Cook, is seeing firsthand the effects the pandemic is having on the mental health of West Tennesseans Working on the front lines of mental health, Anna Cook, DNP, PMHNP, can attest to the fact that the pandemic’s reach is beyond just those who contract the disease.

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Lawsuit Questions Referral Arrangement A summary of complaints & the responses in suit against local providers By JAMES DOWD

Methodist Le Bonheur Healthcare and West Clinic engaged in a patient referral and kickback scheme that generated more than $1.5 billion in new revenue for Methodist and more than $400 million in payouts to West physicians over several years, according to allegations in a lawsuit brought by two whistleblowers against the Memphis medical giants. Jeffrey Liebman, who previously served as Methodist’s CEO, resigned from the organization and filed the suit in 2017. He is now CEO of CharterCARE Health Partners in Providence, R.I. Joining the suit is Dr. David Stern, who served as dean at the University of Tennessee Health Science Center until 2019 and was a Methodist board member until being removed in 2017. The suit was sealed for two years during a (CONTINUED ON PAGE 4)

Fauci Updates Healthcare Professionals on COVID-19 During IDWeek 2020 By CINDY SANDERS

against a virus that had killed more than 230,000 Americans at press time.

In late October, healthcare professionals in infectious disease, healthcare epidemiology and prevention gathered Coronavirus & SARS-CoV-2 virtually for IDWeek 2020, perhaps one of the most conFauci began his presentation by noting the sciensequential conferences in the Infectious Diseases Society tific community has long experience with coronavirus of America’s 57-year history. in humans and in bats and other intermediate hosts. In Day one began with a global event, “Chasing the 2002, he said the world had its first experience with the Sun,” as IDSA joined with partners around the world for pandemic coronavirus SARS with another pandemic 24 hours of global perspectives and data on COVID-19 potential coronavirus in 2012 with MERS. – from clinical presentation, diagnostics and therapeuThe current pandemic coronavirus was recAnthony S. Fauci tics to infection control, mitigation strategies and vaccine ognized at the end of December 2019 as a disease development. Kicking off the special event, Anthony S. Fauci, MD, and was confirmed by the Chinese in the first week of January 2020 director of the National Institute of Allergy and Infectious Diseases for as yet another strain of coronavirus. As the current strain is proxithe National Institutes of Health, discussed the current understandmal to the original SARS coronavirus, it has led to a change in ing of COVID-19 and where the United States stands in the fight (CONTINUED ON PAGE 6)

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PhysicianSpotlight

Geriatrician’s Personal-Touch Practice is ‘Old School in a Good Way’ By LAWRENCE BUSER

For as long as he can remember, Nidal Rahal, MD, has been interested in caring for elderly people. Actually, interested is not quite strong enough. “It’s a combination of passion and personality traits,” said Rahal, who specializes in geriatrics, family medicine, palliative medicine and hospice care. “I have a genuine compassion and patience for elderly people and their families. Some physicians love to perform surgery, some love to deliver babies, and some love to talk to and care for the elderly. I’m one of the latter. My work fits what I have a passion for.” Rahal of East Memphis Internal Medicine sees patients in the office, in the hospital, in nursing homes, assisted living facilities and in hospice settings. In a world of corporate medicine, specialization and government regulations, he worries that what has been done in the name of patient care has taken away an important part of being a physician: the continuity of patient care and the personal touch. “In the current health care system, the direction is to have patients followed up by different doctors with different specialties,” said Rahal, whose office partner is Dr. Randy Villanueva. “So, the continuation and consistency of care is basically the key of what we do. It serves the patients much better. You know the patients, you know the families. You follow up with them and you build a relationship instead of having one doctor see them in one spot and then another doctor grabs the paperwork and sees them at another spot. “We’re old school, but in a good way. The families know that if their loved one gets sick, I’ll be seeing them in the hospital. If they go to rehab, I’m most likely going to see them there. If they’re in assisted living, I’ll see them there. That’s almost nonexistent in the current healthcare formula.” But, Rahal acknowledges, running an old school medical practice is not easy. “There are a lot of 80-hour weeks,” he said with a laugh. “I’m available for my patients by phone 24/7, and I work most weekends. It seriously takes a lot of effort to maintain that continuity and consistency of care. I am thankful to work alongside a great team. “What I do is not a job. It’s a profession. There’s a big difference and that’s very important to me. I don’t clock in and clock out. I’m not done by 5 or 6 or 7. If there’s some need, I’m going to tend to it. I take calls at night whether it’s at 9 p.m. or 3 o’clock in the morning. I have put a lot of commitment and endless hours into this model, and I have memphismedicalnews

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built one-on-one relationships with most patients and their families.” Rahal is the son of a PhD research

chemist. His brother, Dr. Kinan Rahal, is a gastroenterologist in Sarasota, Fla. “There was a lot of emphasis on education growing up,” he recalled. “It wasn’t necessarily on medicine, but on education.” Rahal attended medical school at Damascus University Faculty of Medicine in his native country of Syria. He completed his residency in Family Medicine at the University of Tennessee Health Science Center in 2002 and attended fellowship in Geriatrics at UTKnoxville. After working for seven years as an emergency room physician at Methodist Germantown Hospital, Rahal received training and certification in palliative medicine and hospice care. That laid the groundwork for his current practice involving inpatient geriatrics at Methodist Germantown, outpatient clinical office appointments, and rounding at multiple assisted living facilities in Memphis, Germantown, Southaven and Olive Branch. With his elderly patient population, the onset of COVID-19 pandemic earlier this year had a significant impact on his practice, both personally and professionally. “There wasn’t a day that (patient care) wasn’t day to day with us,” said Rahal. “The first months were extremely stressful. We kept going more than full speed to keep up. Everybody was locked up at home, so we were at the front line, and that applies to all the other doctors.

“COVID-19 has really impacted us in a negative way. I personally admitted all the infected elderly patients I had at the facilities and attended to them at the hospital. It really hits my patient population hard. We have a much higher mortality rate in my world.” His certification in hospice care and palliative medicine allows Rahal to care for his patients and their families even after there is no longer a medical solution to offer. “At some point when an elderly patient gets to a point where less is more, where enough is enough, it is my job to talk to the family, sit them down and maybe help them consider that option,” Rahal said. “It definitely pours into the heart of what I do. “If the family has no more desire to push, we sit and probably make a decision together about transitioning to comfort care in hospice, and perhaps end-of-life pain management. So, with my practice focusing on elderly patients, I’ve been able to combine these aspects together and have one closed circle. I believe this type of practice allows me to provide quality care for my patients. That makes this feel successful.” He says he doesn’t mind that the demands of his practice leave little time to pursue hobbies. “I have two sweet little girls who I adore,” he said, “so I do my long hours and go back home to my loving and supportive wife and my kids. I’m a family man.”

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Lawsuit Questions Referral Arrangement, continued from page 1 Plaintiff Complaints

Defendants Response

From 2012 through 2018, the Methodist Defendants paid West Clinic physicians over $400 million in cash payments in a scheme to induce and reward referrals of cancer patients for hospital admissions, infusion drug therapy, radiation therapy, outpatient procedures, and ancillary services. Throughout the course of their “alliance,” Methodist and West Clinic physicians shared massive profits at the expense of compliance with federal laws. Methodist paid West $25 million in co-management fees without proof that any such services rendered. Methodist invested $7 million in Vector Oncology (formerly known as ACORN), a for-profit research entity controlled by West Clinic physicians. West Clinic’s managing physicians required this $7 million payment as a condition of entering into the “partnership” with Methodist. Approximately 50 percent of the $7 million payment by Methodist was to pay off Vector’s debts, to repay some of West’s physicians for personally financing Vector’s losses.

Defendants deny lawsuit claims, but attorneys declined to comment. Our professional relationship with Methodist complied with the law and resulted in increased access to high-quality cancer care for an underserved patient population. (Dr. Kurt Tauer, founder, chairman and Medical Oncologist for West Cancer Center) We cooperated fully in the government’s investigation of these allegations, and we are pleased the government has decided not to intervene in the lawsuit at this time. The lawsuit lacks merit, and we will continue to vigorously defend ourselves. (Methodist) West vigorously disagrees with the allegations in the complaint and looks forward to having the opportunity to prove them incorrect in a court of law. Together Methodist and West increased access to high quality cancer care in the Memphis area, decreased mortality rates among cancer patients, introduced new and innovative treatments not previously available in the Mid-South, and significantly increased funding for cancer research. (Mitch Graves, CEO of West)

government investigation. In September, 2019, the government decided not to intervene, but the case continues to be monitored, said David Boling, public information officer the U.S Jeffrey Liebman Attorney’s office in Nashville. Neither Liebman nor Stern responded to requests for interviews and attorneys for both sides declined to comment. In addition to the Methodist and West David Stern systems, other named defendants include West executives Dr. Lee Schwartzberg and Erich Mounce, and former Methodist executives Gary Shorb and Chris McLean. West denied the charges. “Over two years ago, The West Clinic became aware that the government was reviewing its affiliation with Methodist Le Bonheur Healthcare. West fully cooperated with the government in that review. In December 2019, it was revealed that the government’s review was the result

of a lawsuit filed by a former Methodist Le Bonheur executive and a former dean at the University of Tennessee’s Health Science Center,” CEO Mitch Graves replied in a written statement. Mitch Graves “West also learned that after conducting an extensive investigation, the government chose not to intervene in this lawsuit. We are disappointed that these individuals have filed this lawsuit. West vigorously disagrees with the allegations in the complaint and looks forward to having the opportunity to prove them incorrect in a court of law.” Methodist also refuted the claims. “Methodist Le Bonheur Healthcare upholds the highest standards and complies with all legal and regulatory requirements. Our professional agreements with The West Clinic and its physicians provided needed medical services for cancer patients,” the healthcare system responded in a written statement. “We are certain that closer examination of our agreements with West Clinic will make it clear that these were agreements built on integrity, and focused on a shared approach to elevating the quality and scope of cancer care

in our community. We cooperated fully in the government’s investigation of these allegations, and we are pleased the government has decided not to intervene in the lawsuit at this time. The lawsuit lacks merit, and we will continue to vigorously defend ourselves.” The suit claims that in 2011, West moved to end its two-decade patient referral partnership with Baptist Memorial Health Care with the intention of building a lucrative cancer patient referral pipeline to Methodist because of an expected “windfall” of profits for both facilities. Plaintiffs allege that West physicians received hundreds of millions in dollars for referring cancer patients to Methodist, and Methodist saw profits jump from increased admissions, therapies and treatments for those patients. Damages to Medicaid and Medicare, the suit claims, exceed $800 million. Under the False Claims Act (FCA), liability would triple that amount, bringing the total damages to more than $2.4 billion. In fraud cases in which the government intervenes, plaintiffs may receive between 15 and 25 percent of the amount recovered by the government. In cases that do not involve government intervention, plaintiffs may receive between 25-30 percent of any proceeds that are awarded.

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The suit asserts that West doctors leveraged Methodist’s status as a nonprofit health care system to gain access to the federal 340B Drug Pricing Program that allows covered entities such as Methodist to obtain expensive cancer drugs at steep discounts. The suit further claims that West profited from the retail sale of those drugs at much higher charges to patients and insurance companies, and alleges that the complexity of the 340B program and the federal government’s “lack of sophistication” in being able to uncover such a partnership provided a “safe” way to share profits. If substantiated, such acts could violate the federal AntiKickback Statute (AKS), which prohibits healthcare systems from offering financial incentives or offers of payment for referrals that would lead to reimbursements from federal health programs. In this case, the suit alleges that from 2012-2018 Methodist paid West physicians more than $400 million in exchange for patient referrals, and those referrals by West physicians generated more than $1.5 billion in revenue for Methodist. In addition, the suit alleges that Methodist paid West $25 million from 2012-2018 for non-existent management services. And Methodist invested $7 million in a West-owned research company, with about $3.5 million of that amount used to reimburse West doctors who had personally financed Vector’s losses. The Methodist/West partnership ended in late 2018 when West announced plans to join OneOncology as a founding member. Defendants point out that timing coincided with a nearly 30 percent decrease in the Medicare payment rates for drugs that covered entities were able to purchase through the 340B program. In early 2019, West purchased its nearly 200,000-square-foot medical building at 7945 Wolf River Boulevard from Methodist. Following the dissolution of the partnership, Methodist announced its own plan to form the Methodist Cancer Institute. Earlier this year, defendants filed a motion to dismiss the suit. No settlement has been reached and the discovery process continues for both sides. A hearing may occur in early 2021.

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Pandemic Pressures & Stress Takes Toll on Mental Health

Psychiatric Nurse Practitioner, Anna Cook, is seeing firsthand the effects the pandemic is having on the mental health of West Tennesseans By SUZANNE BOYD

Working on the front lines of mental health, Anna Cook, DNP, PMHNP, can attest to the fact that the pandemic’s reach is beyond just those who contract the disease. As a psychiatric nurse practitioner in both an inpatient geriatric unit and in her outpatient priAnna Cook vate practice, Cook has seen a surge in demand for psychiatric services since the start of the pandemic and it is a surge that she does not see dwindling anytime soon. The Mississippi native has over 14 years of nursing experience and five years of experience as a mental health nurse practitioner. Cook obtained a master’s degree in nursing from Murray State University in 2010 and a post master’s degree from Vanderbilt University in 2015. She is a board-certified Registered Nurse, adult Clinical Nurse Specialist and Psychiatric

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Mental Health Nurse Practitioner. She completed a Doctor of Nursing Practice (DNP) from the University of Alabama, Huntsville in 2019. Cook started her career in cardiology where she found a passion for the geriatric population. She later began working in nursing homes offering psychiatric services, deciding then to pursue a post master’s degree in order to specialize in mental health. Since that time, she has worked as a regional director for a company providing psychiatric services to long term care facilities in West Tennessee. Later, she began working part time at an inpatient geriatric facility in Martin, Tennessee. “I initially just worked two days a week at Unity in Martin, but realized how much I loved it and moved to four,” said Cook. “I had always liked geriatric patients in general, but the more I worked with them, the more I found it to be so rewarding. I love spending time with them and hearing their stories. Additionally, being able to provide education and emotional support to families of loved ones with dementia is something I feel led to do. I am grateful to

have the opportunity to help them in such difficult situations. As a Psychiatric Mental Health Nurse Practitioner who holds a doctorate, Cook specializes in evaluating, diagnosing, and treating various mental health conditions. She splits her time between an inpatient geriatric program with Unity Psychiatric in Martin, Tennessee, and private practice with iMind Mental Health and Wellness in Jackson. One of her primary roles in both the inpatient facility as well as in her private practice, is to assess the medications a patient is taking and make recommendations. “Often the patient is on too many medications,” she said. “Many times, patients are put on medications with the best intentions but when you look at what they take collectively, there are too many.” In addition to the medication aspect of psychiatry, Cook is also trained to provide psychotherapy for her patients. The clinic employs two Licensed Counselor Social Workers who handle most of the intensive therapy for patients. “When we opened the clinic, it was to offer something

different than what was available in terms of mental health services in our community. The need was there, and we wanted to address that in a way that allowed us to determine the amount of time devoted to each patient,” said Cook. “I try to get all patients in therapy because medications are just a part of treatment. We know the best outcomes are typically gained by a combination of both medication and counseling services. Cook says that, even before the pandemic, the need for psychiatric services had been growing, but it has escalated since March, especially for geriatric patients as well as those that are dually diagnosed with intellectual and coexisting mental health disorders such as anxiety, depressions, and mood disorders. The lack of structure and routine, and increased isolation caused by the pandemic has taken a toll on this population. Depressive episodes are at an all- time high. The influx of new patients needing services has been overwhelming but we are doing our best to keep up. (CONTINUED ON PAGE 8)

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Fauci Updates, continued from page 1 nomenclature with the 2002 outbreak being called SARS-CoV-1 and the current strain as SARS-CoV-2.   “As of two days ago, the numbers throughout the globe have been stunning, making this already the most disastrous pandemic that we have experienced in our civilization in over 102 years,” said Fauci. At the time of his talk in the third week of October, there had been more than 40 million cases and over 1.1 million deaths globally.   

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“Unfortunately for the United States, we have been hit harder than virtually any other country on the planet,” he said.   Comparing the United States to the European Union, which has a larger population than the US, Fauci noted tracking shows the EU peaking a little before the US in March, driven by the outbreak in northern Italy, but then coming back down to a baseline under 10,000 new cases for the seven-day rolling average. “The situation in the United States was a bit more complicated,” he said.  “We had a major peak slightly after the European Union driven by the outbreak in the New York metropolitan area, which at one point early on accounted for about 40 percent of all the cases, hospitalizations and deaths in the United States.” However, he noted, as the New York area went back down to a low baseline, the rest of the country did not. “We began seeing outbreaks throughout the country, as you might expect with a pandemic.”  Unlike the EU, the US never saw the baseline dip below 10,000 cases. Fauci said between April and June, the country’s lowest mark was at 20,000 cases for the seven-day rolling average before the country began seeing increases as operational restrictions were lifted from businesses.  Although cases did come down for several weeks, the US trajectory is on the rise again, much like the EU, which began sharply spiking in mid-October, surpassing new cases in the United States. However, by the end of the month, the US was seeing record-breaking numbers of new cases entering the winter, as well.   Transmissibility & Severity  COVID-19 is spread by respiratory droplets from person to person. Recent evidence points to aerosols that remain in the air over considerable time and distance as a component of the transmission equation. Similarly, contaminated services do occur, but Fauci said the role is likely not nearly as much as person-to-person transmission.  “There are five major principles that I talk about all the time in preventing acquisition and transmission of SARS-Coronavirus-2,”  Fauci stated. “The universal wearing of masks or cloth face coverings; maintaining physical distance where possible; importantly, avoiding crowds and congregate settings, particularly indoors; trying to do things outdoors much more preferentially than indoors; and frequent washing of hands.”   He continued, “These five public health interventions alone have been shown in multiple setting to have a major impact in preventing surges and diminishing surges

after they’ve occurred.” For those who do test positive for COVID-19, Fauci said 40-45 percent of people exhibit no symptoms at all. “But those that do, about 81 percent are mild to moderate where about 15 to 20 percent are either severe or critical with a case fatality rate that varies from a few percent to up to 20 to 25 percent for people requiring mechanical ventilation,” Fauci explained.  Fauci said the scientific community is learning more about manifestations of severe disease and lingering effects. While the most common is acute respiratory distress syndrome (ARDS), he said clinicians are seeing cardiac dysfunction, neurological disorders, hyperinflammation, hypercoagulability, acute kidney injury and multisystem inflammatory syndrome in children (MIS-C).   Fauci added another critical part of the current pandemic is the “extraordinary racial and ethnic disparity” of COVID-19. He said the problem is two-fold with incidence of infection being linked to the front line work done by many in minority communities  that increases exposure to the virus, as well as the prevalence of underlying comorbid conditions that predispose these populations to more severe disease.   

Therapeutics & Vaccines

“The NIH has formed an expert US Treatment Guidelines Panel, which meets regularly and forms a living document online,” said Fauci. The information is available online at covid19treatmentguidelines.nih.gov  and includes expert insights from clinicians around the country and a look at the latest literature.  As for therapeutics, Fauci noted, “Some of the recommended ones you know are remdesivir and dexamethasone. Remdesivir is shown to have been effective in diminishing the time to recovery in hospitalized patients who have lung involvement,” he said. A randomized, placebo-controlled dexamethasone trial showed patients hospitalized with very advanced disease requiring mechanical ventilation, as well as those with high-flow oxygen, saw significantly diminished 28-day mortality.  “However,” he continued, “there are a number of other investigational therapies aimed at early disease.” While more research is required, he said there have been some encouraging results with a number of interventions including convalescent plasma, hyperimmune globulin, monoclonal antibodies and immunomodulators such as those that block inflammation and cytokine inhibitors.   “We here in the United States have taken a strategic approach to COVID vaccine research and development, which means that we’ve made major investments in six companies either in facilitating the development of clinical trial or of buying a product to be ready after the clinical trials are over,” Fauci explained.  The three major platforms being pursued are nucleic acid, viral vectors and protein subunit. With five already in Phase 3 trials, Fauci said, “We feel confident that we’ll have an answer likely in mid-November to the beginning of December as to whether we have a safe and effective vaccine.”   memphismedicalnews

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Addressing a Chronic Killer

HCA Hosts Kidney Disease Roundtable with CMS Administrator Seema Verma By CINDY SANDERS

HCA Healthcare recently hosted Centers for Medicare and Medicaid Services Administrator Seema Verma and Deputy Administrator Brad Smith for a roundtable discussion with health leaders on advancing kidney care. Jonathan Perlin, MD, PhD, president of clinical operations and chief medical offiSeema Verma cer for HCA Healthcare, moderated the event that coincided with an announcement from CMS regarding a new model of care for Medicare beneficiaries with chronic kidney disease. HCA Healthcare, Brad Smith one of the nation’s largest clinical care providers with more than 180 hospitals and over 2,000 sites of care across 21 states and the United Kingdom, was tapped to host the event to facilitate the ongoing discussion on ways to break down silos between chronic kidney disease, kidney failure and treatment protocols including transplantation. Last year, HCA led the nation in performing 418 live donor kidney transplants. Additionally, the health system was responsible for 652 deceased donor transplants, which is more than 7 percent of the kidneys recovered nationwide. While there have been advances in care and expansion of organs deemed acceptable for transplantation, Perlin said clinicians and organizations across the country that work with patients with end-stage renal disease (ESRD) know more can and should be done. “There are too many at-risk patients who progress to late-stage kidney failure; mortality rate is too high; treatment options are expensive, and the quality of life is simply too low,” he stated, adding there are not enough kidneys donated to meet the need. “Kidney disease is a major, prominent, prevalent condition,” Perlin continued. “It’s the ninth leading cause of death in the United States.” He added 37 million Americans live with kidney disease and more than 726,000 progress to ESRD. Each year, more than 100,000 Americans begin dialysis with 20 percent dying within a year and 50 percent dying within five years. Currently, nearly 100,000 Americans are awaiting transplant. Unfortunately, on average, 13 people a day die before a kidney becomes available. In introducing the new model of MEMPHISMEDICALNEWS

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care, Verma said the focus across the federal government has been on finding ways to make healthcare more affordable and more accessible. However, she continued, the way government programs are structured can sometimes create misaligned incentives. “In Medicare, in particular with our ESRD program, that’s exactly what we’ve seen,” Verma continued. “And so, we’ve been really focused over the last year – based on the president’s executive order – to try to specifically improve the lives of people with kidney disease.” As a result, CMS announced finalization of the End-Stage Renal Disease Treatment Choices (ETC) Model on Sept. 18 to transform chronic kidney care for Medicare beneficiaries. Building off President Donald Trump’s Advancing Kidney Health Executive Order, the ETC model encourages increased use of home dialysis and kidney transplants. Verma noted traveling to a hemodialysis center not only eats up a large portion of the day but also potentially exposes ESRD patients to other health threats, including COVID-19. Verma noted Medicare beneficiaries with ESRD who contract the coronavirus have higher rates of hospitalization. With home dialysis, patients are able to shelter in place during the public health crisis while still receiving the care they need. “The model today is part of a larger effort to improve the health, in general, of people living with kidney disease,” Verma said. While the ETC program creates a new payment model, she said the agency has also been focused on improving organ procurement. “The idea is to make sure that we’re doing everything we can to increase the transplantation rate,” she said. Brad Smith, who was tapped to lead the CMS Innovation Center at the beginning of 2020, drilled down on the ETC model. Smith noted the work was very personal for him, as he had a cousin who had been on dialysis for several years before passing away at the age of 28. “And so, this is an issue I’ve always been really interested in and really passionate about,” he noted. Smith said CMS has been looking at the way kidney care is delivered in the United States and working to transform the model over several years. The focus, he added, has been on three big areas: in-home dialysis, transplant rate, and the impact of the pandemic on ESRD patients. In thinking about how the U.S. compares to other countries, Smith pointed to in-home dialysis rates. He said the latest statistics show about 12 percent of

Life consists of many special moments.

But suffering from memory loss could make your patient feel like they’ve been taken away. The Clarity AD Study will be evaluating an investigational drug for those suffering from memory loss. Participants must be 50 to 90 years old, have experienced memory decline over the last year, and have a study partner willing to attend visits with them. Those who qualify and participate will receive study-related testing and medical care as well as a travel stipend. This study is being conducted by: Neurology Clinic, P.C. 8000 Centerview Pkwy • Suite 500 Cordova, TN 38018 For more information:901-747-1111 research@neuroclinic.org

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Pandemic Pressures & Stress Takes Toll on Mental Health, continued from page 5 “There are not a lot of outpatient resources as it is, and since we opened the clinic two and a half years ago, we had seen steady growth,” said Cook. “Since the pandemic, it is almost like a crisis for the practice as we have seen such an increase of people in need of mental health services.” For the general population, things such as being unemployed, job loss, loss of insurance, kids not in school, working from home and having to teach virtual school as well as just being confined with family for months and months are major stressors said Cook. “People who are already anxious, don’t deal with unknowns very well and with the pandemic there has been nothing but uncertainty,” she said. “For patients with an underlying intellectual disorder such as autism, having their world turned upside down by the pandemic can be especially stressful as strive on structure. Constant changes in the rules and regulations has been especially hard on them. I am happy to work closely with Madison Haywood Development Center who are offering intensive outpatient group therapy “virtual classes” that help with coping skills, dealing with depression and anxiety and offering a social outlet for the patients. Even if the classes are virtual, the interaction with their peers has been a great resource. ” Cook says the geriatric population, especially those in nursing homes and assisted living facilities, has been hit espe-

Is the missing

cially hard by the pandemic. The inpatient unit has almost a constant waiting list due to the decompensation in patients that are now needing an inpatient hospitalization. “It has been awful,” she said. “In the beginning, it wasn’t as bad because no one knew how long it would last. As the weeks have worn on and people have been isolated from family, we are having patients coming in that have had a rapid cognitive decline. Some of them may have had some degree of dementia in March but now they are not able to engage at all and have completely shut down. I think it is due to the loneliness factor.” To mitigate the spread of the virus, many facilities would not let patients come out of their room, so it was as though they were in solitary confinement to some degree said Cook. “While it was in their best interest medically, it caused patients to decompensate,” she said. “Treating them has been difficult as the guidelines change frequently. Isolation does not lend itself to dealing with advanced dementia, but we have tried to adapt and engage them as much as we can safely. I feel like the first week they are in the facility and they have to be isolated to ensure they are COVID free, we just cannot make a lot of progress but there is no way around it.” The inpatient facility in Martin is full and Cook says referrals are not slowing down. “We have been pretty slammed the past two months and there is no sign it is going to slow down. COVID caused us

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to make all our rooms private and that is something that is not going to change. We are adding two beds to our 14-bed facility in January due to demand.” For those dealing with COVIDrelated stress, Cook has this advice. “While we want people to stay informed, I recommend limiting media exposure to just a couple of times a day and from reliable sources that provide accurate information. Engage in self-care activities, eat a healthy diet and exercise, even if it is virtually at home,” she said. “Try to avoid turning to things like alcohol or overeating in an effort to deal with stress. These are what we call negative coping skills that could result in further health problems. Know that it is okay to seek help and therapy to change your thought process or just to have someone to talk to. Set goals and how you plan to achieve them. Do not stop engaging in hobbies you like to do. Stay

engaged with others through technology, especially with family members who may not be involved in holiday, social or family activities. Check on people especially if you notice a change in behavior or that they are more withdrawn. Often, someone will go in for what they think is medical treatment and it turns out to be depression related.” I recommend medical clinics be more diligent in screening for depression and anxiety at routine office visits. Cook, who has personally experienced COVID herself, says she has a whole new perspective. “I am being more vigilant about wearing a mask and encouraging others to wear one as well,” she said. “Feeling stress and anxiety right now is normal, don’t feel guilty about it. Big thing is to focus on what you can do to mitigate your risk of getting it. Stay on a routine as much as possible and make time for fun and relaxation.”

Anna Cook, DNP, Psychiatric Mental Health Nurse Practitioner, Clinical nurse specialist, RN, Unity Psychiatric, Martin, TN, acook@imindjackson.com

Addressing a Chronic Killer, continued from page 7 patients in the U.S. get in-home dialysis. “But when you compare that across the world, that’s a pretty low rate – so in the U.K., it’s about 18 percent, and Canada is about 25 percent,” he said. Smith added that although only 12 percent nationally are doing dialysis at home, 85 percent of individuals are actually eligible for that treatment option.  “The second piece is when you look at our transplant rate,” Smith continued. “Of the 61 more developed countries, we’re actually 39th in terms of transplant rate. Only 2.9 percent of  patients actually are able to receive a transplant before they go on dialysis and only about 30 percent of those with ESRD actually have had a transplant, so we feel like there’s a tremendous opportunity to change how we deliver care in this country around end-stage renal disease.”  When it comes to COVID, Smith said, “Our ESRD patients are one of our highest risk groups across the entire country. If you get COVID and you have ESRD, you’re eight times more likely to pass away than the average American.”  To address these issues, the Center for Medicare and Medicaid Innovation has been working on payment transformation over the past five years, staring in 2015 with the comprehensive End-Stage Renal Disease Model with 37 groups taking full capitated risk for their dialysis beneficiaries. “We’ve seen really good results in that model. Hospitalizations have come down; emergency dialysis treatments have gone down; readmissions have gone down,” he said. While the quality of care increased, Smith said CMS didn’t really see the anticipated savings from the program. “Part of the reason for that is really we were starting too late, and we were only starting with patients once they reached

dialysis.”   New models being rolled out in 2021 focus on patients in stage 4 and 5 of chronic disease before they advance to ESRD. “That’s a time when we believe we can have the biggest impact,” he said.  A second lesson from the earlier model was the needle didn’t move on inhome dialysis or kidney transplant, which is why the new ETC model increases reimbursement for in-home dialysis claims. “In the first year, we’ll increase them by 3 percent, then 2 percent, then 1 percent in the third year,” Smith said.   “In addition, and probably even more importantly, we’re putting in place an incentive structure for nephrologists and for ESRD facilities around in-home dialysis and transplants,” he continued. Smith explained each year the percentage of patients for each practice or clinician will be calculated who either get in-home dialysis, are on the wait list for transplant or who receive living-donor transplant. “And then based on that, it will make an adjustment to their Medicare claims. In the first year that could be as much as +4 or -5, and in the last year, year five, that could be as much as +8 or -10,” he said. This demonstration model will roll out to about 30 percent of the country this coming January. The hope is to improve quality, give providers and centers more flexibility and save an estimated $23 million through the program.  However, Smith stressed the savings component isn’t the main driver. “The main goal of the model is to make sure that folks can have the choices that they want and hopefully that we can altogether increase … along with all the other rules that we’re reviewing and regulations we’re rolling out … increase the number of transplants that are happening across the country.”  memphismedicalnews

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GrandRounds Vascular Interventional Physicians Welcomes Dr. David Cohen Dr. David Cohen has joined Vascular Interventional Physicians (VIP), a subsidiary company of Mid-South Imaging. Cohen is a board-certified interventional radiologist with over 15 years of IR experience. He spent the last four years as David Cohen an IR with Vascular Access Center, and prior to coming to Memphis, he practiced in Jackson, TN, with Advance Radiology, PC. Cohen attended Chicago Medical School and graduated in 1999. He completed his fellowship at The University of Colorado and did his residency at the University of Tennessee (Memphis) and UMDNJ-NJMS (New Jersey). With many years of vascular experience, Dr. Cohen will continue to treat patients with a vast range of vascular conditions. His primary focus is helping female patients diagnosed with uterine fibroids and giving them another option besides a hysterectomy. Uterine Fibroid Embolization is a non-invasive procedure that gives women relief from the grueling symptoms caused by uterine fibroids. Dr Cohen has seen successful outcomes with the UFE procedure and looks forward to continuing this focus with VIP. VIP consist of five interventional radiologists. While they also cover Baptist Memphis, Baptist Desoto, and Baptist NEA Jonesboro; they wanted to be able to offer the Mid-South outpatient experiences for interventional procedures. VIP has done just that. VIP is located on the 3rd floor of the Briarcrest Professional Building at 6286 Briarcrest Ave Suite 300, Memphis.

UTHSC Researchers Identify Three Drugs as Possible Therapeutics for COVID-19 Researchers at the University of Tennessee Health Science Center working with colleagues at the University of New Mexico have identified three drugs, already approved for other uses in humans, as possible therapeutics for COVID-19, the illness caused by the SARS-CoV-2 virus. Based on virtual and in vitro antiviral screening that began in the earlier months of the COVID-19 pandemic, the researchers led at UTHSC by Colleen Jonsson, PhD, identified zuclopenthixol, nebivolol, and amodiaquine as promising therapeutics for the virus Collee Jonsson in its early stages. Dr. Jonsson is a professor and the Endowed Van Vleet Chair of Excellence in Virology in the College of Medicine at UTHSC. She also directs the UTHSC Regional Biocontainment Laboratory

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(RBL), where this research was conducted. The university’s RBL is one of roughly a dozen federally funded labs in the country authorized to safely study contagious pathogens. In a paper published in ACS Pharmacology & Translational Science, the researchers propose the drugs as possible candidates for testing in future clinical trials to improve immune response to the virus. Amodiaquine is an older antimalarial, zuclopenthixol is an antipsychotic, and nebivolol is a blood pressure medication. “Particularly in the context of this pandemic, there is a stringent need for high-quality studies that can provide critical knowledge concerning the COVID-19 disease and reliable treatment proposals,” the paper states. “With these caveats in mind, we conceived a computational workflow that included independent in vitro validation, followed by assessing emerging candidates in the context of available clinical pharmacology data, with the aim of proposing suitable candidates for clinical studies for early stage (incubation and symptomatic phases) patients infected by SARS-CoV-2.” Given the need for improved efficacy and safety, researchers propose zuclopenthixol, nebivolol, and amodiaquine as potential candidates for clinical trials against the early phase of the SARS-CoV-2 infection. Comparing the drugs to hydroxychloroquine, the anti-malarial drug most-frequently studied in clinical trials for use as a COVID-19 therapeutic, the researchers examined 4,000 approved drugs and found these three to act similarly to the hydroxychloroquine, and in some cases, more safely. The research indicates they may also improve efficacy when combined in lower doses with remdesivir, an anti-viral given an emergency use authorization by the United States Food and Drug Administration as a therapeutic for COVID-19.

UTHSC biorepository programs as part of the collaboration. One biorepository program began in 2015, when UTHSC and its partner pediatric hospital, Le Bonheur Children’s Hospital, began the Biorepository and Integrative Genomics (BIG) Initiative. The family of every patient was given the opportunity to consent to having any excess blood taken for testing purposes stored in a biorepository in the hospital, identified only by a code, and tied by that code to the patient’s electronic medical records. Prior to the coronavirus pandemic, roughly 150 samples were added each week. Enrollment was temporarily halted because of the virus, but it has resumed with strict precautions. Biorepository samples are intended only for research purposes. For example, when sequenced, samples from the Le Bonheur BIG initiative may provide insight into genetic predispositions for certain conditions such as asthma, sickle cell disease, and epilepsy, and could hold keys for the development of individualized therapies to treat them. The Memphis pediatric biorepository is now one of the largest in the world for children, and in particular, Black children, offering a unique opportunity to expand medical research to a population that in the past has been underrepresented. Genomic information linked up with electronic medical records will allow researchers to look at DNA characteristics of people who develop certain illnesses without specifically knowing who they are according to Robert Davis, MD, MPH, founding director of the UTHSC Center in Biomedical Informatics and the University of Tennessee-Oak Ridge National Laboratory Governor’s Chair in Biomedical Informatics. Dr. Da-

vis, also a professor in the Department of Pediatrics, is a leader in the pediatric biorepository initiative and will be instrumental in growing the program across the UTHSC system in the future.

OrthoSouth Welcomes New Back & Neck Specialist, Winfred B. Abrams, Jr., MD OrthoSouth welcomes interventional spine specialist Dr. Winfred B. Abrams, Jr. to its Spine Center team. Dr. Abrams will see patients with back and neck pain at the group’s Briarcrest Avenue clinic and Southaven, MS clinic. His adWinfred B. dition underscores the Abrams, Jr. continued growth of OrthoSouth’s presence in West Tennessee and North Mississippi. Dr. Abrams is a fellowship trained interventional spine specialist. He completed his fellowship in Pain Medicine at Hershey S. Milton Medical Center, PennState Health in Hershey, PA and his surgical residency at Boonshoft School of Medicine, Wright State UniversityWright-Patterson Air Force Base in Dayton, OH. He is a graduate of UT Health Science Center in Memphis. Dr. Abrams received his B.S. in Chemistry from University of Pittsburgh. He gained much of his medical training in the military, where he served as a Flight Surgeon, Medical Director, and Operational Support Medicine Commander for several years before joining the Johns Hopkins University School of Medicine as a staff physician for a few years prior to his fellowship.   In addition to regular clinic hours, Dr. Abrams joins a team that offers a 24/7 OrthoStat Urgent Care triage line.

UTHSC Collaborates with the Regeneron Genetics Center To Advance Precision Medicine in the Mid-South The University of Tennessee Health Science Center has entered into an agreement with the Regeneron Genetics Center, a subsidiary of Regeneron Pharmaceuticals, Inc., for the company to sequence DNA that has been voluntarily provided and stored as part of a biorepository initiative UTHSC is building in collaboration with its partner teaching hospitals. The collaboration is a key step in advancing the eventual goal of the university, along and its partner hospitals, to provide precision, or personalized, medicine tailored to the individual genomic characteristics of patients. Regeneron, headquartered in Tarrytown, New York, and one of the largest human genomic initiatives in the world, has agreed to provide genetic sequencing of de-identified DNA samples from the

FOCUS TOPICS February/March Ophthalmology • Cardiology Employee Retention • Legislative Issues April/May Women’s Health • Oncology Healthcare Real Estate/Design • Nursing Issues June/July Neurology • Men’s Health • Reimbursement • Pain Management August/Sept Orthopedics • Pediatrics • Health Law • Rehabilitation Trends

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GrandRounds AOA and AMA Stand Against Misrepresentation of Osteopathic Physicians Misrepresentation of osteopathic medicine harms the credibility of the 121,000 osteopathic physicians who care for our nation’s sick and injured. The American Osteopathic Association (AOA) and the American Medical Association (AMA) stand united in an effort to combat the mischaracterization of doctors of osteopathic medicine by media, celebrities and companies. Osteopathic physicians, also known as doctors of osteopathic medicine (DOs), are fully licensed physicians who practice in every specialty area. Doctors of medicine (MDs) and DOs have equivalent training and practice rights. DOs account for approximately 11 percent of all physicians in the United States. They are pediatricians, obgyns, internists, anesthesiologists, psychiatrists, oncologists, family medicine physicians, emergency medicine physicians, dermatologists, plastic surgeons, ophthalmologists, cardiothoracic surgeons, and more. DOs hold some of the most prominent positions in medicine, including overseeing care for our nation’s astronauts, those who serve in the uniformed services, the President of the United States, and former Vice President Biden. Distinct, equivalent training Osteopathic medicine is a distinctive branch of medical practice in the U.S. that developed in parallel to allopathic medicine over a century ago. It was founded on the belief that all systems in the body are interrelated, each working with the other to heal in times of illness. That whole-person approach to care continues today. Like MDs, DOs complete four years of education at accredited medical schools, which includes two years of clinical sciences followed by two years of clinical rotations. DOs and MDs pass comprehensive national licensing exams, and then train side-by-side in residency and fellowship programs for three to eleven years, depending on specialty. Upon completion of their training, the only two types of fully licensed physicians, DOs and MDs, work side-by-side in equivalent roles in hospitals, clinics, laboratories, research facilities and more. DOs receive additional training in osteopathic manipulative medicine (OMM), which is the therapeutic application of manual techniques (i.e. stretching, gentle pressure and resistance) to diagnose, treat and prevent illness or injury. OMM can be used to treat arthritis, stress injuries, sports injuries, headaches, and pain in areas such as the lower back, neck, shoulders, and knees. For some patients, it serves as an alternative to opioids or other pharmaceutical treatments.

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Growth and recognition of osteopathic physicians The practice of osteopathic medicine, which is more than a century old, has grown rapidly in recent decades. The profession expanded 63 percent over the last 10 years and nearly 300% in the past 30 years. Today, one in four of all U.S. medical students attends an osteopathic medical school. Doctors of osteopathic medicine deserve to be honored for their contributions to the health of this nation. Together, the AOA and the AMA ask that those who speak about osteopathic medicine, first learn about the 151,000 osteopathic physicians and medical students who make up this proud profession. For additional information, the AOA is available to provide education resources, materials, and spokespeople.

Dr. Frederick Azar ReElected Treasurer of the American Board of Orthopaedic Surgery Frederick M. Azar, MD, Chief of Staff of Campbell Clinic Orthopaedics and Professor at the University of TennesseeCampbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, has been re-elected to a one-year Frederick M. term as Treasurer of the Azar American Board of Orthopaedic Surgery (ABOS). The ABOS Board of Directors consists of 21 members, which includes 12 Active Directors, six Senior Directors, two Directors-Elect, and one Public Member Director. ABOS Board Members serve one 10-year term while the Public Member Director serves a three-year renewable term. Nominations to the ABOS Board of Directors come from the American Orthopaedic Association, the American Academy of Orthopaedic Surgeons, and the American Medical Association. Dr. Azar was elected to the ABOS Board of Directors in 2016 and serves as Chair of the ABOS Oral Examinations Committee. He specializes in orthopaedic sports medicine and serves as the team physician for the Memphis Grizzlies and local Memphis colleges and high schools. Dr. Azar previously served as the President of the American Academy of Orthopaedic Surgeons. He earned his medical degree at the Tulane University School of Medicine. He completed his Orthopedic Surgery Residency at University of Tennessee-Campbell Clinic and a Sports Medicine Fellowship at the American Sports Medicine Institute, Birmingham, Alabama.

St. Jude Achieves Magnet® Designation for Nursing Services for Second Time For the second time, St. Jude Children’s Research Hospital has received the prestigious Magnet®️ designation by the American Nurses Credentialing

Center (ANCC). Magnet®️ is the gold standard for nursing and represents the highest international recognition awarded by the ANCC. The ANCC Magnet Recognition Program® recognizes health care organizations that demonstrate excellence in nursing philosophy and practice, adherence to national standards for improving patient care, leadership, and sensitivity to cultural and ethnic diversity. Hospitals undergo a rigorous evaluation that includes extensive interviews and review of nursing services, clinical outcomes and patient care. The designation serves as a benchmark for patients to measure the quality of nursing care they can expect to receive at a hospital. St. Jude was first designated as a Magnet® organization in 2015. Magnet® hospitals must provide an annual status report on their progress and must undergo re-evaluation every four years to retain the designation. The benefits of being a Magnet®recognized organization are numerous. National studies have found that hospitals with Magnet® status have lower patient mortality, fewer medical complications and better patient care outcomes. ANCC, a subsidiary of the American Nurses Association, is a certification body for nursing board certification and the largest certification body for advanced practice registered nurses in the U.S. ANCC’s nursing board certification program is one of the oldest in the nation.

Methodist Le Bonheur Healthcare Names Naren Balasubramaniam as Chief Human Resources Officer Methodist Le Bonheur Healthcare announced the appointment of Naren Balasubramaniam as senior vice president and chief human resources officer. Balasubramaniam joins the healthcare system from Workday, the global enterprise reNaren source planning organiBalasubramaniam zation headquartered in Pleasanton, Calif., where, as managing partner, he championed Workday’s efforts to transform enterprise business services for large and complex health systems. Balasubramaniam will serve as the executive leader for the human resources function for MLH with a focus on thoughtfully advancing the organization’s culture, driving a comprehensive talent strategy and enabling organizational capacity and capabilities for operational excellence. Balasubramaniam replaces former CHRO Carol RossSpang, who retired in August. Prior to joining Workday, Balasubramaniam led HR transformation and supported organizational growth at Washington’s Providence St. Joseph Health and Henry Ford Health Sys-

tem in Detroit. In addition, he has led healthcare development and consulting services. In his corporate roles and as an entrepreneur, Balasubramaniam’s relentless focus is creating value and enhancing the human experience. A native of Chennai, India, he has called Michigan home since 1999. Balasubramaniam holds a Master of Social Work, Human Resources and Industrial Relations and a Bachelor of Science in physics from the University of Madras. He is a fellow of the American College of Healthcare Executives (FACHE) and earned his certification as a Global Practitioner of Human Resources from the Society of Human Resources Management in 2008.

PUBLISHER Pamela Z. Haskins pamela@memphismedicalnews.com EDITOR PL Jeter editor@memphismedicalnews.com PHOTOGRAPHER Greg Campbell ADVERTISING INFORMATION 501.247.9189 Pamela Z. Haskins CREATIVE DIRECTOR Susan Graham sgraham@nashvillemedicalnews.com GRAPHIC DESIGNERS Susan Graham, Katy Barrett-Alley CONTRIBUTING WRITERS Suzanne Boyd, Lawrence Buser, James Dowd Cindy Sanders All editorial submissions and press releases should be sent to editor@ memphismedicalnews.com Subscription requests can be mailed to the address below or emailed to pamela@memphismedicalnews.com. Memphis Medical News is now privately and locally owned by Ziggy Productions, LLC. P O Box 164831 Little Rock, AR 72206 President: Pamela Z. Haskins Vice President: Patrick Rains

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GrandRounds MRPC and Methodist Healthcare Install New PET Scanner Memphis Radiological, P.C. is a proud partner with Methodist Le Bonheur Healthcare and are excited to share that Methodist University Hospital’s state-of-the-art digital PET/CT scanner is now installed in the Shorb Tower and is currently scheduling patients. As the newest PET/CT scanner in the Mid-South, patients will be scanned on a PET/CT scanner similar to that of St. Jude Children’s Research Hospital. This new scanner features Q-clear digital technology. With Q-Clear technology, there is reduced background noise and improved detectability of smaller lesions. This allows for more accurate cancer detection and staging. Not only is this technology better for cancer staging, this new scanner allows for shorter exam times which improves patient comfort, reduces patient motion, and results in improved exam quality. To ensure that patients not only receive the best imagining available, all exams are

interpreted by Board Certified Radiologists with advanced training in PET interpretation.

Mid South Internal Medicine Welcomes Stephen M. Johnson, MD Stephen M. Johnson, MD, has joined Mid South Internal Medicine, 7550 Wolf River Boulevard in Germantown, Tennessee. Dr. Johnson is board certified by the American Board of Pediatrics and the American Board of Internal MediStephen M. cine. He is a graduate of Johnson Washington University in St. Louis, Missouri and the University of Alabama School of Medicine. Dr. Johnson completed his residency in Internal Medicine at Ohio State University Medical Center and Pediatrics at Nationwide Children’s Hospital in Columbus, Ohio, where he served as Chief Resident. Dr. Johnson will be seeing patients schoolaged to adult.

Mid-South Pulmonary & Sleep Specialists PC

would like to say

Thank You to our Referring Physicians

For trusting us with your patient’s respiratory and sleep problems

Beth Price, Medtronic, Dr. Rusty Shappley, Nathan Crouch, Medtronic

Surgery Center at Saint Francis Offers New Technology to Treat Incontinence The Surgery Center at Saint Francis, an affiliate of United Surgical Partners International (USPI), is the first in the Memphis, Tennessee area to offer a new solution to the millions of people who suffer from incontinence. The first Interstim™ Micro System, a rechargeable neurostimulator for bladder and bowel control, was implanted in the Memphis area by Dr. Rusty Shappley. The Interstim Micro System by Medtronic is approved by the Food and Drug Administration (FDA), and can offer relief for urinary frequency, urge incontinence, incomplete bladder emptying, and fecal incontinence. Dr. Rusty Shappley’s accomplishment of implanting the first InterStim™ Micro system in the Memphis area comes about 20 years after his father, Dr. Vance Shappley, became one of the first to use the Interstim device in Memphis upon its inception. Effective long-term bladder and bowel control is an unmet medical need by many in the Memphis area who experience regular accidents and/or frequency issues. It can significantly impact all aspects of a person’s quality of life – self-confidence, exercise, activities and even intimacy according to Rusty Shappley, MD. The InterStim™ II and new InterStim Micro systems can provide patients with safe, effective relief from OAB and FI. The InterStim™ II recharge-free system may offer patients more freedom from a recharging routine, the hassle of recharging components, and a reminder they have a disease. The rechargeable InterStim™ Micro system, one of the smallest devices available in the neuromodulation market, can benefit patients who want a smaller, longer lasting device. memphismedicalnews

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Breath Easy. Sleep Well. Mid-South Pulmonary & Sleep Specialists PC 5050 Poplar Ave | Memphis, TN 38157

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