BEHAVIORAL HEALTH/PSYCHIATRY • HEALTH LAW • PULMONARY DISEASE/COPD • CLINICAL TRIALS
November 2017 >> $5 December 2009 ON ROUNDS Labels Unimportant When It Comes To Ability To Breathe Glenn Williams realizes not all his patients understand what a pulmonologist does. But he also understands that when it comes to breathing, labels aren’t Glenn Williams really that important. It’s what he does that counts.
Profile on page 3.
Despite the Effort, Tuberculosis Still A Deadly Threat A doctor’s decades-long battle, and others like it, failed to contain tuberculosis’ fearsome impact. A son’s recollections Samuel Phillips of his dad’s attempt to contain the disease.
Clinical Trials Improve Options For Behavioral Health Patients New Trends Create Better, More Accurate Results By BETH SIMKANIN
New trends are emerging to help physicians who traditionally have faced several challenges when conducting clinical trials. These trends can help researchers avoid bias and obtain more accurate results in clinical trials, according to Valerie Arnold, MD, a psychiatrist and principal investigator for CNS Healthcare, a clinical trials center that explores treatment and medication options. Being consistent and maintaining neutrality in a controlled environment is highly important when conducting a successful clinical trial. Patients must be chosen who fit specific criteria for each trial and maintain a neutral environment to avoid bias. Some patients The use of technology, improved processes and advancements in genomics are improving have several diagnoses the quality of studies, according to several and you have to make Mid-South experts. One of the leading principal investigasure they will benefit tors on clinical trials in the Mid-South, Dr. from the study. Arnold has more than 15 years of experience and has conducted 200 trials. She has led trials – Dr. Valerie Arnold, that have led to approval of well-known medicaprincipal investigator, CNS Healthcare tions such as Ambien, Wellbutrin and Lyrica.
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Community Commitment Inspires Duckett to Guide Baptist’s Growth
Story on Page 5.
A New Action Plan Could Give COPD Attention It Needs Estimates are that between 25 and 30 million Americans are impacted by COPD, but millions are unaware they even have the disease. But now the hope is that a national action plan will bring important changes.
By JUDY OTTO
Politics may often create strange bedfellows, but Greg Duckett claims his early political career not only inspired his active commitment to community service, but also prepared him to wear the multiple hats he has acquired during his
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25 years with Baptist Memorial Health Care Corporation (BMHC) system. After earning his J.D. degree from the University of Memphis Law School, Duckett, now senior vice president & chief legal officer for BMHC, worked with U.S. Senator Al Gore and the Clin(CONTINUED ON PAGE 4)
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Pulmonologist or a Critical Care Doctor? For Glenn Williams, It’s Not the Label It’s the Results That Are Important By RON COBB
As essential as breathing is to human life, one might think everyone would know what a pulmonologist does. But that’s not the case. Doctors who treat Chronic Obstructive Pulmonary Disease are in some cases afflicted with Chronic Pulmonologist Identity Syndrome. Glenn Williams, MD, has been with Mid-South Pulmonary Specialists since 1991. “I don’t think people really understand what a pulmonologist does,” he said. “I have a biking group that I go with, and the guys are all very successful people in their own areas. But when I say I’m in pulmonary critical care, I’ve heard them tell people ‘he’s an anesthesiologist’ or that I’m a heart doctor. “Those are the two things pulmonologists are mixed up with – anesthesia and cardiologists. So a lot of times I just say I’m a critical care specialist because folks can identify with that a little bit easier.” Unless a campaign is launched to raise the profile of pulmonologists, that’s the way it’s going to be for these physicians who treat respiratory diseases. In the case of Dr. Williams, two of his areas of focus are pulmonary hypertension and interventional bronchoscopy. Over the past five years or so, he also has been providing critical care in the heart transplant program at Baptist, along with his Mid-South Pulmonary partners Dr. Roy Fox and Dr. David Munday. New drugs, Dr. Williams said, have drastically changed the approach to pulmonary hypertension. Treatment early on started with an intravenous drug, and through the years that was followed by a series of oral drugs. Hypertension results, he said, when the arteries that go into the lung develop elevated blood pressures, affecting right heart function. Symptoms include shortness of breath, swelling and fluid retention. “Physician awareness has gone way up,” Dr. Williams said. “I think we’re rec-
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ognizing the disease process much more than we used to, and we’re able to intervene much earlier than we used to.” Dr. Williams and his group also treat ARDS (adult respiratory distress syndrome), which could be fatal. “But over the last 10 to 15 years,
there’s been more usage of ECMO,” he said. “This is a technique that we started using, and Baptist is currently the only facility in this area of the country that does this.” Treatment includes cannulating patients and putting them on a lung bypass machine, which oxygenates and ventilates the patient while the lungs are healing. “We’ve probably done around 85 cases in the last four years, myself along with Dr. John Craig. Slowly the communities and outlying areas have become more and more aware that we have this capability. So our referrals are creeping up a little bit each year. It’s a big deal, very expensive and very complicated.” In the area of interventional bronchoscopy, Dr. Williams said, “we do tumor destruction with catheters in the airway, and we can also do stent placement. We have some advanced modes of diagnosis of peripheral lesions with the use of a computer. “So these are all nice techniques that interventional bronchoscopists like doing.” Working with the heart transplant
team at Baptist is probably what occupies most of Dr. Williams’ time these days. In that process, he said, “we’re the critical care guys, so the surgeons do the transplants and place a device called the left ventricular assist device, and our primary function is stabilizing the patient before and after that surgery. “We work very closely with advanced heart failure cardiologists. It’s very much a team approach.” Born in Kansas City and raised in Atlanta, Dr. Williams came to the University of Memphis in 1971 and has never left the city. He earned a degree in chemistry, majored in biochemistry in graduate school and earned a PhD in chemistry. During grad school, he got a part-time job as a med tech at the Newborn Center. “I started to learn a lot of physiology and respiratory medicine with the neonates on the ventilator and their associated physiology,” he said. “I really started to enjoy what I was doing and decided to apply to med school, coupled with the fact that my buddies who finished their graduate degrees in chemistry and biochemistry were telling me there weren’t any jobs out there.” He met Teresa, a neonatal nurse at Newborn Center, and they were married just before Dr. Williams started medical school at UT Memphis. As a third-year resident, he was (CONTINUED ON PAGE 6)
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Community Commitment, continued from page 1
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ton/Gore transition team before Memphis Mayor Dick Hackett recruited him in 1988. First as Director of Public Service, then Director of Housing and Community Development, Duckett became both the youngest Chief Administrative Officer and the first African-American to achieve that role for the City of Memphis. It was a role he held until Hackett’s election loss to Willie Herenton in 1991. In search of employment, he bypassed offers from law firms and private companies when, during his discussions with Baptist’s leadership, he recognized the service component inherent in the healthcare field. “I was a little intimidated initially because of how regulated healthcare is, and the learning curve I knew I would have to undergo,” he confided. However, he added, “I quickly realized that things were changing at such a rapid pace I was not that far behind, because we were all learning!” During the quarter century since he joined Baptist as a vice president in 1992, Duckett has seen—and created—significant change. As the original architect of their in-house legal program, he built a structure that includes eight other staff attorneys, and keeps another 28 attorneys busy on retainer elsewhere, focusing on such specifics as tax issues, certificates of need, and mergers and acquisitions. In 1994 he was promoted to Senior Vice President and became the first African-American chief legal officer for a major healthcare corporation in Memphis. As such, he coordinates and oversees all the legal activity for BMHC, a $2.5-billion enterprise that encompasses 21 hospitals, more than 20,000 employees, and more than 400 physicians employed or under contract. “My principal responsibility,” he said, “is to be the quarterback for all those activities.” He identifies his toughest challenges as staying abreast of reimbursement and regulatory changes, and dealing with mergers and acquisitions, specifically the onboarding of added hospitals such as the soon-to-be-opened Crittenden County facility, which pose both legal and operational challenges. He regards the future of the Affordable Care Act as a major continuing challenge to healthcare providers. Although the number of uninsured patients should theoretically decline as Medicare reimbursements decrease and Medicaid benefits expand, thus covering more people who have not worked in Tennessee and Mississippi, where Medicaid roles were not expanded by the states. “As a hospital, we were hit with the reductions in our Medicare reimbursements, but we didn’t get the increase of uninsured being insured,” he notes. The best response, he believes, is to be as efficient as possible and to negotiate appropriate managed care contracts, which is becoming increasingly difficult. He cites 340B Pharmacy Pricing, a CMS program which allows institutions that treat underserved (i.e. Medic-
aid) patients to purchase certain drugs at deeply discounted prices. The pharmaceutical industry is lobbying to modify that program – reductions which could prevent Baptist’s delivery of care to a number of needy patients – and Duckett continues to write letters of opposition. He warns other issues to watch include: (1)Physician contracting. Extremely closely regulated, it presents a minefield of issues: The only way a patient can be admitted and receive hospital care is by a physician’s order, but, he explains, “Federal laws (anti-kickback and Stark) prohibit me from incentivizing a physician to make referrals to my facility. As such, any contractual and/or employment arrangement for a not-for-profit organization has to be at arm’s length—so there is an added cost, separate and apart from compensation, that this organization has to incur for any physician that is contracted and employed.” Part of that cost requires third-party validation as to the reasonableness of the compensation that is being paid, he further points out. (2) Corporate compliance. The False Claims Act protects whistleblowers, allowing an individual or employee to initiate ‘qui tam’ action if the organization has submitted false bills to the federal government. If proven true, the individual can get up to 25 percent of any recovery by the government. Duckett says fraudulent intent may be misperceived in cases where honest mistakes have been made on an incorrect bill, so watchfulness and proactive compliance checks are essential. (3) Telemedicine raises questions, too: Must a physician in Memphis be licensed in Mississippi in order to provide a telephone consult to a Mississippi patient? Legislatures should be encouraged to make changes that allow healthcare to use technologies that can lower healthcare costs. Duckett’s busy calendar is complicated by his service on a list of boards that includes the National Civil Rights Museum, the Tennessee Board of Regents, the State Election Commission, the Riverfront Development Corporation, and the Greater Memphis Area Chamber of Commerce – opportunities where he can make a difference. “Mindful of the economic disparity in this community, I want to play a role in doing whatever I can to help increase the pipeline for others to be considered, and develop a climate where one’s gender, race, or ethnicity does not preclude them from reaching their full potential.” He still finds family time, however, to spend with his wife of 31 years, a daughter in law school, and a financial advisor son he meets for golf. He feels strongly that “The future of the delivery of healthcare depends on a partnership – a partnership between physicians, allied providers, hospital providers and all. We can no longer, with scarce resources, come to the table with a ‘weversus-they’ mentality.”
This Doctor Threw His Best Punch, But Tuberculosis Is Still Standing
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With pulmonary disease as a focus topic in this issue, publisher Pamela Harris suggested that editor Bob Phillips write an historical account of his father’s journey in medicine. By BOB PHILLIPS
Doctors were still making house calls when my dad was practicing medicine in Memphis. However, when the phone rang at our house the calls were seldom related to healthcare. My dad was Samuel Phillips, MD, and despite having an “MD” after his name in the phone book (remember those?) most of the calls were from people in the entertainment industry. The callers were looking for the Sam Phillips who owned Sun Records, which had a list of entertainers that included Roy Orbison, Jerry Lee Lewis, Johnny Cash and our neighbor at the time, Elvis Presley. The other Sam Phillips evidently had an unlisted number. Because my dad was a doctor, he believed we shouldn’t have one, something that was a constant irritant to my mother. But I thought it was totally cool. I was given the job of answering the phone. It was the best household chore my parents ever gave me. After learning that the callers were looking for the unlisted Sam, I would explain they had the wrong one. Between conversing with all the wrong numbers and having Elvis down the street, I thought I was witnessing what stardom was really like. Perhaps I was. But years later I realized I had a real star living right in my own house: my dad, a man who dedicated his life to medicine, and believed, as the Hippocratic Oath states, “into whatsoever houses I enter, I will enter to help the sick.” Samuel Phillips was born in New York and graduated from the Royal College of Physicians, King’s College Medical School, London, England. I doubt years ago he or anyone else had ever heard of a pulmonologist. He simply said he specialized in pulmonary disease while he spent a good part of five decades trying to eradicate tuberculosis (TB). Also called “consumption,” I am told at one time tuberculosis was feared more than cancer. After interning at Grasslands Hospital in White Plains, New York, he took a position at South Dakota Tuberculosis Sanitorium in Sanator near the Black Hills National Forest. It was a huge facility – a city within itself. And it was remote. The nearest town was Custer (population of 1,987 according to the 2010 census) memphismedicalnews
which is believed to be the oldest town established by European Americans in the Black Hills of South Dakota and Wyoming. Gold was found there in 1874. I’m pretty sure there was no gold when my parents arrived in 1941, but there was plenty of cold weather. The high temperature there between November and April is about 23. The average annual snowfall is 56 inches. My dad said there was so much snow that tunnels were built to connect the buildings. But the weather was perfect for treating TB patients. Research indicated that breathing cold air could be excellent therapy. Each patient’s room had a balcony and every day each occupant was bundled in warm clothing and blankets and placed on their balcony to breathe in the brisk air. When the U.S. entered World War II, my dad wanted to join the Army. However, he was told his job was considered “essential” and he was exempt from service. So he resigned and took a position at City of Hope Hospital in Duarte, California, which was a treatment center for TB. The TB treatment, called pneumothorax, involved surgery. As best I understand it, a portion of the lower rib was removed and the lung was collapsed and treated. The lung became healthy and the rib grew. The healing process took about one year. Then the procedure was repeated on the other side. My dad was there only until he was able to enter the Army. As a member of the medical corps, he was stationed at several military bases, including one in Como, Mississippi, which was a German prisoner of war facility. The job of caring for German POWs was especially distasteful because my mother lost relatives in the Holocaust. Dad was soon transferred to Memphis and Kennedy General Hospital.
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Creating Better, More Accurate Clinical Trials, continued from page 1 “Multi-site, double-blind, placebocontrolled clinical trials are the gold standard,” Dr. Arnold said. “They are considered less influential. It’s considered a high-quality study when the patients and the principal investigator don’t know which patient is getting the drug and which patient is getting the placebo.” Typically, Dr. Arnold conducts clinical trials that are sponsored by pharmaceutical companies. She specializes in behavioral health and studies dealing with patients with attention deficient hyperactivity disorder. “Safety is extremely important,” she said, “We want to make sure the medication works and is safe for a patient to use.
That is why we do trials in a controlled environment.” In addition to safety, clinical trials result in patients being offered better medication options. “Clinical trials are important, especially in mental health, because we can improve efficacy and side effects in newer medications,” said Dr. Anita Varma, MD, a psychiatrist and principal investigator for Research Strategies of Memphis. “Often times patients who are on older medications are not able to function as well because the side effects could add to other health issues. Newer medications may make a patient feel better and more able to function. We are able to inform the patient there are other medication options. “It’s important to understand that mental illness is treatable,” Dr. Varma continued. “We want patients to feel better. Medication compliance in clinical trials is highly important in mental health. It’s through clinical trials that we can offer more treatment options and improve side-effect profiles so patients can function better. We’ve been seeing some newer medications have less side effects.” Dr. Arnold said a double-blind study helps create a neutral environment because neither the patients nor the medical staff knows which patients are taking a certain drug and which patients are receiving a placebo. Medical staff must be trained on how to talk with a patient so they don’t influence or change a patient’s perception during a trial. “You have to be careful because the smallest influence can damage a trial,” Dr. Arnold said. “I just got out of a meeting which discussed how pre-programmed after-hours phone messages can influence a patient. These are small things people don’t even think about, yet how we word something makes a big difference.” Dr. Arnold said she is seeing new trends that aid medical staff in creating a consistent, controlled environment. “We are utilizing more technology,” she said. “Over the last couple of years, companies have required us to video our interactions with patients. We are given feedback from medical experts to make sure that our treatment and wording is
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consistent.” Dr. Arnold said she will have experts who deal with certain illnesses such as post traumatic stress disorder or obsessive compulsive disorder assist in monitoring patients and give feedback. Additionally, she said she is conducting more genetically influenced studies where companies are looking for specific genetic markers in patients to find out how certain medications respond to them. According to the National Human Genome Research Institute, which is a government research entity that funds genetic and genome research, pharmacogenomics is still in its infancy. Pharmacogenomics, the study of how genes affect a patient’s response to drugs, is a more personalized approach to using and developing medications. According to Dr. Arnold, one of the most important processes, and the most challenging for physicians, is choosing the right patient for each trial. “There is not one simple diagnosis,” she said. “Some patients many have several diagnoses and you have to make sure they will benefit from the study.” Dr. Arnold said it’s ideal to have patients from various sources and different geographic locations, as it increases the chances to get the best sample of patients. “It’s important to have different sites because you typically get a better sample this way,” she said. “If you don’t have multiple sites, it could adversely affect a study.” She added that it’s not uncommon for some trials to be conducted at 25 different locations. Multi-site selection in a clinical trial is so important that the University of Tennessee Health Science Center has announced a plan for a new initiative that could bring more clinical trials to Tennessee and result in more research grant money for the state and UTHSC. According to Dr. Steven Goodman, Ph.D., vice chancellor for research at UTHSC, university clinical faculty conduct many clinical trials at various hospitals throughout Tennessee, yet the university doesn’t receive credit for the trials because they are conducted at hospitals the institution doesn’t own. As a result, UTHSC doesn’t receive additional research grant money. “We estimate Steven Goodman that we aren’t getting $30 million of grant money for research that we would otherwise if the university was receiving credit for these trials,” Dr. Goodman said. “Our faculty is doing the work, but the university isn’t getting credit for it.” Goodman presented an idea to Dr. Steve Schwab, MD, chancellor of UTHSC, to create a 501 (c) (3) organization through the University of Tennessee Research Foundation. Identified as the Clinical Trials Network (CTN2), it would provide that any clinical trial that is con-
ducted by a UTHSC faculty member will go through the subsidiary of the foundation and give UTHSC credit for the clinical trial. CTN2 will provide personnel for the trials at the hospitals. Dr. Schwab announced UTHSC’s commitment to the endeavor last month at his State of the University address. State hospitals and health centers affiliated with UTHSC are Methodist University Hospital, Le Bonheur Children’s Hospital, Regional One Health, West Cancer Center, Saint Thomas Health in Nashville, the University of Tennessee Medical Center in Knoxville and Erlanger Health System in Chattanooga. “You can’t get enough subjects from one health center for a clinical trial,” Dr. Goodman said. “You need to have multiple sites to get a good sample.” He is in the process of having memorandums of understandings signed at each location and anticipates CTN2 will be up and running by January 2018. Additionally, Dr. Arnold, who is director of child and adolescent psychiatry at UTHSC in addition to her role at CNS Healthcare, said the National Institutes of Health is considering UTHSC for a comparison clinical trial that will study the side effects of antipsychotic drugs in children and adolescents.
Pulmonologist, continued from page 3
encouraged by one of the pulmonary critical care staff people to pursue that specialty. “I really liked that area of study anyway, so it didn’t take a whole lot of encouragement,” he said. When he finished a fellowship, he, along with Dr. Fox, were offered a job with a fledgling Mid-South Pulmonary. The group has since grown to 19 physicians and one nurse practitioner. The group was primarily focused on the Methodist hospitals at that time, but Dr. Williams was sent east, “and I became the Baptist doctor in the group.” He and Teresa had three children, and raising them became problematic with both parents working jobs in healthcare. “Early on in practice an average week for me was 70 to 90 hours, really bad,” Dr. Williams said. “It’s much better now because I’ve gotten more help and I limit what I do compared to what I did when I was younger.” Finally he urged Teresa to leave her nursing job and stay home with the kids. “So she raised our family, along with me, but she was on the front lines doing most of the work with it. And I think it turned out OK.” All three children have medical degrees. Jason, the eldest, is in private practice with Memphis Obstetrics and Gynecological Association. David is in his third year of a pulmonary critical care fellowship and has plans to join his father at Mid-South Pulmonary. Heather is a thirdyear OB-GYN resident and may join her brother at MOGA. memphismedicalnews
A Plan to Address COPD By CINDY SANDERS
Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of death and fourth leading cause of disability in America, according to the National Institutes of Health. The umbrella term encompasses a number of progressive lung diseases including emphysema, chronic bronchitis and refractory asthma. While the National Heart, Lung, and Blood Institute (NHLBI) identifies 16 million Americans as being diagnosed with COPD, that figure only tells part of the story. The American Lung Association and COPD Foundation both estimate closer to 25-30 million Americans are impacted by COPD . . . but millions are unaware they have the disease. The Diagnosis Issue Jamie Sullivan, MPH, vice president of Public Policy and Advocacy for the COPD Foundation, said one reason people go undiagnosed is because symptoms often aren’t noticeable in the earliest stages. Even when individuals begin to experience increased breathlessness and coughing, Jamie Sullivan it’s easy to pass it off as a cold, allergies or simply part of the aging process and to change behaviors, like avoiding stairs, to mask the problem. Another issue, she added, is that physicians aren’t necessarily asking the right questions during routine visits when the disease might be caught in the early stages. Sullivan noted most diagnoses occur when symptoms have become so severe patients can no longer ignore them. The CAPTURE Study, she added, found most people aren’t diagnosed with COPD until they have already lost half their lung function. Primarily seen as a smoker’s disease, Sullivan said there is also a “shame and blame” element surrounding COPD. However, she noted, there is an increasing understanding that other factors including environment, prematurity, and genetics also add to the burden of the disease. “Our founder John Walsh, who unfortunately passed away earlier this year, saw there was this huge hole in support for COPD patients,” said Sullivan. “He really put out a call to action to the patient and scientific community to come together and find solutions to support the community.” Mounting a Response It has only been since 2013 that COPD rates across all 50 states have been available with the data put forth from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance Survey (BRFSS). Further complicating the memphismedicalnews
issue, there haven’t been national screening parameters, a coordinated action plan, or funding for COPD research at the level of other diseases. However, the hope is all of that might be about to change with the release of the COPD National Action Plan earlier this year. “Prior to the release of the federal action plan in May, there hadn’t been a coordinated federal response,” said Sullivan. Now, she continued, “Here’s a blueprint of how we, as a country, can tackle COPD.” Sullivan said the COPD community had advocated for this type of coordinated response for years. She noted many stakeholders, including the COPD Foundation, had a voice in creating the collaborative plan. Following interagency work groups at the federal level in 2014 and 2015 and a letter from Congress urging next steps in late 2015, Sullivan said NHLBI hosted a town hall meeting in February 2016 open to physicians, patients, researchers and COPD organizations. “That was a great chance for the community to come together to talk about what are the major issues the plan should address and to prioritize goals,” Sullivan noted. Following the town hall meeting and period for public comment, the finalized COPD National Action Plan outlines five key goals: • Empower people with COPD, their families, and caregivers to recognize and reduce the burden of COPD. • Improve the diagnosis, prevention, treatment and management of COPD by improving the quality of care delivered across the healthcare continuum. • Collect, analyze, report and disseminate COPD-related public health data that drive change and track progress. • Increase and sustain research to better understand the prevention, pathogenesis, diagnosis, treatment and management of COPD. • Translate national policy, educational, and program recommendations into research and public health actions. The next steps, Sullivan said, are to move forward with implementation of the plan. What’s Happening Now In the meantime, Sullivan said there are a number of immediate steps to improve care including an emphasis on ensuring everyone is diagnosed properly and on time, enhancing patient education efforts, instituting a personalized treatment regimen to meet a patient’s specific needs, and where appropriate, utilizing pulmonary rehab. “These are all things we don’t need new treatments to do,” she said of deploying an evidence-based approach. Sullivan added the COPD Foundation and others have long advocated for broader use of primary pulmonary
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President Trump Turns to Executive Orders to Reform Healthcare and Stocks Plummet By Denise Burke After repeated failures to repeal and replace the Affordable Care Act (ACA), President Trump took matters into his own hands and started issuing Executive Orders. On October 12, 2017, President Trump released his “Executive Order Promoting Healthcare Choice and Competition Across the United States.” The Order directed agencies to take action to: • allow small businesses to pool together to purchase health insurance, • permit short-term, limited-duration insurance policies to cover 12 months (currently limited to three months), and • expand access to employer-funded Health Saving Accounts. Later the same day, the President announced that the Administration would stop funding cost-sharing reductions available on the ACA Health Insurance Marketplaces until Congress appropriates the funding to cover the subsidies. The ACA, as enacted, requires insurers to offer plans with reduced co-pays and deductibles for persons with very low-incomes, but the ACA does not appropriate the cost-sharing subsidies to pay for the subsidies. Without Congressional authority, and thus, the legal authority to do so, President Obama agreed to pay costsharing subsidies, an action he believed necessary to entice insurers to enter the Marketplace. Ironically, President Obama’s prior actions that exceeded executive authority allowed President Trump to “undo” the action critical to the ACA without Congressional approval. Proponents of the Executive Orders claim that they are aimed at increasing competition in the healthcare marketplace, while critics claim their sole purpose is to undermine “ObamaCare.” Regardless of the intent, the President’s actions had immediate impact on the healthcare and healthcare insurance markets. While provider stock prices fell slightly, healthcare insurers were battered by the news. Centene, which provides services to government-sponsored healthcare programs, lost nearly 6%, managed care company Molina Healthcare lost more than 4% and Anthem was down nearly 3%. The day after signing the Order, the President tweeted “Health Insurance stocks, which have gone through the roof during the ObamaCare years, plunged yesterday after I ended their Dems windfall!” This is a classic case where two wrongs (and a tweet), don’t make a right. Healthcare is too important to individual well-being and the national economy, to be rewritten by each new President without Congressional approval. Healthcare providers and the healthcare insurance markets are complex industries that require significant lead time to adjust to change. Chaotic change unnecessarily stresses the nation’s healthcare system. Bipartisan efforts to stabilize the ACA in a less chaotic manner have been quietly under way since the last failed Republican attempt at full-scale repeal and replace (prior to the executive actions). Senators Lamar Alexander (R-TN) and Patty Murray (D-WA) are sponsoring the Bipartisan Health Care The Author: Stabilization Act of 2017 that would: • make cost-sharing reductions available in the healthcare marketplace to individuals with incomes within 100-250% of the federal poverty level through 2019, • make catastrophic health plans available to everyone (currently only available to persons less than age 30 or individuals with financial hardships), • fund ACA assistance and enrollment programs, which have been faced with budgets cuts, andincentivize states to create innovative ways to improve healthcare. Denise Burke The bill language and a section-by-section summary can be found at www.help.senate.gov/download/bipar-stabilization-section-by-section. A possible second bill has been announced by Sen. Orrin Hatch (R-UT) and Rep. Kevin Brady (R-TX and Chair of the HouseWays and Means Committee). This bill would: • continue funding for cost-sharing reductions for until 2019 (limited to policies that don’t cover abortion), • provide limited relief from the individual mandate (through 2021) and employer shared responsibility mandate (retroactive to 2015), and • increase the contribution limits on health savings accounts. While the outlook for the healthcare industry is shrouded in uncertainty right now, the weeks and months ahead will almost assuredly be filled with new legislative proposals to modify the ACA in meaningful ways. There could even be some level of bipartisan cooperation moving forward but maybe it’s too early for Christmas wishes.
This Doctor, continued from page 5 Named for James M. Kennedy, the hospital opened in 1943 and became the largest Army hospital in the U.S. It was described as a “state-of-the-art medical facility and one of the best equipped hospitals in the nation.” It was located at Park and Getwell, which earlier was named “Shotwell.” During the next three years, 44,000 patients were treated there and an estimated average of 30 surgeries a day were performed. While a large number of the wounded soldiers were paraplegics and quadriplegics many others required treatment for all types of casualties and illnesses, including the chest. My dad became chief of pulmonary diseases. According to author Paul Dudenefer, who wrote a brief, but excellent piece about Kennedy, when the war ended “a census that reached 6,000 patients and the hospital had evolved into a center for research, evaluation, and specialization for psychiatric and penicillin medical care, as well as surgical procedures for neurological, thoracic, and orthopedic cases.” When Kennedy was given to the Veterans Administration in 1946, my dad stayed. He had become chief, pulmonary diseases, and part of the hospital’s research included TB. At Kennedy the clinical trials involved three drugs, usually used in combination. Kennedy proved to be an excellent facility for the trials because patients would be there a lengthy
time. They could be monitored closely and it was easy to ensure they took their drugs on schedule. During this time research also began on lung cancer and the team zeroed in on cigarette smoking. As the evidence began to grow, my dad asked that the cigarette machines that were actually on the TB ward be removed. The administration resisted, but eventually the machines were taken out, much to the displeasure of the patients. This was also about the time my dad talked to me about the evils of smoking. When I asked why there wasn’t more attention given to problems tobacco created, he explained before going public the doctors had to build a stronger case to fight the lawyers in the courtroom. At the same time, successes began to grow involving the drugs and TB. In fact, the effort became so successful that tuberculosis sanitoriums began to close. I remember my dad was excited about going to the closure of one in Memphis. He would be disappointed today. He thought they had greatly reduced the threat of TB. However, it now is the second-most common cause of death from infectious disease (after those due to HIV/AIDS). But I still consider my dad a star. He spent his life fighting a deadly disease, running the risk of contracting it himself. He worked in locations many others would pass on. He never lost his passion or his dedication. That’s a star in my book.
A Plan to Address COPD, continued from page 7 rehab, a non-pharmacologic management option. “Think of it as physical therapy for your lungs with the added benefit of education and support,” she said. Reimbursable at low levels that Sullivan said aren’t sustainable, pulmonary rehab therapy is typically offered only though hospital-based programs. Without enough programs, Sullivan said it’s been hard to gain traction among patients and physicians. Another issue is the time commitment, which entails two hours of education and exercise plus travel time. “To get adherence and compliance with someone, that takes a major commitment,” she noted. “But for the people who do, nearly everyone you talk to will say it changes their life.”
While the therapy is evidence-based, Sullivan said more research is needed to grow awareness and improve reimbursement rates. However, she noted, research funding has been another ongoing issue. “It goes back to the federal response to COPD, which is around $100 million per year gets spent on federal research … which is pennies compared to the impact of the disease,” she said. Sullivan added that while a great deal of progress has been made in understanding COPD and its genetic basis, additional research funding could really accelerate that work. “This coordinated action plan could be the tipping point,” she said. “It has the potential to be if the community rallies around it,” she concluded.
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GrandRounds St. Jude Immunologist Receives Prestigious Research Award Thirumala-Devi Kanneganti, PhD, a member of the Immunology Department at St. Jude Children’s Hospital, received the 2018 Eli Lilly and Company-Elanco Research Award, the American Society for Microbiology’s oldest and most Thirumalaprestigious prize. Devi In addition, she was Kanneganti also recognized by the Society for Leukocyte Biology with the 2017 Dolph O. Adams Award, which recognizes excellence in research into cellular and molecular mechanisms of host defense and inflammation. Kanneganti, who joined the St. Jude faculty in 2007, leads a lab that studies the fundamentals of innate immunity, the body’s first line of defense against infection. Her work explores how our body and the immune system respond to infectious diseases, and has proven critical in determining how our immune system affects the development of several debilitating diseases, including cancer. The award stated, in part, “Kanneganti is a visionary scientific leader who has made major discoveries in understanding how foreign nucleic acids and other microbial products trigger inflammasome activation and inflammation.” Research from her lab has been published in more than 190 original peer-reviewed publications, with many of the studies appearing in top-ranking scientific journals. She is a regularly invited speaker at scientific conferences around the world and serves as the Chair of the National Institute of Health Innate Immunity and Inflammation study section. “Her efforts are highly regarded in the immunology community and her research has helped raise the profile of our department,” said Peter Doherty, PhD, Emeritus faculty member in the Department of Immunology and Nobel Laureate.
West Cancer Center Launches Integrative Oncology Division West Cancer Center has added an Integrative Oncology Division to be directed by Sylvia Richey, MD. Dr. Richey has been an oncologist with West for 12 years at both the East Campus in Memphis and the Corinth, Mississippi, site. Erich Mounce, Chief Sylvia Richey Executive Officer for West Cancer Center, said, “The launching of our Integrative Oncology Division is another important building block toward our preparation to become a fully comprehensive cancer center. We are memphismedicalnews
grateful that one of our leading medical oncologists has taken on this project with passion and a commitment to put our patients at the heart of all the things we do.” Dr. Richey plans to continue to see breast cancer patients at the Memphis location while building the Integrative Oncology Division. The concept of integrative oncology involves combining conventional treatments with supportive therapies. West plans to supplement its current survivorship and palliative care services with new programs such as art therapy, music therapy and acupuncture to enhance the experience for current patients.
Fertility Associates of Memphis Wins ‘Center of Excellence’ Designation Fertility Associates of Memphis has been designated as a “Center of Excellence” by Optum Health. Center of Excellence (COE) network status is granted to facilities meeting specific criteria and is an invitation-only program. Optum’s decision to award Fertility Associates of Memphis with an active Center of Excellence status was based on the experienced physicians and staff who “deliver successful clinical outcomes, offer comprehensive reproductive services, demonstrate exceptional facility operations, provide continuous quality assurance and preserve industry accreditation.” The designation allows Fertility Associates of Memphis an opportunity to provide treatment for complex patient conditions while minimizing patient expenses.
Campbell Clinic Plans Expansion in Germantown Campbell Clinic has retained Rendina Healthcare Real Estate to be its representative in connection with the design, development and construction of a new facility on the clinic’s existing Germantown campus. Rendina is a national, full-service developer of healthcare real estate headquartered in Jupiter, Florida. Preliminary plans call for the construction of a new four-story medical office building on a currently vacant 5-acre parcel immediately adjacent to the clinic’s current location at 1400 South Germantown Road. The clinic purchased the property in 1992 The facility is slated to include outpatient orthopedic clinical space, expanded physical therapy and imaging suites and an ambulatory surgery center with eight operating rooms. An option to lease a portion of the new building to third-party tenants upon completion is also under development. The facility will add approximately 120,000 square feet of new space to the Germantown campus at a cost expected to be near $30 million. The City of Germantown Planning Commission has approved the preliminary and final site.
C R E S T W Y N B E H AV I O R A L H E A LT H conveniently located near historic Germantown, is a state-of-the-art treatment center where adults and adolescents can receive life-changing care for mental health and substance use disorders. At Crestwyn Behavioral Health, patients have the opportunity to work in close collaboration with experienced professionals whose skills are equaled only by their compassion and dedication. Each person who heals at Crestwyn Behavioral Health will follow a personalized treatment plan that incorporates the therapeutic and educational activities that are best suited to their unique strengths, needs, and goals.
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GrandRounds Two Memphians Honored with Four Freedoms Award Two Memphians, Dr. Bashar Shala, MD, of the Memphis Islamic Center and a cardiologist who has been practicing in Memphis for the past 17 years, and Rev. Dr. Steve Stone of Heartsong Church, were recently presented Bashar Shala with the Franklin D. Roosevelt Freedom of Worship Medal during ceremonies in New York. The recognition was for their work to foster unity between the Chris- Steve Stone tian and Islamic communities in Memphis. The story about the friendships they helped build between two churches – one Methodist and one Muslim -- across the street from each other in Cordova, has drawn international attention. During the award presentation, the audience was told: “In 2008, these places of worship became neighbors in a city where many residents may not have been prepared for a cultural shift. Nevertheless, they welcomed each other with open arms and have created lasting bonds of friendship and solidarity among their congregations. Together, they represent the altruistic and openhearted ideals of Franklin and Eleanor Roosevelt and their belief that the values we hold in common are stronger than the differences that set us apart.” The Four Freedoms Awards are presented each year to men and women whose achievements have demonstrated a commitment to the principles President Franklin D. Roosevelt proclaimed as essential to democracy in his historic speech to Congress on January 6, 1941: freedom of speech and expression, freedom of worship, freedom from want, and freedom from fear.
Azar Elected Treasurer of American Board of Orthopaedic Surgery Frederick M. Azar, MD, Chief of Staff of Campbell Clinic Orthopaedics and a professor at the University of Ten-
nessee-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, has been elected to a oneyear term as Treasurer of the 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. All 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. Each organization nominates four physicians two out of every three years and the Board votes for one candidate from each nominee slate. Officers are current Board members elected by other Board members. For a full list of ABOS Board Members, go to abos.org/ about-abos/board-of-directors.aspx. Azar was elected to the Board in 2016 and specializes in sports medicine. He serves as the team physician for the Memphis Grizzlies and Memphisarea colleges and high schools. He was previously President of the American Academy of Orthopaedic Surgeons. Azar earned his medical degree at the Tulane University School of Medicine.
nio. Dr. Ford did his residency at UTCampbell Clinic and his fellowship in joint preservation, resurfacing and replacement at Washington University. * Dr. Benjamin W. Sheffer has joined Campbell Clinic as a pediatric orthopaedic surgeon. He earned his undergraduate degree at Texas A&M University and went on Benjamin W. to graduate from mediSheffer cal school at Texas Tech University Health Sciences Center. Dr. Sheffer completed his residency at the John Peter Smith Hospital Department of Orthopaedic Surgery and his fellowship at UT-Campbell Clinic. * Dr. Tyler J. Brolin has joined Campbell Clinic as a shoulder and elbow specialist. A graduate of Concordia College, he went on to earn his medical degree at The University of North Da- Tyler J. Brolin kota School of Medicine and Health Sciences. Dr. Brolin did his residency at UT-Campbell Clinic and subsequently completed The Shoulder and Elbow Fellowship at The Rothman Institute at Thomas Jefferson University.
Three Physicians Join Staff at Campbell Clinic Orthopaedics
West Cancer Center has named Dr. Eric Reiner as the its Director of Oncological Radiology for the Diagnostic and Interventional Radiology Department, Prior to joining the West Cancer Center, Reiner served as AssociEric Reiner ate Professor of Diagnostic Radiology for the Division of Interventional Radiology at Yale University/ Yale-New Haven Hospital in Connecticut. During his time at Yale University, he also served as an active member on the Medical School Curriculum Committee for Radiology, Medical Director of the Yale New Haven Hospital PICC Service, Chairman of the Formulary Committee at the Heart and Vascular Center and Fellowship Director for Interventional Radiology. He earned his Bachelor and Masters of Science in Biomedical Engineering at Rensselaer Polytechnic Institute in Troy, New York. Reiner was employed at US Surgical Corporation, a medical device company, before continuing his studies and earning a Doctor of Osteopathic Medicine degree at the University of New England College of Osteopathic Medicine in Biddeford, Maine. Dr. Reiner completed an internship in Internal Medicine at Hospital St. Raphael before completing his Residency in Diagnostic Radiology at Albany Medical Center in New York; where he was elected Chief Resident.
Campbell Clinic Orthopaedics, which has four clinics located in the Memphis area, including after hours urgent care clinics in Germantown and Southaven, has added three physicians to its staff. They are: * Dr. Marcus C. Ford has joined the team of physicians at Campbell Clinic Orthopaedics as a total joint replacement specialist. A graduate Marcus C. Ford of the University of Kansas, he went on to earn his medical degree from the University of Texas Health Science Center in San Anto-
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West Cancer Center Names Eric Reiner Director of Oncological Radiology
All-Day Excel Workshop Scheduled November 16
The MidSouth MGMA will hold an all-day special training session provided by Nate Moore with Moore Solutions on Thursday, November 16, at the Racquet Club, 5111 Sanderlin. Moore will discuss using Excel in health care practices. There is no cost to the Midsouth MGMA membership. A continental breakfast will be available at 7:30 am with the first session – Basic Training – scheduled for 8 am to 11:30 am. Lunch and vendor networking will be from 11:30 am to 1:00 pm. The second session – Advanced Training – will be held from 1:00 pm to 4:30 pm. For more information email Janice Cooper at email@example.com
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SIX RECENT TENNESSEE HEALTHRELATED LAWS YOU SHOULD KNOW By Arthur S. Richey This article highlights six recent changes and developments in Tennessee state laws that could potentially impact hospitals, physicians, and other providers.
1. Licensure of Pain Management Clinics. Before July 1, 2017, the Tennessee Department of Health (“DOH”) maintained a certification system for pain management clinics. Effective July 1, 2017, however, this prior certification system has been replaced by a licensing requirement. Under the new law, generally, no one may operate one of the following Arthur S. Richey without a license: (1) a privately owned clinic where any Tennessee-licensed healthcare provider prescribes or dispenses opioids (noncancer related), benzodiazepines, barbiturates or carisoprodol to a majority of its patients for 90 days or more in a 12-month period; or (2) a privately owned clinic advertising pain management services. Certain clinics providing interventional pain management are exempt from the license requirement. The most burdensome of the new requirements are: (1) the pain management clinic medical director must qualify as a “pain management specialist” providing a large array of specific clinical and administrative services; and (2) if DOH has reasonable suspicion that a clinic is operating as an unlicensed pain management clinic, DOH may conduct an unannounced inspection at any time. The inspected clinic will be deemed to be operating as an unlicensed pain management clinic unless the clinic can provide documentation demonstrating that it does not meet the definition of a “pain management clinic.
2. Identification of High-Risk Opioid Prescribers. As of July 1, 2017, DOH will investigate and identify high-risk opioid prescribers based on clinical outcomes (e.g., patient overdoses) and will convey that information to the prescribers’ licensing boards. The licensing boards will notify the prescribers of their high-risk status and the remedial actions they must take over a period of time. Prescribers
failing to complete the required remedial actions may face licensure disciplinary action.
3. Waiver of Liability Clauses May Be More Enforceable Than You Think in the Healthcare Setting. In a recent Court of Appeals of Tennessee case, a transport company providing non-emergent transportation services was not held liable for a patient’s fall because the patient signed a waiver expressly releasing the transport company from all claims of ordinary negligence. This case illustrates that waiver of liability clauses may be more enforceable than previously thought in situations where services provided to patients are not considered to be professional services. Thus, hospitals, physicians, and other providers should consider including these clauses (or modifying existing clauses) to clarify that patients are expressly waiving all claims of ordinary negligence in the event an employee, agent, or independent contractor the clinic or facility furnishes non-professional medical services.
their respective fee schedules once every 12 months. Arthur S. Richey is a member of the Healthcare Regulatory and Transactions Group at Butler Snow LLP. He focuses his practice on healthcare law, commercial contracting, regulatory compliance counsel and advice, and mergers and acquisitions. Learn more about Butler Snow’s healthcare practice at butlersnow.com.
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4. Treatment of Minors for Sexually Transmitted Diseases. Effective July 1, 2017, certain healthcare providers, such as physicians and advanced practice nurses, may examine, diagnose, and treat minors infected with sexually transmitted diseases without the knowledge or consent of the minor’s parents.
5. Continuing Medical Education Credit (“CME”) for Volunteer Healthcare Services. Effective May 11, 2017, certain healthcare providers may obtain one hour of CME for each one hour of volunteer healthcare services, subject to a maximum annual amount of the lesser of eight hours or 20% of the total annual amount required for the applicable license.
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6. Required Notice Before Changes to Reimbursement Policies. Effective January 1, 2019, a commercial payor must provide 60 days’ prior notice to providers of any material changes made by the payor to its provider manual or reimbursement rules and coverage policies. Such payors must provide at least 90 days’ prior written notice to a provider before implementing any change to a provider’s fee schedule. Health insurance entities can only change
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Memphis Medical News November 2017