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FOCUS TOPICS PEDIATRICS • REIMBURSEMENT

Your Middle TN Source for Professional Healthcare News

PHYSICIAN SPOTLIGHT PAGE 2

Jeffrey Neul, MD, PhD

ON ROUNDS

TJC Sharpens Focus on Healthcare Access for Children While America’s federally funded and supported health programs continue to face an uncertain future, the Tennessee Justice Center is taking steps to ensure nearly a million kids in the state have the healthiest futures possible ... 3

Patients First, No Matter what Hat You Wear When asked how I manage wearing the different hats of pediatrician and president of the Tennessee Medical Association, the state’s largest professional organization for doctors, my answer is always the same. It’s all about the patients ... 5

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Addressing Adolescent Angst in a Digital World By CINDY SANDERS

The Truman Show, a satirical 1998 film, followed the everyday life of fictional character Truman Burbank as he grew up in front of millions as the unwitting and unsuspecting ‘star’ of a television program. When the film debuted, reality television was still in its infancy. While there had been a few shows over the years depicting clips of police stings or funny videos, Jersey Shore and Keeping Up with the Kardashians were still several years away, and Facebook, Twitter and Instagram were unknown commodities. Today’s teens have grown up as conscious actors in their own reality shows with carefully cultivated selfies and no detail too small to share and like. Yet, the unrelenting access comes with its own pitfalls where cyberbullying can quickly escalate, and it’s all too easy to believe everyone else’s life is picture perfect. Jess. P. Shatkin, MD, MPH, a member expert of the American Academy of Child and Adolescent Psychiatry, noted growing up in a digital age is very different than what parents and providers experienced in their own adolescent years. Whether because of more stressors, improved diagnostics or a combination of both, adolescent depression and anxiety are on the rise. “Most of our studies suggest that about 15-17 percent of kids will have had a major depressive episode by the time they hit 18,” said (CONTINUED ON PAGE 4)

Who’s Ready for MACRA? Hint: Not the Target Audience

By CINDY SANDERS

In late June, the American Medical Association commended the Centers for Medicare & Medicaid Services for proposing several new policies to allow added flexibility in Medicare Access and CHIP Reauthorization Act (MACRA) implementation. Just over a week later, results from a survey conducted by the AMA and KPMG LLP made it clear why that flexibility was so desperately needed: fewer than one in four physicians in a decision-making role felt ‘well prepared’ to meet the new quality reporting requirements in 2017. MACRA, which was signed into law April 2015, makes fundamental changes to the way Medicare Part B will pay physicians and other clinicians under the Quality Payment Program (QPP) beginning in 2019 but based off of performance in 2017. The new payment methodology replaced the universally hated SGR formula with a system (CONTINUED ON PAGE 8)

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PHYSICIAN SPOTLIGHT

Leading the Way

Dr. Jeffrey Neul Joins VUMC as Kennedy Center Director By MELANIE KILGORE-HILL

Vanderbilt’s Kennedy Center has pioneered cutting-edge research in developmental disabilities for more than a half century. The center begins a new chapter this month with the arrival of child neurologist Jeffrey Neul, MD, PhD. Previously division head of Child Neurology and vice chair for Developmental Neurosciences at the University of California, San Diego, Neul stepped into his new role of director of the Kennedy Center Aug. 1, bringing his vast expertise in genetic research to VUMC.

Finding his Path

Originally from Chicago, Neul earned his undergraduate degree from the University of Illinois at UrbanaChampaign and his medical and doc-

torate degrees from the Pritzker School of Medicine at the University of Chicago. He then completed his residency and fellowship in child neurology at Baylor College of Medicine and Texas Children’s Hospital. As one of the nation’s foremost authorities on Rett syndrome, or RTT, Neul plans to continue his commitment to research and treatment of the diagnosis he first stumbled across quite by accident. “In 1999, I was finishing med school and wanted to go into child neurology and asked a professor what I should train for,” Neul said. “He picked up a journal laying on a desk and read that a gene had just been found for Rett syndrome. The timing was serendipitous.”

Rett Syndrome 101

Diagnosed by a simple blood test, Rett syndrome is most often misdiagnosed

as autism, cerebral palsy, or non-specific developmental delay found exclusively in girls. It affects roughly 5,000 U.S. families with 200 new cases diagnosed annually. “The field became energized in 2007 when genetic work showed we might be able to reverse the course of the disease,” Neul said. “It changed the way people thought about it.” Neul’s 14-year stint at Baylor included involvement in one of the first industry sponsored clinical trials, and he looks forward to participation in the second phase at Vanderbilt. “We’ve seen a real change in attitudes and a lot more interest from the science and pharma industries for developing treatments,” Neul said of the syndrome, which affects 1 in 10,000 live female births. While general recognition of the disorder has increased, he said a fair amount of providers still struggle to recognize symptoms. In 2010, Neul helped establish clinical consensus criteria to try to simplify diagnosis of Rett syndrome. “The big thing is if you have a girl who’s lost skills, like the ability to talk or use her hands, think about Rett syndrome,” he said, noting the typical age of diagnosis is three years. “After a diagnosis is made, people may interpret the prognosis as gloomy, but there’s a lot of opportunities for these children to improve their quality of life.”

New Role in Nashville

In his new role, Neul plans to split his time between providing clinical care for patients with Rett syndrome and other neurogenetic disorders and continuing his

clinical research, which includes participation in a National Institutes of Health study he’s been a part of since 2003. Neul said he’s eager to make a difference in developing ideas of tailoring care toward individuals with developmental disabilities. “The Kennedy Center has a long history of really capitalizing on behavioral and educational intervention for these disorders,” he said. “I’m excited to see how we integrate those targeted interventions with more biomedical interventions, because the future is going to capitalize on the intersection of medical and biomedical.” As for his move to Nashville, Neul said it was an easy decision given the reputation of the center. “The Kennedy Center has a long-standing interest in all neurodevelopmental disorders and has been a leader nationally,” he said. “This is an opportunity to be a part of that and help foster and enhance those ongoing efforts and to improve the lives if people with developmental disabilities.” While much of his own research is rooted in Rett syndrome, Neul said the Kennedy Center’s mission is much broader than a single diagnosis. “There’s a large group of individuals doing research and delivering care, and it’s my job to foster and broaden those efforts and to recruit people who may not have previously been involved in research in these disorders,” Neul said. “I’m very interested in making additional connections within other Vanderbilt departments that haven’t previously worked on these discoveries but might have new approaches.”

Blog Log The Nashville Medical News Blog features additional insights and information from a cross-section of industry leaders. The blog can be accessed directly through NashvilleMedicalNews.Blog or from the homepage of the main website. NEW IN AUGUST: Dave Chaney, vice president of the Tennessee Medical Association, shares information on “A New Conference for a Changing Healthcare Climate.” The inaugural TriMED Healthcare Education Summit takes place Sept. 8-9 at the Music City Center. A collaborative effort of a number of organizations within Tennessee’s healthcare community, the conference features more than 60 hours of CME content on a wide range of critical healthcare topics. Benita Harp, COO for Life Credit Union, which is a financial cooperative solely dedicated to serving those who work in and for the healthcare community, explores smart financial strategies in “Planning for Life.” Austin Madison, senior vice president with The Crichton Group, discusses “ValueBased Payments: An Emerging Trend in Employer-Sponsored Healthcare Strategy” in an in depth article exploring the current landscape, healthcare consumption, cost control mechanisms, reference-based pricing, and other considerations. Michael Winter & Lindsay Youngbauer with Diversified Trust, a comprehensive wealth management firm with an office in Nashville, explain the importance of healthcare professionals considering long-term care (LTC) insurance as a key aspect of wellness and financial planning for themselves and their patients.

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TJC Sharpens Focus on Healthcare Access for Children By MELANIE KILGORE-HILL

While America’s federally funded and supported health programs continue to face an uncertain future, the Tennessee Justice Center is taking steps to ensure nearly a million kids in the state have the healthiest futures possible.

Protecting Tennessee’s Kids

In April, the TJC announced the addition of attorney Kinika Young as director of Children’s Health. The newly created position was made possible after the organization was awarded a grant from the prestigious David & Lucile Packard Foundation for its “Insuring America’s Kinika Young Children – Reaching the Finish Line Project.” Previously a partner with Nashvillebased law firm Bass, Berry & Sims, PLC, Young has been tapped to lead TJC’s efforts to protect and improve public health insurance programs that serve 980,000 Tennessee children. She has also been charged with working to ensure all Tennessee children have access to the resources they need to grow up healthy. “I had been doing pro bono work for the Justice Center and was looking for an opportunity to help people more directly,” said Young, a former Big Brothers Big Sisters of Middle Tennessee mentor. “Given the current political climate, I saw the need to get more involved with fighting for social justice issues for children since they’re our future.”

Changing Policies & Lives

TJC Executive Director Michele Johnson said Young’s commitment would better help the TJC navigate the increasingly controversial healthcare landscape. “Children’s health is something we’ve always done, and this position gives us the ability to really bring the best in health policy that’s sound and will have positive benefits for decades,” said Johnson, who co-founded the organization more than 20 years ago. “Kids who have a healthy start will earn more as adults, and they’ll be less likely to have trouble with school and drugs and alcohol,” she said. “Giving kids a healthy start means they’ll have more full and successful lives as adults, which will benefit us for generations. We want to provide every amount of resources we can invest in making sure they have healthy starts.” Proposed budget cuts could equal a $500 million loss annually to existing state health programs. “We’d be faced with either rolling back eligibility or cutting services like therapy to many children,” Young said. Provider reimbursement also could take a hit, meaning fewer doctors might accept Medicaid/TennCare patients, wait times could be extended, and medical services could be limited. “We’ve made some good progress in recent years making sure nashvillemedicalnews

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Tennessee kids are insured,” said Young. “Currently only 4 to 5 percent of the state’s children are still uninsured, which is the lowest number in recent history. We don’t want to go backward.” Many of the state’s more than 60,000 uninsured children lack coverage due to complicated rules and parents who don’t understand the process. Too often, middle class families face a lifetime of medical bills simply because they’re unaware of eligibility options, the TJC has found. In other cases, children who are natural born citizens remain uninsured because of the parents’ legal status and fear of deportation. Regardless of the reason, Young said uninsured children account for much of the uncompensated care absorbed by Tennessee hospitals and providers, which consequently impacts every family and community in Tennessee.

“Our long-term goal is to improve on the health safety net system for children and to get the uninsured rate down further,” said Young.

A Partner to Families, Providers

In addition to partnering with families, Young also works with providers to clarify common misconceptions about government-funded programs. “Many doctors still haven’t heard of us and don’t realize how we can actually benefit them as an ally in their practice,” she said. The TJC helps providers navigate the system and advocates for patients who might be denied coverage by HMOs. Young also educates providers who don’t accept TennCare about the program and discusses the full impact of the state’s Medicaid system with those who do.

Children comprise more than half of Tennessee’s state-funded healthcare program participants. Recent statistics show that of Tennessee’s 1.5 million children, nearly 57 percent are covered by TennCare (the state’s Medicaid program) or CoverKids (the state’s Children’s Health Insurance Program). Employer-sponsored or other health plans cover another 37 percent of the state’s children, 1 percent are enrolled in plans through the Affordable Care Act’s HealthCare Marketplace, and a little more than 4 percent have no coverage. “We want to make sure every child who’s eligible gets health coverage,” Johnson said. “It’s a huge goal, but by partnering with providers, community and church groups, we can accomplish that if we try. Healthcare has become very polarized, but we can’t lose it to politics. It’s too important to Tennessee’s children.”

You Be the 1

Local Couple’s Campaign for Kindness By CINDY SANDERS

While silver is a typical gift for a 25th wedding anniversary, local couple John and May Bumpus decided a better option was to provide teens with a silver lining. The parents of two were out to dinner celebrating 25 years of marriage when the conversation turned to the rising number of suicides and violence among teens. Alarmed at the trend, they began discussing what they could do to make a difference. Instead of taking an anniversary trip, they decided to sink those resources into creating a video and community campaign. You Be the 1 encourages everyday action to help those with hidden issues. With assistance from Father Ryan High School and DVL Seigenthaler, the couple filmed vignettes to create a teaching video and launched a website with links to area resources – youbethe1.com. “The teenage years can be isolating, and the issues youth face are more complex than ever,” said May Bumpus. “By also raising awareness of the many organizations standing by to help, we hope to connect young people with professionals who can address these often serious needs.” Launched this past February on National Random Acts of Kindness Day, the ongoing campaign encourages both adults and teenage peers to actively practice empathy and kindness. In the glossy world of social media, Bumpus said it’s all too easy for teens to believe no one else has issues or anxiety, making those who struggle feel even more alone … even if that hurt is well hidden. “To look on the outside, everything looks normal and fine, but if we dig a little deeper, everybody has issues. Nobody’s life is perfect,” she noted. “Take a minute, stop, open your eyes

John and May Bumpus

and try to make a positive difference in someone’s life,” she continued of the message behind the campaign. “That difference could be anything – a smile, an ‘Are you okay today?’ – as opposed to just walking by.” She added, “We wanted people to try to make a positive difference in any way they feel comfortable. We might not be able to do everything, but we can do something.” The vignettes occur in everyday spaces for teens including the classroom, gym and

lunchroom. The short clips depict teens suffering from a number of challenges, including cyberbullying, stress, eating disorders, depression and abuse. Bumpus said the visuals are nuanced to allow for discussion when used by schools, organizations or healthcare providers. She added the goal is that the video be widely utilized as a teaching tool or conversation starter and said it’s available at no charge to anyone interested in using it. The couple has partnered with a number of nonprofits, and the website features contact information for resources dealing with each issue, including Beneath the Skin, Stars Nashville, Boys and Girls Club of Middle Tennessee, Oasis Center, the Anxiety and Depression Association of America, and Renewed: Eating Disorders Support. The hope is that the list of area support services will continue to grow on the website. The video is accessible online at youbethe1.com. To ask about having an organization or resource added to the video, please email inquiries to Christian Lail at christian.lail@dvlseigenthaler.com. “I know it’s overused … and I use it all the time … but it really does take a village. We all need to help out on this,” concluded Bumpus. “Love and kindness are never wasted.”

Teens Face Very Adult Challenges 1 in 3 has been a victim of cyberbullying. 1 in 10 has been diagnosed with an eating disorder. 1 in 3 will be involved in an abusive relationship. 1 in 5 will experience depression before they reach adulthood. 1 in 3 feels overwhelmed by stress. AUGUST 2017

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Pediatric Rounds UnitedHealthcare Children’s Foundation Medical Grants

Tennessee families in need of financial assistance for child medical costs have the option to apply for a UnitedHealthcare Children’s Foundation (UHCCF) grant. In Tennessee, UHCCF has awarded more than 280 grants since 2013 and is encouraging more Tennessee families to apply this year. Qualifying families can receive up to $5,000 per grant with a lifetime maximum of $10,000 per child, to help pay for their child’s healthcare treatments, services or equipment not covered, or not fully covered, by their commercial health insurance plan. To be eligible for a grant, a child must be 16 years of age or younger. Families must meet economic guidelines, reside in the United States and have a commercial health insurance plan. Grants are available for medical

expenses families have incurred 60 days prior to the date of application as well as for ongoing and future medical needs. Families do not need to have insurance through UnitedHealthcare to be eligible. Please direct families that might benefit from a medical grant to www. UHCCF.org. Note, only parents or legal guardians are eligible to apply on behalf of a child.

Monroe Carell Earns Top Honors from U.S. News & World Report

For the tenth consecutive year, Monroe Carell Jr. Children’s Hospital

at Vanderbilt has been named among the nation’s leaders in pediatric healthcare by U.S. News & World Report in their annual Best Children’s Hospital rankings. Eighty-one of the 187 surveyed hospitals were ranked among the

top 50 in at least one specialty. Monroe Carell was nationally ranked in a maximum of 10 out 10 pediatric specialty programs. Monroe Carell’s Division of Urology, which has consistently been a top 10 elite pediatric specialty program, came in at No. 7 in the 2017/2018 rankings. Neonatology jumped from 26th in the nation to No. 9. Cancer moved up from 18th to 16th; Orthopaedics went from 14th to 13th; Pulmonology improved from 17th to 13th; Diabetes & Endocrinology moved from 31st to 24th; and Gastroenterology and GI Surgery went from 22nd to 21st. Other specialties ranked this year: Neurology & Neurosurgery (26), Cardiology & Heart Surgery (23), and Nephrology (31).

Addressing Adolescent Angst in a Digital World, continued from page 1 Shatkin, professor of Child are now happening much & Adolescent Psychiatry more rapidly. “Kids have and Pediatrics at New York the opportunity to be University and vice chair exposed to a lot more than of Education for the NYU they ever have before,” he Child Study Center. pointed out. “Almost a third – 32 Shatkin – author of the percent – of adolescents forthcoming book “Born to between 14 and 18 will Be Wild: Why Teens Take meet DSM (Diagnostic Risks, and How We Can and Statistical Manual of Help Keep Them Safe,” Mental Disorders) criteria which comes out in early for an anxiety disorder,” he October – explained the continued. “Depression is adolescent paradox is that high, but it looks like anxi- Dr. Jess Shatkin, NYU professor despite great strength, teens ety is higher … and both are of Child & Adolescent Psychiatry are also incredibly vulnerand Pediatrics and author of the troubling.” able. That hardwired riskupcoming book ‘Born to be Wild.’ Shatkin said depression taking coupled with frontal and anxiety have increased lobes that are still developwith each successive generation since behaving can lead to unsafe behaviors that have ioral health professionals began monitoring real-world consequences without the matusuch statistics at the end of World War II. rity to fully discern the range of outcomes. While he was quick to say data on the effects For example, he continued, “We need of social media is still emerging, he noted to teach our kids media literacy.” Shatkin the larger the audience to witness mistakes pointed out how many commercials, televiand failures, the worse kids are going to feel sion programs and videos sell sex or glorify about those missteps. “We know now that risky behaviors. “Companies have a right the brain’s pain sensors not only respond to to do it, but we should teach our kids to be physical pain but also to emotional pain,” savvy,” he stated. “Technology is here to he explained. stay,” Shatkin continued. “We’ve given our kids this great opportunity, but it’s like putTeens as Risk-Takers ting kids in a swimming pool with sharks. Shatkin said teens taking risk is part of We have to learn to limit it.” the natural evolutionary order. For millions of years, he noted, the young utilized their Early Intervention strength, energy, speed and fearlessness to Although it’s never too late to talk to hunt and stay up all night to protect the vilteenage patients about safe behaviors, introlage from wild animals and other dangers. ducing guardians to evidence-based parent“Our brains and our bodies evolve ing strategies while children are still young much more slowly than our society is movhas proven to be most effective. ing,” he said of those ingrained risk-taking “We know that certain types of parentbehaviors necessary for surviving in the wild ing work better than others,” pointed out but not required in today’s modern world. Shatkin. He added providers play a critiAdditionally, Shatkin said societal changes cal role in presenting and reinforcing these

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concepts. Clinical and developmental psychologist Diana Baumrind outlined three basic types of parenting – authoritarian, authoritative and overly permissive. Shatkin said evidence over time has shown authoritative parenting … the midpoint between overly strict and no rules … produces the best results not only in young children but as those kids grow into teens and begin spending more time with friends. Shatkin said authoritative parents are supportive but also set strong limits. They are warm and affectionate but not overly permissive, use effective communication tools, and try to ‘catch’ their children being good. “Fewer than one in five of our parenting commands should be negative,” Shatkin said. “If there’s one thing we know about kids, and people in general, it’s that we’re motivated by reward … and never is that more true than during our teen and early adult years because of high levels of dopamine,” he explained. While rewards for meeting or exceeding behavior standards are most effective, Shatkin said that doesn’t mean privileges can’t be taken away when needed. The ubiquitous phone offers both carrot and stick. First, he said parents should be very clear when presenting a child with a phone what the expectations and limitations are. “The phone is a reward so you set it up as a reward,” Shatkin said of advice to share with parents. He added it should be clearly communicated that having a phone is a privilege that the adolescent must continue to earn, or it can be taken away for a period of time. However, he continued, it’s most effective if the period is relatively brief and if children have a way to earn back the privilege. Shatkin said if a phone or other privilege is taken away for more than a day, kids

forget the ‘why’ of the punishment and just think parents are just being mean, which diminishes the impact of the lesson. “Use these as teasers to get them to the zone where you want them to be,” he said of taking away privileges.

Warning Signals

Pediatricians and other primary care providers are often a first line of defense for young patients feeling anxious or experiencing depression. Shatkin encouraged providers to reach out routinely to parents and patients to see if there are any red flags that should be addressed. Warning signals include a persistent change in mood, crying or tearfulness, changes in sleep patterns or complaints of not being able to sleep, hanging out with a new group of friends not known to parents, no longer engaging in activities or with people they used to enjoy, expressions of anxiousness, physical changes like weight loss/ gain or appearing ‘spaced out,’ and slipping grades. “If a parent is concerned … if a pediatrician feels out of their depth … then absolutely get a consultation with someone trained in child and adolescent psychiatry,” said Shatkin. He praised the movement toward colocation with primary care and behavioral health providers under one roof. However, he also said the increasing need to address emotional and behavioral issues has been coupled with a shortage of child psychiatrists. “From a mental health perspective, there’s a huge workforce issue,” Shatkin noted. He advocated for providing physicians, nurses and therapists with a better grounding in diagnosis and treatment of mental health issues. “The earlier we intervene, the better kids do,” said Shatkin. “We need to catch more in the primary care office.”

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Patients First, No Matter what Hat You Wear When asked how I of trust with my patients and manage wearing the diftheir families who look to ferent hats of pediatrician me for advice and answers and president of the Tento their questions. It’s an nessee Medical Association, incredible responsibility, the state’s largest profesand one that I do not take sional organization for doclightly. tors, my answer is always The pediatric commuthe same.  It’s all about the nity has a responsibility to patients. challenge parents and their As physicians, we children to make the lifeendured years of education style changes they need to and training to earn the improve their health status By NITA W. SHUMAKER, MD right to become a physician Chattanooga Pediatrician & Tennessee –  changes that  our society because we want to help Medical Association President needs to ease the financial people. We are healers by burden on our healthcare nature and view the medical profession as system. We must encourage families to not a job, but a calling. That inherent paseat healthier, more nutritious meals. We sion is still what drives me on a daily basis, must teach patients who are less educated whether I am interacting with my patients and living in lower socioeconomic strata and their families, or working with my how to overcome food deserts. We must peers in TMA to advocate for our profesbe a resource to support parents in movsion and our patients. ing away from sugar and fast food to fruits Of course I become frustrated when and vegetables. We must help them underparents make poor choices that adversely stand that nutrition is not just about weight affect their children. I can see the long and appearance; it directly affects a child’s view of what medical and psychological sleep, energy level, alertness, performance problems those choices will yield. Howin school, and emotional well-being.  ever, that frustration leads me to underWe must also counsel our patients stand that I have information that the and families to get more physically active. parents don’t have. And they have chalPhysical education is all but gone in publenges that I can’t always see. It’s a partlic schools, making it even more important nership, and my job is to love, to educate, for parents to promote physical activity at to support, to encourage, and to anticipate home. My generation and those before me consequences of the choices made.  played outside. More recent generations That  role  for me  is  as  consultaare inside in front of a screen – TV, comtive as it is medical. We have a responputer, smartphones –  obstructing  their sibility as physicians not just to diagnose sleep, and their intellectual  and  physiand treat, but also to actively engage our cal development.  Electronics and smart patients in conversations around imporphones didn’t come with instructions, and tant healthcare topics and good decisionwe are just now seeing the aftereffects of making. I work hard to develop a rapport the electronic invasion into our families.

Switching hats as TMA president, my primary focus is still on patients and finding more effective ways to fight the biggest public health crisis affecting our state and nation – the opioid crisis. Tennessee for years has been ranked among the worst states for prescription drug abuse, overdose deaths and Neonatal Abstinence Syndrome (NAS). Physicians have contributed to the supply of what we  initially thought were helpful drugs.  Now that we know the risks of addiction, we have worked hard to change the prescribing culture within the medical community.  Data shows a drop in the total amount of opioid prescriptions for pain in the past five years, and a  report last year  National Safety Council  listed  Tennessee as one in just four states “making progress” in the fight against prescription drug abuse. TMA and other concerned stakeholders in and outside of the healthcare community have helped create rules requiring  pain management education for prescribers, issued state-sanctioned opioid prescribing guidelines, and strengthened laws regulating pain clinics or pain management services. The Controlled Substance Monitoring Database (CSMD) has reduced the incidence of doctor shopping by 50 percent since 2011. It’s much harder now for addicted patients to fraudulently obtain prescriptions from a legitimate healthcare provider in Tennessee.

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Tennessee Debuts Safe Stars

First State to Set Up Safety Ratings for Youth Sports Leagues

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September – Holy MACRA! November – Compliance, Billing Fraud & False Claims – Oh My! January – What the H? HIPAA, HITECH, HITRUST March – Practice Management Best Practices

© VANDERBILT UNIVERSITY

A new rating system called Safe Stars was launched July 13 and will give parents the ability to check and see if youth sports leagues in Tennessee follow staterecommended safety protocols. A collaboration between the Tennessee Department of Health and the Program for Injury Prevention in Youth Sports (PIPYS) at Vanderbilt, Safe Stars is the nation’s first statewide safety rating system for all types of youth leagues.     Youth sports leagues, such as those for soccer, will now be able to earn safety ratings in Tennessee. “Tennessee will be the first state to ever have a program like this,” said Alex Diamond, DO, MPH, director of PIPYS and assistant professor of Orthopaedics and Rehabilitation and Pediatrics at Vanderbilt. “This has never been done for community or youth leagues on a statewide fashion.” Participation by sports leagues is voluntary. The program awards bronze, silver and gold star safety ratings. The bronze designation covers the most important safety protocols: emergency action plan, background checks on all coaches, constant presence of a CPR/AED certified coach, severe weather policy, anaphylaxis emergency plan and coaches being trained to recognize and manage concussion and sudden cardiac arrest incidents. Leagues that meet two more safety protocols get a silver rating. Those that achieve four more are awarded a gold rating.  The state has launched a website https://tn.gov/health/article/the-safe-stars-initiative with information and links on how coaches can achieve a Safe Stars designation.

We have made progress and can point to some measurable results, but we still have a lot of critically important work to do. The number of overdose deaths continues to rise even though prescriptions are going down. We have to continue identifying, educating and penalizing healthcare providers who are overprescribing, inadvertently or otherwise, and weed “pill mills” out of operation. The CSMD, along with stronger regulations for pain clinics and pain management services, has helped, but we must do a better job educating  doctors, nurses and physician assistants on safe and proper prescribing habits by incorporating  screening based on diagnosis and patient scenarios.  Options and funding for addiction treatment are limited across the state. We will continue to advocate for more funding to treat addition. We have to decrease the stigma associated with opioid addiction and treat it as a chronic disease, routinely requiring more than 24 months of medical intervention. Finally, we have a responsibility to continue educating our patients and the general public at every turn about the dangers of opioids and how to safely and properly dispose of unused drugs.  As the Tennessee Medical Association continues to support physicians in navigating patients through this complex world of medicine, our focus will always be patients first.

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NMGMATen Minute Takeaway By CARA SANDERS

The second Tuesday of each month, practice managers and healthcare industry service providers gather at KraftCPA headquarters for the monthly Nashville Medical Group Management Association (NMGMA) meeting. During the June luncheon, Nic Cofield, business development manager for Jackson Thornton Technologies, spoke about the importance of protecting your practice in the age of the healthcare hack. Cofield helps educate and protect companies and practices against cybersecurity threats. He noted many healthcare organizations have taken significant steps like encryption and installing firewalls to safeguard their practice and protected health information (PHI). While providers have gotten smarter … so have the bad guys who now target specific information. The biggest weakness facing security for employers, he said, is the education of employees and staff.  “In most situations, incidents caused by employee actions are not the result of malicious intent. Rather, the majority of cases stem from a lack of understanding and an overall sense of complacency,” explained Cofield.  The five biggest threats to organization’s cybersecurity are phishing, vishing, SMiShing, USB baiting, and imperson-

Jackson Thornton’s Nic Cofield shares the devious means criminals use to gain access to PHI.

ation and tailgating. Phishing is the deceitful practice of sending emails pretending to be from reputable companies in order to compel someone to reveal their personal information, like passwords and credit cards. For example, the email from a prince of a foreign country claiming you’ve come into a large sum of money if only you’ll send your

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social security number. Of course, criminals have gotten much more sophisticated with the bait the days. Because newer safeguards are being taken, hackers have evolved to spear-fishing, which is a more targeted way of phishing using social media platforms in order to obtain information like club affiliations and member organizations to personalize and target the attack. A little detective work can make an email seem much more legitimate. Cofield recommended employees pay extra attention to email URLs and improper grammar, which is often a sign the email has been sent by someone for whom English isn’t a native language. He said extra precautions are especially necessary for any message requesting document downloads, requiring quick action after sharing frightening information, or any type of online banking alert. Vishing, which is similar to phishing, finds the attacker using the phone to impersonate trusted sources or authorized organizations. Vishing most commonly targets areas of highly focused customer interactions, like the front desk or billing. Sometimes the scam utilizes two calls with the first being reconnaissance and a follow-up caller using the information collected to make an information request seem more legitimate, One example might be the impersonation of IT support with a request of password information to download a software patch or update remotely.  Another threat that is gaining popularity is SMiShing, which utilizes text-based hacks and tricks users to download malicious software onto the device. Typically, the text says action is required and includes a link. Attackers also utilize in-person methods of hacking through USB baiting and impersonation and tailgating.  USB baiting involves planting a USB device with the goal of having a user find the device and plug it into a computer. For example, a guest might drop a USB device in the lobby or inconspicuously lay it on the edge of the front desk before leaving the building. The hope is that a good Samaritan will plug in the device to see if they can obtain any information about who left it behind in order to return it. When they do this, the hacker is able to encode malicious software into their system. Finally, hackers are able to utilize impersonation and tailgating to gain access to sensitive information. Social engineers are now posing as technicians, delivery people, and pest control reps amongst other things in order to exploit weak access controls and gain physical access to restricted areas. Cofield said a vishing expedition could uncover the name of a network provider. With a quick internet search, it’s easy to download a logo from that company and have a polo shirt made with the emblem on it to look official. These people can also ‘piggyback’ off of authorized users in order to gain access by asking for someone to hold the door for them or claiming to have left their access badge at home.  Cofield said the best way to prevent

these hacks from occurring is to make sure employees are aware of these situations and know how to react in each scenario. He also suggested training should go beyond basic education and that companies should implement a Security Awareness Program that has a set routine of education and training sessions that can be scored and tracked on an ongoing basis. For those in the medical profession, the HIPAA Security Rule requires the implementation of these programs for all members of the workforce. Employees should be regularly tested on their knowledge to make sure that everything is implemented correctly and to address areas of weakness. While all of these safeguards are important and should be implemented, Cofield emphasized that it is still crucial to constantly update your system and procedures in order to maintain safety and try to stay a step ahead. “If someone wants to get to you, they’ll get to you,” he cautioned. “What additional layers can you add? What policies can be put in place?” Cofield questioned. People make mistakes, he said. Therefore, it’s important for organizations to understand the many different ways in which systems can be compromised, create a security awareness program, and then train, test, and retrain employees regularly to try to minimize risks. For information on upcoming NMGMA events or to learn more about the association, go online to nmgma.com.

Mark Your Calendars Health:Further • Aug. 22-25 More than 2,000 healthcare innovators are expected at Music City Center for the annual Health:Further Festival. For a full agenda, tickets, Summit of the Southeast and general info, go to healthfurther.com. TriMED Healthcare Education Summit • Sept. 8-9 The inaugural TriMED Healthcare Education Summit will take place at Music City Center next month, bringing together multiple healthcare organizations to offer more than 50 hours of diverse CME on the most critical topics in healthcare delivery.

Partner organizations are the Tennessee Chapter of the American College of Physicians, Cumberland Pediatrics Foundation, Tennessee Department of Health, Tennessee Medical Association, Tennessee Psychiatric Association, Tennessee Society of Anesthesiologists, Tennessee Association of Long Term Care Physicians, Tennessee Geriatric Society, and Vanderbilt University School of Medicine For details, go to trimedtn.com.

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Cash in Hand By CINDY SANDERS

Editor’s Note: This article is a continuation of a conversation that began last month with George Buck of Frost-Arnett at the NMGMA meeting. Intrigued by the regulations that govern when, where and how a medical debt can be collected on the back end, I reached out to George and colleagues to discuss best practices for providers when it comes to money matters. Frost-Arnett, a full-service accounts receivable management (ARM) company focused on the healthcare industry, traces its roots in Nashville back to 1893. While nearly every aspect of the business and regulatory environment has changed over the nearly 125 years since the company’s founding, one truism has remained constant: the best opportunity to collect money owed is at the point of service. Alan Clayton, COO for Frost-Arnett, said a number of steps should be taken whenever possible before a patient ever walks through the door, including obtaining appropriate pre-authorizations, providing patients with pre-service estimates, and verifying insurance Alan Clayton and contact information. “One of the things providers can do is collect co-pays, but a lot of times that just

doesn’t happen,” said Clayton. He added, “You have a 100 percent contact rate at the point of service when they are right there.” One of the issues, said George Buck, president emeritus, is quite simply that people aren’t comfortable asking for money. “We talk a lot about natural-born athletes or natural-born leaders … there are no natural-born people who are good at asking for money.” George Buck Buck added, “Historically healthcare has not been as aggressive in collecting co-pays and deductibles, and it’s a culture shock to the patient.” CEO Jason Meyer said a key reason for the shift is because of the changing payer mix with increased responsibility falling on the patient. He noted the patient’s share of cost has increased from historically about 5 percent responsibility to as much as 25 percent today. Jason Meyer “Healthcare providers are becoming much more sophisticated in educating consumers in advance,” he said. “Before, when the patient bucket was 5 percent of the revenue stream, they were much less incentivized to educate the

patient on what their responsibility was going to be.” With patients taking on more financial obligation, there is also greater competition for those dollars. Buck noted a procedure in an outpatient setting could result in a patient receiving bills from the surgeon, anesthesiologist, lab, and surgery center. “They’re all trying to collect from the same pool of money from the patient. While some providers offer cash or prompt pay discounts, those tend to happen in cases where a patient is uninsured or not accessing insurance benefits for a service. Clayton said it’s important for providers to know what the policy is with the patient’s insurance company. He noted insurers often don’t allow discounts on deductibles because that is the patient’s cost-share portion of the bill. Clayton added patient-friendly billing statements are critical for patients to actually see and understand what they owe and why. Ideally, a statement includes details on the various services provided to create a total cost, any insurance discounts applied, how much the carrier is paying and the amount of the patient’s financial responsibility. Unfortunately, he said, “We don’t see as much of that as we’d like.” Buck added, “In cases where it’s feasible, have a well thought out financial policy and get that to the patient early.”

“If you educate the consumer early – tell them what their responsibility will be – you’re going to have a much higher probability of payment,” Meyer affirmed. Should the bill wind up in collection, the ‘garbage in, garbage out’ rule applies to the data turned over to the ARM company. Clayton stressed it’s imperative to verify a patient’s contact information and insurance coverage. It’s equally critical that coding be done correctly on the front end and that the information turned over for collections has been checked as being for the correct patient – Jane C. Doe is different than Jane F. Doe. Buck added the Consumer Financial Protection Bureau (CFPB) continues to crack down on healthcare collections. “The CFPB mantra is ‘collect the right debt from the right person in the right way,’” he said. “The integrity of the data and our ability to substantiate the data is going to be even more important going forward.” To maximize revenues, the trio of experts agreed providers must educate patients about financial responsibilities in advance whenever possible, collect copays at the point of service, make sure any amount to be billed is clearly explained, and verify data is correct if a past due bill ultimately has to be turned over for collection.

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Who’s Ready for MACRA? continued from page 1 that links payments … and penalties … to performance under one of two tracks: Merit-Based Incentive Payment System (MIPS), which increases or decreases physician fees based on whether or not certain quality and efficiency benchmarks are met across four domains: quality, cost, advancing care information, and improvement activities; and Advanced Alternative Payment Model (APM), which offers a more stable and favorable fee schedule and bonus but also requires physicians to take on more risk. Since many physicians and practices do not meet the initial qualifying criteria for APM participation, the majority will be paid under the MIPS track. While the overarching MACRA concept is generally well received, the devil for most clinicians is in the details. Responses to the AMA/KPMG survey of 1,000 active physicians who have been involved in decision-making roles related to QPP for their practice raised a number of red flags. The survey found: • 56 percent of respondents plan to participate in MIPS in 2017 & 18 percent are expecting to qualify for the higher, more stable payment from APM. • 51 percent of decision-makers felt ‘somewhat knowledgeable’ about MACRA or QPP, 41 percent had heard of MACRA or QPP but didn’t consider themselves knowledgeable, and only 8 percent described themselves as ‘deeply knowledgeable’ on the subject. • 70 percent have begun the process to meet QPP requirements in 2017, but only 23 percent of that group feels ‘well prepared’ to do so. • 90 percent felt the reporting requirements were ‘slightly’ (37 percent) or ‘very’ (53 percent) burdensome. AMA President David O. Barbe, MD, MHA, said the organization had conducted a previous survey within a general physician population that showed a very low percentage having an awareness of MACRA. However, he added, the hope was that the disconnect among ‘rank and

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file’ physicians wouldn’t be there when speaking directly to physicians in a leadership capacity. “That was equally dispiriting,” Barbe said. “Fewer than 25 percent in physician decision- Dr. David O. Barbe making roles have what they would consider adequate knowledge of MACRA … and we’re halfway into this first reporting year. These are scary statistics.” Larry Kocot, JD, national leader of the Center for Healthcare Regulatory Insight at KPMG, said although there was some good news to share from the survey, “83 percent said they needed more help and understanding. That’s one of my bottom line takeaways.” Larry Kocot He added that 66 percent said their biggest challenge was the time required to report. The survey also indicated physicians don’t expect the time burden to lessen in subsequent reporting years. Kocot said other concerns were the need for better understanding of the scoring (57 percent), cost of reporting (53 percent), and the need for improved organizational infrastructure to meet reporting requirements (49 percent). “We found the problems were pretty consistent across practice sizes so these aren’t unique,” he said. Barbe noted the AMA has advocated for more exclusions and flexibility for physicians in this first year. ‘Pick Your Pace,’ for example, gives physicians the option to not participate at all and receive a negative 4 percent adjustment; submit something … even just one improvement activity … and avoid a penalty; submit 90 days of data to potentially receive a small positive payment adjustment; or submit all of 2017 data for a moderate positive payment adjustment. Similarly, feedback about the burden on small practices led CMS to increase exclusionary low-volume thresholds from less than $10,000 in Medicare charges and seeing fewer than 100 Medicare patients to less than $30,000 in charges or seeing fewer than 100 Medicare patients. Additionally, clinicians in their first year of Medicare participation are exempted from reporting requirements. Kocot added CMS has invested substantial resources to help physicians get prepared and have seemed willing to work with providers as evidenced by the enhanced flexibility in this first year. He also noted the work has continued smoothly despite staff changes in the wake of the presidential election. “Both administrations deserve credit for not missing a beat,” Kocot said. “The want to bring physicians to a point where they can operate comfortably in a new payment environment that ultimately will be more beneficial to patients and bring some sustainability to the healthcare system’s financial landscape.” He added, “Aligning physician incentives with quality and other performance targets will lead to greater rewards for phy-

sicians and better healthcare for patients.” While supportive of a payment system that rewards high-quality, evidencebased care, Barbe said moving to MACRA has been a two-edged sword. “On the one hand, it does actually represent an improvement. We do have reduced reporting requirements than before.” However, he continued, “It’s still a significant burden for practicing physicians to figure out what measures to report.” Adding to that burden are different reporting requirements across all payers. “Why can’t we all agree here are the three measures important for diabetes? Here are the four for hypertension. Let’s all work together toward the same measures,” he said of the bigger quality picture across public and private payer sources. Barbe noted some practices have had to hire extra staff to gather data and pull reports. “There are many practices who have found it costs more to comply than to pay the penalty. Rewards should be commensurate with the amount of effort to comply and report.” It’s frustrating, Barbe said, for physicians who feel like they learned the requirements for PQRS or Meaningful Use to switch gears once again. “Just about the time they figure out the game, the rules change,” he pointed out. That said, Barbe noted prior experience with reporting programs might have helped physicians with QPP preparation.

The survey showed past participation appears to have positively impacted physician readiness for MACRA. “While progress has been made in preparing physicians for the move from volume in the fee-for-service payment model to value in alternative payment models, it is important that we do even more to assist physicians with the transition,” agreed Kocot. He also said the shifting payment model is inevitable. “CMS is not going to walk away from this transition from volume to value,” said Kocot. “We could do a better job of bringing people along, but we’re not going to turn back.” Although the survey confirmed worries that physicians aren’t confidently prepared for MACRA, Barbe said it also helped AMA in their quest to continue assessing readiness gaps and focus educational efforts. One such resource is AMA’s “Do One Thing Now for QPP” page located at ama-assn/qpp-reporting. The page walks physicians through the steps to successfully avoid a penalty in 2019 for the 2017 reporting year. Despite current concerns and ongoing tweaks to the process, Barbe said physicians do want to see a transition to value-based practice. “I am optimistic that we can improve not only the quality of care for patients but the practice environment for physicians so the frustration level begins to come down,” he concluded.

Care 24/7 Moves to Nashville Company Shifts Focus to MACRA, Population Health

Last month, officials with Care 24/7 announced a relocation from Knoxville to Nashville as the provider of care coordination services shifts its focus to MACRA-preparedness and provider-based population health management. In concert with the move, the company recently added two value-based care experts in an expansion of its management team. The company’s core services will remain the same and include Chronic Care Management (CCM), Transitional Care Management (TCM), and Annual Wellness Visits (AWV). These services, which help providers bill for additional revenues, will now fit into a larger quality reporting system as mandated by MIPS and APMs.   Huy Nguyen, MD, co-founder and executive board chair, plans to centralize all Care 24/7 operations in Nashville to ensure maximum clinical oversight and a streamlined organizational structure. The news came as a report was released by AMA/KPMG (see page xx) reveals that many primary care physicians still feel woefully unprepared for MACRA, with 90 percent of surveyed physicians finding reporting requirements confusing and burdensome. Nguyen, an emergency physician by training, said he is Dr. Huy Nguyen pleased to refocus his team on the broader value of providerbased population health, which he sees as “an exciting opportunity to help providers understand and achieve the value and potentially large returns that come from fully leveraging new value-based CMS regulations. This ‘New Model’ can seem disruptive and overwhelming, but I see it as an incredible opportunity to get providers to act increasingly like insurers – identifying and mitigating risk – and to get patients to gain insight into their health and better comply with their care plans.” The company also recently hired Keith Rye as chief strategy officer and promoted Holly Clark to chief operating officer.  “We are excited to be part of the dynamic Nashville healthcare ecosystem,” Nguyen said. “U.S. healthcare is in need of innovation and entrepreneurship, and Nashville is its incubator.”

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To Whom It May Concern:

Just read your July issue and wanted to make an observation. In your article, “Reforming Healthcare Reform,” I read much of the same misinformation being announced by the media and state and federal legislators. There were several areas, but I will stick to one. The graphs and statements made toward the end of the article are misleading. I realize you did not conduct the survey, but you are using it as a platform for your opinion. The graphs suggest that 63 percent of U.S. adults believe AHCA will negatively impact their household. 63 percent of U.S. Households would total 200,970,000 individuals, less those under 18 years of age. Even then, that is a lot of citizens, especially when ACA directly affects only 51,000,000 total individuals. This number includes the uninsured and those currently covered under ACA exchange programs. The second graph is the most telling. 64 percent of U.S. adults say they are less likely to re-elect their representatives if they vote for AHCA. Since ACA and AHCA directly affects 51,000,000 people where did 64 percent of the population get the notion that AHCA would affect … well everyone? Probably from articles like the one you and others publish. Legislators are not trying to fix the problem, as if they have a clue what the problem is, they are trying to get re-elected. They take the attitude that whoever fixes the problem must get credit for doing so. I take the attitude that the only way to fix the healthcare cost crisis is for somebody to make less money. The problem at hand has been handled incorrectly from the beginning by both parties and incorrectly followed and reported by the media. Every aspect of every solution put forward is connected to financing. There is nothing of significance related to behavior and responsibility (that has) been placed on the table, other than work requirements if enrolled in Medicaid, which brought jeers of boos from the crowd. These are the aspects at the heart of the disagreement. The folks we talk to are not concerned about the negative impact of reforming ACA. They are concerned about the real issue – Medicaid expansion. — Bob Shupe, REBC® CEO ESP, LLC Editor’s Note: We are committed to sharing multiple viewpoints regarding healthcare finance and delivery reform. We have reached out to Bob Shupe – who leads Brentwood-based ESP, a company of fee-based health management consultants working primarily in the public entity sector – and plan to circle back to him and to others in the coming months to share frontline client experiences and thoughts on improving the viability and sustainability of healthcare in America. nashvillemedicalnews

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Buying & Financing Ownership in an ASC By JIM SHAUB

For more than 30 years, ambulatory surgery centers (ASCs) have offered physicians an investment opportunity to perform eligible cases in an outpatient facility as an extension of their practice. Governed by the Federal Physician Self-Referral Act (often called the Stark Law) of 1993, physicians may have ownership in ASCs under certain “safe-harbor” provisions, broadly defined as: • The physician must derive one-third of their practice income from procedures performed at the ASC, • The ownership must be purchased at fair market value, • Ownership must not be tied to referrals, • The investment return must relate to the ownership percentage, and • The ASC or its investors may not provide financing to the physician. Today, there are 34 states that currently have some form of a Certificate of Need (CON) program, which can impact local ASC growth and the ownership decision. The initial ASC set-up and ongoing compliance regulations can be complex, time consuming, and expensive, with punitive consequences if not adhered to. The ASC industry largely consists of 100 percent physician-owned facilities (approximately two-thirds) and joint venture (JV) facilities where an ASC management company and/or a hospital (one-third) have ownership in partnership with physicians. These corporate partners are highly skilled in managing the operations of the center and monitor ongoing regulation change for proper compliance. The sheer number of operating ASCs suggests a pretty saturated industry so not many new centers are being built each year. Usually, a physician interested in an ASC today opts for investment in an existing center, rather than starting a new one. There are pros and cons when considering whether to buy into a physicianowned center or a JV with corporate partners. By joining with a management company and independent owner, the physician has chosen to allow experts in the industry to manage the ASC. Our experience is that professionally managed ASCs generally produce higher profit margins and allow physicians more time to focus on their patients and the practice of medicine. Nevertheless, there are many reasons why physicians choose not to enter a joint venture with corporate partners, and that can also be an attractive option. There are many legal, tax and financial considerations when contemplating an ASC investment, and there are numerous experts in these fields who physicians should consult before making an investment. Specifically, the ASC’s operating agreement specifies the rules for how the ASC will be administered and governed. This agreement typically will contain

detailed provisions for the purchase of ownership, transfers of ownership and termination of ownership. It will also address the financial terms, distributions of profits and valuation for the sale of ownership. Prior to a purchase of shares in an ASC, a physician and any advisors should carefully review this agreement. Once a physician has made the decision to buy into an ASC, then the question of “fair value” must be addressed. ASC buy-in investments often run from $100,000 to $300,000, largely dependent on how financially successful the ASC is and the case volume. A physician should take the time to understand how the investment is valued and evaluate the likelihood for continuing success. If a buy-in amount is less than $100,000, then the center is probably new, not highly profitable or the number of shares being offered is small. If the buy-in amount is over $300,000, then the ASC is likely a mature center and very successful. Many physicians buying into ASCs are in the early years of their practice and don’t have the financial strength yet to use cash or assets to obtain a bank loan. Other physician buyers may be financially well situated but have committed their resources to other personal or professional pursuits. Thus, physicians frequently elect to finance a buy-in investment and often turn to a familiar local bank. Banks can be a good source of capital but often require a “blanket” lien on the physician’s personal assets, a spousal guarantee, and sometimes an assignment of disability and life insurance. It is important for the physician to understand the terms of this “personal loan,” which may impact their future borrowings or sale of personal assets. Another financing option is to utilize a specialty healthcare lender to provide a loan – likely under terms and structure tai-

lored to the underlying ASC business, not the physician’s personal assets. These companies are often competitive with banks on interest rates but have added expertise in the ASC industry, which can be advantageous if the center undergoes unfavorable or adverse changes. Specialty lenders focus on the underlying strength of the ASC the physician is considering and have a keen understanding of all aspects of center financials and governance. A loan with a specialty healthcare lender is typically collateralized only by the physician’s purchased shares, thereby eliminating the need for additional guarantees and liens on personal assets. Repayment terms are matched with the expected distributions and can usually be structured with a cushion for income taxes and no monthly “out of pocket” for the repayment of the loan. As with any major investment, physicians need to consider a broad range of factors and consult with experts in order to make an informed decision. In addition to regulatory and operational considerations, a physician must also think about their personal goals to discern whether the timing is right to invest in an ASC and then look at the various financing options available to best meet those goals. Physicians Financial Partners (PFP), and Jim Shaub, a partner, have been providing physician buy-in and practice loans, as well as ASC facility construction and real estate loans, for over 10 years to ASC management companies and independently owned ASCs throughout the U.S. PFP also provides receivables financing and collections services, as well as consulting services for purchase, development and revenue cycle needs of physicians and ASCs. For more information, contact jshaub@ physiciansfp.com.

Wishes Granted Vanderbilt University School of Nursing (VUSN) recently received a $1.22 million grant to support Doctor of Nursing Practice (DNP) students who plan to become nursing faculty. The award brings the funds the school has received for the program since 2008 to $7.3 million. This latest award is part of the U.S. Health Associate Professor Karen Hande, DNP, ANPBC, CNE, (standing), who participated in the Resources and Services Administra- NFLP while earning her doctorate from VUSN, tion’s Nurse Faculty Loan Program works with nursing students. (NFLP). DNP students planning to teach can receive a NFLP award that underwrites VUSN tuition, books, fees and associated costs. After graduation, loan recipients employed as nursing faculty in any school of nursing in the United States for four years will have 85 percent of the loan forgiven. Saint Thomas Health has awarded a $100,000 Community Benefit Grant to the YMCA of Middle Tennessee to support its Healthier Communities Initiative (HCI) program at the Northwest Family YMCA in Nashville. Built on the concept that communities can work together to support healthy choices, examples of the HCI program include helping families put nutritious food on the table by bringing farmers markets with fresh fruits and vegetables to neighborhoods where healthy food options are scarce.

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PHOTO: JOE HOWELL/VANDERBILT

LETTER TO THE EDITOR

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Reimbursement Rounds New Player/Payer in Town

Oscar Health, a technology-driven health insurance startup based in New York has entered a strategic partnership with industry giant Humana to offer commercial health insurance to small businesses in the Nashville MSA. The announcement follows the recent launch of Oscar for Business in April 2017. The new plans will be available this fall, pending regulatory approval. This partnership leverages Humana’s experience in provider collaboration, coordinated care, and health and wellness with Oscar’s technology and data-driven approach to member engagement. The combined goal of the pairing is to make healthcare an easier, more reliable and affordable experience for small businesses members through technology and connected care. The health insurance product features Oscar’s concierge care teams that use data-driven alerts to help members with their care, 24/7 access to telemedicine and care search tools, and a mobile experience to empower members to manage their health. “We started Oscar for Business to bring a seamless, consumer-focused health experience to more Americans, and we’re excited to have the opportunity to work with Humana to serve members in the Nashville area,” said Mario Schlosser, CEO and co-founder of Oscar Health. Mario Schlosser “This partnership is about coming together to reimagine health care coverage for small businesses and their employees, with an emphasis on simplicity and the end-to-end consumer experience,” noted Humana Group and Specialty Segment President Beth Bierbower. Officials with Humana and Oscar said they chose to introduce this partnership in Nashville because it is home to one of the fastest growing small business communities in the country and has established itself as a hotbed for health technology innovation. Under the Nashville partnership, Humana and Oscar will initially focus on commercial health insurance for small businesses with 50 or fewer employees in the nine-county Nashville area.

CMS Payment Proposals Garner Mixed Reactions

Key stakeholders have mixed reactions about several new payment proposals from the Centers for Medicare & Medicaid Services for calendar year 2018. One the plus side, both the American Hospital Association (AHA) and American Medical Association (AMA) are pleased with the added flexibility in implementing MACRA to help avoid penalties under the Quality Payment Program. Additionally, Tom

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Nickels, executive vice president of the AHA said, “We also encourage CMS to provide additional opportunities for clinicians to earn incentives for partnering with hospitals to provide better quality, more efficient care through advanced alternative payment models.” The AMA generally had a positive reaction to the CMS update of the physician fee schedule proposed rule. “The annual physician fee schedule update is a chance for CMS to modify Medicare policy to ensure the best possible treatment options for patients,” said AMA President David O. Barbe, MD. “The AMA is encouraged by many of the proposed changes and applauds the Administration for working with the AMA to address physician concerns.” The AMA supported the invitation for public comment on regulatory relief and commended CMS for moving forward to expand coverage of the Medicare Diabetes Prevention Program (DPP) model to Medicare patients at risk of developing type 2 diabetes. Additionally, the AMA expressed appreciation that CMS made an effort to address concerns that the proposed payment model was too restrictive in linking payments to performance over a short period of time by extending the time period for patients to meet weightloss targets. On the flip side, the AHA was displeased with CMS proposals to slash 340B drug payment rates and payments provided in off-campus outpatient departments. Nickels released a statement saying CMS had issued “several poorly designed policies that will do real damage to patients’ access to care.” He noted, “For 25 years, the 340B Drug Pricing program – which enjoys broad, bipartisan support – has been critical in expanding access to lifesaving prescription drugs to low-income patients in communities across the country. The patients who benefit from the much-needed 340B program are the ones who will have their access to care threatened.   “Cutting Medicare payments for hospital services in the 340B program is not based on sound policy. Additionally, this proposed rule punishes hospitals for a policy outside of CMS’ jurisdiction. It is unclear why the Administration would choose to punitively target 340B safety-net hospitals serving vulnerable patients, including those in rural areas, rather than addressing the real issue: the skyrocketing cost of pharmaceuticals.” Additionally, Nickels said, “CMS at the same time is proposing further cuts to Medicare rates for services hospitals provide in ‘new’ off-campus hospital outpatient departments. This proposal also appears to have a questionable policy basis and is yet another blow to access to care for patients, including many in vulnerable communities without other sources of healthcare.”

GRAND ROUNDS VUMC Partners with Walgreens Last month, Walgreens and Vanderbilt University Medical Center (VUMC) announced that a subsidiary of VUMC would operate and provide all clinical services at 14 retail health clinics within Walgreens stores across Middle Tennessee. The announcement builds upon the continued relationship between Walgreens and Vanderbilt Health, which has included infusion services provided throughout the Middle Tennessee market and Walgreens pharmacy participation in VUMC’s clinically-integrated network. The existing Healthcare Clinics at these locations, currently managed by Walgreens, are planned to transition to VUMC in November, and will be an extension of the Vanderbilt Health System. The clinics, which will be known as Vanderbilt Health Clinic at Walgreens, will offer a number of services including laboratory tests and treatments for common conditions and minor injuries.

The Little Clinic Collaborates with Results Physiotherapy In other retail health clinic news, The Little Clinic, a wholly owned subsidiary of The Kroger Co., has collaborated with Results Physiotherapy to offer patients additional treatment solutions for a wide variety of conditions and injuries with a collective commitment to help patients live pain-free without prescription opioid medications. Clinics in Tennessee, Kentucky and Southern Indiana will participate in the collaboration. The collaboration between The Little Clinic and Results Physiotherapy is designed to provide an on-going treatment solution for patients with chronic pain, mobility or balance issues, minor orthopedic injuries and certain post-pregnancy issues. Results Physiotherapy will provide a free consultation and recommendation to patients, which may include physical therapy treatment if necessary.

Let’s Give Them Something to Talk About!

Awards, Honors, Achievements HCA CMO and President of Clinical Services Jonathan Perlin, MD, and Community Health Systems CMO and President of Clinical Operations Lynn Simon, MD, were both recently named to Modern Healthcare’s list of “50 Most Influential Physician Executives & Leaders” for 2017. Last month, Tony Heard was announced as the new chair of the Saint Thomas Health Board of Directors. A partner with InfoWorks, Heard joined the board in 2011, serving as the finance committee Tony Heard chair. In a ceremony held in Nashville at the end of June, HCA Healthcare presented the 2016 HCA Healthcare

Awards of Distinction. One of the recent winners was Mohammed Elayan, PharmD, BCOP, clinical pharmacist with the Sarah Cannon Cancer Institute at TriStar Centennial Medical Center, who won an Innovators Award for developing a dosing strategy that produces the desired therapeutic results for patients while minimizing medication waste. LifePoint Health CEO Bill Carpenter has been tapped to serve as co-chair of the Nashville Area Chamber of Commerce Partnership 2020, the organization’s economic development initiative. Saint Thomas West Hospital has earned The Joint Commission’s Gold Seal of Approval® and the American Heart Association/American Stroke Association’s Heart-Check mark for Advanced Certification for Comprehensive Stroke Centers, which represent symbols of quality from their respective organizations.

Y O U R M I D D L E T N S O U R C E F O R P R O F E S S I O N A L H E A LT H C A R E N E W S

PUBLISHED BY: Graham | Sanders Publishing, LLC PUBLISHERS Susan Graham & Cindy Sanders SALES 615.397.2836 Cindy Sanders Maggie Bond, Pam Harris, Jennifer Trsinar MANAGING EDITOR Cindy Sanders csanders@nashvillemedicalnews.com CREATIVE DIRECTOR Susan Graham sgraham@nashvillemedicalnews.com CONTRIBUTING WRITERS Melanie Kilgore-Hill Cara Sanders Cindy Sanders Jim Shaub Dr. Nita Shumaker CIRCULATION subscribe@nashvillemedicalnews.com —— All editorial submissions and press releases should be emailed to: editor@nashvillemedicalnews.com —— Subscription requests or address changes should be mailed to: Nashville Medical News 105 Spring Ridge Lane Nashville, TN 37221 615.646.3916 • (FAX) 615.673.8819 or e-mailed to: subscribe@nashvillemedicalnews.com

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© 2017 CHRISTINA BIRKINBINE

GRAND ROUNDS

Dr. Tim Jones receives the Council of State and Territorial Epidemiologists’ Pumphandle Award from CSTE Vice President Dr. Joe McLaughlin.

The Birthing Center at Saint Thomas Midtown Hospital is scheduled to open September 2017. Officials said the Birthing Center is unique because it pairs a natural birthing experience and holistic, highly specialized maternity care in a home-like environment but with immediate access to a hospital with a full range of healthcare services.  Expectant families can soften the lights, play their own music and move freely about the private, home-like suites.  The Birthing Center also offers labor tubs, birthing balls, squatting bars, in-room refrigerators, large flat screen

AdamsPlace Opens New Memory Care Unit Last month, AdamsPlace celebrated the grand opening and ribbon cutting for their new 13,469 square-foot Memory Care Center. Staff and community leaders also gathered to celebrate the 20th anniversary of the NHC senior care community located in Murfreesboro. The new $4.2 million Memory Care addition allows AdamsPlace to expand services to residents with memory loss, including Alzheimer’s disease. The addition provided 23 private apartments in a specially designed area to meet the needs of these residents. Additionally, AdamsPlace offers residential living, assisted living and a health center, which includes specialized services such as rehabilitation care and continuing care.

NHC CEO Steve Flatt celebrates the new Memory Care addition to AdamsPlace.

Jones Honored Nationally State epidemiologist Tim Jones, MD has been named the 2017 recipient of the Council of State and Territorial Epidemiologists’ Pumphandle Award. The national award, recognizing achievement in the field of applied epidemiology, is aptly named as a reminder of how removing a pumphandle from a contaminated well helped stop an 1854 cholera outbreak in London. Jones, who is assistant commissioner of the Tennessee Department of Health Communicable and Environmental Disease and Emergency Preparedness division, has authored more than 150 peer-reviewed publications, works as a reviewer for 29 journals and serves on the editorial board of five journals, including as chairman of the Centers for Disease Control and Prevention Morbidity and Mortality Weekly

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New Facilities

The Children’s Hospital at TriStar Centennial officially celebrated the opening of its new pediatric emergency room last month. Full-time, pediatric emergency medicine physicians staff the 6,000-square-foot facility, which houses seven beds and cutting-edge equipment designed for pediatric patients. The new ER opened its doors to patients on July 24.

Read More Grand Rounds online.

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GRAND ROUNDS televisions, labor stools, individualized nursing care, nitrous oxide for pain relief, and lactation support.

Saint Thomas Files CON

Last month, Saint Thomas Health filed a Certificate of Need application to expand services to meet anticipated healthcare needs of the growing Rutherford County population. Pending HSDA approval, Saint Thomas Rutherford Hospital plans to add 72 inpatient beds and additional capacity for outpatient services, at a project cost of more than $55 million. Additionally, Saint Thomas Health filed a separate CON application for investing in a $16.2 million surgery center to better meet current and future outpatient needs. Hearings on both projects will be conducted in October.

Pal to Lead VICC Cancer Health Disparities Program Clinical geneticist Tuya Pal, MD has joined Vanderbilt-Ingram Cancer Center as associate director of Cancer Health DisDr. Tuya Pal parities. Pal also has been named Ingram Associate Professor of Cancer Research, as well as associate professor of Medicine. A faculty member in the Vanderbilt Hereditary Cancer Clinic, Pal will focus on clinical and re-

search efforts to ensure all patients have access to the latest tests and treatments for cancer and genetic tests for cancer risk. Previously, she was an associate member at the H. Lee Moffitt Cancer Center in Tampa, Fla., and associate professor of Medicine at the University of South Florida. She is widely published and the recipient of multiple research grants from the National Cancer Institute and private foundations. Born and raised in Canada, Pal received her medical degree from McGill University in Montreal, completed a residency in pediatrics at Washington University in St. Louis and a fellowship in clinical genetics at the University of Toronto.

Eckstein Named LBMC Shareholder Accounting and business consulting firm LBMC recently announced Andrew EckAndrew Eckstein stein has been named shareholder, helping lead the firm’s Transaction Advisory Services Practice. Eckstein has more than 13 years of professional experience in audit and M&A transaction services and was recipient of the 2017 M&A Advisor Emerging Leaders Award. He has extensive experience in healthcare transactions across multiple industry sectors and has led deal teams in transactions ranging from behavioral health and acute care

to nurse staffing and medical supplies. Previously, he was a director in Duff & Phelps, LLC’s Transaction Advisory Services group in Chicago. “I am excited to welcome Andrew

as a shareholder in the Transaction Advisory Services Practice. He has been instrumental in our efforts to expand this service line to accommodate the vast growth as we problem solve for our cli-

3+3 = More Primary Care Physicians

Leaders from Meharry Medical College and Middle Tennessee State University recently signed an agreement to develop an accelerated pathway where aspiring physicians could complete an undergraduate degree and medical degree in six years through a fast-track program with select, high-ability students spending three years at each institution. Meharry President James Hildreth, MD,  and MTSU President Sidney A. McPhee, EdD, launched the partnership at a State Capi- State officials joined Meharry President Dr. James Hildreth (L) and tol  signing ceremony MTSU President Dr. Sidney McPhee for the signing of an innovaon June 22 that high- tive agreement designed to produce more primary care physicians through an accelerated path. lighted the unique collaboration between the private and public institutions. State officials helped bring the two schools together after Hildreth initially proposed an accelerated bachelorsto-doctoral degree. “It is imperative to increase the number of primary care physicians in the state and to incentivize them to practice in underserved areas if Tennessee is to improve the overall health of its citizens,” said Hildreth. Students selected for the program would be eligible for financial aid from a $750,000 commitment put forward by the state if they commit to working in underserved areas of Tennessee for a specific duration of time, which is still to be determined. Meharry and MTSU are currently developing a joint admissions process and criteria for selection into the program with a goal of accepting the first undergraduate students at MTSU for the Fall 2018 semester.

It’s time to get back to your bucket list. F

or more than 45 years, NHC has provided quality, rehabilitative care to people of all ages. With skilled therapists and decades of experience providing compassionate post-surgical care in locations close to home, you can get back to what’s important to you. So what’s first on your list?

Discover NHC and get back to life. Visit NHCcare.com to learn more about our rehabilitative care services, to explore our full range of services and to find the NHC nearest you. To learn more about our homecare services, visit MyNHChomecare.com.

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Nashville Medical News August 2017

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