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FOCUS TOPICS EMERGENCY PREPAREDNESS • PAIN MANAGEMENT & ADDICTION

Your Middle TN Source for Professional Healthcare News The Osher Center: Healing Mind, Body & Spirit Once considered “alternative” in American healthcare, integrative medicine is now a widely respected, evidence-based option for pain management, and The Osher Center for Integrative Medicine at Vanderbilt is leading the way ... 2

Innovative Meharry Program Helps Mothers with Opioid Addiction One of the major issues across our nation is the increasing abuse of opiates. In fact, the White House commission examining the nation’s opioid crisis recently recommended that the opioid epidemic be declared a national public health emergency ... 5

Moving Forward on Health Reform Four Questions for THA’s Craig Becker Tennessee Hospital Association’s Craig Becker discusses ACA reform and what’s needed to protect access to care in Tennessee ... 11

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The New Face of Opioid Addiction

Specialists Address Disturbing Trends, Skyrocketing Death Rates ities like Cumberland Heights primarily treated those suffering from alcoholism a decade ago. Fast-forward to 2017, and the 50-year-old program regularly sees housewives, teenagers and executives – all patients addicted to prescription opioids and, more recently, heroin. “Eight years ago you rarely saw heroin in Nashville,” Sledge said. “When Tennessee became more aggressive with the Controlled Substance Monitoring Database Program, it cut down on multiple prescriptions from multiple prescribers, which tightened up the illegal supply and drove cost up.” To help prevent abuse, pharmaceutical companies also made the drugs less dissolvable. That shift opened doors for mom-andpop heroin dealers to PHOTO: ©KLENOVA set up shop, offering an alternative that’s cheaper, easier to get, and more potent than prescription opioids. Today, heroin is often the most popular opioid for

By MELANIE KILGORE-HILL

More than 2.5 million Americans suffer from opioid use disorder, which contributed to more than 33,000 overdose deaths in 2015, according to figures from the Centers for Disease Control and Prevention. A growing number of treatment strategies are being deployed in hope of breaking the addiction cycle and bringing healing to families in Middle Tennessee and beyond.

The New Face of Addiction

“Once upon a time, opioid addiction was limited to healthcare professionals with access,” said Chapman Sledge, MD, FASAM, chief medical officer at Cumberland Heights. An addiction specialist for more than 20 years, Sledge said facil-

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Difficult Conversations

Alive SHARE Helps Providers Find the Right Words By CINDY SANDERS

PHOTO: JOE BUGLEWICZ

ON ROUNDS

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Simply getting the first words out is often the hardest part of initiating a difficult conversation. To help physicians and other providers gain handson, situational experience, Alive Hospice recently launched Alive SHARE. “It’s provider training, but our name says it all,” explained Alive President and CEO Anna-Gene O’Neal, RN, MSN, MBA. “It’s Supporting our patients and families through Honesty, Autonomy, Reflection and Empathy.” Available for both individuals and groups, the program utilizes actors to explore the range of emotions and reactions to difficult news through scripted scenarios, which are tailored to meet participants’ learning objectives. Typically there are four or more scenarios that build upon (CONTINUED ON PAGE 6)

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HEALTHCARE ENTERPRISE

The Osher Center: Healing Mind, Body & Spirit By MELANIE KILGORE-HILL

Once considered “alternative” in American healthcare, integrative medicine is now a widely respected, evidencebased option for pain management, and The Osher Center for Integrative Medicine at Vanderbilt is leading the way. Founded in 2007, the Nashville clinic is one of six Osher Centers worldwide dedicated to healing the mind, body and spirit. The center blends traditional medicine with proven, mind and body research-based therapies including yoga, meditation, acupuncture and massage.

Rethinking Pain

Research Director David Vago, PhD, said the holistic, interprofessional team helps patients adopt a somewhat non-traditional attitude toward chronic pain. “The crucial Dr. David Vago aspect of pain is that no one wants to experience it so we typi-

cally turn away from it and want it to go away now,” Vago said. “One thing The Osher Center does in general is to help change the relationship to pain so that it’s not something we want to avoid or get rid of … but rather approach and accept. That’s a huge part of our model.” Part of that conversation is challeng-

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ing patients to rethink the traditional definition of “health,” often viewed as lack of disease. “That’s not our only definition,” said Linda Manning, PhD, assistant professor in the Department of Psychiatry at Vanderbilt University Medical Center and interim director of The Osher Center. “If we could make all pain go away, we would be delighted; but the reality is chronic pain by definition lasts more than three months, Dr. Linda Manning often times after an original injury has healed. It’s about the brain telling the body it’s in pain so we work with relationships that help us improve quality of life and function optimally.”

Treatment after Opioids

Traditional pain treatment protocols stem from decades-old medical training focused solely on physical relief. “An important quality of pain is also its emotional aspect,” Vago said. “Providers often just deal with the physical by prescribing opioids with no fear of addiction or concern for the emotional aspect of the pain itself.” That model triggered the current opioid abuse epidemic and bolstered the prescription pain management industry. “When you experience chronic pain, there’s almost always anxiety and depression, and symptoms can actually change the way the brain physically interprets pain signals,” said Manning, a clinical psychologist. “The sensitization of the central nervous system is exasperated by

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emotional pain, and opioids are a BandAid that doesn’t fix the issue.” While The Osher Center won’t prescribe opioids, providers sometimes rely on medications proven to reduce hyperactivity of the central nervous system, often triggered by physical or emotional trauma and making patients more vulnerable to the sensitization process. They also work with opioid patients in multiple stages of treatment. “Many use opioids appropriately but don’t like the side effects and want to try something different,” Manning said. “We take people anywhere along the spectrum and have them learn strategies to help with the pain. Many choose to come off opioids altogether, and many have tried everything and aren’t getting any relief. We help give them tools to cope.”

Better Tools for Pain Management

Group training is also an important part of The Osher Center’s model. That’s because patients treated with opioids often experience social isolation, sending them further down the rabbit hole of anxiety and depression. “Opioid patients can’t continue high quality relationships because opioids dull everything,” Manning said. “We work with patients around social isolation, and our group approach helps patients in similar circumstances feel like they’re not alone.” Patients also are trained in mindfulness, a systematic form of mental training in which patients become more aware of mental habits and how they react to pain and cravings for pain relief. “Mindfulness affects specific brain networks that improve attention and regulate negative emotion and mental habits,” Vago said. “It helps train patients to be more adaptive at managing those skills.” Meanwhile, practices like yoga work with both body and mind, training the body to engage in parasympathetic responses. “Yoga training allows you to take it off the mat and engage in that relaxation response more readily,” said Vago, noting the body’s natural response is to tense up when in pain.

The New “Normal”

Proven effectiveness of the integrative model means it no longer bares the “alternative” label from the federal government and National Institutes of Health. In fact, The Osher Center accepts Medicare and private pay insurance and sees patients across the economic spectrum. “Science is finally catching up,” Vago said. “Integrative medicine is equal to or better than traditional medicine alone in terms of outcomes. The evidence is there. It’s just good medicine.” nashvillemedicalnews

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Taking the Bull by the Horns TMA Looks at Strategies to Curb the Opioid Crisis By CINDY SANDERS

The national opioid epidemic is a multifactorial problem that will require crossdisciplinary interventions to move the needle on addiction. Tennessee Medical Association President Nita W. Shumaker, MD, has made it a priority to work with providers across the state to ensure physicians are a key part of that solution. “We are, by some Dr. Nita W. Shumaker accounts, number two in the nation in the number of opioids that are prescribed,” Shumaker stated. Certainly there is plenty of blame to go around as to why opioid use has dramatically increased over the past three decades. Recently, a number of states have sued pharmaceutical companies alleging deceptive marketing practices that encourage overprescribing. Shumaker and others also point to a 1980 letter that appeared in the New England Journal of Medicine citing only a 1 percent addiction rate for those receiving opioids in acute pain situations in an inpatient setting. A recent analysis (NEJM, June 1, 2017) on the impact of that correspondence found

the letter has been cited in more than 600 articles with the vast majority of authors using it as ‘evidence’ of opioid safety. In addition, 80.8 percent of those articles neglected to mention the patients referenced in the original letter were hospitalized when receiving the drugs for acute, rather than chronic, pain. No matter how the nation got to this point, Shumaker said it’s critical to implement changes to reverse the trajectory of addiction and overdose deaths. Several measures have been implemented over the last few years including mandatory opioid prescribing education for physicians in order to maintain licensure. “We’ve already made good choices on the back end,” Shumaker said of efforts by organized medicine that include identifying high prescribers, broadening education, and closing down pill mills. “The Tennessee Medical Association’s particular focus this year is on front-end prescribing,” she continued. Shumaker said TMA is working in partnership with state health and substance abuse experts, Tennessee Nurses Association, Tennessee Hospital Association, Tennessee Pharmacy Association, the Dental Board, addiction specialists, legislators and opioid task force members across the state to document and share what’s already being done. “Many people are doing good

things, but they are all operating in silos,” she noted. “My hope would be that once we document successful programs and what makes the biggest impact, that we share with others in the state.” Shumaker added, “My particular focus as TMA president this year is to work with the large medical centers and academic centers to start drilling down on their own data.” She added the goal is to use data and peer comparisons to better understand optimal dosing and duration following various procedures to establish guidance, recognizing medical judgment might dictate different directions based on an individual’s specific profile. Citing a recent study in The Journal of Pain that followed patients prescribed opioids after orthopedic surgery, Shumaker noted, “The average patient was prescribed 80 pills, and the mean number of days they took the opioids was seven. Of patients who reported completing their therapy, as many as 85 percent of them said they had unused pills remaining.” Shumaker added the study found only 16 percent said they knew how to store the drugs safely, and just 11 percent locked them up. “Only 22 percent knew how to dispose of the drug, but … here’s the kicker … only 4 percent actually did.” In addition, Shumaker is promoting

the TMA’s Stop, Drop and Roll campaign for primary care providers. “When a new patient comes in with lower back pain, you stop and don’t prescribe an opioid for a chronic issue and talk to them about other modality options,” she said. “The drop is for those who already are on opioid medications that you have a plan over six months or an appropriate time to decrease the amount/ dosage of opioids they are on and introduce other paint management methods.” “The roll is because there are going to be some people who you can’t drop their dosage, or it becomes clear they have addiction issues,” Shumaker continued. “They need to be rolled to paint management or addiction specialists as appropriate.” She noted that by prescribing less medication after procedures and lessening the number of prescriptions started, Tennessee physicians could be leaders in shifting the culture in the state. “Those two measures alone will make a huge change in how many new people become addicted to opioids,” she said. “We want to support our physicians and give them the tools and the data so we understand how we compare to our peer group and work together to establish best practices to decrease opioid use in the management of chronic pain and take better care of our patients,” Shumaker concluded.

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Addressing Opioid Addiction in America AMA Leader Discusses Progress, Challenges By CINDY SANDERS

In late 2014, the American Medical Association convened a task force to better evaluate prescription opioid use and abuse. “The purpose of the task force was to amplify the effort that was already underway by physicians to address the epidemic but also to coordinate and collaborate those efforts,” said Patrice A. Harris, MD, MHA, chair of the AMA Opioid Task Force and immediate past chair of the AMA Board of Trustees. Harris, an Atlanta-based psychiatrist, said the 27-member task force is comprised of representatives from state medical societies, national specialty societies, and the American Dental Association to include a broad range of perspectives. In the spring of 2016, the task force released five initial steps to Dr. Patrice A. Harris address the national epidemic, adding a sixth recommendation earlier this year. This spring, the group published a progress report highlighting signs of improvement but also recognizing how far there still is to go to end the national opioid addiction crisis.

Recommendations

The first recommendation, said Harris, “was to encourage physicians to register for and use their state PDMPs – Prescription Drug Monitoring Programs.” Harris added the task force recognizes not all PDMPs are created equally. Although some aren’t as up-to-date or as user friendly as physicians might hope, she said being registered and involved gives providers a platform to work with state officials to improve the system. “Our second recommendation was to continue to enhance our education and training around appropriate prescribing, and around substance abuse disorders, as well as pain,” Harris said. The third recommendation, she continued, was to support comprehensive treatment for pain and substance abuse disorders, including increased access to medication-assisted treatment such as buprenorphine. “The fourth recommendation was to work together to reduce the stigma associated with substance abuse disorders, as well as chronic pain,” she continued. Harris added that as a psychiatrist, she has been a firsthand witness to the stigma associated with substance abuse. She noted addiction is often seen as a character flaw or moral failing instead of as a brain disorder. Because of the existing stigma, Harris said individuals might be deterred from seeking the assistance they need to get better. “These are medical dis4

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orders,” Harris stressed of those dealing with chronic pain and addiction. The increased use of naloxone was central to the fifth recommendation. “We encouraged physicians to co-prescribe naloxone to patients who they thought were at high risk of overdose,” said Harris. She added it was important for states to review Good Samaritan laws to protect those who dispense the rescue medicine and to ensure first responders have access to naloxone. “Earlier this year, we added a sixth recommendation to encourage safe storage and disposal of all opioids … actually all medications,” she said. This summer, the AMA launched an opioid education microsite with nearly 300 educational and training resources across three major categories including detailed information on the six recommendations from the AMA Opioid Task Force, state medical resources, and medical specialty society resources. To access the microsite, go online to: end-opioid-epidemic.org.

Progress Report

Increasing awareness has brought progress. Between 2012 and 2016, the number of opioid prescriptions decreased by more than 43 million with every state experiencing a reduction in prescriptions. Although the nation saw an overall 16.9 percent decline, there were still more than 215 million opioid prescriptions written in 2016, according to data from CDC, Quintiles IMS. More physicians and other healthcare professionals are using their statebased PDMPs. The number of registered PDMP users jumped from 471,896 in 2014 to more than 1.3 million in 2016 – a 180 percent increase. Additionally, the PDMPs were used more than 136 million times in 2016, a 121 percent increase from 2014. There has also been a significant jump in the use of naloxone with almost all 50 states now having naloxone access laws. In the second quarter of 2015, there were 4,291 naloxone prescriptions dispensed. That represents a 1,170 percent increase over prescriptions in the fourth quarter of 2013. In just the first two months of this year, 32,659 naloxone prescriptions were dispensed. Additionally, more physicians are

being educated on safe prescribing practices, pain management and addiction treatment. There has also been a 27 percent increase in the past 12 months in the number of physicians certified to provide office-based medicationassisted treatment for opioid use disorders. “We absolutely are seeing progress, but we are not declaring victory,” said Harris. “This is still a significant issue, and the major drivers of this issue have evolved.”

Big Picture

“At the end of the day, physicians are prescribing opioids to treat pain,” said Harris. “It’s important we make available non-opioid and nonpharmacologic alternatives.” However, she continued, that also raises the issue of having payers look at practices and policies to ensure available benefit and payment structures don’t disincentivize the use of alternative evidence-

based treatment options including physical therapy and cognitive behavioral therapy. She added the AMA supports the recommendations regarding pain and research found in the comprehensive National Pain Strategy. Yet, she noted, “Pain is a very complex bio/psycho/social phenomenon – no two people experience pain the same.” Although there might not be a ‘one size fits all’ number when it comes to dispensing opioids after a procedure or for chronic pain, research and patient surveys have provided better parameters for physicians to follow. Harris concurred with former AMA President Steven Stack, MD, who called for physicians to prescribe opioids judiciously and to start at the lowest effective dose for the shortest duration of time. “Physicians should be judicious, but there should be some flexibility,” Harris said. Ultimately, she concluded, the decision to prescribe or not to prescribe … and how much to prescribe … should be left to the physician based on the individual needs of each patient.

Presidential Commission On July 31, the President’s Commission on Combatting Drug Addiction and the Opioid Crisis released a preliminary report calling on President Donald Trump to declare the issue a national emergency. Last month, the president did just that. Data from the Centers for Disease Control and Prevention show overdose deaths from prescription opioids in American have quadrupled since 1999 alongside sales of these medications. According to the CDC website, “In 2015, more than 15,000 people died from overdoses involving prescription opioids.” This number doesn’t include those who overdose on heroin and other non-prescription opioids, yet the groups are closely linked. A 2013 review by the Substance Abuse and Mental Health Services Administration (SAMHSA) found nearly 80 percent of Americans using heroin reported misusing prescription opioids first. The commission, which is led by Governor Chris Christie (R-NJ), cited the most recent CDC figures estimating 142 Americans die every day from some type of drug overdose. In a letter to the president, the commission members noted, “The average American would likely be shocked to know that drug overdoses now kill more people than gun homicides and car crashes combined.” Further illustrating the impact of overdoses, the group continued, “America is enduring a death toll equal to September 11th every three weeks.” The challenges, the report continued, have evolved as the nation and medical community have sought to address the epidemic. With tightening controls over access to prescription opioids, use of street opiates including heroin and fentanyl have escalated. A significant number of those with addiction issues also have a co-occurring behavioral health disorder. And treatment is limited by a shortage of providers, cost of care, motivation to seek help, and other access issues. The commission outlined a series of recommendations to begin to turn the tide on drug addiction, starting with the request that the president declare a national emergency. While the president has publicly stated he “officially” declares the epidemic an emergency, there is actually a formal process that must be taken to unlock the legal authority and pave the way for increased federal funding to attack the problem. At press time, that formal process had not yet been completed. Other recommendations by the commission included rapidly increasing treatment capacity, mandating prescriber education, and establishing a fund to enhance access to medication-assisted treatment (MAT). More detailed information about these and other recommendations is available online at NashvilleMedicalNews.com.

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Innovative Meharry Program Helps Mothers with Opioid Addiction One of the major issues across our nation is the increasing abuse of opiates. In fact, the White House commission examining the nation’s opioid crisis recently recommended that the opioid epidemic be declared a national public health emergency. While this is not a new problem, it is By DR. LLOYDA affecting a broader WILLIAMSON range of people (lower, middle, and high socio-economic class). Multiple factors contributed to this epidemic including the pharmaceutical industry’s encouragement to healthcare providers to eliminate pain, and organizations such as the Joint Commission on Accreditation of Healthcare Organizations including pain as a vital sign to be treated. When treating patients, unfortunately, providers didn’t understand the addictive nature of opiates. While opiates treat pain, they also have an effect on mood, causing a state of euphoria. The major problem is it changes our brain function and the reward pathway in our brain so when individuals use opiates for a certain amount of time, issues of dependence can become a problem. If people are prescribed opiates for an appropriate pain situation, for a limited amount of time, and given a limited amount of medication, issues of dependence can be limited or monitored. Unfortunately, in recent decades, that did not occur so many individuals in the public had access to more prescription opiates than they needed. It is true that many people take opiates appropriately for a limited amount of time, and dependence does not become an issue for them. However, most do not dispose of the medication, and it remains in their house for individuals who are seeking opiate medications to access. Frequently those medications are stolen by friends or family members who visit. The Lloyd C. Elam Mental Health Center at Meharry Medical College has several programs to treat substance use disorders. One program that stands out as unique is the Rainbow Program. This program is designed to treat pregnant and postpartum women with substance use disorders. These women have been included in the increasing number of people who use opiates. Opiate overdoes can result in death … and for a pregnant woman, death can occur to her and her unborn child. As part of the Rainbow Program, women with opiate addictions can receive medication-assisted treatment in the form nashvillemedicalnews

.com

of Buprenorphine. This medication is an opiate, but it is different than heroin, fentanyl or other opiate pain medications. When individuals are prescribed Buprenorphine, it prevents several problems from occurring. First, the individual doesn’t get the emotional high from this medication. Next, it blocks other mediations from attaching to the receptor in the brain. Third, it prevents individuals from going into withdrawal. People with opiate addictions greatly use excess opiate medications either to prevent themselves from going into withdrawal or to experience the euphoric or pleasant feeling. When individuals are treated with Buprenorphine, they receive a prescription for the medication that helps them take a consistent amount and avoid excess use and contact with dirty needles. It also helps them learn to think clearly. The women in our Rainbow program are also required to receive counseling while they receive this medication. Many are able to taper off Buprenorphine after they have received adequate treatment and counseling. For those who do not taper off Buprenorphine, it allows them to maintain functional lives without increasing inappropriate use of the opiate medications. Individuals with addictions often need treatment for several months while their brains recover from exposure to substance abuse. The Rainbow program allows women to be in treatment at the facility for 90 days, providing significant support toward their recovery. Mothers in this program are allowed to have their toddler children with them at the facility up to age three. Childcare is provided during the weekdays, which allows the mothers to participate fully in the recovery process. Their program not only includes classes about addiction but also includes parenting classes. The Rainbow program provides a longer length of stay for treatment, as well as the Buprenorphine which many other programs do not do. The Department of Psychiatry at Meharry Medical College obtained grants from the Tennessee Department of Mental Health and Substance Abuse Services to fund the Rainbow Program and to provide Buprenorphine treatment. These funds allow us to serve all individuals, including those without insurance coverage. We believe these programs save lives and help pregnant women with addiction receive comprehensive addiction treatment. Lloyda Williamson, MD, DFAPA is chair and professor of the Department of Psychiatry and Behavioral Sciences at Meharry Medical College.

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Specialists Address Disturbing Trends, continued from page 1

Enter medication-assisted therapy (MAT) including fast-acting opioid antagonist drugs, now a standard in pharmacies and emergency departments nationwide. In fact, certain antagonist therapies are available without a prescription in many states, including Tennessee. Also growing is the number of in- and out-patient treatment options now available. At Cumberland Heights, patients undergo an evidence-based, 12-step recovery process that focuses on spiritual healing, as well as physical. In 2016 the program treated more than 2,000 men, women and adolescents through their two main campuses and 10 outpatient offices.

Mental Health & Addiction

Fully addressing an addict’s mental health also is imperative. Kevin Lee, CEO of Nashville-based JourneyPure, said the majority of addicts struggle with mental illness related to anxiety, depression, OCD or bipolar disorder. “Our approach to addiction treatment is to first get an Kevin Lee examination done to identify possible mental illness,” said Lee. “That’s one reason we founded JourneyPure, because so many adults with chronic mental illness have spent time in psychiatric hospitals without addiction ever being addressed.” Lee said 70 percent of addicts are between the ages of 20-35, many of whom developed mental illness after using drugs. While the company serves all demographics, JourneyPure also offers programs specifically for professionals struggling with addiction. The company treats more than 3,000 new patients annually at facilities in Kentucky, Florida, Mississippi and Tennessee, including a Knoxville program specifically for expectant mothers. However, Lee said only 10 percent of addicts who would benefit from treatment receive it. “They’re embarrassed because they think they can’t leave work or don’t have the money,” he said. “We want them to know it’s available and that it can be an enjoyable and rewarding process.”

A Lifelong Journey

While inpatient treatment programs traditionally last 30-60 days, those with substance abuse disorders typically face a 6

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vide medications for that.” CleanSlate, which is relocating its Massachusetts headquarters to Nashville in 2017, currently treats more than 6,000 patients in eight states (and growing). Working closely with mental health providers, CleanSlate’s care coordinators ensure patients continue to receive medical and behavioral therapies as long as necessary.

Breaking the Cycle

Like Sledge and Lee, Russo-Appel said the stigma around addiction is changing. “Many believe addiction is found in the lower socioeconomic class or the homeless, but it’s startling to see the num-

ber of high functioning, well educated people battling this,” she said. That’s because addiction so often starts with a valid prescription for chronic pain. “PCPs and other providers are all coming into an understanding that this has gotten out of control,” she said. “We now have task forces and doctors signing pledges on how to prescribe opioids moving forward.” Russo-Appel said stopping the addiction cycle begins with prevention efforts as early as grammar school. “We need more awareness programs and access to care,” she said. “The heart of our mission is access. How do we get treatment to as many people as we can?”

Difficult Conversations, continued from page 1 each other during the training session. Between each, trained facilitators break down what just occurred, looking at what worked well, what might be improved, and introducing new skills to use during the next scenario. Pilot participants have noted the reflection and introspection that are critical components of the training carry on long after the session ends.

Changing the Cultural Conversation

Healthcare providers are trained to identify symptoms and initiate interventions. While critically important, O’Neal said it’s equally necessary to remember the patient at the center. Illustrating the point with a personal story, O’Neal shared a family friend had an aggressive brain tumor and already had begun experiencing the neurological and mental status changes that accompanied his diagnosis. When he wound up in renal failure, an ER resident notified his wife that the hospital would start dialysis, but the man’s family said ‘no,’ recognizing the process would simply frighten and confuse him even more. “The intervention for acute renal failure is dialysis, but where did that fit for this person?” asked O’Neal. She added the ‘right’ clinical intervention isn’t always the best or only option. “How do we put the person back in the center of the decisionmaking?” The way to do that, she continued, is by being honest with Anna-Gene O’Neal patients and family members. Instead of only offering one treatment path with the patient feeling like there is no other choice, the SHARE program helps providers lay out all options, including allowing the disease to take its natural trajectory with support and comfort interventions only. In order to make an informed decision, O’Neal continued, families and patients truly have to understand the benefit and burden of all options. “Then let the patients make the deci-

up the interaction. Just behind the bedroom, out of sight of participants, is a control room where facilitators observe each scene. The audiovisual system allows participants and facilitators to review and discuss each scenario to enhance the experience through reflective learning and skill-building. In addition to introducing a set of communication skills not typically taught during medical training, O’Neal said the program has identified system process issues – particularly among group trainings when various participants are unsure of what their role should be in the conversation. Often physicians opt to undergo the training, which takes several hours, on their own. O’Neal said it’s important not to worry about peer opinion during the process. “It’s a safe zone,” she noted, adding that if a participant does a great job … then great. However, she continued, “If they do an awful job, it’s okay to fail because it doesn’t go outside of these walls – and that’s the whole point. If you’re going to struggle, struggle here … don’t struggle with the patient and family.” While the simulation lab is specially equipped for the SHARE training, the program is also portable. Trainings have been conducted at a number of facilities in Middle Tennessee and beyond as it rolls out nationally. Alive has trademarked the program, which includes copyrighted materials, and hosts ‘train-the-trainer’ sessions for organizations that wish to license the program to use throughout their system. O’Neal said the SHARE program has taken communications models outside the healthcare industry and merged those concepts with empathic training found in healthcare to create a unique approach. Whether the trainings are conducted onsite or in the field, she noted the objective remains the same. “The goal is that everyone is successful. Everyone is going to leave here with a higher level of skill than when they came in,” O’Neal said. “To see confidence come out is really important.” Those interested in learning more about the program can go online to alivehospice.org and click on the ‘For Healthcare Professionals’ tab or call the main office at 615.327.1085. PHOTO: JOE BUGLEWICZ

Evolving Therapies

lifetime struggle with addiction. Maria Russo-Appel, MD, medical director for CleanSlate Addiction Treatment Centers Eastern Division, said patients who stop medications have an 80 percent chance of relapse. “Graduating from treatment is really an old concept in addiction medicine so we don’t frame our programs around that,” she said. “We Dr. Maria Russo-Appel understand that this is a potentially lifelong disease, and we pro-

PHOTO: JOE BUGLEWICZ

first-time users, leading to more overdoserelated deaths than ever. “The thing that’s a game-change is the rate at which people are dying and the desperation among families,” Sledge said. “It’s so incredibly dangerous because the potency has changed. With prescription opioids, we knew what to expect from a single Dr. Chapman Sledge dose … but with heroin, it’s difficult to judge potency.”

sion that’s best for them. It comes back to what’s important in someone’s life. How do they want to live? How do they define quality of life as an individual?” Those are questions, O’Neal pointed out, that providers can’t answer. “There are four components of medical ethics – there’s beneficence, nonmaleficence, autonomy and justice,” she continued. There are times when the first two – doing good and doing no harm – actually are in opposition. “When benefit and burden collide, who is best to make that decision?” questioned O’Neal. “When that occurs, autonomy has to take over, and autonomy is from the patient’s end.” Alive SHARE was created in recognition of how difficult these conversations are for most people. “You’re going to have to deal with your uncomfortable component … and we can help you with that … but you can’t not be open and honest and direct – and you can also do that while being compassionate and empathetic and understanding and succinct.” She added that culturally, as a clinical society, it’s important to look at pain differently and recognize that pain can be emotional or spiritual in addition to being physical. Broadening the definition opens new options to treating ‘pain’ in the way that’s most important to the individual at the center.

Program Mechanics

For those participating in the training at Alive’s Nashville office, a specially equipped simulation lab has been created that replicates a bedroom with actors portraying the patient and family members. The room includes cameras and microphones to pick

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Developing Healthcare Ventures PHOTO CREDIT: © 2017, DONN JONES

By CARA SANDERS

was invested in healthcare companies. Venture capital investment in healthcare IT companies surpassed that of healthcare service companies in 2012 and now represents the largest share of venture capital in Nashville healthcare companies. “NCN’s focus is not only on helping entrepreneurs connect with investors but also on helping them strategically align with resources to ensure success,” said Sid Chambless, executive director of NCN. “Today’s discussion featured some important insights into the types of successful partnerships NCN strives to support.” “We are fortunate to have some of the world’s greatest healthcare entrepreneurs right here in Nashville,” said Council President Hayley Hovious. “As a catalyst for leadership and innovation, the Council is proud to spark new ideas around entrepreneurism by hosting discussions such as the one we heard today.” Bradley served as presenting sponsor of the program with LBMC and W Squared, now part of the LBMC family, as supporting partners.

On Aug. 17, nearly 250 healthcare industry professionals gathered at the Westin Nashville to attend the “Developing Healthcare Ventures: Investor and Entrepreneur Collaboration” panel, an annual event put on by the Nashville Health Care Council and Nashville Capital Network (NCN.) The panel, which featured two pairings of executives and investors in high-growth companies, provided insights on what makes partnerships successful in a rapidly changing climate. This year’s panel From L-R: Eric Johnson, Nancy Brown, John Donahue, Rob Metcalf, and Curt Thorne. included John Donahue, CEO of axialHealthcare, a bigger mission for what you want to Access to a network can open key doors.” with investor Nancy Brown, a venture accomplish and receiving insight from the Brown and Donahue credit their partner from Oak HC/FT, as well as Rob board.” partnership’s success with a mutual underMetcalf, CEO of Concert Genetics, with In 2016, the Council and NCN standing and respect of one another. “It’s board member Curt Thorne. Moderator released a comprehensive report on the important to look for someone with a sinEric Johnson, dean of Vanderbilt Univerlocal venture capital marketplace, which cere and genuine commitment to the missity’s Owen School of Management, led found more than $1.6 billion in venture sion,” explained Donahue. “If there isn’t the panel. capital funds had been invested into 300 a clear and shared understanding for the Nashville-based axialHealthcare, different Nashville-based companies since future, there could be a problem.” Brown founded in 2012, is a pain medication and 2005. Almost $1 billion of this capital agreed, adding, “We do healthcare deals pain care solutions company, which partthat we actually want to do, no matter ners with health insurers nationwide. The how big or how small.” company’s solutions optimize pain care Concert Genetics, which was founded outcomes, improve financial performance in 2010, is a technology company specialfor health benefit providers, and reduce izing in streamlining genetic test selection, opioid misuse. Last year, the company ordering, payment, and management secured $16.5 million in funds from Oak for clinicians, hospitals, laboratories and HC/FT to grow its customer base and health plans. The Franklin-based comimprove technologies to expand. pany has generated more than $9 million in funding in the last six years. “My advice is to keep your awareness on the ‘why,’” said Thorne. “Many times, entrepreneurs become enamored with their product and the world revolving around that product rather than the larger picture. We have a monumentally dysfunctional healthcare system, and there is a great opportunity to create real value with improving the healthcare of society.” “Working closely with investors to set the larger, overall mission for our Rob Metcalf shares insights on strategically growing company has been key,” Metcalf said. a start-up company by working closely with investors “Thinking beyond the day-to-day work – that bring a different perspective to daily operations. about how we will make a larger impact on patients – it’s fun to have a board that encourages that kind of vision.” “I was an entrepreneur before I was Thorne added, “As long as you’re an investor, and it is important for both doing something that matters, your risk is perspectives to understand the long game smaller for the long term.” and be on the same page with the overall All of the panelists agreed that goal,” Brown said of crafting an effective relationships and open lines of comworking relationship. WE CARE about the FUTURE of HEALTH CARE munication are what make successful Donahue concurred, imploring At Belmont University we are thoughtfully and strategically educating the collaborations work in the first place. entrepreneurs to reach out to investors next generation of practitioners, researchers, innovators, entrepreneurs “Success in business is substantially about for guidance. “Emerging entrepreneurs and executives for the future healthcare marketplace. Learn more about getting the right people in the right seats,” should never be afraid to ask for anything Proud founding partner of the our leading edge programs at belmont.edu/healthcare. said Thorne. but should always be humble and genuTennessee Health Care Hall of Fame Metcalf added, “Regular communiinely seek advice from their investors.,” cations and keeping them [stakeholders] said Donahue, “Don’t be afraid to ask for Learn more about the Health Care Hall of Fame at TNHEALTHCAREHALL.COM informed is important. It’s about setting nonconventional investor assets, as well. nashvillemedicalnews

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Disaster Preparedness: Are We Ready? By KELLY PRICE

Hope for the best, prepare for the worst. The old adage is still sound operational advice when dealing with the everevolving realm of public health disasters and threats. With emerging health hazards, escalating levels of dangerous activities, and devastating natural disasters included in the ‘all cause’ mix, the officials responsible for the community’s health and safety have found they must continually update, evaluate, adjust, prepare and communicate their preparedness plans to a diverse set of stakeholders. The question isn’t just when but also what the next attack of man or nature will produce. The good news is there is credible evidence that even one person who knows and understands what to do in the moment of an impending disaster can save thousands of lives. In the Nashville area, the Tennessee Highland Rim Healthcare Coalition is a resource to make sure there are many who know what to do in case of emergency. The organization offers disaster response training, develops rescue plans, and evaluates potentially dangerous scenarios to design the best response to short or long term incidents that have a public health and medical impact within the Tennessee Emergency Medical Services (EMS) Region Five. The state is divided into eight EMS regions that coordinate planning, organizing, equipping, training and evaluating the healthcare systems working within their respective geographic boundaries. Each region is charged with knowing how to mobilize medical attention and response personnel in times of emergency, how to enlist and register personnel as part of the coalition, as well as identifying the most dangerous threats and the ones for which they are best prepared to resist. Addition-

ally, the coalitions are charged with the evaluation of the preparedness of health systems and providers in their region. James Tabor, MSM, CEP, who serves as regional hospital coordinator for Public Health Emergency Preparedness for the Tennessee Highland Rim Coalition, said the willingness to work together is critical when it comes to ‘boots on the ground.’ He added he is proud of the expanded outlook the coalition has incorporated into its operations. “We understand that sharing information and knowing each other makes a huge difference in response to a crisis. A disaster is not when you want to meet people or the first time,” he observed. The Tennessee Highland Rim Healthcare Coalition meets the third Thursday of each month at the Lentz Public Health Department on Charlotte Avenue in Nashville to focus on preparing for public health and medical emergencies including, pandemics, floods and other natural disasters, and acts of terrorism that have increasingly become part of the stress of living in the 21st century. This year alone they have coordinated response to 12 events, including having plans in place for the large crowds that gathered for the recent solar eclipse. Although the group spends a lot of time thinking about how to best respond to potential threats, their role is actually different. Tabor explained, “The Highland Rim Coalition is not a response agency. It is a highly trained team that is available to help coordinate responses by deploying medical personnel in times of emergencies.” Members of the coalition are trained to recognize that accurate and up-to-date information can make a huge difference in an effective response to a crisis. The old model for response meant sending help based on a facility’s number of beds. Now

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 SEPTEMBER: J. Jason James, DO, FACOI, a hospitalist at NorthCrest Medical Center and founder of Sango Internal Medicine and Wellness in Clarksville, looks at practical ways to prevent hospitalist burnout. Colbey Reagan, a partner at Waller with deep experience in healthcare regulatory issues, delves into ethical marketing practices. Does growth and consolidation lead the addiction treatment industry to start policing itself when it comes to ethics and marketing? Howard Taylor, PhD, laboratory director for Addiction Labs of America, shares how the opioid addiction has fueled the need for new lab tests. With illicit chemists inventing synthetic opioids at an alarming rate, new drugs are being developed that are stronger and easier to smuggle into the country. The ability to test for these new substances is a critical component in providing treatment to those suffering with addiction, and Nashville is home to the only lab in the country that’s now testing for a broad range of these synthetic opioids.

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allocations are made using formulas to ensure resources and care can be spread to expand to all of the areas where it is needed. Disease outbreaks, natural catastrophes, and public violence aren’t just reruns of problems seen before. Instead, each trigger event features new twists, weapons and consequences for responders to evaluate and understand. Continually updated protocols and policies are offshoots of new experiences and scenarios. Leadership of the Highland Rim team includes Chairman Jeff Mangrum, director of emergency preparedness for Vanderbilt University Medical Center and a trauma nurse by training; Co-chairman

Jason Erlewine, emergency preparedness coordinator for TriStar Hendersonville Medical Center who helped make that hospital the first in Middle Tennessee to earn a ‘storm ready’ designation; and Treasurer David Wheeler, system safety officer/emergency preparedness coordinator for Medxcel based at St. Thomas Health. In addition to Tabor, who is with the Metro Nashville Pubic Health Department, Donita Woodall with the Tennessee Department of Health also serves as a key contact. For more information on the Tennessee Highland Rim Health Care Coalition, upcoming trainings and available resources, go online to tnhrhcc.com.

New Antiviral Drug Inhibits Epidemic SARS, MERS & More A new antiviral drug candidate inhibits a broad range of coronaviruses, including the SARS and MERS coronaviruses, a multi-institutional team of investigators recently reported in Science Translational Medicine. The findings support further development of the drug candidate for treating and preventing current coronavirus infections and potential future epidemic outbreaks. Coronaviruses are a genetically diverse family of viruses that infect birds and mammals, with most coronavirus strains limited to infecting only certain hosts. Human coronaviruses, for example, cause up to 30 percent of common colds. In the last 15 years, however, coronaviruses have demonstrated their ability to jump into new species. Zoonotic (animal) coronaviruses have infected humans, causing severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), severe diseases with high mortality rates ranging from 10 percent for SARS to 40 percent for MERS. The MERS-coronavirus continues to cause new infections in the Middle East. “There’s a real concern that the MERS coronavirus could escape broadly when millions of people visit Saudi Arabia for the Hajj,” Mark Denison, MD, the Craig-Weaver Professor of Pediatrics and professor of Pathology, Microbiology and Immunology at Vanderbilt University School of Medicine, said of the event happening at the beginning of September. But to date, there has been no effective antiviral drug for any known coronavirus, he noted. Denison and his team at Vanderbilt have studied the basic biology of coronaviruses for more than 20 years. In an effort to find chemical tools that would allow them to probe viral replication, graduate student Brett Case screened a series of compounds selected and provided by Gilead Sciences. Case demonstrated that one of the compounds was highly active against coronaviruses in cultured cells. The finding was a surprise, Denison said, because compounds in the same class (nucleoside analogs) have normally failed to inhibit coronavirus replication. The compound, called GS-5734, is currently in clinical development for treatment of Ebola virus disease. Dennison’s longtime collaborator Ralphy Baric, PhD, and his team at the University of North Carolina demonstrated that GS-5734 inhibits SARScoronavirus and MERS-coronavirus replication in multiple in vitro systems, including cultures of primary human airway epithelial cells, which are the cells infected by respiratory coronaviruses. The researchers also showed that GS-5734 was effective against a circulating human coronavirus, bat coronaviruses, and bat coronaviruses that are considered “pre-pandemic” because they can infect cultured human cells. Using a mouse model of SARS, the investigators demonstrated that both prophylactic and early therapeutic administration of GS-5734 reduced viral load in the lungs and improved respiratory functions. “This compound shows broad activity against a variety of human and animal coronaviruses and represents an exciting potential therapeutic for a family of viruses prone to emergence from animal reservoirs,” Denison said. Denison and his team at Vanderbilt will continue to use the compound “as a probe to try to understand the biology of the virus, how and why this drug works, and to identify new targets for inhibiting coronaviruses,” he said. “This is an exciting example of how pursuing fundamental research to understand the mechanisms of virus replication and pathogenesis can lead to an important compound with therapeutic potential.”  

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In Case of Emergency New CMS Rule Implementation Deadline Nears By CINDY SANDERS

Healthcare providers and suppliers have long been expected to have an emergency preparedness plan in place. However, a final rule from the Centers for Medicare & Medicaid Services posted last fall clarifies expectations and sets in motion penalties for those who aren’t in compliance. The need for such carefully considered plans and procedures was on full display recently as healthcare providers and facilities worked tirelessly to keep patients safe in the wake of the damage and catastrophic flooding from Hurricane Harvey. Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers was published in the Federal Register on Sept. 8, 2016 and went into effect on Nov. 16 of that year. It is a new CoP/ CfC (condition of participation/condition for coverage), and all 17 supplier and provider types are impacted by the rule. The looming deadline for full compliance and implementation is Nov. 16, 2017. A CMS spokesperson explained the new disaster preparedness requirements offer a comprehensive guidance to ensure providers and suppliers could sustain all hazard threats. Those threats include internal and manmade emergencies, as well as natural disasters most likely to occur in an area. Internal emergencies might include equipment or power failures. Manmade

emergencies could cover cyberattacks or active shooters, and response to natural threats should incorporate thoughts on handling disruptions of essentials such as food and water if roads were impassable. While there are a number of steps, the spokesperson said the regulations were written in a straightforward manner so there shouldn’t be any confusion about expectations. Each provider and supplier group has its own set of regulations incorporated into its conditions or requirements for certification. The spokesperson noted the requirements are tiered and tailored to each group. For example, outpatient providers are not required to have policies regarding the provision of subsistence needs. The specific guidance sets, which are downloadable from the CMS website, are more detailed but generally require: • An an all hazards risk assessment to look at the best ways to respond and recover from a broad spectrum of manmade and natural disasters, • Development of policies and procedures based on the risk assessment including subsistence needs and plans to evacuate, shelter in place, and track patients and staff during an emergency, • Creation of a communications plan to ensure proper coordination with local, regional, tribal, state and federal emergency preparedness systems and agencies, • Implementation of training and test-

ing programs including drills and exercises to test the emergency plan, and • Review and update of the risk assessment, policies and procedures, and communications plan at least annually, along with meeting yearly training and testing requirements. Providers are required to conduct two testing exercises annually with one being a full-scale, community-based exercise. However, the regulation allows some flexibility with the recognition that a full-scale community drill might not be feasible so there are some options to replace that training with one that is based on the individual facility. Additionally, if an actual emergency occurs that tests the plan, the facility would be exempt from a full-scale exercise for one year following the emergency. The spokesperson said CMS identified a need for more consistency in emergency planning and response in the wake of Superstorm Sandy. He said findings in an OIG report released after the 2012 hurricane led CMS to create more specific requirements and guidance to address preparedness gaps. The OIG report highlighted one hospital, noting the facility had adequate backup generators on the 13th floor to protect them from potential flooding. However, the fuel pumps to run the generators were located in the hospital’s basement, which had quickly flooded. Ultimately, the hospital created a ‘bucket line’ in which staff passed fuel up 13

flights of stairs to keep the generators running until the hospital could be evacuated. Another key finding from the OIG report was that a number of staff members struggled to use alternative procedures to deliver care in the face of power outages. Reliant on automated processes, a number of administrators reported having staff members who didn’t know how to manually deliver IV therapy at the right rate or properly suction intubated patients by hand. The CMS spokesperson said surveyors would monitor compliance during the certification and re-certification process or in post-event evaluations. While full implementation is expected by the November deadline, he did say there should be some flexibility in this first year if a training exercise hadn’t yet been completed but was scheduled for the coming months. Failure to comply with the final rule is anticipated to follow enforcement efforts in other areas ranging from citations with the opportunity to take corrective action all the way up to termination from participation in the Medicare and Medicaid program in the most egregious cases. The main expectation, the spokesperson concluded, is for facilities to conduct a thoughtful and comprehensive assessment of threats and responses so that their patients, staff and community will benefit from that forethought in case of emergency.

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NMGMATen Minute Takeaway MIPS & MACRA – Secrets to Beating the Curve By CARA SANDERS

The second Tuesday of each month, practice managers and healthcare industry service providers gather for the monthly Nashville Medical Group Management Association (NMGMA) meeting. During the August luncheon, JulieKarel Elkin, member in the Nashville office of law firm Spicer Rudstrom PLLC, shared “secrets” to successfully prepare for the new Medicare Access & Chip Reauthorization Act (MACRA) performance standards to ‘beat the curve.’ Julie-Karel Elkin MACRA and the Merit-based Incentive Payment System (MIPS) track are being used to help practices move to a value-based incentive pay system. As with any major change, Elkin said it was critical to get psychologically and physically prepared, recognizing the new system is going to take more time and money and cause initial frustrations … but there isn’t really a choice. “Your practices are going to be mea-

HCA Hurricane Relief

Nashville-based HCA Healthcare, which has 177 hospitals and 119 freestanding surgery centers in 20 states and the United Kingdom, has announced a donation of $1 million to the American Red Cross to help people affected by Hurricane Harvey. In addition, HCA will match employees’ donations to the HCA Hope Fund, the company’s employee assistance nonprofit organization, up to $1 million. “HCA’s culture of caring is never more evident than when adversity strikes, and I’m proud to say that over the last few days countless members of the HCA family have pulled together to support the needs of our facilities in Houston and Corpus Christi,” said HCA Chairman and CEO Milton Johnson.

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sured against the performance standards of MIPS,” said Elkin. Because MACRA is revenue neutral, there will be winners and losers when it comes to achieving bonuses or being assessed penalties. “Money is going to come from one practice and go to another practice,” she said. Elkin added, “The goal … just like in college … is we want to beat the curve. We want to make sure we’re above that line so we’re not the practice where the money is coming from.” The first step, she said, is to look up your provider number by going to qpp.cms.gov/participation-lookup. Full participation began in 2017 to impact revenue in 2019, but providers have a number of “pick your pace” options in this first reporting year. Those who didn’t opt to participate for the full year also have the opportunity to report for 90 days. To do that, however, Oct. 2 is the absolute latest date to start. This first year also offers the opportunity to avoid a penalty by reporting on one measure before the end of 2017. There are six submission methods that are MIPS compliant, but not every reporting method supports all measures. Two of those reporting methods – CMS web interface and CAHPS for MIPS survey – required a pre-registration that has already passed. Elkin said it is important to make sure information is reported accurately via the right method. Like a GPA, she said, MIPS scores are reported in a cumulative manner – the higher an initial score is, the better for a practice in the future. MIPS is judged based upon the Composite Performance Score (CPS), which is measured in four improvement categories. The total score in this first year is broken

down as follows: 60 percent on quality (replaces PQRS), 25 percent for advancing care info (replaces EHR and Meaningful Use), 15 percent for clinical practice improvement activities (new), and 0 percent on cost (not used in 2017 but will be a factor later). For full credit in 2017, healthcare professionals must report up to six quality measures from a list of 271 and one outcome measure for a minimum of 90 days in order to earn up to 60 points. Next is the advancing care information category that allows up to 155 points to be earned, although only 100 points can actually be used. There are two tracks –the objectives and measures track or a transitional track. Improvement activities, which nets a maximum of 40 points, requires reporting on activities that improve clinical practice. There are 92 activities under nine subcategories. Providers can submit data on two high-weighted activities, 1 high-weighted and two medium-weighted activities, or up to four medium-weighted activities. While the final factor of cost doesn’t count now, Elkin said it’s coming so providers certainly need to keep it in mind going forward. Much like weighted grading categories in a college class, the CPS is achieved by figuring a point total in each category and then adding the category totals together. For example, if a provider earned 50 out of 100 points for the advancing care information category, which is weighted at 25 percent, they would earn 12.5 points in this category (50/100 = .5 x 25 = 12.5 points). An ideal MIPS score should be above the baseline to avoid penalty. “You want to push your score as high up as you can so you can stay at the top of that curve,”

MGMA Releases 2017 Regulatory Burden Survey: MIPS Tops the List The results of the Medical Group Management Association (MGMA) 2017 Regulatory Burden Survey reveal there is no shortage of opportunity to reduce regulatory burdens on physician practices. At a time when medical groups are transforming the way they do business to improve the coordination of patient care and enhance operational efficiency, nearly half report spending more than $40,000 per FTE physician, per year, to comply with federal regulations. In the MGMA survey, medical practices identify the following regulatory issues as “very” or “extremely” burdensome: the Medicare Merit-Based Incentive Payment System (82 percent), lack of national electronic attachment standards (74 percent), audits and appeals (69 percent), and lack of EHR interoperability (68 percent). Within the MIPS program, medical groups cite clinical relevance (80 percent) as their top concern. “The magnitude of regulatory demands on physicians forces medical group practices to needlessly focus precious time and resources on administrative tasks instead of patient care,” said MGMA President and CEO Halee Fischer-Wright, MD, MMM, FAAP, CMPE. “MGMA calls for national effort to relieve physician practices from excessive government regulation and looks forward to working with both the Administration and Congress to find meaningful solutions.” The survey includes responses from 750 group practices, with the largest representation from independent medical practices with 6 to 20 physicians. For a summary and full survey results, visit mgma.org/regrelief.

explained Elkin. She suggested practices and professionals alike should not submit the minimum because it will have a negative effect on the bottom line in the future and will ultimately end up costing money down the line. “Don’t slack your freshman year and then work on boosting your GPA for the rest of your college career,” she noted. “If I convince anyone of anything … it’s please don’t do nothing,” Elkin concluded. Beginning with the Sept. 12 luncheon, NMGMA will have a new meeting location at West End United Methodist Church.

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Moving Forward on Health Reform Four Questions for THA’s Craig Becker By CINDY SANDERS

The Tennessee Hospital Association, along with the American Hospital Association and most major provider organizations, opposed recent House and Senate plans to repeal and replace the Affordable Care Act. THA President and CEO Craig Becker recently answered questions on where those efforts fell short for Tennessee hospitals and what he would like to see going forward to protect access to care. Craig Becker NMN: What were the key sticking points for the THA in the recent Senate GOP healthcare reform efforts and how might those issues impact Tennessee hospitals? Becker: THA remained opposed to the BCRA due to its dramatic long-term cuts and structural changes to Medicaid funding and its failure to address the instability in the individual insurance market. With a major shifting in financial responsibility for Medicaid to individual states starting in 2020, TennCare projected a 10-year cost to the state of roughly $7.1 billion. Having lived through TennCare budget shortfalls in the past, we

know all too well the difficult decisions that must be made in these situations – enrollee benefits are eliminated and provider reimbursement is slashed. Our state simply cannot afford to be in such a situation. The potential for added uncertainty in the individual insurance market because of relaxed benefit requirements for insurers stood to increase premiums for older, sicker adults. The combination of the state impact of Medicaid reform and the changes to the individual market made the plan untenable for many senators. Lastly, steep cuts to Medicare reimbursement for providers will place additional strain on hospitals and healthcare professionals. Healthcare costs increase at a much more rapid rate than other consumer costs. Although important, Medicaid reform truly is an unrelated issue, which should be dealt with in a separate legislative process. NMN: How have hospital reimbursements been impacted under ACA, and what impact did not expanding Medicaid have on Tennessee? Becker: Overall, the Affordable Care Act has dealt a major blow to Medicare reimbursement for hospitals. Much of the costs associated with the ACA are funded through steep reductions in Medicare provider reimbursement, and without Medicaid expansion in Tennessee, there

has not been enough new reimbursement revenue to cover the Medicare losses. While there has been a slight reduction in charity care as a result of increased coverage through the insurance exchange, there remains an uncompensated burden of more than $1 billion annually in Tennessee. Couple this reality with a sicker, older, and more uninsured population in rural communities across the state, and you see facilities in those areas continuing to struggle. It is even more difficult for them to maintain the delicate balancing act of cost efficiency and quality healthcare than their urban counterparts. Since 2013, nine rural hospitals have closed in Tennessee – the second highest closure rate in the nation – and the loss of reimbursement and continued cost of uncompensated care is certainly a big contributor to this trend. THA data show the state’s 61 rural facilities provided more than $292 million in uncompensated care in 2015. That number includes about $124 million in unreimbursed TennCare costs. The challenges and threats to rural hospitals are very real and federal action is needed to begin to provide a path for stabilizing these facilities. NMN: What are the critical components

required for THA to support ACA repeal and/ or replace efforts? Becker: As hospitals, we need to see a plan that provides stability to the individual insurance market and ensures the continuation of coverage for the millions of Americans – and more than 200,000 Tennesseans – who receive coverage through the exchanges. Moreover, if elements of the ACA are repealed, there would need to be meaningful replacements in place at the time of repeal. It is becoming increasingly clear that a bipartisan approach to these challenges is necessary for success. As for Medicaid reform, hospitals continue to view this as an unrelated task and something that should be addressed more thoughtfully in a separate legislative process. NMN: Final thoughts? Becker: Many of Tennessee’s rural hospitals are in a tough financial situation, and there is little to think it will get better unless we make efforts to change how we pay our rural hospitals or incentivize how that care is delivered. There needs to be a rethinking of how we provide healthcare in our rural communities and how we make sure there is still a medical presence in those communities. People who live in rural areas deserve the same access to care as those in the urban settings.

HELP from D.C. Last month, Senate Health, Education, Labor & Pensions (HELP) Committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D.-Wash.) announced two bipartisan healthcare hearings for September. The first hearing is with state insurance commissioners and the second with governors to look at stabilizing premiums in the individual insurance market. Alexander announced Gov. Bill Haslam has been selected as one of five governors asked to testify before the committee. Tennessee Department of Commerce & Insurance Commissioner Julie Mix McPeak, who also serves as president-elect of the National Association of Insurance Commissioners, has been aksed to testify, as well. “While there are a number of issues with the American healthcare system, if your house is on fire, you want to put out the fire … and the fire in this case is in the individual health Lamar Alexander insurance market,” said Alexander. He added his goal was to be able to provide peace of mind before the end of the month to those who purchase health insurance on the individual market. He noted Congress must act by Sept. 27, the deadline for insurance companies to sign contracts with the federal government to sell insurance products on the federal exchange in 2018. “At these hearings, we will hear testimony from state insurance commissioners and governors — those closest to the problem — on steps Congress can take to help make insurance available at affordable prices,” said Alexander. “Any solution that Congress passes for a 2018 stabilization package will have to be small, bipartisan and balanced. It should give states more flexibility in approving insurance policies by improving section 1332 of the Affordable Care Act, as well as fund the cost-sharing reduction payments to help stabilize premiums for 2018.” Murray concurred that it would take a bipartisan effort to begin to address the nation’s healthcare challenges after the Senate failed to pass reform measures along purely party lines. “It is clearer than ever that the path to continue making healthcare work better for patients and families isn’t through partisanship or backroom deals. It is through working across the aisle, transparency, and coming together to find common ground where we can,” she said. Alexander and Murray have successfully navigated a number of bipartisan efforts impacting the healthcare industry including the successful passage of the 21st Century Cures Act and the recent FDA User Fee Agreements.

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SEPTEMBER 2017

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GRAND ROUNDS Mark Your Calendars Holy MACRA! • Sept. 27 With the final opportunity to start the 90-day reporting period for MACRA just around the corner on Oct. 1, the experts at KraftCPAs are hosting a panel discussion to help get everyone ready for the new quality payment program. Part of the ‘Healthcare Helpings’ series, registration and breakfast are at 8 am with the program beginning at 8:30 am. For details and to register, go to kraftcpas. com. Neighborhood Health Breakfast • Sept. 28 Stephen Loyd, MD, medical director for the Division of Substance Abuse Services for Tennessee Department of Mental Health and Substance Abuse Services, will be the guest speaker at the second annual event benefitting Neighborhood Stephen Health. Registration opens Dr. Loyd at 7 am, breakfast begins at 7:30 am at Belmont University’s Maddox Grand Atrium. To register, go to neighborhoodhealthtn.org. THA Annual Meeting • Oct. 11-13 THA’s 79th Annual Meeting will be held in Nashville at the Music City Center. This year’s theme, Tennessee Hospitals: The Pulse of Our Communities  focuses on the integral role hospitals play in shap-

ing neighborhoods, cities and rural communities. For a full schedule or to register, go online to www.tha.com/annual.

Pino Named Saint Thomas West & Midtown COO

Joseph R. Pino, FACHE, has been named chief operating officer for Saint Thomas Midtown Hospital and Saint Thomas West Hospital. Previously, he was assistant COO and line leader of Cardiovascular Services at the two hospitals. Before joining Saint Thomas, Pino was COO and interim CEO at Mercy Hospital in Miami. Pino earned his undergraduate degree from the University of Florida and an MHA from the University of Florida’s College of Public Health and Health Professions. 

Corey to Lead Lipscomb School of Nursing

Healthcare veteran Ruth Corey, DNP, has been appointed executive director of Lipscomb University’s School of Nursing. She brings more than 30 years of experience as a practitioner and in nursing education and research to Lipscomb’s College of PharDr. Ruth Corey macy & Health Sciences. Previously, Corey was director of nursing and academics at Marian University at Saint Thomas Health. She began her career as a registered nurse in Florida, where she also served as a family nurse practitioner

before entering higher education. She earned a bachelor’s and master’s degree in Nursing from the University of Central Florida and a Doctor of Nursing Practice from Nova Southeastern University.

Torch to Lead Waller’s Healthcare Department

Waller recently announced Paula Torch has been named executive director of the law firm’s Healthcare Department. In her role, she will work closely with the firm’s healthcare industry team, board of directors and practice group leaders to expand the firm’s work Paula Torch in the healthcare industry. Torch most recently served as vice president and senior research analyst for Nashville-based Avondale Partners. Prior to that, she served as vice president of Equity Research for Barclays Capital in San Francisco. She is a graduate of Fordham University in New York.  

Let’s Give Them Something to Talk About!

Awards, Honors, Achievements Vanderbilt University Medical Center has been named to the Becker’s Hospital Review roster of 100 Hospitals and Health Systems with Great Oncology Programs. Evelyn Yeargin has been named president of National Alliance on Mental Illness Davidson County (NAMI-Davidson). As president, she will work with board members to build fiscal stability and assist in the planning and delivery of NAMI-Davidson services. Yeargin serves as Evelyn Yeargin director of Advocacy for nonprofit behavioral health organization Mental Health Cooperative. In other Mental Health Cooperative news, the organization has been awarded $2.6 million from the Tennessee Department of Mental Health and Sub-

stance Abuse Services as part of the PreArrest Diversion Infrastructure Grants. MHC and other recipients use the funds to reduce or eliminate the time individuals with mental illness, substance use, or co-occurring disorder spend incarcerated by redirecting them from the criminal justice system to community-based treatment and supports. Middle Tennessee is home to three members of the recently announced American Heart Association’s Greater Southeast Affiliate (GSA) Board of Directors for the 2017-2018 fiscal year. Local directors include: Kiersten Espaillat, DNP, APN, stroke coordinator, Vanderbilt University Medical Center; Dawn Rudolph, chief experience officer, Saint Thomas Health; and Keith Wolken, chairman and CEO of SMS Holdings Corporation.   Local companies Compassus, a network of community-based home health, palliative and hospice care programs, and Cumberland Consulting Group, a leading healthcare advisory, implementation and outsourcing services firm, have been named to the Inc. 5000 list of fastest-growing private companies. Behavioral health provider Centerstone recently announced Col. (Ret.) Thomas W. Mahler Jr. has been named chair of its Board of Directors for Centerstone Military Services. Mahler, of Winchester, Tenn., has served as a board member since 2003. A past chair of the Centerstone Research Thomas W. Institute board, he also Col.Mahler Jr. serves on the Centerstone Foundation board. Carol Etherington, MSN, RN, FAAN was recently elected as chair of the Metropolitan Board of Health of Nashville and Davidson County where she has served as vice chair since 2014 and as a board member since 2009. Additionally, board members elected Francisca Guzman as vice chair.  Guzman has been a Board of Health member since 2014.  

TriStar Opens Simulation Learning Center

Last month, HCA’s TriStar Health System celebrated the grand opening of its new Simulation Learning Center (SLC). Located at the TriStar Medical Plaza in Antioch, this new facility offers TriStar healthcare providers a stateof-the-art clinical learning environment that simulates an actual healthcare setting. The 13,000-square-foot facility represents a $3 million investment supporting the TriStar Nurse Residency program. The center will provide workforce development and continued learning opportunities for the nearly 4,000 nurses who work at TriStar’s 22 hospitals. The SLC is custom-designed to reflect actual TriStar care environments with cutting-edge simulation equipment and technology. Instructors can observe employees’ training from three control rooms that overlook the center’s 15 simulation beds. The facility even includes 19 simulated patients of varying ages and interactivity.

Read More Grand Rounds online.

NashvilleMedicalNews.com

September 2017 NMN  

Nashville Medical News September 2017

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