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FOCUS TOPICS ENT & ALLERGY • HEALTH DISPARITIES & SOCIAL DETERMINANTS

Your Middle TN Source for Professional Healthcare News

PHYSICIAN SPOTLIGHT PAGE 2

Daniel Sacks, MD

ON ROUNDS

Filling the Gap Between Health and Healthcare The cobbler’s children have no shoes. Nashville is the epicenter of the nation’s health services sector. In fact, healthcare is a $78 billion industry in Middle Tennessee. Yet, like the shoemaker’s children standing in their bare feet, Nashville consistently winds up near the bottom of most every ranking when it comes to the health of its population ... 8

LHC in D.C. Five Questions for Claire Cowart Haltom On March 13-14, the Nashville Health Care Council’s Leadership Health Care (LHC) initiative led a group of more than 100 healthcare leaders on its annual two-day delegation to Washington, D.C ... 10

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Meharry Investigators Seek to End Racial Health Disparities By MELANIE KILGORE-HILL

It’s no secret that ethnicity and health disparities are strongly linked, and the Meharry Clinical and Translational Research Center (MeTRC) is working to connect the dots. Established in 2008, the MeTRC grant has cultivated minority researchers by funding their projects and built an infrastructure of laboratories, training, and support staff. Funding for the center first came as a $4 million annual gift for five years from the National Institutes of Health in 2009. The grant was successfully renewed in 2014 with a total budget of $15 million for five years.

Bench to Bedside

Translational research is a newer branch of scientific research that turns lab discoveries into successful, real world treatments. MeTRC scientists seek to understand diseases and health disorders that disproportionately impact minorities so that strategies for cure can be implemented. “There are significance differences in terms of incidence, prevalence and different levels of disease when you compare different ethnic groups,” said Samuel E. Adunyah, PhD, chair and professor of Biochemistry and Cancer Biology at Meharry. “It could be linked to where we live, or it could be genetic factors or other factors including socioeconomics.” (CONTINUED ON PAGE 6)

Dr. Samuel Adunyah – principal investigator and executive director of MeTRC and chair and professor of Biochemistry and Cancer Biology at Meharry Medical College – is pictured with 2016 Student Poster Competition participants.

Peanut Allergies: A Hard Nut to Crack

New Guidelines, Potential Therapy Offer a Shift in the Prevailing Wind By CINDY SANDERS

Peanuts are considered one of nature’s healthiest foods … unless, of course, you are one of the three million Americans allergic to peanuts and tree nuts. For those with severe allergy, even minimal exposure to peanut protein could prove deadly.

Updated Guidelines

While it might seem counterintuitive to parents fearful of harming their children, the potential severity of an allergic reaction is one

of the reasons … backed by science … that clinical guidelines were changed in January to call for a much earlier introduction of peanuts in the diet. For years, healthcare providers have told new parents not to introduce peanut products until the age of two. Yet, the incidence rate of peanut allergies has continued to climb in the United States. In January, the National Institute of Allergy and Infectious Disease (NIAID), along with the American Academy of Allergy, Asthma & Immunology (AAAAI) plus 24 other (CONTINUED ON PAGE 4)

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PHYSICIAN SPOTLIGHT

Finding His Way Home Nashville Native Daniel Sacks, MD, Now Practicing at OAT ear tubes to bigger head and neck cancer surgeries, so it’s a really broad spectrum.”

By MELANIE KILGORE-HILL

Otolaryngologist Daniel Sacks, MD, has come home to Nashville … and couldn’t be happier. Having recently completed his training, Sacks was excited to join the medical staff at Otolaryngology Associates of Tennessee (OAT), which has offices near Williamson Medical Center in Franklin and on the TriStar Centennial Medical Center campus.

New Kid on the Block

The Long Way Round

Raised in the Bellevue community, Sacks attended University School of Nashville before heading south to earn bachelor’s degrees in both science and art from the University of Florida. After returning to Nashville to attend Vanderbilt University School of Medicine, Sacks once again packed his bags – only this time he headed north to complete internship and residency at the University of Connecticut Health Center in Farmington. While in Connecticut, he did extensive research on inner ear biomarkers and vertigo and participated on the winning team at the American Academy of Otolaryngology Academic Bowl. There’s no place like home, though. “I was so excited to get back,” said Sacks of his recent move. Having accepted an invitation to join OAT, he now resides in Nashville with his wife and three-monthold son. “I was fortunate to make it work.” All in the Family For Sacks, the road to otolaryngology was paved early. As a child, he underwent ear tube surgery performed by otolaryngologist Ronald Cate, MD, who offered

Sacks’s mother, an audiologist, a job at the practice. Fast forward 25 years, and Sacks now works alongside both Cate and his mother JoAnne, caring for patients of all ages. “My mom really influenced my decision to go into this, and she’s as happy for me to be here as I am,” Sacks said.

Doing What He Loves

Sacks said the diversity of patients and procedures in an ENT practice was also appealing. “There’s a really nice variety in something that’s a fairly focused specialty,” he said. “You have a full array of patient demographics, from infants to elderly and everyone in between. From a surgical standpoint, you also deal with the smallest procedures like tongue ties and

As a freshman physician in a practice of upper classmen, Sacks said he’s learning a lot from his more experienced colleagues. He’s bringing some new tricks to the table, as well. “The fundamentals of ENT have not changed remarkably over the last generation, although technology has allowed for less invasive approaches,” he said, citing the now common endoscopic removal of brain tumors through the nose. It’s a surgery he performs in addition to other skull-based procedures alongside his neurosurgery colleagues. Another ENT win includes the increasing popularity of allergy drops over traditional shots. “There’s really good data behind the utility of allergy drops, which are placed under the tongue and help patients avoid needles and trips to the doctor’s office,” Sacks said. “While a lot of groups still don’t offer them, we specialize in it and have a lot of patients who enjoy the convenience of being able to do that at home.”

The Future of ENT

Sacks is also eager to begin offering bone anchored hearing aids (BAHA) for patients with conductive hearing loss. While a hearing aid tries to push sound through the damaged part of the ear, the BAHA System uses the body’s natural ability to conduct sound to bypass the damaged outer and middle ear, sending clearer, more crisp sound directly to the inner ear. Another device the practice is work-

RICHARD ROMERO JOINS HORNE LLP HORNE LLP welcomes Richard Romero, CVA, PAHM, CHFP, as a director in healthcare in the firm’s Nashville office. Richard serves clients across the nation, specializing in consulting and valuation of business enterprises and financial arrangements, litigation support and regulatory compliance. The HORNE Healthcare valuation team understands the urgency inherent in every transaction, and puts a team in place to start immediately on virtually any project. Responsiveness, experience, accuracy and current market information – that’s what you want in a partner in disruptive change. To contact Richard, please email Richard.Romero@hornellp.com or call 615-312-9038.

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ing to launch is the Inspire Upper Airway Stimulator for patients with obstructive sleep apnea. During the night, Inspire monitors every breath and delivers mild stimulation to the hypoglossal nerve, which controls the movement of the tongue and other key airway muscles. By stimulating these muscles, the airway remains open during sleep. Sacks performed the first Inspire procedure at Hartford Hospital in Connecticut, and he is trying to bring the program to OAT. Yet another game changer for sinus patients is the use of steroid-eluting stents, now replacing high dosage oral steroids. “The absorbable stent dissolves in the sinus cavity after a month and releases steroids topically so it provides local inflammatory reduction without having the side effects of an oral drug,” he explained.

A New Generation

Sacks said otolaryngologists are now seeing different types of diagnoses, as well. For example, widespread use of the haemophilus influenzae vaccine has nearly eliminated occurrences of Epiglottitis, once considered a common emergent diagnosis. Additionally, the demographics of head and neck cancers are changing dramatically. “Historically head and neck cancers have been related to cigarette and alcohol exposure, but there’s been an upturn in people with HPV-related head, neck and throat cancers,” he said. “This has resulted in a remarkably different patient population, as we’re now seeing younger patients who are otherwise healthy with less traditional risk factors.” The good news, Sacks continued, is that they’re typically more sensitive to radiation therapy. Sacks continues to build his practice and is accepting referrals at both the Nashville and Franklin Otolaryngology Associates of Tennessee offices.

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Coming to Their Senses

Vanderbilt Smell & Taste Center Offers Hope for Patients with Sensory Loss MANDY WHITLEY PHOTOGRAPHY 2016

By MELANIE KILGORE-HILL

A new initiative at the Vanderbilt Bill Wilkerson Center is offering hope to those with often overlooked, yet increasingly common symptoms. The Vanderbilt Smell and Taste Center kicked off in January with a monthly clinic designed to diagnose and begin treatment of smell and taste disorders.

Cause & Effect

Otolaryngology professor Rick Chandra, MD, said the dedicated focus is meant to streamline patient care and foster awareness of the problem. “Symptoms of smell and taste loss are fairly prevalent because of larger conditions in Middle Tennessee like allergies, polyps and sinus congestion,” Dr. Rick Chandra Chandra said. “A lot of people don’t even realize they have allergies or nasal polyps and just come to the ENT with symptoms of smell loss.”

Retraining the Senses

Dr. Timothy Trone administers a smell and taste test to a patient as Drs. Justin Turner, Paul Russell and Rick Chandra (L-R) observe.

Chandra said the new center is a place for those with unknown causes of smell loss, as well as those whose loss is associated with something more common that hasn’t yet been identified. Allergies, nerve loss, head trauma and neurological issues all are contributing factors.

Why Smell Matters

Blog Log The new 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 APRIL Troy Abruzzo, a master practitioner with North Highland, begins the countdown to the upcoming Centers for Medicare & Medicaid Services Social Security Number Removal Initiative. In addition to providing background on the SSNRI, Abruzzo helps providers think through the steps required to adequately prepare for the identifier change. Jonathon P. Cornelius, MD, a board certified orthopaedic surgeon with Hughston Clinic Orthopaedics, discusses robotic total knee replacement. Cornelius specializes in sports medicine disorders, orthopaedic trauma, minimally invasive joint replacements, and MAKOplasty Robotic Joint Replacement.

The loss of smell or taste might seem trivial, but it’s life changing for those it affects. “If you take the sense of smell out of the equation, all sense of flavor is lost,” Chandra said. That’s because the tongue can only distinguish salty from sour from sweet. “What people come in complaining about as a loss of taste or flavor is often a loss of smell,” he said. “We tend to use the words ‘taste’ and ‘flavor’ interchangeably, but taste only refers to what the tongue is doing … and all it can do is distinguish salty from sweet from bitter,” he continued. To those for whom smell loss is a primary complaint, quality of life is greatly diminished. “Loss of smell is something you wouldn’t think about as being detrimental to quality of life unless you lose it,” Chandra noted. “Patients typically need a lot of counseling about what the diagnosis is and the prognosis, as treatment can take a very long time. It’s not just a single ENT visit.” Chandra’s team of specialists explores all possible causes including allergen sensitivity, toxic exposures and possible head trauma. They also look for underlying medical causes, including viral infections or family history of neurological disorders like Alzheimer’s disease or Parkinson’s. “It’s more than just a stuffy nose that needs sprays,” he said. “Figuring out what’s wrong takes time and is often labor intensive.”

Treating Loss of Smell

For some patients, regaining smell

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with smell disorders comes from an explanation of what’s wrong,” Chandra said. “They want to know the underlying cause and prognosis. There’s therapeutic value in that.” According to Chandra, most patients dismiss symptoms for a long time before seeking help. “If the patient has a stuffy nose and watery eyes, it’s completely medically legitimate to treat them like any other allergy patient,” he said. “If the primary complaint is, ‘Doctor I can’t smell,’ that’s a different situation.”

may be as simple as polyp surgery or allergy treatment. For others, head trauma can cause damage to smell nerves, or a severe cold can trigger secretion of chemicals that cause permanent loss of smell. Sometimes, just identifying the problem can be therapeutic for patients. “Much of the satisfaction from patients

In cases where surgery or medication won’t bring relief, rehabilitation often involves olfactory retraining. Patients will inhale recognizable scents like vanilla, cinnamon and eucalyptus in a specific order several times a day. Over time, the therapy has been shown to improve the body’s ability to detect and identify odors. “The smell neurons in your nose can regenerate, and they’ll try to grow back and hook up with the memory and emotion part of the brain,” Chandra explained. “Smell nerves that have grown back or survived inflammatory or traumatic insult can stimulate those and impact the brain so that patients can learn to identify new odors.”

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Peanut Allergies: A Hard Nut to Crack, continued from page 1 organizations, recommended children at high risk of peanut allergy be introduced to peanuts at four to six months instead of avoiding all peanut-containing foods. The about-face was prompted by findings from the NIAID-funded Learning Early About Peanut (LEAP) allergy trial, which showed children at high risk of developing a peanut allergy were far less likely to do so (an 81 percent relative reduction) when introduced to peanuts before turning a year old. After the LEAP results came out, the NIAID convened a panel of experts for a review of literature and other studies that culminated in the addendum updating the 2010 Guidelines for the Diagnosis and Management of Food Allergy in the United States. The new addendum, which was published in the Jan. 5 edition of the AAAAI’s Journal of Allergy and Clinical Immunology, has detailed information on when and how to introduce peanuts to infants at three different risk levels. The new guidelines also call for adults to consult a healthcare provider before introducing peanuts to a child’s diet. Infants at highest risk of peanut allergy – those with severe eczema, egg allergy or both – should be brought to a specialist for peanut sIgE or skin prick testing to assess signs of allergy and to decide the safest way to introduce the peanut, which could include supervised feeding under the watchful eye of a healthcare provider. In the LEAP study, only 1.9 percent of infants at high risk of allergy who were introduced to peanuts early went on to develop a peanut allergy by age five, as compared to 13.7 percent of children in the same risk group who avoided peanuts. To access the addendum guidelines, go online to the ‘Diseases and Conditions’ section of NIAID.NIH.gov.

Peanut Patch

For those who have already developed a peanut allergy, a new form of epicutaneous immunotherapy has continued to show promise in clinical trials. The Viaskin® Peanut patch has progressed from a

Phase Ib safety trial launched in July 2010 to two Phase III trials now underway focused on safety, long-term efficacy and real world use. Luis Salmun, MD, senior vice president of Global Medical Affairs for clinical-stage biopharma company DBV Technologies, said the company’s novel patch mechanism is very exciting and could be used with other allergens and diseases, as well. In addition to the peanut patch, DBV Technologies is exploring the platform to address milk and egg allergies and is in a Phase I trial for pertussis. “This is a new platform for technology that uses the skin as an immune organ … not just a barrier but actually as an immune organ,” said Salmun. The Viaskin technology differs from other patches presently on the market, such as those to wean individuals from smoking, “The kind of patches that are used currently are absorbed quickly through the skin,” Salmun explained. “With the Viaskin patch, what’s Dr. Luis Salmun different is that there is a space between the patch and the skin. This membrane is electrostatically charged with peanut protein. The space allows for the very slow release of the peanut protein from the patch to the skin.” He continued, “Once deposited on the skin, it (peanut protein) binds to Langerhans cells, the antigen-presenting cells, and goes directly to the lymph nodes, bypassing the bloodstream.” Salmun pointed out this route, which was studied in animal models, minimizes the chance of systemic reaction and anaphylaxis. “That is one of the key advantages of this technology.” Thus far found to be most efficacious in the pediatric population, Salmun said the dose released in children aged four11 is 250 micrograms – approximately 1/1000th of a peanut in each patch. “What is so exciting is that such a negligible amount of peanut protein can lead to such

an immune response,” noted Salmun. At the recent AAAAI annual meeting, a team from DBV presented findings from a two-year extension of their successful yearlong, double blind, placebocontrolled, randomized trail for Viaskin Peanut. In the two-year extension arm, participants were treated with a daily 250 µg peanut patch. At the end of the third year, 83.3 percent of children aged six-11 showed response to treatment, as compared to 53.6 percent at the end of the one-year trial. In this trial, a responder after three years of treatment was defined as a patient who reached an eliciting dose equal to or greater than 1,000 milligrams of peanut protein, or had a greater than 10-fold increase of the eliciting dose compared to the patient’s baseline eliciting dose at the beginning of the Phase II trial. Similarly, children using the Viaskin Peanut patch saw a marked increase in the amount of peanut they could ingest during food challenges. At study entry, the median cumulative reactive dose was 44 milligrams of peanut protein. For those who completed three years in the extended trial, the median cumulative reactive dose rose to 1,440 milligrams. Salmun pointed out, “The goal of Viaskin is to decrease the chances of a reaction to an accidental exposure … not to eat PBJ sandwiches.” However, he continued, it’s an important goal given the number of Americans with peanut allergies and the difficulty in predicting the severity of reaction on any given day, which might range from a skin reaction to severe anaphylaxis. “The incidence of peanut allergy has increased significantly over the past decade,” he added. While the latest studies have shown increased tolerance by extending use of the patch from one year to three, Salmun said there isn’t an exact answer at this point as to the optimal timeframe for wearing the disposable patch. “How to stop … when to stop … we don’t have an exact answer at this time,” he noted. In fact, Salmun continued, “I don’t think there’s going to

THA Releases 2017 Rural Impact Report In late March, the Tennessee Hospital Association (THA) issued its 2017 Rural Impact Report, which found the state’s 61 rural hospitals provided 15,654 jobs with a total annual payroll of more than $791 million. Given the rate of employment and associated revenue, the report’s authors said rural healthcare could represent up to 20 percent of a community’s employment and income. For Tennessee as a whole, the impact of rural hospitals resulted in $994 million for the state’s economy. “Tennessee’s rural hospitals are the cornerstones of their communities,” said Craig A. Becker, THA president and CEO. “These facilities employ thousands of people and serve as major economic engines in their respective communities. In addition, they often are among the only options for rural residents when they 4

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need quality, affordable healthcare services.” Tennesseans in rural areas are frequently older and more likely to suffer from a host of chronic conditions, such as diabetes, that often lead to Craig A. Becker additional complications. The report noted rural hospitals, which account for nearly half of the state’s acute care facilities, provided almost $300 million in uncompensated care in 2015 (the most current data year) including $94.6 million in charity care. Additionally, the state’s rural hospitals delivered 12,224 babies and accounted for 980,808 Emergency Department visits in 2015. In light of recent conversations regarding federal healthcare reform, rural

hospitals could face more challenges when it comes to financial viability, which Becker said threatens the ability for facilities to continue providing quality care, especially when it comes to the uninsured and underinsured. Becker continued, “These facilities face a unique set of issues that are far different from their urban counterparts, such as the recruitment of healthcare providers and limited financial resources and capital. They’re under a constant threat of potentially closing their doors, which would leave entire communities vulnerable.” The report noted six rural hospitals have closed in Tennessee since 2014. The full report is available for download from the News section of the association’s website at THA.com or from our website at NashvilleMedicalNews.com.

be a black or white answer … it will have to be evaluated by the physician.” Results from the latest Phase III studies are expected in the second half of 2017. What is already known is that patients have been able to tolerate the patch very well with no serious adverse events being reported. The trials have also enjoyed well over 95 percent compliance rate for the small, easily applied patch. Salmun said there are no constraints or restrictions with the patch and that children in the trials have been able to swim, run and play sports as normal.

In a Nutshell Quick facts and stats about food allergies according to FARE (Food Allergy Research & Education): • Researchers estimate that up to 15 million Americans have food allergies. • Potentially deadly, food allergies affect 1 in every 13 children in the United States, which equals about two children in every classroom. • Food allergies are on the rise. According to a study released in 2013 by the Centers for Disease Control and Prevention, food allergies among children increased approximately 50 percent from 1997 to 2011. • The CDC reported food allergies result in more than 300,000 ambulatory care visits a year for children under age 18. • Food allergy reactions account for more than 200,000 emergency department visits each year … about one every three minutes. • Food allergy is the leading cause of anaphylaxis outside the hospital setting, and teenagers and young adults with food allergies are at the highest risk of fatal food-induced anaphylaxis. • Children with food allergies are 2-4 times more likely to have other related conditions like asthma and other allergies. • Having a parent who suffers from any type of allergic disease – from hay fever or eczema to asthma or food allergies – increases a child’s risk for food allergies. • Food allergies can begin at any age and cross all races and ethnicities. • Eight foods account for the majority of all reactions: milk, eggs, peanuts, tree nuts, soy, wheat, fish and shellfish. For more information, go online to foodallergy.org.

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Accounting for Social Risk Factors in Value-Based Payment Healthcare providers are becoming more responsible for ensuring the efficiency and quality of the care they provide to Medicare beneficiaries. The shift toward value-based payment models means that measurements of efficiency and quality of care are increasingly used to de- BY MELINDA termine financial bo- BUNTIN, PHD nuses and penalties. A recent report by a committee of the National Academies of Sciences, Engineering, and Medicine (NASEM, formerly the Institute of Medicine) —on which AND AIDEN LEE one of us served —finds benefits of adjustment of such measures for both clinical and social risk factors. Clinical risk factors are physiological attributes that can be associated with increased risk of certain diseases and health outcomes: they are already used to adjust quality and efficiency measures. Social risk factors are patient attributes such as low socioeconomic position, minority race or ethnic background, minority sexual orientation or gender identity, or

Table 1: Data Availability on Social Risk Indicators (Source: NEJM) Social Risk Indicators

More data online at NashvilleMedicalNews.com

Data Availability Data available for use now

Some data available for use; research needed to improve accuracy

Insufficient data available now; research needed on how to best collect data

Research needed on relationships to quality, costs, and outcomes and how to best collect data

• •

Socioeconomic position Income Educaiton level Dual eligibility for Medicare and Medicaid Wealth Race, ethnic group, and cultural context Race or ethnic group Language spoken County or origin Extent of acculturation Gender and sexual orientation Gender identity Sexual orientation Social relationships Marital or partnership status Living with others vs. alone Amount of social support Residential and community context Extent of neighborhood deprivation Urban vs. rural residence Adequacy of housing Other environmental factors

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• • •

• •

• •

Source: Buntin, MB, Ayanian, JZ. Social Risk Factors and Equity in Medicare Payment. NEJM. 2017 Feb 9; 376:607-510. Adapted with permission from the National Academies of Sciences, Engineering, and Medicine.

living in a deprived setting. Research has shown that these social risk factors influence health-related outcomes: patients with these attributes have worse health outcomes, and providers that disproportionately serve them ap-

pear to, as well. If they are not measured and adjusted for as clinical risk factors are, providers who serve disadvantaged populations could be unfairly penalized.1 In addition, providers might work to reduce the effects of social risk factors but

doing so could require additional staff effort and costs. If social risk factors beyond providers’ control are not accounted for, and providers serving disproportionate numbers of patients with high degrees of social risk are penalized, then disparities in health outcomes could widen. Thus, in order to achieve the goal of accounting for social risk factors in Medicare payment programs and compensating providers fairly, the NASEM committee was commissioned to “specify criteria that could be used in determining which socioeconomic status factors should be accounted for in Medicare quality measurement and payment systems.”1 The committee found that these goals could be reached with a combination of approaches. Specifically, depending on the measure and context, a combination of approaches might be used to account for social risk factors without masking real differences in performance. The approaches are: • Stratified public reporting by social risk factors within reporting units to illuminate how providers serve those with risk factors. (CONTINUED ON PAGE 10)

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Meharry Investigators Seek to End Racial Health Disparities, continued from page 1 Racial Disparities

Diseases where racial disparities are most prevalent include HIV/AIDS, cancer, diabetes, cardiovascular disease and neurological disorders. MeTRC focuses on many minority populations with an emphasis on African Americans and Latinos. Adunyah said the highest prevalence of HIV/AIDS in the U.S. is among African Americans in the Southeast, with both young African American men and women at higher risk of the disease than other races. In addition, prostate cancer rates among African American men are almost 2.5 times higher than that of Caucasian men (see below). “What are the factors that cause that?” Adunyah asked. “That’s the huge question, and the solutions are on different fronts.”

Finding Solutions

Identifying genetic risk factors requires a team of scientists, including cancer biologists, molecular biologists, immunologists, and microbiologist partnering with providers, while social determinants require public health officials, communities and population-based scientists working together. Churches also play an important role in reaching minorities for their inclusion in such studies. “Community-based participatory research is important because you can’t just go to a community and tell them what’s wrong,” said Adunyah. Investigators often work with churches

and religious groups to reach a particular community. “If you ask someone to provide blood samples for you to take back to the clinic, they will only participate if they trust you,” he said. Locally MeTRC has partnered with the state health department, Tennessee Center for AIDS Research, diabetes groups and the Meharry-Vanderbilt Community Engaged Research Core, which builds relationships between scientists and community organizations. They’ve also partnered with Nashville schools to form the Meharry/ Vanderbilt/Tennessee State University Cancer Partnership, funded through a National Cancer Institute grant. “By bringing groups of different disciplines together, you’re creating translational linguistics so the findings in one group can be used by the findings in another group,” Adunyah said. “That translates into patient care. You can’t tackle it from one front.”

Making Strides

MeTRC has made great strides, particularly in the area of HIV/AIDS research. “We now understand more about how the virus spreads and genetic message coding,” Adunyah said. “We understand more how the virus integrates into the DNA of a host cell … and are able to look at those areas that can be targeted for drug development to inhibit those areas.” MeTRC researchers have also participated in findings that revealed a link

between cocaine and amphetamines and their ability to interfere with the efficiency of HIV/AIDS drugs. Another discovery involves a condition related to end stage renal disease in HIV/AIDS patients, which is found in about 18 percent of African Americans. “We’ve been able to identify genes and proteins that predispose individuals to that disease,” Adunyah said. “That’s very important because we can begin to have ideas and strategies to block that from a person with renal disease.” These findings have been supported by similar findings from other institutions. Additional findings by MeTRC investigators could affect utilization of painkillers in a broader population. The discovery involves a difference in pain perception among Caucasians and African Americans.

Looking Forward

In 2016, MeTRC received funding from the National Institute on Minority Health and Disparities, a branch of the National Institutes of Health. They’re also part of a new initiative called eMERGE – a national network organized and funded by the

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A Community Partner

Locally, MeTRC is looking to partner with area providers outside their usual network, including oncology groups that see minority populations. Adunyah said those relationships often bring about amended protocols from study review boards to allow for outside participants. “We’re always looking for more collaborators,” Adunyah said.

PSCAN: Nashville General’s Prostate Screening Initiative By CINDY SANDERS

Keeping pace with the business needs of healthcare providers.

National Human Genome Research Institute that combines DNA biorepositories with electronic medical record systems for large scale, high-throughput genetic research. “We try to find out whether the genomic makeup of individuals is related to different types of cancer so you can recommend them for specific treatment through precision medicine,” Adunyah said. The MeTRC investigators have committed to testing 500 African Americans with early cancer diagnosis or at risk for cancer to potentially identify specific genetic changes in those individuals related to their cancer. Meharry is the only historically black college among those participating in this groundbreaking initiative.

Kelvin A. Moses, MD, PhD, FACS is leading a screening initiative at Nashville General Hospital to reach out to men at high risk for prostate cancer. “We want to encourage African-American men to participate because of higher incidence of prostate cancer and higher risk of high- Dr. Kelvin Moses grade cancer in black men,” explained Moses, who is chief of Urology at Nashville General Hospital. The project, funded through the end of 2017 with a grant from Astellas Pharma US, is available at no charge to the men being screened. In addition to African-American men, Moses said other target populations include those who are uninsured, on public insurance, or who haven’t been previously screened. “It’s open to anyone who has never had prostate cancer screening before,” said Moses, who also serves as an assistant professor in the Department of Urologic Surgery at Vanderbilt and as a urologic oncologist at Vanderbilt-Ingram Cancer Center. He added the clinic – offered on seven dates through the end of the year – includes a PSA test, DRE (digital rec-

tal exam), an electrolytes and lipid panel, blood pressure check, information about prostate cancer, and a connection to follow-up care. “We’re making sure men have a follow-up with a primary care physician,” noted Moses. “And if they don’t have one, we’ll get one scheduled for them.” Additionally, the clinic staff will help those with abnormal PSA or DRE numbers get an expedited appointment with a primary care provider. Moses said the follow-up is a key factor because too often men get a PSA number and don’t know what to do with it. “We’re trying to keep people from falling through the cracks.” Moses continued, “We acknowledge that there is controversy about PSA screening for the general population. However, we are trying to screen smarter by targeting high-risk populations who bear the highest burden of prostate cancer.” He added black men are at 2.4 times more risk of death from prostate cancer than their Caucasian counterparts. “Black men overall are less likely to be screened … and if diagnosed, are less likely to receive treatment.” Moses said the education component is as critical to the program as the screening assessment. “The key to smarter screening is patient engagement, shared decision-making, and assessment of overall health,” he concluded.

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For additional dates or to have a patient schedule a screening, call 615.341.4282 and ask for an appointment as part of the Prostate SCAN event.

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Addressing Health in the Community By CINDY SANDERS

As America rethinks the care delivery system yet again, there is a growing recognition that health happens in neighborhoods and on playgrounds … through vending machines and water pipes … and at bus stops and in classrooms all across the nation. Experts focused on population health recognize access to healthcare providers is only one driver of outcomes, albeit an important one. Yet, they believe moving the needle on health in the United States will require addressing socioeconomic and environmental factors outside of what has traditionally been considered the healthcare system. “What we’ve seen is that under the Affordable Care Act there have been large gains in coverage,” said Samantha Artiga, director of the Disparities Project for the Kaiser Family Foundation (KFF). However, she continued, “There’s a growing recognition that Samantha Artiga health coverage is one key component, but there are a variety of other components, too. Health is influenced by a broader array of factors. To really improve health, you have to address the social determinants.” Artiga coauthored the KFF issue brief, ‘Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity,’ with Harry Heiman to explore both the problem and potential solutions. In the brief, the authors wrote, “Based on a meta-analysis of nearly 50 studies, researchers found that

social factors, including education, racial segregation, social supports, and poverty accounted for over a third of total deaths in the United States in a year.” To address this issue, communities are utilizing innovative measures including ‘health in all policies’ and ‘place-based’ approaches. The former has been gaining traction over the last two decades and encourages policymakers and decisionmakers to consider health consequences in non-health sectors. Much like an environmental impact study, a health assessment evaluation might engage education leaders to consider the consequences of vending machine contents or a developer to consider the health impact of installing sidewalks. An example of a place-based approach is the Philadelphia Healthy Corner Store Initiative, which has brought healthier foods to more than 600 corner stores and resulted in a 60 percent increase in the sales of fresh produce. “As we documented in the brief, we’ve seen initiatives in a number of sectors,” Artiga noted. “We’ve also seen how to better integrate social determinants within health.” Rebecca Tyrell, a senior consultant for Advisory Board with deep expertise in population health, agreed Rebecca Tyrell social determinants are increasingly becoming part of the health equation. “Providers who have typically not been in the business of talking to patients regularly about non-clinical needs are now asking how to screen for issues and then how to access resources,” she

A Technological Approach Trenor Williams, MD, former founder and CEO of Clinovations, recently launched Socially Determined, which utilizes a service-enabled tech platform to integrate the social determinants of health with clinical data. Williams explained his new venture was born of three beliefs. The first, he said, is that social determinants “have a legitimate impact on healthcare outcomes, healthcare utilization, and healthcare spend.” Second, he continued, is that despite best efforts, information pertaining to a patient’s social risk factors is either not captured or not done so in a codified, consistent way. Third, there are an increasing number of risk-based contracts for which this type of information is vital. “We believe a part of the solution is going to be enabled by technology,” Williams noted. The first step, he continued, is to collect the data from a variety of sources … not the least of which is from patients, themselves. The next step is to make sense of the data through risk scoring to highlight a patient’s areas of need. The third, and perhaps most difficult piece, is putting together a care management and referral plan based on the data. Williams said this piece couldn’t fall solely on the physician but would require assistance of a broader care team. By overlaying community resource information into a technology platform that works with current EHR systems, Williams said it becomes possible to link patients at the point of care to critical supports within the community. “We believe that this area outside of the hospital, outside of the clinic – in the community – is the place that’s going to make a real difference in healthcare outcomes and people’s lives,” he concluded. Go online to NashvilleMedicalNews.com to read the expanded article.

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said. “The issue at hand is how do we connect the dots?” Yet, she said, effective community partnerships make sense on multiple levels. She recently penned ‘Building the Business Case for Community Partnership: Lessons from the BUILD Health Challenge’ to explore steps to extend care, engage patients, and improve cost and quality. With limited time and a heavy clinical burden, Tyrell said a number of hospitals and practices are turning to non-clinical staff members to create an inventory of resources and link patients to needed services. “In many cases, they are high school-educated individuals who are well connected in the community and have a familiarity with the community resources,” she noted. An innovative program by ProMedica in Ohio looks to destigmatize hunger. Tyrell said the system has partnered with community agencies to bring food pantries onsite to the hospital campus. Every primary care visit includes two simple questions to screen for food insecurities. Those identified as being at risk are given a food prescription. “They are trying to medicalize the issue and connect patients directly to food rather than referring them to an outside entity,” explained Tyrell. “It also plays a big role in reducing the stigma.” Tyrell counsels clinical clients to assess needs and start with one project.

Transportation, she noted, is a relatively low-lift barrier to address through ride share services or community transportation resources. “Start with whatever seems feasible with whatever resources you have available,” she noted. “You can always scale your efforts from there.” She added, “Don’t be overwhelmed by the range of possibilities or options. There will always be more needs in your community than you’ll be able to address right away.” While more individuals, including policymakers, now recognize health happens in a broader context than the narrow constructs of the delivery system, Artiga said that piece should not be underestimated. “When looking at what’s at stake in the current environment, the potential coverage losses under the American Health Care Act could make it more challenging to address social determinants of health because the health coverage piece provides a connection point to assess needs and to connect individuals to broader services in the community.” Even if there are more hurdles to clear in the future, Tyrell said she believes efforts to integrate health would continue to gain momentum. “Regardless of your political affiliation, we’re all focused on how to lower the cost of care while improving quality, and addressing the social determinants of health is a key lever to doing that because it allows us to go further upstream.”

Quality.

The Hallmark of Our Practice

NAS HVILLE VA SCU L A R & VE IN INSTITU TE

Every provider strives for quality, but we do more...we measure ours. We have invested heavily in the Vascular Quality Initiative™ sponsored by the Society for Vascular Surgery. The VQI is a databse that measures our results and compares them with vascular surgeons and practices around the United States. We believe to be really serious about quality, you must measure it. That’s why NVAVI is the only vascular surgery practice in Middle Tennessee that fully participates in VQI. But more than just measuring quality, the experienced team led by Dr. Patrick Ryan uses data to continually enhance best practices and improve outcomes. We hope you will allow us the privilege of partnering with you to treat your patients. You can rest assured they will receive the best evidencebased care and that you will be kept in the loop throughout the process.

DR. PATRICK RYAN

www.nvavi.com 330 23rd Avenue North, Suite 100 | Nashville, TN 37203 | 615.321.6100

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HEALTHCARE ENTERPRISE

NashvilleHealth: Filling the Gap Between Health and Healthcare The cobbler’s children have no shoes. Nashville is the epicenter of the nation’s health services sector. In fact, healthcare is a $78 billion industry in Middle Tennessee. Yet, like the shoemaker’s children standing in their bare feet, Nashville consistently winds up near the bottom of most every ranking when it comes to the health of its population. Addressing this dichotomy was the impetus behind NashvilleHealth, an initiative launched in late 2015 by Sen. William H. Frist, MD, and healthcare veteran Caroline Young. “NashvilleHealth is a convening organization to bring diverse groups together to set collaborative goals and execute action toward improved health,” said Young, who serves as executive director. The organization partners with other agencies and thought leaders to take a broad view of health by focusing on behaviors that impact health along with the social determinants that threaten wellbeing. Frist noted, “We have to address the equity issues surrounding health. The zip code you live in is more important than your genetic code … and the genetic code is important.”

Health vs. Healthcare

Calling on his years of experience as a surgeon and a legislator crafting healthcare policy, Frist said, “What a lot of people consider health is really just healthcare services and healthcare delivery – but that’s only about 15-20 percent of what defines our overall health and wellbeing.” Returning home after representing Tennessee for 12 years in D.C., Frist increasingly wondered how he could best position himself to improve the health of the 650,000 people living in Nashville. The answer was straightforward … but not easily accomplished. “The goal has to be to address the dramatic gap between Nashville’s high quality medical infrastructure and the health of many of our citizens,” Frist said. To do that, he reasoned, “It’s going to take a countywide, collaborative, inclusive initiative aligning all the nonprofit, for profit, and public health entities around the goal of improving the overall health of individuals, families and members of all of Nashville.” Young agreed, “We felt in a city as rich in resources, philanthropy, and know-how, there had to be a better way to improve health outcomes.” She continued, “In my work at the Health Care Council, I had seen the positive results when there is a connected network of energetic and talented professionals and hoped to bring some of those learnings to the community health side.” 8

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smoking here in Nashville than in other cities on average.” To help move the needle on smoking cessation, NashvilleHealth is one of the collaborators on ‘Quittin’ Time in Tennessee.’ Young noted, “With Quittin’ Time, we are working with the Tennessee Department of Health and the Governor’s Foundation for Health and Wellness to shine a spotlight on tobacco use in Tennessee and connect those who want to quit with resources.” Hypertension: In 2013, 23 percent of Nashville deaths were due to heart disease, according to the CDC. NashvilleHealth is part of a new six-member community steerSen. Bill Frist joins other health officials, including Tennessee Department of Health Commissioner ing committee that includes the Women’s Dr. John Dreyzehner (far left), to discuss strategies and resources for tobacco cessation. Health Alliance, the Office of Mayor Megan Barry, Metro Public Health as an Economic Health Department, Driver Meharry-Vanderbilt AlNashville has enjoyed the liance and Saint Thomas reputation as one of America’s Ascension Health for a ‘it’ cities for a number of years. first-of-its-kind effort to Yet, Frist said the designamake a broad impact on tion would evaporate if health heart disease and stroke doesn’t become a priority for in women. Nashville was business leaders and policymakselected as the debut site ers. of the Cities and Com“It’s not sustainable if the munities with Heart Inihealth of our population contiative, which kicked off tinues to rank below Austin, Mayor Megan Berry kicks off an exciting new initiative to improve women’s heart health in in late February. Dallas-Fort Worth, Raleigh- Nashville. Child Health: In Durham, Denver … all our addition to a high infant peer cities,” he pointed out. faith community, academic community, mortality rate, nearly 30 percent of NashFrist noted Tennessee is one of the unand environment,” said Young. “These are ville children live in poverty and Davidson healthiest states in America, and the Robert the people in the trenches with expertise County ranks 87th out of the state’s 95 counWood Johnson Foundation ranks Davidson and who are guiding our work.” ties for child wellbeing. NashvilleHealth County 30th out of the state’s 95 counties for and partners are looking at interventions the factors that drive health. High obesity, Boots on the Ground addressing a host of issues impacting chilsmoking and infant mortality rates don’t Young said NashvilleHealth partnered dren from infancy onward. make a great sales pitch when trying to atwith the Vanderbilt Department of Health “We’re very excited about a Nashville tract new companies to Nashville. Policy early on to explore areas of need. Infant Vitality initiative that we are leading “If you move here, you have a higher Recognizing every issue couldn’t be adin partnership with the Metro Department chance of your baby dying than anywhere dressed at once, a great deal of due diligence of Public Health and Meharry to make else in the country … it’s not exactly a helped identify critical needs. sure more babies see their first birthday Chamber message,” Frist said wryly. Ultimately, Young said, the organizain Nashville,” Young said. “Through data “Health is fundamental to the economic tion decided to focus on three main areas to and community feedback, we learned unprosperity of Nashville/Davidson County. start: tobacco use, hypertension and child safe sleep is a leading cause of infant death Without a healthy workforce, our jobs canhealth. The next step was to hold commuso with partners, we’re launching a public not be maximized. Our economy and the nity meetings to bring in local and national awareness campaign on safe sleep praccity will lose.” experts around these issues. Young extices,” she added. It’s a message that increasingly resoplained within each of the three key topics, nates with city leaders. Leveraging expertise NashvilleHealth is adopting strategies that The Bottom Line and support from the business community fall into four areas of engagement – cliniTo make a difference in the health of is one of the reasons the NashvilleHealth cal interventions, community engagement, the population, Frist said there were three Board of Directors includes senior leadermass media, and policy advocacy. key phases, starting with the recognition a ship from Bridgestone, UBS, the Nashville “We now have suggested interventions problem exists. The second phase was to Area Chamber of Commerce and Vector in each of these focus areas that we are colidentify innovative solutions to target the Management alongside healthcare industry laboratively pursuing,” said Young. “There biggest areas of need. Now, Frist continued, titans. was already great work going on among our it’s time to move to the third phase. “We Similarly, the organization’s Steering partners. We’ve been really honored to help have to deploy those solutions or otherwise Committee draws from a cross section of amplify these local efforts.” individuals are going to die earlier than the industries, public entities, and community Tobacco Use: “Tennessee has one generation before and live less healthy lives.” organizations to inform the program of of the highest smoking rates in the nation The bottom line, Frist concluded, is to work. “The Steering Committee is comat 22 percent, and Nashville is right at 21 make a demonstrable difference. “Our goal prised of 25 individuals who really reprepercent. The CDC goal is 12 percent,” is to improve the health and wellbeing of all sent the diverse determinants of health in said Frist. “There are 40,000 more people Nashvillians in a measurable way.” our city – health, safety, environment, the (C) 2017 STATE OF TENNESSEE

By CINDY SANDERS

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CityHealth Unveils Health Policy Ratings for Largest U.S. Cities By CINDY SANDERS

In mid-February, CityHealth released its first round of ratings for public policies impacting health in the nation’s 40 largest cities, including Memphis and Nashville. The new initiative is a project of the de Beaumont Foundation, which focuses on transforming public health by supporting local and state agencies through collaborative partnerships, strategic programs, research and funding grants. “Cities have been increasingly the leaders on innovation, on how to create a healthier environment for their citizens,” CityHealth Principal Investigator Shelley Hearne, DrPH, explained of starting with the nation’s largest metropolitan areas. Raising awareness of impactful city policy also offers the biggest bang for the buck with close to 80 percent of Americans now living in cities of varying sizes across the nation. “We are increasingly becoming an urbanized environment,” Hearne noted. Each of the cities in this initial round of ratings were awarded gold, silver, bronze or no medal in nine policy categories that officials with CityHealth identified as evidence-based, attainable policies to create healthier, more vibrant, prosperous communities. “When you have thousands of policies to choose from, it’s really hard for city leaders to know where to start,” Hearne said. “We took a look at what was the best evidence out there and what were the key drivers of health,” she added of the narrowing-down process. Ultimately, Hearne said the team zeroed in on the key social determinants of

Here’s how Nashville fared in the nine key policy areas. For more detail, go online to CityHealth.org, select Nashville and then click on ‘Learn More’ under each policy heading. Employment Benefits: Earned sick leave policies: Education: Universal, high-quality pre-kindergarten: GOLD Affordable Housing: Inclusionary zoning policies: Active Living/Transportation: Complete streets policies: GOLD Public Safety: Zoning regulations on alcohol outlet density: SILVER Tobacco Control: Tobacco 21 policies: Environment: Comprehensive smoking bans: **Food Safety: Restaurant grading policies: Nutrition: Healthy procurement policies: ** Editor’s Note: I actually questioned this as Nashville does require restaurants to prominently display food inspection scores. After reviewing with the Legal Services team, Shelley Hearne with CityHealth replied that existing law as currently written doesn’t qualify for a medal … but it’s very close. The sticking points are that the state doesn’t require the inspection reports have a numerical score (although they do by current practice) and that the law only says the report must be placed in a ‘conspicuous location’ rather than outside the establishment or immediately inside the door to provide patrons with info before making a dining decision. “Tennessee should be applauded for both making the inspection report accessible and for having a numerical grade. We would encourage them to go one step further and ensure the numerical score is readily visible at the door to everyone living, working, and playing in the state. Strong food inspection programs and an informed public are a powerful force for preventing foodborne outbreaks,” Hearne said.

health, researching policies related to education, affordable housing, active living and transportation, employment benefits, tobacco control, public safety, nutrition, environment, and food safety. “We decided to pick one policy from each of those areas,” she said of the filtering process. The next step was running possible

policy solutions through the “pragmatic test.” Hearne said they convened an advisory group that included hospital leaders, public health officials, a mayor and local chamber of commerce representative, among others. Several possible policy measures with strong evidence of impacting health didn’t make it through the prag-

NMGMATen Minute Takeaway The second Tuesday of each month, that teams are much more productive and practice managers and healthcare indusderive genuine satisfaction when in a state try service providers gather at KraftCPA of flow. headquarters for the The flow concept monthly Nashville Medical was pioneered by Mihaly Group Management AssoCsikszentmihalyi, PhD, a ciation (NMGMA) meeting. psychologist who has conDuring the March luntributed significant work to cheon, Marion Karr, executhe understanding of human tive vice president of Avery happiness, satisfaction, fulPartners and creator of Acfillment and creativity. The complishment Culture ©, idea behind flow is that inspoke about the importance tense and focused concentraof creating mission-driven tion on the present moment teams that develop self-awareallows one’s subjective expeness of internal motivation to rience of time to be altered. maximize output. A classic Essentially, the more focused Marion Karr, Avery Partners win/win situation, employees an employee is on their work, who work in ‘flow’ accomplish more and feel the more likely they are to get ‘lost’ in it and more pride in their work, while employers achieve a much higher level of productivity optimize talents and skill sets. in a shorter amount of time. Karr said if Karr helps executive leaders and employees can achieve flow in their work, employees pinpoint the ways the organithey find the experience of their duties to be zation is better because each team memintrinsically rewarding. ber is present. He has helped numerous He added when employers take the healthcare organizations embrace the idea time to get to know their employees and nashvillemedicalnews

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by Cara Sanders

the skills they possess, it is much more likely overall productivity and efficiency will increase along with employee satisfaction. Employers, he said, must find the best intersectional space where skills meet challenge for their employees in their daily duties. “Performance drops in boredom just as much as it does in anxiety states,” Karr pointed out. His biggest takeaway for employers and physicians alike is that there is an importance in placing value in an employee’s skills, hobbies, and activities. The receptionist who loves to check her Facebook and Twitter accounts might be the perfect person to put in charge of keeping the organization’s social media accounts current. The social nurse who gets everyone together for lunch could be just the right person to plan the office holiday party or patient appreciation event. Ultimately, employees who are allowed to tap into skills they enjoy take more pride in their work and produce a more accomplished, thoughtful product.

matic test, largely because cities weren’t able to control the parameters. Hearne said the nine specific policies selected were supported by evidence, were realistic to implement, and in fact, had cities that had already successfully put them in place. Examples include setting 21 as a minimum age to purchase tobacco products, instituting healthy procurement policies to set smart nutrition standards for all foods served and sold on city property including nursing homes and jails, and inclusionary zoning policies to set aside a percentage of affordable apartments or condos in new developments. Next, it was time to rate policy. Hearne said a legal team out of Temple Law School did the legwork. “It’s a team of lawyers that literally went through the existing laws, executive orders, and regulatory codes for all 40 cities … and that would include the state law, county law and the city,” she said of the exhaustive process. Five cities – Boston, Chicago, Los Angeles, New York, and Washington, D.C. – achieved gold status by earning five or more medals across each of the nine policies. An additional five cities earned silver designation, nine earned bronze recognition, and 21 earned no medal. Nashville and Memphis fell in the last category with each city only earning three medals across the nine policy areas. “The bravo is both cities got a gold in quality pre-kindergarten,” said Hearne. “People don’t think of that as a health policy, but it is.” She added cities with high quality, universal pre-K programs see a decrease in teenage pregnancy and increase in high school graduation rates. “On the flip side, both cities didn’t get a medal for clean indoor air. The state has preempted the cities from being able to regulate the way they see fit to implement smoking laws.” Hearne stressed, “This isn’t a ranking. The ideal here isn’t meant to be a ‘gotcha.’ This is a tool for city leaders. We’re looking at how we get all the cities into a gold status.” To that end, she said the de Beaumont Foundation is committed to working with cities, setting up learning communities, and sharing expertise to help move policy in these nine critical areas.

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LHC in Washington, D.C. Five Questions for Claire Cowart Haltom On March 13-14, the Nashville Health Care Council’s Leadership Health Care (LHC) initiative led a group of more than 100 healthcare leaders on its annual two-day delegation to Washington, D.C. This year’s event provided delegates with an inside look at the state of healthcare policy under the new Trump Administration and predictions about what developments might unfold to impact Nashville’s $78 billion healthcare industry. The delegation featured discussions with members of Congress, administration officials and national thought leaders about key healthcare policy issues, the state of investor-owned community hospitals, healthcare information technology and more. Claire Cowart Haltom, shareholder with Baker Donelson, is vice chair of the Leadership Health Care board and a regular attendee of the annual delegation to D.C. She assists healthcare organizations and insurance companies with complex business transactions, strategic market analysis, regulatory compliance, state approvals, licensing issues, corporate practice of medicine issues, clinical integration opportunities, and antitrust concerns. Additionally, Haltom provides strategic policy and government relations advice to clients on federal and state public policy matters. She sat down for a Q&A with Nashville Medical News about the recent LHC trip.

Participants in the LHC Delegation to D.C. had the opportunity to ask questions directly to key policymakers and thought leaders helping shape the future of healthcare.

nally to take the $3 trillion we spend on healthcare every year (that’s $100 million per hour) and make sure the government spends that money as effectively as possible. We’ve seen a lot of positive changes in recent years as CMS has started to shift from volume-based payments to valuebased payments, but there’s still a lot of work to be done.

NMN: Having heard various viewpoints over two packed days, is there a specific area of concern that you will continue to follow? Haltom: We hear NMN: What were the a lot about the health inkey takeaways from the trip? surance marketplace, but Haltom: Strap in the reality is that Medicfor a wild ride. The Reaid is the sleeper issue publican plans to repeal that could make or break and replace Obamacare the Republicans’ efforts will mean another tufor healthcare reform. multuous few years in Medicaid is far more healthcare as our induscomplex and covers milClaire Cowart Haltom try reacts to the changing lions more people than landscape. Most of the the exchanges. I work speakers felt confident with a number of nonthat the American Health Care Act will profit health systems across the United be signed into law this year, but whether States – many in states that have not exthe Republicans can build upon that mopanded Medicaid. These hospitals suffered mentum and pass legislation to implement the same reimbursement cuts under the Republican ideas – such as selling health ACA as hospitals in states that expanded insurance across state lines – remains to Medicaid but didn’t receive any of the upbe seen. side offered by Medicaid expansion. I’ll be As Chip Kahn, the president of the watching the Medicaid discussions very Federation of American Hospitals said, closely because these changes will have an the only thing we can be sure of is that echo effect throughout the industry. there will be tweets from the president. NMN: What made you want to attend this NMN: What there a speaker or presentayear’s trip to Washington? tion that left a particularly strong impression? Haltom: This is my fifth time atHaltom: Patrick Conway’s contending the LHC Delegation to DC. The versation with Senator Bill Frist offered thing that keeps me coming back is that I a refreshing perspective on how a comget to hear directly from the health policy mitted public servant is trying to effect change-makers in Washington as change positive change from the inside. Conway is happening. is the chief medical officer for CMS and With no press in the room, the memis a career employee – not a political apbers of Congress, the government reprepointee. He is leading the effort intersentatives, and industry executives can 10

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speak candidly about their concerns, ideas, and predictions. These insightful discussions help me advise my clients on the issues that they need to be thinking about next. I don’t know of any other organization that provides this kind of access year-after-year. NMN: Any final thoughts? Haltom: Healthcare is constantly changing, but the next few years will be extremely important for our industry. The Trump Administration has signaled that they intend to revisit a number of agency

U.S. Rep. Jim Cooper addresses the delegation at one of the LHC sessions.

rules and interpretations that were previously implemented by the Obama Administration. Now is the time for healthcare organizations to be meeting with CMS, HHS, and other agencies to explain the business impact rules and interpretations have on companies operating in the marketplace.

Accounting for Social Risk Factors, continued from page 5 • Adjusted performance measures to standardize estimates of quality. • Direct adjustment of payments to providers who disproportionately serve those with social risk factors. • Restructured payment incentives to reward improved quality or high-value care. The committee also found that development of new data sources and methods of measurement would be beneficial in identifying indicators of social risk. Table 1 shows the five major categories of measures considered important by the committee, and specific examples of measures in each category, which may be ready for use. One example is that data are ready for use on dual eligibility for Medicare and Medicaid (an indicator of low income), and the Medicare program could use them to adjust measures of – and penalties for – hospital readmissions. In addition, work to improve the accuracy of social risk data and use it for

payment and quality measurement would likely benefit providers and patients in Nashville.1,2 Davidson County’s poverty rate is higher than the U.S. average, and Nashville has a higher proportion of citizens who are members of minority races and ethnicities. 3 Accounting for social risk factors that a significant numbers of Nashvillians face would not only benefit the providers who serve these disadvantaged populations, but those directly affected by social risk factors themselves. Melinda Buntin, PhD is a Professor of health economics and the Chair of the Department of Health Policy at Vanderbilt University’s School of Medicine. More about her Department can be found at https:// medschool.vanderbilt.edu/health-policy/ or by following @VUHealthPol. Aiden Lee is a senior at Vanderbilt University studying Medicine, Health, and Society with a concentration in Health Policies and Economies.

National Academies of Sciences, Engineering, and Medicine, Accounting for social risk factors in Medicare payment. Washington, DC: National Academies Press, 2017. 1

2

Buntin, MB, Ayanian, JZ. Social Risk Factors and Equity in Medicare Payment. NEJM. 2017 Feb 9; 376:607-510.

People Living Below Poverty Level by Race/Ethnicity, Nashville TN. HealthNashville.org (2015). Retrieved: March 9, 2017, from www.healthynashville.org Data Source: US Census Bureau, American Community Survey. 2011-2015. 3

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GRAND ROUNDS CarePayment Announces New Owner, Moves HQ to Nashville

In March, Cedar Springs Capital, LLC, together with Crestline Investors, Inc. acquired majority interest in CarePayment, a patient financial engagement company with more than a decade of experience partnering with providers to offer patients zero percent interest payment programs. Additionally, the new majority owners are investing significant capital to support the company’s growth initiatives and moving CarePayment’s headquarters from Portland, Ore., to Nashville, where it first opened an office in October 2015. The majority of the executive team is currently located in Nashville and additional employees will be added as the company experiences near term growth.

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, Jamie McPherson, Jennifer Trsinar MANAGING EDITOR Cindy Sanders csanders@nashvillemedicalnews.com CREATIVE DIRECTOR Susan Graham sgraham@nashvillemedicalnews.com CONTRIBUTING WRITERS Dr. Melinda Buntin Melanie Kilgore-Hill Aiden Lee Cara Sanders Cindy Sanders 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 Nashville Medical News is published monthly by Graham | Sanders Publishing, LLC. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Nashville Medical News will assume no responsibilities for unsolicited materials.        All letters sent to Nashville Medical News will be considered the newspaper’s property and therefore unconditionally assigned to Nashville Medical News for publication and copyright purposes.

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Nashville General Hospital Foundation Event

On Saturday, March 11, Nashville General Hospital Foundation hosted a Jazz Brunch and Silent Auction with special performance by Eric Blue and Richard Griffin. All proceeds raised will benefit Nashville General Hospital Foundation for patient healthcare services. Pictured (L-R) Dr. Joseph Webb, Carolyn McHaney-Waller, Glenn Bradley and Lyn Plantinga

Awards, Honors, Achievements

HighPoint Health System Market Chief Financial Officer Bob Barrett has been named “CFO of the Year” by LifePoint Health®. The award is given annually to one CFO within LifePoint’s network of more than 70 hospitals who best exemplifies the Bob Barrett company’s core values of , honesty, integrity, trustworthiness, compassion, and ethical and legal compliance. Franklin-based predictive analytics and cash flow valuations technology company Healthcare TTU, which was founded by Pearson Talbert and Chris Birk, has been chosen for participation in the Cedars-Sinai Accelerator Powered by Techstars. Saint Thomas West Hospital and Saint Thomas Midtown Hospital have received a three-star rating, the highest possible, from the Society of Thoracic Surgeons (STS) for overall quality regarding two heart procedures: isolated coronary artery bypass surgery or graft (CABG) and isolated aortic valve replacement (AVR). The ratings are particularly noteworthy because just 21 of 1,024 participants in the STS Adult Cardiac Surgery Database received the highest possible rating for both isolated CABG and isolated AVR.  Additionally,

three-star ratings were awarded to just 9.55% of the participants for isolated CABG and just 7.48% of the participants for isolated AVR. Vanderbilt University Medical Center is among the top hospitals in the United States performing liver transplants, according to a recent report published in the American Journal of Transplantation. Vanderbilt performed 149 adult liver transplants between July 2015 and June 2016 (FY16). The volume ranks the center at No. 4 in the nation based on data released by the Scientific Registry of Transplant Recipients (SRTR). TekLinks has announced Cisco has renewed the company’s Gold Certification, Master Collaboration Specialization, and Cloud and Managed Services Master Specialization. Only 156 U.S. companies are Cisco Gold Certified. There are 80 Master Collaboration Partners in the country and 53 Cloud and Managed Services Master partner. The American Cancer Society (ACS) has recognized TriStar Health, an HCA affiliate, for working with local organizations to help save more lives through screening for colorectal cancer.  

STH Acquires daVinci® Xi

With 10 years of robotic surgical experience and almost 5,000 completed robotic surgical procedures, Saint Thomas Health has taken the next technological step by adopting use of the daVinci® Xi Surgical System. This state-of-the-art technology uses advanced robotic, computer and optical technologies, including a 3D high definition vision system. The daVinci® Xi Surgical System enables efficient access throughout the abdomen and chest and expands on previous technology to include wristed instruments, 3D-HD magnification so the surgeon has a close-up view of the operating area, intuitive motion and an ergonomic design.

Watts to Lead National Health Care for the Homeless Council

The Nashville-based national organization, which serves as a leading voice for the advancement of homeless healthcare and secure housing issues, has named G. Robert (“Bobby”) Watts as its new CEO. Watts, who most recently served as executive director of New York City’s Care for the Homeless

succeeds the Council’s founding Executive Director John Lozier, who retired in late December. A graduate of Cornell University and the Columbia University Mailman Bobby Watts School of Public Health, Watts led New York’s Care for the Homeless for 11 years, during which time the organization tripled in size. He also served as the finance officer of the New York City HIV Health and Human Services Planning Council, a steering committee member of the New York City Medicaid Managed Care Task Force, and a member of the New York State Interagency Council on Homelessness.

Wisniewski Joins InfoWorks as Healthcare Principal

InfoWorks has added 20-year healthcare industry veteran Mark Wisniewski as a principal consultant to the Nashville-based management consulting firm. A seasoned healthcare executive with a focus on both inpatient and outpatient settings, his career spans Mark Wisniewski the healthcare industry, including specialties in business and technology strategy, EHR design and implementation, and advanced business intelligence. For the past five years, he served in executive leadership for Mental Health Cooperative. Wisniewski earned is MBA from Vanderbilt Owen School of Management and his undergraduate degree from Trevecca Nazarene.  

Schlacter Promoted                          In late March, the Nashville Health Care Council announced Katie Schlacter has been promoted to senior director of communications and content strategy. Schlacter, who previously served as director of communications, joined the Council staff in 2012. In her role Katie Schlacter as senior director, she will continue to lead all communications activities on behalf of the Council and its initiatives, while playing a strategic role in directing content for the organization’s extensive events and offerings.

Building Expansion Planned for VUSN

The Vanderbilt University School of Nursing will soon break ground on a new 29,947-square-foot addition connecting to its existing buildings on the Vanderbilt campus. Construction is expected to begin in late spring and be completed August 2018. The $23.6 million facility will be built at the intersection of VUSN’s historic Godchaux Hall and the Patricia Champion Frist Hall near the south side of the Heard Library. The five-floor structure will house technologically advanced classrooms, conference and seminar rooms, student services offices, faculty offices and a state-of-the-art simulation Architect’s rendering of the new Vanderbilt University School of Nursing expansion as teaching lab that will allow complex skills development and seen from 21st Avenue. (Hastings Architecture Associates LLC/Vanderbilt University real-time feedback on students’ clinical nursing skills. The School of Nursing) building’s virtual classroom will incorporate leading-edge online and distance technology to facilitate distance learning and its interactive classroom will facilitate large and small group interactions with electronic methods that allow for sharing of group data and findings. APRIL 2017

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GIVE YOUR FINANCES THE SAME CARE AS YOU DO YOUR PATIENTS. In today’s uncertain markets, having a bank that tends to your financial health is vital. First Tennessee Medical Private Banking can help with today’s needs and tomorrow’s goals. Our Relationship Managers offer guidance and solutions tailored to medical professionals. So you can focus on your priority: your patients. To make an appointment with a Relationship Manager, please contact: Matthew Harrison Vice President Medical Private Banking ph: 615-514-6055 email: mrharrison@ftb.com

Glenn Bradley Vice President Medical Private Banking ph: 615-514-6054 email: gmbradley@ftb.com

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3/22/17 12:15 PM

April 2017 NMN  

Nashville Medical News April 2017

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