BCMS Script Newsletter December 2022

BCMSScript.

Newsletter of the Bucks County Medical Society Winter 2022

President’s Message

OUR MISSION

The Bucks County Medical Society strives to advance the professional and personal development of its physician members by providing educational and practice related resources as well as legislative advocacy. Moreover, the Bucks County Medical Society seeks to promote optimal outcomes for our patients as well as the public health of the Bucks County community.

Greetings!  I hope you enjoy reading this semi-annual membership newsletter.

The Bucks County Medical Society has been quite active this year.

First, we have engaged in legislative advocacy. We held a virtual roundtable meeting with our local representatives providing a voice to our local physicians on topics including restrictive covenants, prior authorization, access to mental health care, and the venue rule.

Second, the Bucks County Medical Society delegation to the Pennsylvania Medical Society House of Delegates meeting was actively engaged in shaping important resolutions such as physician contract mandates and the supervision of non-physicians.

Further, we are supporting our local physicians professionally by providing a multi- part series, “How to Sustain Your Practice in Today’s Turbulent Times.” The first program addressed E&M documentation guideline changes to help physicians optimize their time and revenue and policies to protect office practices.

Finally, the Society’s philanthropic arm is financially assisting our community. We have supported several local non-profit organizations which provide care for the underserved. This year’s recipients are the Ann Silverman Community Health Clinic, A Woman’s Place, Bucks County Health Improvement Partnership, Bucks County Opportunity Council, and Family Service Association of Bucks County. We have also started to build a scholarship fund for medical students from our county. This fund will require a near-doubling before scholarships will be able to be distributed. Please contact us to see how you can help make that happen.

It has been exciting to be a part of the Bucks County Medical Society’s engagement locally and at the state level this year. As always, all members are welcome to reach out to me or to any members of the board as we continue to find ways to support our local physicians. Please contact us at buckscms@pamedsoc.org.

Thank you for being a member of the Bucks County Medical Society!

Dan Latta, MD, FACS President, Bucks County Medical Society

Happy Holidays and all the best for the New Year ahead.

How to Select the Best Screening Test for Breast Cancer

David Levin, D.O., Radiologist in Bucks County

Patients at Average Risk

A patient at average risk should start with a mammogram, shown to reduce breast cancer deaths in women between ages 40 and 74. Deaths from breast cancer were steady for over 40 years prior to mammography’s introduction in the early 1990s; then declined by 38%, due to advances in treatment and early detection.

Technology has advanced the ability to detect breast cancer. The following tips, based on randomized controlled trials, observational studies, and American College of Radiology (ACR) expert analysis, aim to guide you.

Assess a patient’s risk

Patient history is key to their risk for breast cancer. Online risk models1 utilize additional factors. Certain patients may benefit from genetic testing.

Risk factors of particular concern for breast cancer

• Genetic predisposition, mutations (e.g., Ashkenazi Jewish descent)

• Strong family history of cancer

• Chest or mantle radiation therapy before age 30

• Personal history of lobular neoplasia or atypical ductal hyperplasia

Black and white women have similar incidences of breast cancer, but Black women are 19% more likely to die of the disease, likely due to tumor biology and other factors. All women, particularly Ashkenazi and Black, should be evaluated for risk by age 30.

Breast density is the biggest factor in cancer risk and is present in approximately 50% of U.S. women. Extremely dense breasts can increase a woman’s risk of cancer 4.7 fold. The greater amount of functional, or “dense,” breast tissue, the larger amount of tissue which can become cancer and, since cancers and functional breast tissue both appear white on mammography, the cancer is not readily visualized.

Digital breast tomosynthesis (DBT) or “3D mammography” uses low-dose radiation to identify small abnormalities that may be obscured by surrounding tissues. These may represent early, node-negative cancers with a more favorable prognosis, lower recall, and higher cancer detection rate. Traditional mammography provides better visualization of calcifications that can be a sign of cancer. Mammography risks include stress of recall for additional imaging and biopsy, and radiation exposure. ACR recommends yearly screening mammography for average risk women starting at age 40. When to stop is based on life expectancy, comorbidities, and if you would treat a cancer.

Patients at High Risk

A patient whose lifetime risk of breast cancer is at least 20% is considered at high risk and may benefit from yearly MRI that is over 90% sensitive for breast cancer. However, it is expensive, involves contrast injection, and will detect benign lesions that prompt biopsies.

Breast Ultrasound

ACR recommends ultrasound for women at elevated risk who cannot undergo MRI. Screening ultrasound can also be used in cases of increased breast density where this will pick up 3.2 cancers out of 1,000 women not otherwise detected; however, it also finds benign lesions that prompt biopsies. Directed ultrasound assesses lesions seen on mammography or felt on exam.

Regardless of risk or other studies, a patient should still get a mammogram every year. If you have questions, consult your radiologist who will be happy to help.

1 https://emedicine.medscape.com/article/1945957-overview#a10

This article is abridged from the original:

Abused Elders and Suicide: What do we know?

Tony Salvatore, MA, Director of Suicide Prevention at Montgomery County Emergency Service

Elder abuse and elder suicide are tragedies that increasingly claim members of our community. Often victims are frail and vulnerable. Suicide risk in abused and neglected elders is seldom assessed.

What is elder abuse?

Elder abuse is intentional harm to an elder by a trusted person. Caregiver neglect accounts for just over 20% of substantiated reports. Financial exploitation and physical, emotional, and sexual abuse make up the balance of cases. Elder abuse affects roughly one of every ten adults age sixty and over annually according to the National Council on Aging.

The Pennsylvania Department of Aging reports that there are over 6000 substantiated elder abuse investigations in the state annually. In fiscal year 2017/2018, there were 723 cases investigated in Bucks County. Elder abuse reporting is mandatory for caregivers. However, incidents involving family members may go unreported by victims because the abuser may be a spouse or child and their lifeline.

What is elder suicide?

The Pennsylvania Department of Health reports that in 2012-2016, statewide there were more than 1600 suicides in persons age 65 and above, well over 300 such deaths yearly. In 2016, in Bucks County, suicides occurred in 16 elder victims, or about one-fifth of total suicides.

Principal risk factors for elder suicide

• Physical and psychological harm

• Sexual assault

• Domestic conflict

• Financial loss

• Social isolation

• Psychological disorders

• Cognitive impairments

• Incapacitating medical illnesses

• Other impediments to independent living

How do they overlap?

Most elder abuse victims are women while most elder suicides involve men. Both elder abuse and suicide occur most frequently in those whose ability for selfcare and autonomy is impaired. Abuse and neglect among older men is significantly under-reported and elder suicides are undercounted. Risk factors for both conditions are similar.

Where is the research?

While in 1995 it was noted, “Additional research is needed to establish the strength of any relationship between abuse and self-destructive behaviors in late life,” studies remains sparse. Data suggest that factors preceding suicide include an abusive relationship, self-neglect, self-harm, depression, disability, and social isolation. 3, 4

What can we do?

Primary care clinicians who serve elderly patients are among those who can identify individuals at potential risk of elder abuse and suicide.

Cues to identify elders at risk of abuse and suicide

Who can help in Bucks County?

24/7 Reports:

Bucks County Area Agency on Aging (800-243-3767) Pennsylvania Protective Services Hotline (800-490-8505)

Crisis: Lenape Valley Foundation Crisis Center (800-499-7455) National Suicide Prevention Lifeline 988

Prevention: Bucks County Suicide Prevention Task Force (https:// namibuckspa.org/bucks-county-suicide-preventiontask-force/)

Prevent Suicide PA (www.preventsuicidepa.org)

1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107573/

2 https://doi.org/10.1027/0227-5910.16.3.104

3 https://www.cdc.gov/mmwr/volumes/67/ss/ss6702a1.htm?s_cid=ss6702a1_w

4 https://www.sciencedirect.com/science/article/abs/pii/S0149763421001640

Bucks CMS Leadership News

Bucks CMS recognizes with deep appreciation the outstanding leadership and dedication of our current president, Daniel Latta, MD, FACS and welcomes incoming president, Hannah Do, MD. The leadership transition will take place in January.

Congratulations to Rachael Sampson, MD

Recognized as one of PAMED’s Top Physicians Under 40 in 2022! Read about Dr. Sampson’s recognition here: https://tinyurl.com/32wh74a3

Do you know a talented early career physician who is already performing at a high level? Nominations for Pennsylvania’s Top Physicians Under 40 are due Jan. 15, 2023. Submit your nomination here: https://tinyurl.com/264edeyd

WELCOME

New Members:

Kristine Alcantara

John Allred, MD

Edmund Appiah-Kubi, MD Whitney Bachow, MD

Rishi Patel, MD

Lavanya Petchetti, MD

Roger Pomerantz, MD

Marion-Anna Protano, MD

PAMED’s Everyday Hero Award showcases talented physicians who probably don’t view themselves as heroes, but to patients and colleagues they are.

Do you know a Pennsylvania physician who goes above and beyond to help patients? Nominate a physician for the Everyday Hero Award here: https://pamedsoc.org/membership/awards/PAMED-EverydayHero-Award

Please renew your PAMED and Bucks CMS membership now. Thank you to members who have already renewed. Best wishes this holiday season and in the New Year.

Script.

William Barba III, MD Matthew Barnas, MD Emily Brown, MD Priya Dhanaraj, MD Eric Dichter, DO William Filmyer, MD Maria Golow, DO Igor Goykhman, DO Michael Kates, MD Mayurathan Kesavan, MD James Kilcoyne, DO Yan Kiriakov, DO Ruijing Liang, DO Erica Linden, MD

Ann McLaughlan, DO Jesse Olsen, MD Maria Palomata, MD Michael Parke, DO

Reinstated Members:

Joseph Alagna Jr., DO

Diana Bush, MD

Moshe Chasky, MD

Tina Chuong, DO Gerald Green, DO

Tina Joseph, DO Brian Kelly, DO Daria Kemp, MD

Channarayapatna Kishan, MD Kristin Krupa, MD

Jeffrey Rosett, MD

Dominic Ruocco, MD

Scott Sadel, MD

Inthushi Selvanayagam, MD

Thomas Shultz, MD

Anum Siddiqui, DO

Richard Siderits, MD

Monica Stanley, DO Javier Taboada, MD

Stephanie Taormina, MD

Anna Thomas, MD

Amanda Unger

Kalpana Vuppali, MD

Pamela Walker

Paul Weibel Jr., MD

Bonnie Wright, MD Kimberly Zawistoski, DO

Kelly Krupa, MD

Raghava Reddy Levaka Veera, MD

Pranay Patel, DO

Brian Resnick, DO

Katrina Shchupak, MD

Allen Terzian, MD

Jesse Victor, MD

Gregory Vincent, MD Patricia Zahner, MD

Daniel Latta, MD, FACS

Hannah Do, MD

Current Colon Cancer Screening

Jerome Burke, MD, FACG, Gastroenterologist in Bucks County

Colorectal Cancer (CRC) is lethal yet preventable. There are roughly 150,000 cases diagnosed yearly with 50,000 annual fatalities in the United States. The overall 5-year survival for CRC is 60% but when discovered at an early stage (Stage A or B) survival rate jumps to 90% making strategies that enable early detection vital. Physicians and public health officials are dismayed that upwards of 35% of the eligible population does not participate in CRC screening. The reasons for this are complex and include lack of access to testing for vulnerable and lowincome communities, embarrassment and fears about testing and lack of a systematic approach to screening by health care professionals. Nonetheless, there has been a gradual decrease in CRC morality in the United States over the past two decades at least partly attributable to robust screening protocols. In comparison, other developed countries have seen a rise in CRC.

The lifetime risk for CRC in the U.S is 5% overall, but men have a 20% higher incidence. African Americans have a 20% higher incidence than Caucasians and are more likely to be diagnosed at a more advanced stage. Approximately 30% of CRC have sessile serrated lesions which more often occur in the right colon, are sometimes flat and harder to detect on colonoscopy, and likely have a more aggressive biology.

Over 90% of CRC cases are diagnosed after age 40. Environmental factors impact risk. Increased risk is linked to smoking, moderate to heavy alcohol use, obesity, high intake of red meat, diets low in fiber, diabetes, low levels of physical activity, and low socioeconomic status. Factors associated with decreased incidence include high physical activity, diets rich in fresh fruits and vegetables, supplemental calcium, Vitamin D, folate, and aspirin.

Multiple options are available for screening. One might say that the best screening test is the “one that gets done.” The method chosen for CRC screening in the population is most often driven by patient preference,

advice by primary care clinicians, and cost. The American College of Gastroenterology advises that the most efficient and effective strategy for CRC screening is either FIT testing annually or colonoscopy every ten years. Since the best results for FIT testing are obtained when this is done annually, this requires diligent follow up by health care professionals and patients.

the procedure is performed by an examiner who scores high on quality metrics.

Advisory boards recommend screening the general population between ages 45-75 based on evidence from multiple studies. Barriers to screening persist. Insurance status is a primary determinant of which patients are screened and how. Patients with private health insurance have higher screening rates compared to those with government sponsored insurance. Those with no health insurance have the lowest screening rates. Many African Americans and individuals with low socio-economic status have higher CRC mortality because of disparities in health system access to screening, diagnosis, and treatment. Most screening in the U.S. occurs on an “opportunistic basis” which is arranged at the discretion of a primary care clinician or a request by patients to be screened.

Colonoscopy is the most sensitive and specific study in detecting CRC and premalignant polyps. It can be therapeutic when these lesions are detected and resected. Best outcomes occur when the procedure is performed by an examiner who scores high on quality metrics.

Organized screening processes boost CRC screening rates and include mail notification, email reminders, phone calls and utilization of EMR reminders. A study by Kaiser Permanente in Northern California with 4 million members demonstrated a rise in screening rates from 38% in 2000 to 82% in 2015 by utilizing these measures. The effects of the COVID19 pandemic on screening for CRC are yet to be elucidated but no doubt will be deleterious and will challenge physicians and patients going forward. While March is colon cancer awareness month, let us do our part as physicians to advance CRC screening throughout the calendar year.

Risk Class

High Risk

Screening Age Approach

First-degree relative with CRC Advanced adenoma Inflammatory bowel disease Genetic Syndrome

Age 40 or 10 years earlier than the diagnosis of the index case whichever is earlier

Colonoscopy Average Risk Absence of above factors Age 45-75+ (USPSTF) Endoscopy Imaging Stool based studies See below

Test method Advantages Disadvantages

Colonoscopy High sensitivity and specificity Diagnostic and therapeutic capability

Every 10 years High cost Extensive bowel preparation Time off work

Anesthesia Risk of complications Operator dependent Flexible sigmoidoscopy Limited bowel prep No sedation No time off work

Every 5 years Do with stool test Uncomfortable

Proximal colon not visualized Capsule endoscopy Noninvasive Good sensitivity Good specificity

CT Colonography Noninvasive Moderate cost Good sensitivity (except rightside or flat lesion)

Full bowel preparation Moderate cost Positive test requires colonoscopy

Every 5 years

Full bowel preparation Radiation Lower sensitivity Positive test requires colonoscopy Fecal Immunochemical Testing (FIT) 1 stool sample Accurate Low cost No preparation necessary

Must process within 24 hours Annual Guaiac Based Fecal Occult Blood Test (gFOBT)

Low cost Wide range sensitivity High specificity

Multi- Targeted Stool DNA Tests with FIT Higher sensitivity than FIT No bowel preparation Non-invasive

3 stool samples, successive days Limit diet and food for test

Every 3 years Lower specificity than FIT High cost

Advisory boards recommend screening the general population between ages 45-75 based on evidence from multiple studies. Barriers to screening persist. Insurance status is a primary determinant of which

This article was abridged and charts based on information in the full article: https://www.buckscms.org/coloncancerawareness2022.html

Colorectal cancer screening can prevent the development of cancer in the first place by employing colonoscopic polypectomy to short circuit the progression of precancerous lesions to invasive cancer.

Current Colon Cancer Screening

patients are screened and how. Patients with private health insurance have higher screening rates compared to those with government sponsored insurance. Those with no health insurance have the lowest screening rates. Many African Americans and individuals with low socio-economic status have higher CRC mortality because of disparities in health system access to screening, diagnosis, and treatment. Most screening in the U.S. occurs on an “opportunistic basis” which is arranged at the discretion of a primary care clinician or a request by patients to be screened.

Organized screening processes boost CRC screening rates and include mail notification, email reminders, phone calls and utilization of EMR reminders. A study by Kaiser Permanente in Northern California with 4 million members demonstrated a rise in screening rates from 38% in 2000 to 82% in 2015 by utilizing these measures. The effects of the COVID19 pandemic on screening for CRC are yet to be elucidated but no doubt will be deleterious and will challenge physicians and patients going forward. While March is colon cancer awareness month, let us do our part as physicians to advance CRC screening throughout the calendar year.

This article was abridged and charts based on information in the full article: https://www.buckscms.org/coloncancerawareness2022.html

Does the Nordic-European Initiative on Colorectal Cancer (NordICC) study1

Daniel Latta, MD, FACS, Colorectal Surgeon in Bucks County

Short answer is no.

This recent study enrolled more than 84,000 patients who had not previously had a screening colonoscopy, randomized to either receive or not receive an invitation to have a colonoscopy. The authors reported that colonoscopy was found to reduce the risk of colorectal cancer over a period of 10 years; however the reduction in risk of death from cancer was not statistically significant.

There are several limitations of this study including inadequate polyp detection rate and duration of follow up. Most importantly, only 42% of the patients invited to receive a colonoscopy completed their colonoscopy. In adjusted analysis, colonoscopy was estimated to reduce the incidence of colorectal cancer by 31% and the risk of colorectal cancer–related death by 50%. .

Major societies involved with colorectal cancer care, including the American Gastroenterological Association and American Society of Colon and Rectal Surgeons continue to support the role of screening colonoscopy to prevent, diagnose and treat colorectal cancer.

1https://www.nejm.org/doi/10.1056/NEJMoa2208375

Thank you to the Bucks County Medical Society Members who are PAMPAC Members in 2022 (as of December 3, 2022)

Commonwealth Club – $1000 and up John J. Pagan, MD, FACS

Capitol Club – $500 to $999

Judith E. Gallagher-Braun, MD

Marilyn J. Heine, MD, FACEP, FACP | Marion E. Mass, MD

Keystone Club – $300 to $499

Robert S. Mirsky, MD | Howard D. Rosenman, MD Mary B. Toporcer, MD

Sustainer Level – $200 to $299

Matthew Bohning, MD | Jessica A. Feldman, MD

John T. Gallagher, MD | Rachael M. Sampson, MD

Other Contributors – less than $200

Arvind R. Cavale, MD | Robert D. Hahn, MD

Bindu Kansupada, MD, MBA | Daniel R. Latta, MD, FACS David A. Levin, DO | David S. C. Pao, MD

call into question the benefit of screening colonoscopy?

#fixpriorauth: Headway Made, More to Do

Marilyn Heine, MD, Physician in Bucks County

Prior authorization, where insurance companies review and potentially deny medical services and pharmaceuticals prior to treatment, remains a principal frustration for patients and physicians. This utilization management policy is overused, costly, opaque, burdensome to physicians, and harmful to patients due to delays in care.

The Bucks County Medical Society, Pennsylvania Medical Society, and American Medical Association (AMA) actively advocate to reform prior authorization. These efforts are part of coalitions with specialty societies and patient advocacy groups. Goals are to remove barriers to care, decrease burdens for physicians, ensure timely patient care, and improve health outcomes.

AMA data compiled from annual surveys of more than 1,000 practicing physicians illustrate the negative impact of prior authorization policies. In the 2021 survey, 34% reported it led to a serious adverse event, such as hospitalization, disability, permanent bodily damage, or even death, for a patient in their care. 93% reported associated care delays. 82% said it can at least sometimes lead to patients abandoning treatments.

Prior Authorization (PA) and Patient Harm

(Source: AMA 2021 Survey)

34% of physicians report that PA has led to a serious adverse events for a patient in their care.

24% of physicians report that PA has led to a patient’s hospitalization.

18% of physicians report that PA has led to a lifethreatening event or required intervention to prevent permanent impairment or damage.

8% of physicians report that PA has led to a patient’s disability/permanent bodily damage, congenital anomaly/ birth defect or death.

In addition, research from the federal government demonstrates that prior authorization leads to delays in patient care and inappropriate denials of medically necessary services. 2, 3

2 https://oig.hhs.gov/oei/reports/oei-09-16-00410.pdf

3 https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf

Over 4 years ago, the AMA convened stakeholders including insurers who signed a Consensus Statement with meaningful reforms to prior authorization. Insurers have largely not kept to this commitment and legislative action is warranted.

Pennsylvania enacts prior authorization reform

Pennsylvania recently enacted reforms to address state-regulated health plans. This affects gatekeeper commercial insurance plans and Medicaid managed care organizations, including CHIP. The new law establishes uniform standards for prior authorization, medication-assisted treatment for opioid use disorders, and step therapy. These health plans will be required to have a portal and other measures to streamline the prior authorization process. They cannot require prior authorization for an emergency service. Read more about the new law here: https://tinyurl.com/4pp8b7v6

Federal advocacy to #fixpriorauth

Advocacy remains active at the federal level. In the 117th Congress, to streamline prior authorization processes in Medicare Advantage plans, the AMA and Federation including PAMED have been actively advocating for passage of the “Improving Seniors’ Timely Access to Care Act of 2022.” This legislation, as originally introduced, garnered more than 300 bipartisan House cosponsors and the support of approximately 500 physician, hospital, patient, and insurer organizations; it passed the House. We have urged the Senate to pass a widelysupported bipartisan companion bill.

Take action here: https://tinyurl.com/3ayacpwy

Also in Congress, the AMA and Federation support the “GOLD CARD Act” which would exempt from Medicare Advantage prior authorization requirements physicians who meet a certain approval rate. The AMA urges the Centers for Medicare and Medicaid Services to exercise the agency’s existing authority to protect care access for patients receiving government-related health benefits and reduce administrative burdens for physician practices.

Be sure to visit https://fixpriorauth.org/

Great

at Bucks Legislative Roundtable

Bucks CMS members and local legislators met at a virtual Legislative Roundtable October 7, 2022. This is an annual event that is well attended by both physicians and legislators. It is a wonderful opportunity for local legislators to hear “firsthand” from their physician constituents about issues that directly impact their patients. The dialogue helps build relationships. Legislators on the call appreciated the conversation and weighed in on a number of topics including prior authorization, mental health, and the medical liability venue issue. This is the kind of legislative advocacy that pays dividends down the road.