Round-up Magazine December 2014

To learn more visit www.mcmsonline.com

TREATMENT OF EBOLA THROUGH TELEMEDICINE:

EBOLA, MEDICAL SYSTEMS, & PUBLIC HEALTH POLICY:

Telemedicine can be an effective tool to prevent Ebola disease transmission, control spread of the disease, and facilitate access to timely and appropriate clinical care. Page 14

Working together, the medical and public health systems in Arizona can protect the public from Ebola. Clear communication and decisive actions based on CDC guidelines and scientific evidence must be the foundation for success. Page 22

round-up Volume 60 • Number 12 • December 2014

Providing news and information for the medical community since 1955.

Congratulations to Dr. James Pehoushek the winner of our photo cover contest, page 4.

PRESIDENT’S PAGE:

FEATURE ARTICLE:

PRACTICING MEDICINE:

Dr. Miriam Anand reflects on her 2014 Round-up editorials and her term as MCMS President as she looks forward to 2015 under the leadership of Ryan Stratford, MD, 2015 President. Page 8

According to a report published online by the journal Health Affairs and produced by the Centers for Medicare and Medicaid Services, the growth in U.S. health spending for 2013 is the lowest since 1960.

Mary Agnes Carey with Kaiser Health News breaks the report down and shares details of the money trail. Page 24

Being proactive about the process of prescribing controlled substances will help limit your practice’s susceptibility to prescription theft and/or forgery. In this month’s article, Jeremy Wale, JD, Risk Resource Advisor with ProAssurance, shares his thoughts on prescription theft and forgery with Round-up readers. Page 28

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round-up 8

14 22 24

28

december 2014

president’s page Trust. How did we lose it and how do we get it back? public health Treatment of Ebola in the digital age. public health Ebola and public health policy.

feature article Growth in the U.S. health spending in 2013 is lowest since 1960.

practicing medicine Rx theft and forgery: How it happens and what you can do about it.

In every issue Opinion ..............................................................................................................................................................................7 Patient Education Handout..............................................................................................................................................11 Healthcare Happenings....................................................................................................................................................20 Marketplace ....................................................................................................................................................................31

On the cover and the winner of the photo contest: (left to right) Eugene Probosco and James Pehoushek, MD, MPH. Mr. Probosco is a patient of Dr. Pehoushek.

Dr. Pehoushek is affiliated with Allergy & Dermatology Specialists. He is a graduate of the Uniformed Services University of the Health Sciences in Bethesda, MD; completed his internship at the Eisenhower Army Medical Center at Fort Gordon, GA; and his specialty training at Walter Reed Army Medical Center and Bethesda National Naval Medical Center. He received his masters degree in public health (MPH) from the University of California, Los Angeles.

He has been a member of the MCMS since 2004.

Thank you to everyone who submitted a photo for the cover contest! Runner-up submissions:

Dr. John Adan MCMS member since 2002 4 • Round-up • December 2014 • A monthly publication of the MCMS

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round-up:

providing news and information for physicians and the healthcare community since 1955 Round-up Staff

MCMS 2014 Officers

Editor Jay Conyers, PhD

President-Elect Ryan Stratford, MD

Editor-in-Chief Miriam K. Anand, MD Advertising, Design and Production Candice Scheibel Advertising

To obtain information on advertising in Round-up, contact MCMS.

phone: 602-252-2015 advertising@mcmsonline.com Postmaster

Send address changes to: Round-up, 326 E. Coronado Rd., Phoenix, AZ 85004 mcmsonline.com

facebook.com/MedicalSociety twitter.com/MedicalSociety

President Miriam K. Anand, MD

Vice President Elizabeth McConnell, MD Secretary Kelly Hsu, MD

Treasurer Mark R. Wallace, MD

Immediate Past-President Daniel Lieberman, MD Board of Censors

Nathan Laufer, MD, Chair Daniel Lieberman, MD

Michael R. Mills, MD, MPH Ryan Stratford, MD

Thomas E. McCauley, MD James R. Meador, Jr., MD Anthony T. Yeung, MD

linkedin/MaricopaCountyMedical Society

Board of Directors

Periodicals postage paid at Phoenix, Arizona.

Jennifer Hartmark-Hill, MD

Volume 60, No. 12, December 2014.

Round-up (USPS 020-150) is published 12 times per year by the Maricopa County Medical Society, 326 E. Coronado, Phoenix, AZ 85004.

To subscribe to Round-up Magazine please send a check for one-year subscription of $36 to Round-up Magazine, 326 E. Coronado Rd., Phoenix, AZ 85004 or visit mcmsonline.com/subscribe.

2012-2014

Tanja Gunsberger, DO Kelly Hsu, MD

Susan Whitely, MD 2013-2015

Adam M. Brodsky, MD John L. Couvaras, MD

Steven R. Kassman, MD

Robert J. Standerfer, MD 2014-2016

Lee Ann Kelley, MD Richard Manch, MD May Mohty, MD

Anita Murcko, MD

6 • Round-up • December 2014 • A monthly publication of the MCMS

published by the:

Round-up is a publication of the Maricopa County Medical Society (MCMS). Submissions, including advertisements, are welcome for review and approval by our editorial staff at roundup@mcmsonline.com.

All solicited and unsolicited written materials and photos submitted to Round-up will be treated as unconditionally and irrevocably assigned to and the property of MCMS and may be used at MCMS’ sole discretion for publication and copyright purposes and use in any publication, website or brochure. MCMS accepts no responsibility for the loss of or damage to material submitted, including photographs or artwork. Submissions will not be returned.

The opinions expressed in Round-up are those of the individual authors and not necessarily of MCMS. Round-up reserves the right to refuse certain submissions and advertising and is not liable for the authors’ or advertisers’ claims and/or errors. Roundup considers its sources reliable and verifies as much data as possible, but is not responsible for inaccuracies or content.

Readers rely on this information at their own risk and are advised to seek independent legal, financial or other independent advice regarding the content of any submission.

No part of this magazine may be reproduced or transmitted in any form or by any means without written permission by the publisher. All rights are reserved.

opinion

Letters to the Editor Dr. Anand,

I have been a member of MCMS since I came to Phoenix in 1970. I retired from active practice in 1998.

[Round-up Magazine] Volume 60, November 2014 is a dramatic and delightful improvement of its publication. I have been impressed and in agreement with Dr. [Miriam] Anandâ&#x20AC;&#x2122;s ideals and presentations since her election. The digital age and outpatient and office surgeries have diminished the interactions between physicians and physician communities. (Much as neighborhood communities have diminished.) Hail to MCMS and Dr. Anand!!

Jim Callison, MD

Dear Dr. Callison,

Thank you for your kind words. It is an unfortunate fact that physician collegiality, especially here in the Valley, is not what it once was and you accurately touch upon some of the reasons for this. As you mention, this seems to reflect changes in our community at large in recent decades. While there are no easy answers, the MCMS looks forward to sponsoring social events for current and prospective members in the coming year and perhaps this will be a step in the right direction. I am pleased that you enjoyed our November issue and thank our Executive Director and CEO, Jay Conyers, PhD, and Communications and Membership Director, Candice Scheibel, for working tirelessly to make Round-up a valuable publication for our members.

Sincerely, Miriam K. Anand, MD

Connect with your Society. Letters and electronic correspondence will become the property of Round-up, which assumess permission to publish and edit as necessary. Please refer to our usage statement on page 6 for more information. Email: mcms@mcmsonline.com â&#x20AC;˘ Call: 602-252-2015

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president’s page

TRUST. How did we lose it and how do we get it back?

By Miriam K. Anand, MD

A

s 2014 draws to a close, so too does my term as President of the Maricopa County Medical Society (MCMS). As predicted, 2014 was a year of change for medicine both on a national and local level and, since “nothing is as constant as change,” we can expect that things will not remain static for long.

As I have tried to emphasize through my editorials this year, physician unity is a necessary factor in seeing to it that changes are made for the better. Unfortunately, however, physicians are often painted out to be the bad guy and are perceived by some as being greedy and selfish. Our concerns about declining reimbursements are seen as coming from people who, “make too much money,” and are complaining about losing some of it. There is a stereotype that physicians have so much time on their hands, that they spend the bulk of their time golfing. As someone who doesn’t even know how to golf (despite growing up here), I find that interesting.

Miriam Anand, MD President Dr. Anand is an Allergy and Immunology specialist practicing in Tempe. She is the Society’s 120th President, and has been a MCMS member since 1998.

Allergy Associates & Asthma, Ltd. Tempe Office 1006 East Guadalupe Road Tempe, AZ 85283 Phone: 480.838.4296 Email: manand@mcmsonline.com

Last month [Round-up, November 2014] I gave some examples of how I fear that the changes imposed upon medicine are resulting in the declining quality of care. Since then, I only continue to learn of more experiences that would support this, including those outlined in the letter from Dr. Frank J. Fara published in the October edition of Round-up. I won’t outline each and every legislative change, insurance change, or change in who controls how medicine is practiced that have led us to where we are now, as I believe that most are familiar with them. Suffice it to say, most physicians are trying to practice in a system that has been forced upon us. This is not an excuse for not providing quality care, however, but just a statement on why it is becoming more difficult to do so. Some may argue that the lack of physician unity allowed this to happen and that we therefore share in the responsibility for the current state of medicine. Either way, most of the changes have not been physician-driven, yet we are the ones who are most likely to be concerned about what is in the best interest of our patients. I often wonder what the ratio of law or business students that choose their career path “to help people” is compared to medical students. It seems to me that most of us chose medicine to be able to make a positive difference in people’s lives, yet we seem to have less and less influence in being able to do this.

We are often still the ones perceived as the bad guy when we don’t have time to spend with a patient or are forced to look at our computer screen instead of the patient. Patients perceive these as examples of lack of caring on the part of the physician, not realizing that factors such as decreased reimbursement, bundling, and Meaningful Use are some of the real culprits. Our staff often takes the brunt

8 • Round-up • December 2014 • A monthly publication of the MCMS

president’s page of patient frustrations when trying to collect higher co-payments and deductibles despite the fact that the amount a patient owes is determined by the insurance companies, not physicians. Healthcare consumers, unaware of the costs of keeping up with the ever increasing bureaucracy of practicing medicine today, seem to have the impression that each dollar collected goes directly into the physician’s pocket. Furthermore, there are commercials and billboards inviting patients to sue us if they have experienced side effects from medications we prescribed or devices used in surgery that were later found to be defective.

“...We invite you to participate on a committee and also invite your suggestions for further ways in which we can better meet your needs. It is time for most of us to renew our MCMS membership. If you have not already done so, I urge you to renew yours and also to encourage colleagues who are not members to join.” – Miriam Anand, MD The media also does not help bolster the public’s impression of physicians. Earlier this year, a local news station ran stories every day for a week about “healthcare nightmares.”

Promotions for the series included the announcer saying something like, “When going to the doctor becomes a nightmare….” Interestingly, however, of the stories that they ran, the vast majority involved health insurance or billing “nightmares,” yet the tagline suggested that the bad experience had something to do with the physicians.

In the meantime, most patients are unaware of the origins of the changes in the healthcare system and many younger physicians and those in training do not have an appreciation for the outside influences on medicine. Unlike Dr. Fara, most patients would not know that a physical exam should be an integral part of most physician visits, especially when establishing care with a primary care physician. They would also not have the medical expertise to know when decisions are being made based on coverage or other factors rather than the specific medical issues at hand.

So what can be done to improve how the public views physicians? We need to start by re-establishing the fact that we are the best advocates for our patients and their care. Not

legislators. Not insurance companies. And not those who treat medicine as a business whose sole purpose is generating income. We also need to make the public aware of where the obstacles in their care are really coming from. While a unified physician voice is important, real positive change in our current healthcare system will likely not be seen until the American people wake up and realize that the changes occurring in medicine are not driven by those motivated by helping them and are not in their best interest. One wonders how far the pendulum will have to swing until the public sees what we have been seeing for years. Until that time, we must continue to strengthen our voice by participating in organizations such as ours, so that physician influence can play a strong role for positive change in the future. It would certainly be refreshing if changes could start occurring to assist us in providing hassle free quality care to our patients.

There have been some positive changes for the MCMS this year. During his first year as our Executive Director, Jay Conyers, PhD has made a number of improvements. Many of you have seen and have commented on the changes in Round-up over the past year. We also recently upgraded our website and have made some much needed renovations to the Society building. We look forward to holding membership and social events there in the future. Less glamorous, but still important, was the hard work by our by-laws committee to prepare by-laws that are up to date and more relevant. We also developed and implemented a Policy Committee to help us address issues that are important to our members and the community. There are other changes in the works that will allow us to move forward to be that strong, collective physician voice and to have an impact on improving the practice of medicine in our community.

We look forward to continuing to build upon these changes and to enhancing the work of all of our committees in the coming year. We invite you to participate on a committee and also invite your suggestions for further ways in which we can better meet your needs. It is time for most of us to renew our MCMS membership. If you have not already done so, I urge you to renew yours and also to encourage colleagues who are not members to join.

Thank you for allowing me to serve as your President in 2014. I look forward to further positive changes for our Society in 2015 and know that we will be in good hands under the leadership of Ryan Stratford, MD. ru

A monthly publication of the MCMS • December 2014 • Round-up • 9

Compliments of the:

Physician Referral Line p: 602-252-2844 w: mymcms.com/providersearch/ e: mcms@mcmsonline.com

Who is really pulling the strings in Medicine?

Why does it seem that my physician spends more time with the computer than with me?

Initially, it was thought that electronic health records would have a lot of advantages. They would allow physicians and other medical personnel faster access to patient records, without having to track down a paper chart. It was also thought that it would be easier to exchange information to the patient’s other physicians.

This may be true in large medical facilities or hospital groups that all have access to the same records, but this has not turned out to be the case for most physicians and practices outside of these facilities. It also takes longer for most physicians to enter the records into the computer than it did for them to keep paper notes. To add to the problem, the government requires physicians to keep electronic records in order to avoid decreased payments from Medicare. In order to meet the requirements, however, the government mandates that certain benchmarks be met and documented. This is called “Meaningful Use.” Some of these benchmarks may be important for improving care, but many are time consuming and distracting for the physician and don’t significantly increase the quality of care. Concern for meeting these benchmarks forces the physician to focus on the computer and takes attention away from the patient.

Why does my physician spend less time with me and seem so rushed?

Many of the changes that have resulted in today’s rushed visits started in the 1980’s and 1990’s. Medicare changed how payments to physicians were determined and managed care took a much stronger foothold.

Medicare and insurances determined what would be paid for physician visits and those payments decreased.

Costs to pay staff, buy supplies, rent space, and for utilities, however, have not decreased. Furthermore, insurances have continued to make it more and more difficult for physicians to be paid for their services. They also require more prior authorizations for care, which means

that the physician has to spend extra time justifying why he or she wants to perform a certain test or use a certain treatment. More employees need to be hired in order to keep up with all of the bureaucracy.

In the meantime, payment is lower for “cognitive services” than for procedures. “Cognitive services” refer to the mental processing of information about the patient’s symptoms, physical exam findings, test results, and other medical conditions to form a diagnosis and plan for treatment. Physicians in specialties that do not perform many procedures, such as primary care physicians, therefore get paid less. This is despite the fact that they often treat patients with complicated illnesses or conditions that should require more of their time to allow them to ensure that all the conditions are being adequately treated. Physicians are rarely paid for handling issues over the phone, reviewing test results, or filling out paperwork, all of which can be time consuming. Thus, the only way for them to keep up with decreased payments and increased costs is to see more patients. Since there are only so many hours in a day, they must spend less time with each patient.

Why are physicians complaining about cuts in payments? Don’t doctors make enough money?

Many people do not realize the expense required to become a physician. To become a physician, one must normally complete a 4 year degree or Bachelor’s degree.

The specific classes required are more rigorous than those required for most other degrees and the students must perform at the top of their class to even have a chance of being considered for medical school. Medical school itself requires another 4 years and the curriculum is very intense. While some may be able to hold a part time job during their college years, it is virtually impossible to have time to earn money during medical school.

The average debt for those who go to medical school is $167,000. Once graduating from medical school, how-

ever, most physicians must complete a minimum of 3 years of residency training before they complete the education required to practice unsupervised medicine, but many specialties require more. The current median salary for a resident is $50,000, but many work up to 80 hours a week. Most physicians, therefore, are at least 29 years old when they start earning higher salaries, but many are in their early 30’s. Compare this to 22 to 26 years old for most other careers. Even after training, most physicians still work more than 40 hours per week due to weekend shifts and night call.

As your co-payments and deductibles increase, you may be under the impression that those increased payments go directly into the physician’s pocket. First, if your physician owns all or part of his/her practice, money brought in must be divided for employee salaries, supplies, rent, utilities, and all of the other expenses that a business incurs. Physicians who are employed usually make a salary, although some may receive a bonus for meeting certain targets. The business or hospital that employs them also has expenses.

In some cases, they perform a much higher number of procedures, which brings in more total revenue for the hospitals. Some hospitals are “for-profit” facilities, and most private “non-profit” facilities perform quite well financially. The “non-profit” facilities have the added advantage of not being required to pay local property and federal income taxes.

Many hospital CEO’s make over a million dollars per year. For examples of payments to hospital CEO’s, visit: http://kaiserhealthnews.org/news/hospital-ceocompensation-chart/. CEO’s of health insurance companies make even more than that. To learn more, visit: http://www.publicintegrity.org/2014/06/09/14912/ skyrocketing-salaries-health-insurance-ceos and http://www.healthcare-now.org/health-insurance-ceopay-skyrockets-in-2013. These CEO’s make at least 10 times what the physician treating you makes.

Why aren’t physicians protesting the changes that negatively impact their ability to provide care?

Most physicians chose their profession because they wanted to make a positive difference in people’s lives.

They often speak to colleagues, friends and family members about their struggles. One area where physicians have admittedly failed is in coming together as a collective force to successfully fight the changes made by the government, legislators, insurance companies, the impact of malpractice lawsuits, and all of the other entities that have led medicine to where it is today.

Some may recall that insurances attempted to “gag” physicians from discussing the negative effects of insurance decisions on the healthcare to their patients in the 1990’s. Many of those controlling the business of healthcare have money and influence to lobby legislators and influence information released by the media.

Physicians are spending the bulk of their time trying to care for patients and, as discussed above, this is becoming more difficult and time consuming. Many physicians feel overworked and burn out is not uncommon.

They have resigned themselves to working in this current system or are looking at career options outside of patient care. Older physicians are opting to retire earlier than they might have otherwise. For many physicians, it can feel like David versus Goliath trying to fight all of these political entities and their PR machines.

Unfortunately, all of the above mentioned factors are having an impact on your healthcare, but further changes with potential negative impacts continue to be proposed. (For a recent example, see www.publicintegrity.org/2014/10/27/16043/health-insurers-presshigh-deductible-low-benefit-policies.)

The concern is that, as things continue to decline, fewer of the best and brightest will continue to choose a career in medicine. Newer physicians are being trained under the current system and, as a result, may have a different view towards patient care. Some may say that physicians don’t have it any harder than those who pursue other careers, but it is important to remember that these are the people who will be taking care of you and your loved ones when you get sick.

So what can I do?

One reason that so many changes have occurred to lead us to where we are today is that the American public is unaware of the forces behind these changes. It is not entirely their fault. A lot of money is spent by those who are the true profiteers in healthcare to create PR campaigns to mislead the public. Until the public becomes aware and informed and speaks out, this will only continue. It is concerning to think about how much worse things could get before the majority of the public is aware. Will it be too late by then? What you can do is inform yourself about the issues raised here and encourage your friends and family to do the same. Then, speak out. Contact your legislators. Spread the word.

Do whatever needs to be done so that our healthcare system can change for the better.

maricopa county medical school facts

Midwestern University

UA School of Medicine – Phx

A.T. Still University

• Midwestern University offers 14 graduate-level healthcare degree programs, and currently serves 3,158 students. As of 2014, Midwestern University has graduated 7,147 healthcare professionals. More than 2,800 MWU alumni live and practice in Arizona.

• The UA College of Medicine – Phoenix is a full, four-year program based in downtown Phoenix focused on training individuals to become exemplary physicians, scientists and leaders.

• A.T. Still University (ATSU), the nation’s first college of osteopathic medicine, offers 23 graduate-level programs in healthcare fields at campuses in Kirksville, Mo., and Mesa, Ariz., and online.

• The College proudly incorporates innovation in the curriculum, preparing students to be physicians for tomorrow, utilizing technology, simulation and advances in medicine. The College is a separately accredited medical school.

• ATSU is home to more than 700 employees and an average annual enrollment of 3,100 students from 35 countries.

• The University’s Glendale Campus is the home to Arizona’s largest medical and pharmacy schools, as well as the state’s only optometry and podiatry schools.

• The University opened Arizona’s only four-year veterinary college in August 2014 with an investment of more than $180 million.

• Midwestern University operates four community healthcare clinics: the Dental Institute, Eye Institute, Multispecialty Clinic, and the Companion Animal Clinic at the Animal Health Institute.

• The Midwestern University Clinics serve more than 20,000 patients annually.

• Midwestern students and employees provide nearly 10,000 hours of community service annually.

• The College has more than 75 campus faculty and more than 800 community faculty.

• The Health Sciences Education Building built in 2012 is a state-of-the-art, 268,000 square-foot, six story facility with lecture halls, a simulation center, clinical education suites, an anatomy lab, offices and various flexible classrooms.

• The College offers dualdegree programs including a MD/MPH (Masters in Public Health) and MD/MBA (Masters in Business Administration).

• ATSU consists of two colleges and four schools on two campuses and online including the Kirksville College of Osteopathic Medicine; Arizona School of Health Sciences; College of Graduate Health Studies; Arizona School of Dentistry & Oral Health; School of Osteopathic Medicine in Arizona; and Missouri School of Dentistry & Oral Health.

• Dedicated to preparing students with a commitment to continue its osteopathic heritage and focus on whole person healthcare, students, faculty and staff participate in numerous international mission trips and provide thousands of hours of community service to underserved areas annually.

A monthly publication of the MCMS • December 2014 • Round-up • 13

public health

Treatment of Ebola in the Digital Age

By Ana Maria Lopez, MD, MPH, FACP

The boy's eyes are captivated by the voice of the woman in the white starched coat. She seems to be speaking directly to them from the television screen.

His mother's face relaxes for the first time in weeks as she holds him and repeats in a soft voice as if to convince herself, "The quarantine is over."

Although not a current reality, medicine has entered the digital age, and this scene may be tomorrow’s reality.

Ana Maria Lopez, MD Professor of Medicine and Pathology, Medical Director, Arizona Telemedicine Program, University of Arizona Cancer Center Dr. Lopez received her medical education from Jefferson Medical College of Thomas Jefferson University in Philadelphia. She completed her residency in internal medicine and fellowships in general internal medicine and medical oncology at the University of Arizona.

She also holds a master’s degree in public health with a focus on health administration and policy from the Mel and Enid Zuckerman College of Public Health at the University of Arizona.

Dr. Lopez joined the faculty of the University of Arizona College of Medicine upon completion of her training and earned tenure in 2009.

She can be reached by email to: alopez@uacc.arizona.edu.

Telecommunication technologies impact almost all medical specialties with tools ranging from “full-service” telemedicine systems that allow a nearcomplete physical exam to be conducted at a distance, to tele-home health units, to self-monitoring devices partnered with mobile technologies. Digital tools may serve as critical missing puzzle pieces towards the primary goal of Ebola preparedness efforts: control of disease transmission.

The Disease and Transmission

Ebola is a disease transmitted through close contact. Those at greatest risk for disease transmission are friends, families, and healthcare workers. Keys to control of disease transmission are: early identification and monitoring of contacts, and early identification and treatment of those with the disease.

There are many ways digital tools could impact the process of diagnosing and treating a disease like Ebola. One example would be an Ebola hotline to serve as the point of entry for care.

Triaging through an Ebola Hotline

A single national Ebola hotline number could connect an at-risk patient to a trained Ebola screener who can assess the patient’s likelihood of exposure, clinical acuity, and need for care. The hotline number could produce an audio or audio/video connection depending on how the at-risk patient chooses to access the service. A screener would then follow an evidence-based decisiontree to conduct the assessment. The screening process limits exposures while facilitating care for the person potentially exposed to Ebola.

14 • Round-up • December 2014 • A monthly publication of the MCMS

public health Triage outcomes would include:

• No probability of exposure: triage to timely education regarding Ebola risk exposure immediately after contact with the screener.

• Low probability of exposure: triage to required follow-up after public health assessments of the possible contact.

• High probability of exposure without symptoms, with internet access, and with access to an online communication device: triage to virtual follow-up — patient receives a link to a secure video connection through which, at least, daily video nurse assessments including temperature monitoring take place.

Ongoing public health assessment to confirm the exposure.

• High probability of exposure without symptoms, with internet access, and without access to an online communication device: triage to virtual

follow-up—patient receives an internet enabled tablet for the video nurse assessment and a Bluetooth enabled digital thermometer for temperature monitoring via a commercial same-day mailing service. Ongoing public health assessment to confirm the exposure.

Caring for High Risk Patients Remotely

All patients with a high probability of exposure to the virus and who are without symptoms would receive a Bluetooth enabled digital thermometer for temperature monitoring via a commercial same-day mailing service. The uniformity of the Bluetooth enabled digital thermometer is intended to assure accurate temperature assessments.

These types of virtual nurse-based assessments in accord with best practice guidelines, would allow the patient to stay in her/his home community and environment while receiving appropriate surveillance for early intervention and minimizing community risk.

A monthly publication of the MCMS • December 2014 • Round-up • 15

public health • Ceiling cameras controlled by both the local and the distant site.

“Telecommunication technologies impact almost all medical specialties with tools ranging from “full-service” telemedicine systems that allow a near-complete physical exam to be conducted at a distance, to tele-home health units, to self-monitoring devices partnered with mobile technologies.” — Ana Maria Lopez, MD, MPH

Patients with a high probability of exposure or known exposure with acute symptoms of Ebola, i.e. fever, nausea, vomiting and dehydration, need urgent supportive and therapeutic care that minimizes exposure to the virus.

ambulance staffed by trained personnel who are equipped with the appropriate safeguards to minimize risk. The staff could also be virtually connected to Ebola treatment experts en route to the treatment center.

Once identified as an individual who needs clinical care, safe transfer to the treatment center could take place via a fully interactive video-enabled

At the designated treatment center, patient rooms would be set up along the e-ICU model with the goal of facilitating care while minimizing risk. Rooms would be equipped with:

Safe Transfers via Video Enabled Ambulance

Minimizing Risk in Patient Rooms

• Telemedicine physical exam attachments.

• Bidirectional voice activated microphones.

• Wearable technologies that facilitate continuous vital sign monitoring.

• Seamless access to the patient’s electronic record including laboratory and radiographic findings.

Akin to the e-ICU model, the patient’s care may be supported virtually as feasible. Centralized experts could provide 24-hour regional care for Ebola by means of distance monitoring tools, centrally controlled high-definition digital cameras, and electronic attachments that allow for physical exam assessments.

These same telecommunications tools could be utilized to keep the patient connected to her/his family and friends during the treatment process, thus reducing the sense of isolation and depression.

Managing Ebola Care with Telemedicine

Maximizing the use of digital tools in the care of patients with Ebola exposure or infection may enable patients to stay closer to home and minimize the risk of disease transmission brought on by need to travel for care. Telemedicine may also minimize health professional exposure by delivering care virtually.

Telemedicine can be an effective tool to prevent Ebola disease transmission, control spread of the disease, and facilitate access to timely and appropriate clinical care. ru

16 • Round-up • December 2014 • A monthly publication of the MCMS

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public health facts Did You Know?....

There are approximately 2,800 local health departments in the United States serving a diverse assortment of populations ranging from less than 1,000 residents in some rural jurisdictions to around eight million people, as in the case of the New York City Department of Health.1 Local Health Departments (LHD) are structured differently in each state and may be centralized, decentralized or have a mixed function. Therefore, the level of responsibility and services provided by LHDs varies dramatically, and, correspondingly, the way resources are determined and allocated differs significantly.

A 2008 study found that median local public health spending was $29.57 per capita in 2005, while funding ranged from an average of $8 per person in the lowest 20 percent of communities to nearly $102 per person in the top 20 percent of communities.2 A July 2011 study in Health Affairs found that increased spending by local public health departments can save lives currently lost to preventable illnesses.3 Excerpts from: Investing in America’s Health: 2014 — A State-by-State Look at Public Health Funding and Key Health Facts; May 2014; Jeffrey Levi, PhD, Executive Director, Trust for America’s Health, and Professor of Health Policy Milken Institute School of Public Health at the George Washington University; Laura M. Segal, MA, Director of Public Affairs, Trust for America’s Health; and Rebecca St. Laurent, JD, Health Policy Research Manager, Trust for America’s Health Source:

1. Meyer J. and Weiselberg L. “County and City Health Departments: The Need for Sustainable Funding and the Potential Effect of Healthcare Reform on their Operations.” Health Management Associates, A Report for the Robert Wood Johnson Foundation and the National Association of County & City Health Officials. December 2009.

2. Mays GP and Smith SA. “Geographic Variation in Public Health Spending,” 2009

3. “Public Health Infrastructure – A Status Report” (Atlanta, Georgia: Centers for Disease Control and Prevention, 2001);

Key Health Facts U.S. Total

State with Highest/Worst

State with Lowest/Best

15.4%

Texas (24.6%)

Massachusetts (4.1%)

AIDS Cumulative Cases Aged 13 and Older (2011 Yr. End)

1,146,271

New York (202,741)

North Dakota (184)

Alzheimer's Estimated Cases among 65+ (2025)

6,479,700

California (660,000)

Alaska (7,700)

13.5%

Hawaii (17.6%)

Tennessee (9.3%)

1,660,290

California (171,330)

456.7

D.C. (1,106.1)

ADULT HEATLH INDICATORS % Uninsured, All Ages (2013)

% Asthma Prevalence (2010) Cancer Estimated New Cases - (2013) Chlamydia Rates per 100,000 Population (2012)

Wyoming (2,700) New Hampshire (233.0)

Diabetes, % Adults (2012)

N/A

West Virginia (13.0%)

Alaska (7.0%)

Fruits and Vegetables intake, % who consume fruit and vegetables 5+ times daily (2011)

N/A

West Virginia (7.9%)

D.C. (25.6%)

2,318

California (364)

AK, D.C., HI, ME, WV (0)

Hypertension, % of Adults (2011)

N/A

Alabama (40.0%)

Utah (22.9%)

Obesity, % Adults (2012)

N/A

Louisiana (34.7%)

Colorado (20.5%)

Physical Inactivity, % Adults (2012)

N/A

Arkansas (31.5%)

Oregon (16.3%)

% Pneumococcal Vaccination Rates 65 and Over (2012)

68.8%

New Jersey (61.6%)

Oregon (76.2%)

% Seasonal Flu Vaccination Rates 65 and Over (2012)

60.1%

Nevada (50.5%)

Syphilis Rates per 100,000 Population (2012) % Tobacco Use – Current Smokers (2012)

5.0 19.6%

Tuberculosis Number of Cases (2012)

9,945

Human West Nile Virus Cases (as of 12/03/13)

Iowa (70%)

D.C. (26.7) Montana (0.2) Kentucky (28.3%) Utah (10.7%) California (2,191)

Wyoming (3)

CHILD HEALTH INDICATORS % Uninsured,under 18 (2012) AIDS Cumulative Cases Under Age 13 (2011 Yr End)

8.9% 9,521

Nevada (18.3%) New York (2,457)

D.C. (2.1%) Wyoming (2)

% Asthma - High School Students (2011)

N/A

Maryland (28.7%)

Iowa (16.0%)

Fruit Indicator – % High School Students (2011)

N/A

Kentucky (23.0%)

New York (36.8%)

High School Dropout Rate - % of 9th- to 12th-grader who dropped out of public schools (2009-10)

3.4%

Arizona (7.8%)

New Hampshire (1.2%)

Immunization Gap, % of Children Aged 19-35 Months Without All Immunizations (2012)

31.6%

Alaska (40.5%)

Hawaii (19.8%)

6.2

Mississippi (9.7)

Alaska (3.8)

% Low Birthweight Babies (2012 Preliminary Data)

8.0%

Mississippi (11.6%)

Alaska (5.6%)

Obesity, % High School Students (2011)

N/A

Obesity, % of 10 to 17 Year Olds (2011)

N/A

Infant Mortality – Per 1,000 Live Births (2010 Final Data)

Pre-Term Births % of live births (2012 Preliminary Data) Tobacco: % Current Smokers High School Students (2011) % of High School Students who consume recommended levels of vegetables (2011)

Alabama (17.0%) Colorado (7.3%) Mississippi Oregon (9.9%) (21.7%)

11.5%

Mississippi (17.1%)

Vermont (8.7%)

N/A

Kentucky (24.1%)

Utah (5.9%)

N/A

Indiana (9.0%)

West Virginia (18.7%)

Source: The Centers for Disease Control and Prevention

A monthly publication of the MCMS • December 2014 • Round-up • 19

healthcare happenings

Fall Prevention Outreach Courses

Live CME Activity — Human Trafficking and Its Health Consequences A.T. Still University (ATSU) is gearing up for the annual

“Still Standing Fall Prevention Outreach” winter series. The eight-week courses are scheduled to start January 2015.

According to the Centers for Disease Control and Prevention, falls are the leading cause of both fatal and nonfatal injuries among older adults. It is without doubt that falls in the elder population are a pressing public health concern in our community. According to the Arizona Department of Heath Services, Arizona continues to have one of the highest fatal fall injury rates in the country for both men and women.

Free of charge and open to the public, this is a community health education program aimed at helping elders prevent falls and address their fear of falling. Since the program’s inception in 2008, more than 2,000 Arizonans have participated. Students from a variety of ATSU healthcare disciplines will be reaching out to approximately 20 sites Valley-wide. Interested participants should call the site location nearest them. Site details may be accessed by visiting www.atsu.edu/fallprevention.

For additional information please contact Elton Bordenave at ebordenave@atsu.edu. ru

Thursday, January 29, 2015 • 5-6 pm

Mercy Gilbert Medical Office Building McAuley Conference Room, 3420 South Mercy Rd. Gilbert, AZ 85297

Presented by Gloria Halverson, MD, Adjunct Professor, Medical College of Wisconsin, this one-hour CME lecture focuses on the topic of human trafficking and its consequences. At the conclusion of this presentation, participants will be able to: identify risk factors for human trafficking; recognize the types of physical symptoms common to trafficked victims; and, describe mental health issues that are common to this population.

There is no fee for the course and registration is required.

For more information and to register visit https://www.dignityhealth.org/stjosephs/classes-and-events/class-registration.

St. Joseph’s Hospital and Medical Center (SJHMC) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. St. Joseph’s Hospital and Medical Center designates this live activity for a maximum of 1 AMA PRA Category 1 Credit.™ Physicians should only claim credit commensurate with the extent of their participation in the activity. ru

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20 • Round-up • December 2014 • A monthly publication of the MCMS

Do you know of any Healthcare Happenings?

Share the information with Round-up readers.

Email mcms@mcmsonline.com.

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public health

Ebola and Public Policy

By John Middaugh, MD

M

edical and public health policies need to be based on scientific evidence. As experience provides new evidence, policies can be revised to make the most efficient use of resources. Ebola outbreaks have been known for over 40 years, and a great amount of knowledge exists about their control and treatment. Ultimately, the outbreak will need to be controlled in Africa. More cases of Ebola will occur in the U.S. and many other countries around the world. But, resource-rich countries will be able to prevent an outbreak although some limited transmission is to be expected.

John Middaugh, MD Dr. Middaugh is a Public Health Consultant and retired Epidemiologist. His previous positions include Director, Division of Community Health and Chief Health Officer for the Southern Nevada Health District.

He joined MCMS upon re-location to Arizona in 2014.

He can be reached at jpmidd@cox.net.

Persons who fall ill with Ebola become very sick. Their symptoms are not trivial and are not likely to be able to be hidden or ignored. Among the most profound symptoms are projectile vomiting and diarrhea. When people first develop symptoms, usually fever and malaise, they are not infectious to others.

Prior to the onset of symptoms of illness, they are not able to transmit the virus to anyone else.

The reason that healthcare workers have been among those most frequently infected is that they are caring for very sick persons who at the end of their lives have massive viremia. The infectious dose of Ebola virus is very small.

During the last several days of illness prior to death, the patient develops a massive viral load, making them highly contagious. However, with meticulous attention to hygiene and use of Personal Protective Equipment (PPE), healthcare providers can avoid becoming infected.

All healthcare workers caring for patients who have Ebola disease must be trained in use of PPE. Experience has shown that at least two people need to be present to insure that PPE are worn properly and taken off properly. Active, hands-on, and real-time training is critical. Healthcare facilities that anticipate needing to provide treatment for Ebola patients should consider developing Ebola treatment teams so as to limit the number of healthcare workers who have direct patient contact. These teams can work together to assure the highest standard of use of PPE and hygiene and disinfectants.

The Centers for Disease Control and Prevention (CDC) has recently issued updated guidelines for assessing risk of persons who might have Ebola (October 27, 2014). Healthcare providers, especially those in emergency rooms and urgent care centers, who might be the first persons to provide care to a patient need to be familiar with these risk categories. They can quickly establish if the

22 • Round-up • December 2014 • A monthly publication of the MCMS

public health

â&#x20AC;&#x153;...Let us make sure we remember the past and use our experience to now respond to the Ebola outbreak. Let us be certain to base our policies and actions on science and proven public health and medical strategies that have worked to control Ebola in Africa in the past and will be effective in doing so here in the United States now.â&#x20AC;? â&#x20AC;&#x201D; John Middaugh, MD

patient falls into a high risk or some risk category and then act accordingly.

All others provide little to no risk of having Ebola disease or being infectious â&#x20AC;&#x201C; that is, able to transmit the virus to others.

During the 1980â&#x20AC;&#x2122;s the United States and the world was confronted with a horrifying disease, AIDS. Many jurisdictions reacted sensibly with compassion and science-based policies and treatments. But, regrettably, there were others at a national, state, and local level that reacted with fear, prejudice, and hostility. Let us make sure we remember the past and use our experience to now respond to the Ebola outbreak. Let us be certain to base our policies and actions on science and proven public health and medical strategies that have worked to control Ebola in Africa in the past and will be effective in doing so here in the United States now. Let us also learn from our recent mistakes in balancing use of isolation and quarantine police powers.

The decision to employ public health powers to isolate and/or quarantine must be grounded in the best science.Depriving freedom and stigmatizing a person or persons is a grave decision.

Public health authorities should do so only as a last resort, and use provisions that are the least restrictive while protecting the public health.

Once a decision to isolate or quarantine is made, the person(s) who are subject to the orders have due process rights to have their case presented to the courts so that there is an independent entity to weigh the strength of the evidence and balance of individual rights and freedom compared to protecting the public health. It is noteworthy that although New Jersey Statutes require due process and such protections, they were ignored recently when the governor quarantined a public health nurse.

Subsequently, the nurse was released from the New Jersey quarantine order and travelled to Maine. Maine public health authorities issued a quarantine order and the nurse challenged the order in court. The Maine judge weighed arguments from the nurse and the Maine public health authorities and ruled that the evidence did not support the quarantine order. He released the

nurse from quarantine. The nurse was not infected, she did not transmit the virus to anyone, and she remained healthy.

All public health authorities should review their statutes and regulations so they have clear knowledge and explicit procedures to employ isolation and quarantine, if needed. They should identify their appropriate colleagues who will be participants as members of the action team, including their legal counsel (attorney general or lead counsel), law enforcement, first responders, public health laboratory, and the medical treatment and evaluation team.

Public health authorities should also develop an Ebola response team that is trained in use of PPE and how to assess a possible case and identify contacts who might have been exposed, using the most recent CDC guidelines.

The CDC has warned that the efforts to control the outbreak of Ebola in Africa will need to be sustained for a long period. No easy answer has emerged. Working together, the medical and public health systems in Arizona and the United States can protect the public from Ebola. Clear communication and decisive actions based on CDC guidelines and scientific evidence must be the foundation for success. ru

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A monthly publication of the MCMS â&#x20AC;˘ December 2014 â&#x20AC;˘ Round-up â&#x20AC;˘ 23

feature article

Growth In U.S. Health Spending In 2013 Is Lowest Since 1960

A

By Mary Agnes Carey, Kaiser Health News ccording to the Centers for Medicare and Medicaid Services (CMS), national health spending grew 3.6 percent in 2013, the lowest annual increase since CMS began tracking the statistic in 1960.

Spending slowed for private health insurance, Medicare, hospitals, physicians and clinical services and out-of-pocket spending by consumers. However, it accelerated for Medicaid and for prescription drugs, according to the report1, published online by the journal Health Affairs.

Mary Agnes Carey Mary Agnes Carey is a senior correspondent for Kaiser Health News. She has covered health reform and federal health policy for more than 15 years as an editor at CQ HealthBeat, as Capitol Hill Bureau Chief for Congressional Quarterly and at Dow Jones Newswires.

A frequent radio and television commentator, she’s been featured on the PBS NewsHour and on NPR affiliates nationwide, Ms. Carey has a thorough understanding of both the policy and politics of health reform. She worked for newspapers in Connecticut and Pennsylvania, and has a master's degree in journalism from Columbia University.

Contact her at maryagnesc@kff.org or @MaryAgnesCarey Reprinted with permission from Kaiser Health News (KHN). KHN is a nonprofit national health policy news service.

Healthcare spending has grown at historically low rates for the past five years, which is consistent with declines generally seen during economic downturns, such as the Great Recession that crippled the U.S. economy at the end of 2007. Looking ahead, “the key question is whether health spending growth will accelerate once economic conditions improve significantly; historical evidence suggest that it will,” noted the authors, who are from the CMS Office of the Actuary.

They also pointed out, however, that in the near term, the health sector will, “undergo major changes that will have a substantial impact” on consumers, providers, insurers and sponsors of healthcare. These are the result of the health law’s creation of online marketplaces, its expansion of Medicaid, a shared federal-state healthcare program for the poor and disabled, and restraints the law made to the Medicare program, the analysts found.

“The balance of these and many other factors over the next few years will determine how the historically low health spending growth from 2009 to 2013 is viewed: as the temporary aftermath of the great recession or the beginning of a new era,” the authors wrote.

The study found that healthcare spending rose to $2.9 trillion, or $9,255 per person, in 2013. As a share of gross domestic product, healthcare remained at 17.4 percent, the same share since 2009, the CMS researchers found.

The 3.6 percent spending growth for 2013 tracks a CMS estimate from September2 and is 0.5 percentage point lower than 2012.

Spending on Medicare grew 3.4 percent in 2013, down from the 4 percent growth in 2012. The difference was due mostly to slower growth in enrollment and spending changes included in the healthcare law, including reductions in federal payments to the private Medicare Advantage plans that

24 • Round-up • December 2014 • A monthly publication of the MCMS

feature article offer an alternative to traditional Medicare. The automatic two percent federal budget payment cuts, known as sequestration, also played a role in reducing Medicare spending, which was nearly $586 billion in 2013. The program accounted for 20 percent of national health spending, according to the report. Fee-for-service expenditures, which account for 72 percent of total Medicare spending, were up 1.7 percent in 2013. Medicare Advantage spending increased 7.8

percent in 2013, a slower growth rate that the 10.6 percent increase in 2012.

The growth in Medicare per-enrollee spending was relatively flat, increasing 0.2 percent after a growth rate of less than 0.1 percent in 2012. The authors credited younger and healthier baby boomers entering the program.

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A monthly publication of the MCMS • December 2014 • Round-up • 25

feature article

Medicaid spending increased 6.1 percent in 2013, following growth rates of 2.5 and 4 percent, respectively, in 2011 and 2012. A variety of factors, including increases in hospital care — which accounts for 36 percent of Medicaid spending — contributed to the cost increase. The federal government and state and local governments spent $449.4 billion in 2013 on Medicaid, accounting for 15 percent of total national health expenditures.

Medicaid enrollment grew 2.7 percent during that time frame, the first acceleration since 2009. Some of the 2013 increase was due to new beneficiaries who enrolled as part of the health law’s provision that allowed states to expand their Medicaid programs ahead of the 2014 expansion. Other key takeaways from the report include: • Nearly 190 million people – or 60 percent of the population – were covered by private health insurance in 2013. Premiums grew 2.8 percent, compared to an increase of 4 percent in 2012. Low overall enrollment growth, greater usage of high deductible plans and other benefit design changes and the health law’s medical loss ratio and rate review provisions contributed to the decline, CMS found. Private health insurance enrollment increased 0.7 percent last year, the third straight year of growth.

• Consumer out-of-pocket spending, including co-payments and deductibles or payments for services not covered by a consumer’s health insurance, was $339.4 billion in 2013, or 12 percent of national health expenditures. The 2013 growth was down from the 3.6 percent growth in both 2011 and 2012.

• Spending for physician and clinical services grew 3.8 percent in 2013 to $586.7 billion, a slow down from 2012 when spending grew 4.5 percent. Expenditures for hospital care increased 4.3 percent in 2013, slower than the 5.7 percent rate of growth in 2012. Total spending growth for retail prescription drugs rose 2.5 percent last year, compared to 0.5 percent in 2012.

Drug spending growth increased in 2013 for several reasons, among them higher prices for brand-name and specialty drugs. ru Sources:

1. http://content.healthaffairs.org/content/early/2014/11/25/ hlthaff.2014.1107; 2. http://kaiserhealthnews.org/news/health-costs-inflation-cms-report/

26 • Round-up • December 2014 • A monthly publication of the MCMS

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practicing medicine

Rx Theft and Forgery: How It Happens and What You Can do About It

By Jeremy A. Wale, JD

P

rescription medication abuse is rampant throughout the United States.

According to the Centers for Disease Control and Prevention (CDC), 16,500 people died in 2010 from overdoses tied to common narcotic pain relievers1. In 2009, 15,500 people died from opioid painkiller overdoses, more than deaths from heroin and cocaine combined2. According to the CDC, approximately 1.4 million ED visits in 2011 were a result of pharmaceuticals misuse and/or abuse3.

Who is stealing prescription drugs?

Jeremy A. Wale, JD ProAssurance Risk Resource Advisor Mr. Wale is a licensed attorney in Michigan where he works as a Risk Resource advisor for ProAssurance. He has authored numerous articles about mitigating medical professional liability risk. He also conducts loss prevention seminars to educate physicians about new and emerging risks.

Copyright © 2014 ProAssurance Corporation This article is not intended to provide legal advice, and no attempt is made to suggest more or less appropriate medical conduct. ProAssurance is a national provider of medical professional liability insurance and risk resource services. For more information about the company, visit www.ProAssurance.com.

Pharmacists, pharmacy techs, nurses, receptionists, doctors, patients, and even police officers have been caught stealing or forging prescriptions, stealing prescription pads, or stealing prescription medications. It can happen anywhere, by anyone.

How does this affect you?

Prescription theft or forgery by an employee in your practice may have legal and ethical ramifications for all professionals employed by the practice.

If the practice fails to take proper precautions to prevent these actions, an injured person may attempt to sue for negligence. If you have a medical practitioner practicing medicine under the influence of narcotics, there are myriad negative ramifications affecting patient care, patient safety, or staff safety. You may also discover recordkeeping errors or inaccurate medical records.

A healthcare provider also may encounter issues with the federal Drug Enforcement Administration (DEA) if there is suspected drug diversion going on in the practice. A DEA investigation could result in suspension or even revocation of a healthcare provider’s DEA license.

Prescription theft and/or forgery could lead to loss in business, unhappy staff, increased medical errors, increased malpractice exposure, and more challenging defenses of potential malpractice claims.

What can you do?

Electronically prescribing medications can help limit the availability of paper prescription pads in your office. Electronic prescriptions also may

28 • Round-up • December 2014 • A monthly publication of the MCMS

practicing medicine have the added benefit of preventing pharmacy staff from making alterations to the prescription.

One of the best ways to prevent prescription pad theft is to keep them under lock and key. Only trained healthcare providers with prescription-writing authority should have access to prescription pads. It is also a good idea to avoid presigning prescription pads.

In addition, most states have an electronic drug monitoring program aimed to combat prescription drug abuse. These programs track prescriptions given to each patient. Some states allow practitioners to request a patient’s prescription data to help determine whether the patient may be abusing prescription drugs. If you have a patient displaying possible drug-seeking behavior, you may want to consider obtaining data from your state’s electronic program to help determine if there is an issue. Be sure to check your state’s laws regarding access to this information; you may need to submit a formal request. Some states will not dispense this information to healthcare providers.

Maintaining accurate medication lists and limiting refills are also good ways to help determine whether a patient is abusing prescription medications. You may want to consider using NCR (no carbon required) prescription pads so your practice has accurate records of exactly what was prescribed and to whom.

Being proactive about the process of prescribing controlled substance will help limit your practice’s susceptibility to prescription theft and/or forgery. ru Sources:

1. Koba M. “Deadly epidemic: prescription drug overdoses.” USA Today. July 28, 2013. http://www.usatoday.com/story/ money/business/2013/07/28/deadly-epidemic-prescription-drug-overdoses/2584117/. Accessed September 3, 2014.

2. Buntin J. “America’s biggest drug problem isn’t Heroin, it’s doctors.” http://www.governing.com/topics/health-human-services/govbiggest-drug-problem.html. June, 2014. Accessed September 3, 2014.

3. “Prescription drug overdose in the United States: Fact Sheet.” Centers for Disease Control and Prevention Web site. http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html. Updated July 3, 2014. Accessed September 3, 2014.

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