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Contents SPRING 2015
2013-2016 CCMS OFFICERS President
Winslow W. Murdoch, MD
with 26 Working Rare Diseases
Mian A. Jan, MD, FACC
Vice President Bruce A. Colley, DO
Secretary David E. Bobman, MD
Treasurer Liza P. Jodry, MD
Physician Burnout vs. Fulfillment Why It’s Not a Fair Fight
Board Members Mahmoud K. Effat, MD Heidar K. Jahromi, MD John P. Maher, MD Charles P. McClure, MD
Susan B. Ward, MD
Chester County Medicine is a publication of the Chester County Medical Society (CCMS). The Chester County Medical Society’s mission has evolved to represent and serve all physicians of Chester County and their patients in order to preserve the doctor-patient relationship, maintain safe and quality care, advance the practice of medicine and enhance the role of medicine and health care within the community, Chester County and Pennsylvania. The opinions expressed in these pages are those of the individual authors and not necessarily those of the Chester County Medical Society. The ad material is for the information and consideration of the reader. It does not necessarily represent an endorsement or recommendation by the Chester County Medical Society. Chester County Medicine is published by Hoffmann Publishing Group, Inc., Reading PA 19608 HoffmannPublishing.com For advertising information, contact Karen Zach 610.685.0914 firstname.lastname@example.org
Chester County Health Department
Physician Burnout Growing Problem, Major Concern
18 Anti-Thrombin Agents: Blessing or a Curse? 24
The 2015 OIG Work Plan: What Exactly Is It, and Why are Physicians Always So Interested?
30 Website Explains Process for Obtaining Your Mcare Refund
In Every Issue 6 14 22 34
President’s Message PAMED Legislative Update The Art of Chester County Membership News & Announcements
32 CCMS Membership: Resources You Need Chester County Medicine is published by Hoffmann Publishing Group, Inc. Reading, PA I HoffmannPublishing.com I 610.685.0914 I for advertising information: email@example.com
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edical schools select students with perfectionistic traits and the ability to persevere, putting off personal, family, and emotional needs through long periods of hard work to accomplish a goal. Early in our training, we are exposed to chaos that takes its toll. We learn to suppress our emotional response in order to act in a rational but empathetic way to achieve the goals of care. We must persevere and immediately be present for the patient in the next exam room. Rapid evolution of medical innovation, technology, knowledge, and varying, often conflicting “best practice” guidelines make our challenges even more difficult. The self-perception of the best doc that we can be revolves around how we are accepted by our patients and fellow colleagues. Making a tough diagnosis, collaborating and offering sage advice that adds to the care of an ill or suffering person, having a simple or difficult procedure lead to a return of our patient to function or reduction of suffering gives us immense energy and reminds us of why we do what we do. Medicine has always been a demanding mistress. These energizing victories and the mutual acceptance that accompanies them are hard-won battles but they don’t happen every day. As a result, health care provider burnout is as old as the profession, and no small wonder. We are trained to identify, label, and treat the imperfections in others. When the imperfection is in ourselves, it is dissonant with our persona as “the doctor.” We try to blame it on outside factors: difficult administrators, employees, patients. We become unpleasant to be around. We grouse on arriving home, kick the dog,
and blame all the imperfections in our lives. Family, friends, coworkers and colleagues start to drift away. Isolation and frustration can ensue. The victories that once energized us seem to go unnoticed and unappreciated, even when they are. Our work can lack meaning. We have all felt this way from time to time. Thankfully, most have been able to rebalance. But that is getting harder, and the incidence of occupational burnout among physicians is becoming more endemic. Reports show that in certain specialties—emergency medicine, internal medicine, and family practice—up to half our colleagues on any given day are experiencing significant symptoms of burnout. Medical mistakes and patient safety really do suffer in measurable ways. This is no longer an individual disruptive physician problem, but a pandemic.
What Changed? In our current era of care delivery, there is a gathering army. It is far larger than the number of licensed health care providers, nurses, and medical office staff involved in direct patient care. This powerful Government, Hospital, Insurance, Pharmaceutical, Trial Attorney, Maintenance of Certification Industrial Complex Army has injected itself between the doctor and the patient, as well as between doctors themselves. They profit hugely from the high cost of care. They control many levers of cost. They are an accelerant for physician and nurse burnout. They are mostly unaware, or do not care, about their negative influence. The unintended (or intended?) consequence is a scenario where they have all circled their wagons at a distance. They
are shooting at the ones providing the care, who stand in the center. They flood the news and influence policy with published reports that focus on how licensed health care providers are the ones singlehandedly driving up the cost of care; providing too many procedures; recklessly endangering patients; overprescribing; providing highvolume, low-value care, etc. These reports deflect focus from themselves, as they account for 85% of every health care dollar spent. In the name of righting all these wrongs, they devise and justify actions that further increase the emotional and fiduciary costs of care. We all see their projectiles— precertifications, prior authorizations (without sharing their determining rule sets with the caregivers), medical directors (also under tremendous pressure) deciding appropriate care, backroom deals for which medications or generics will be covered that fly in the face of common sense, mandated documentation of often meaningless data to prove quality or to submit a bill, backed by threats of fines or worse. The more they shoot in, the more they feed the already inherently strong flame of physician burnout. Doctors are trying to compensate by forming ever larger groups. They demand higher payments for care to offset the army of staff that is required to deflect the attack of the wagon circle. We give our practices away to large corporate entities, so we can “just be an employee,” but with all the liability and little control. Costs keep rising. We continue to persevere as we are trained to do, until we end up burned out, barely noticing the positive feedback from those we care for. I suppose eventually, the circled wagons will self-destruct due to relative attrition of potential targets in the middle. Conversely, we can start to work together and reframe the conversation and raise awareness of this systemic problem. What better way than each of us taking a proactive stance and getting involved in some form of patient or physician advocacy. Engaging in local hospital administration awareness as well as county, state, national, or specialty societies can also be energizing. We owe it to ourselves, we owe it to those who will follow and stand on our shoulders, and we owe it to our respected colleagues.
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Growing Problem, Major Concern By John P. Maher, MD, MPH
“Physician burnout”: Is it real? Is it imaginary? If it is real, then is it new? Is it a fad term or just a new name for an old problem?
recent review of several major English language sources by this author sheds some fascinating light on this topic. To some, the term “burnout” has little relevance; some don’t really believe it exists. But, to others—especially the medical professionals affected by it—burnout is a large, increasing, and evolving syndrome. This problem has significant adverse impact on physicians, the quality of their clinical practice, malpractice, and health care costs, and thus ultimately on patients and the entire health care system. Our quick, and clearly not exhaustive, review of the literature and various Web sites, revealed an interesting evolutionary pattern to both the terminology and the characteristic elements that now, in whole or in part, make up the syndrome of physician burnout. As far back as the early 1980s, articles began to appear in both the medical and the psycho-social literature, indicating a significant impact of physician dissatisfaction with the new trends and developments affecting the once proud profession of medicine: government regulations, thirdparty payer interventions, lack of tort reform, and everincreasing demands on physician time. Soon more articles began to appear about the declining morale of practicing physicians. Ultimately, and perhaps inevitably, by the turn of the century, we find more and more the phrase “physician burnout” occurring in the literature. While noting that people in all service professions can be affected by burnout, Gundersen (Ann Int Med 7/17/01) states that physicians are often prone to the syndrome because of their personality traits. He quotes the Dalhousie University Medical Humanities program, saying that “physicians have this complex which also says they must succeed at everything,” so they can become exhausted by all the additional pressures superimposed on them. CHESTER COUNTY
Dr. Linda Clever, founder of RENEW and member of the National Academy of Sciences IOM, writes that exhaustion is pretty common in many professional fields, “particularly where people care... (so) if you don’t care you won’t get exhausted.” However, she continued: “the changing climate in medicine (increased administrative duties, managed care, et al.) is affecting the way physicians work, and it could make them more prone to burnout and exhaustion. Physicians never expected what’s happening in medicine to happen, so many were surprised and affronted by this and thus more physicians are saying, “‘I’ve had it!’... ‘Medicine is changing’... ‘It’s not as rewarding for people’… ‘There’s too much paperwork, administration and hassle.’” According to various authors, there is an identifiable complex of characteristics, some or all of which make up the syndrome of physician burnout: “fatigue, exhaustion, inability to concentrate, depression, anxiety, insomnia, irritability, damaged personal relationships, and sometimes increasing use of alcohol and drugs—but from a professional point of view, perhaps the most distinctive characteristic of burnout is a loss of interest in one’s work or personal life, a feeling of just going through the motions.” (list of symptoms aggregated from many of the articles cited) According to the Association of Professors of Medicine (Am J Med 8/1/01), “burnout is a long-term stress reaction seen primarily in the human services professions—it is a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment. Over the past twenty years, many aspects of medicine have changed: decreasing autonomy, decreased status of physicians, and increased work pressures.” Thus, they find, “burnout is an unintended and adverse result of such changes.” In a New York Times article (8/23/12), P. Chen, MD, writes that burnout is widespread among medical students and doctors-in-training. In addition, doctors who have been practicing for anywhere from a year to several decades are just as susceptible to becoming burned out. The implications of their burnout may be devastating and immediate for the doctors and their patients. Doctors suffering from burnout are more prone to errors, less empathetic, and more likely to 8
treat patients like diagnoses or objects. They are also more likely to quit practicing altogether. According to Chen, the research casts a grim light on what it is like to practice medicine in the current health care system. Doctors are thwarted by the limited time they are allowed to spend with patients, stymied by the everchanging rules set by insurers and other payers on what they can prescribe or offer as treatment, and frustrated by the fact that any gains in efficiency offered by the use of electronic medical records are so soon offset by numerous newly devised administrative tasks that must also be completed on the computer. Shanafelt, et al. (JAMA 10/8/12) found that physicians are significantly more likely to have symptoms of burnout and to be dissatisfied with their work-life balance than the U.S. general population. Correspondingly, Linzer, et al. (J Gen Int Med 12/1/14) report burnout rates ranging from 30% to 65% across specialties, with the highest rates incurred by physicians “in the front lines” such as emergency medicine and primary care. While the 2014 Physicians Foundation survey found some encouraging trends for physicians’ moods and their tendency to recommend medicine as a career to their children, a 2015 Medscape survey reflects a similar pattern to that described by Shanafelt. The combined total of research findings
appears to suggest a highly prevalent and systemic problem threatening the foundations of the U.S. medical care system in which 1 out of 2 physicians has symptoms of burnout. Shanafelt feels that the origins of this problem are rooted in the environment and care delivery system, rather than in the personal characteristics of a few susceptible individuals. He therefore concludes that policy makers and health care organizations must address the problem of physician burnout for the sake of both physicians and their patients. This corresponds to the advice of A. Murray (Burnout Research, Elsevier, 1:1, June 2014) who states that the health care system should replace “the pathogenic approach” that focuses on treating the disease of the individual physicians affected, with an approach that would focus on interventions needed to address the process issues within the system itself which are the actual triggers of the long-term development and maintenance of professional job burnout.
John P. Maher, MD, MPH, is the former director of the Chester County Health Department and a long-time member of the Chester County Medical Society Board of Directors.
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Physician vs. Fulfillment Burnout Why It’s Not a Fair Fight By Dike Drummond, MD
hy does having a sense of satisfaction and fulfillment as a modern doctor seem like such a struggle at times? An invisible daily battle is going on daily between our search for a fulfilling career in medicine and the hidden forces of physician burnout. In this article, originally published in the Sermo Speaker Series and on KevinMD.com, I will outline why this is not a “fair fight” and the latest physician burnout research evidence on what you can do to even the odds.
What Is Physician Burnout Anyway? We each know what it feels like to be burned out, toast, fried, and spent after a long weekend on call or a tough night at the hospital. If you are able to recover your drive and energy before you return to work, great job. I hope your resilience continues. The difference between stress and physician burnout is this ability to recover in your time off. Physician burnout begins when you are NOT able to recharge your batteries between call nights or days in the office. You begin a downward spiral that has three distinct symptoms. • Physical and Emotional Exhaustion • You are emotionally drained, depleted, and worn out by work and not able to recover in your nonworking hours. • Depersonalization • The development of a negative, callous, and cynical attitude toward patients and their concerns (“my patients are so #%*&!”). • The cardinal sign here is cynicism, sarcasm, and feeling put upon by your patients. • Reduced Sense of Personal Accomplishment • The tendency to see your work negatively, without value or meaningless (“what’s the use?”) and see ourselves as incompetent.
The standardized questionnaire measuring these three scales of physician burnout is called the Maslach Burnout Inventory (MBI). The inventors of the MBI described physician burnout as: “… an erosion of the soul caused by a deterioration of one’s values, dignity, spirit, and will.”
The Burnout – Engagement Continuum Physician burnout can be thought of as one extreme of a continuum with career engagement on its other end.
Physician Burnout <——–> Physician Engagement The feelings associated with full engagement in your career are ones of fulfillment and satisfaction. You feel your work makes a positive difference in people’s lives and your career has true meaning. Engagement is the emotional gold standard for career success and at the opposite end of the continuum with physician burnout.
It’s a Battle Out There, and It’s Not a Fair Fight The forces of physician burnout and physician engagement are in daily conflict with each other. Much of the battle lies outside of our normal awareness. While we focus on our patients and their issues, our practice environment is filled with invisible stresses that constantly pull us toward the physician burnout end of the continuum and actively block our experience of engagement. Left to our own defenses, the average hard-working doctor is at a significant disadvantage in this battle. When we are dealing with physician burnout, it’s not a fair fight, plain and simple. Let me lay out some of these physician burnout building blocks so they are in plain view for all of us.
Please Note: Each of these physician burnout supporters is a daily stress of practicing medicine that exists in addition to all the work you do to maintain your clinical skill set. I call these “invisible” because they are not WHAT you do at work, they are built into HOW you deliver your services. To set the stage for this titanic struggle … Imagine a boxing ring. Bright lights in your eyes. The noise of the crowd filling the stadium in anticipation of what is to come. You are sitting in your corner, gloves on, nervous, waiting for the bell to ring to start the match (your work day). Physician Burnout is over in the opposite corner, smiling at you with a look of calm confidence. Burnout is a lot smaller than you thought … with a reputation for tenacity and powerful body punches. Suddenly you notice a whole host of trainers, coaches, and support staff in the Physician Burnout corner. What the … ?
Here is a partial list of the invisible daily stresses who make up the team in Physician Burnout’s corner. Being a Doctor Is Stressful … Period The “most stressful” professions are characterized as having a high level of responsibility and little control over the outcome. The practice of medicine certainly fits that description and is consistently on the short list of professions with the highest inherent stress levels. This is a tough job that saps our energy every single day. We Work With Sick People All Day Long (Duh!) Our days are filled with intense encounters with sick, scared, or hurting people…with all the emotional needs that come with an illness. This naturally draining environment is compounded by our typical lack of training on how to create and maintain boundaries with our patients. Balance, What Balance? Medicine has a powerful tendency to become the “career that ate my brain,” pushing all other life priorities to the side. Our training reinforces our innate workaholic tendencies. As we get older, with more family responsibilities, the tension between work and our larger life is a major stressor for many. Lack of training in how to create and maintain boundaries—this time between work and life—is a part of this perfect recipe for physician burnout. A Leadership Role You Are Not Trained For You graduate into the position as leader of a health care CHESTER COUNTY
delivery team without receiving any formal leadership skills training. By default we learn a dysfunctional top down leadership style. Medicine and the military are the only professions where the leaders “give orders.” This adds additional stress. (Burnout’s smile just got a little bigger.) The Doctor as Rate Limiting Step in the System We are the “bottleneck” in the provision of services on this same health care team. The team can only go as fast as we can—and we are often behind schedule. Pressure mounts to perform at full steam all day long. This nonstop pressure is a key factor in physician burnout once you are in practice. The Closed Door Creates a Black Box We are isolated from the rest of the patient care team by the exam room door. We don’t know what they are doing and they don’t understand our situation simply because the majority of care occurs behind that closed door when we are one-on-one with our patients. Who’s Paying for This? The financial incentives are confusing at best. The patient is often not the one paying for our services and many of them receive their care with no personal investment on their part. You may have to deal with over a dozen health plans with different formularies and referral and authorization procedures of which the patient is blissfully unaware. A Lawsuit Waiting to Happen The hostile legal environment causes many of us to see each patient as a potential lawsuit. This fear factor adds to the stress of all the points above. The Job Isn’t Over Until the Paperwork Is Done Documentation requirements are a constant work overload. What you have to do—and document—to get paid is a game where the rules are always changing. Who Am I Working for This Week? The ongoing wave of practice consolidation in many metro areas means you could be solo this week and working for the hospital the next. These shifting organizational structures can destroy years of effort invested in building your work team and profitability. Politics and “Reform” Political debate drives uncertainty about what your career will look and feel like in the future. All the pundits share the same complete lack of understanding about our
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Feature day-to-day experience as providers in the trenches of patient care. There is no track record of common sense. We simply don’t know what to expect. (Burnout LOVES that!) Things Eventually Get Stale The 10-year threshold when your practice suddenly seems to become much more of a “mindless routine,” losing its ability to stimulate your creative juices each week. All of a sudden it seems as if medicine is “no fun anymore.” Physician burnout can quickly grab the upper hand. Wow That Is a Long List—and I Am Just Getting Started Most of these factors are clear to us when I state them out loud, yet they operate invisibly, beneath the surface of our awareness in a normal office or hospital work day. Each is a member of the corner labeled Physician Burnout. Which begs the question…
Who Is in Your Corner? What are we bringing to this fight? What is our personal motivation to take on this opponent and think we can hold physician burnout at bay? • We are extremely intelligent, quick learning, hard working with a drive to do our best. Once we know the tactics to defeat burnout, no one will work harder at putting them into action. • Our connection to “WHY” we are a doctor—to our purpose. The quality of this connection varies day-by-day. However, it is a source of immense power and endurance when the connection is clear. • We have invested over a decade of our lives in our medical training and are not going to give up easily. • We get paid well enough to be in “the 5%.” • We are respected members of the community. • Our families love and support us. We can draw strength from them. • We have a life outside medicine where we can recharge and recuperate. You might think of this as “resting between rounds.”
Round Two: Residency 27-75% of residents are burned out at any given time, depending on specialty. Round Three: Private Practice Numerous global studies involving nearly every medical and surgical specialty indicate that approximately 1 in 3 doctors is experiencing physician burnout at any given time with some studies showing physician burnout prevalence as high as 60%.
Everyone Pays a Price in This Fight — Unfortunately The presence of physician burnout has been shown to • Decrease physician’s professionalism and the quality of medical care they provide • Increase medical errors and malpractice rates • Lower patient compliance and satisfaction with medical care • Increase rates of physician substance abuse, suicide, and intent to leave practice
How Can You Tip the Odds in Your Favor and Beat Physician Burnout? What can be done? Is physician burnout an inevitable consequence of the choice to become a doctor … immutable, like gravity? Not by any means. The day-to-day nature of the battle between physician engagement and physician burnout mandates a role for active prevention, regular monitoring and aggressive treatment. Recent research shows the efficacy of specific burnout prevention and treatment measures on both the personal and organizational level.
Personal Burnout Prevention Measures • Self-awareness and mindfulness training • Appreciative inquiry • Narrative medicine • Work-life balance and healthy boundaries between work and nonwork life areas • Lowering stress by • Learning effective leadership skills • Exerting control where possible over your work hours (women physicians are leading the way here) • Creating focus where possible on work activities that provide the most meaning
Most Importantly: Just like Rocky Balboa, we can take a huge amount of punishment. Our ability to simply “take it on the chin” and just keep comin’ is our tactic of last resort.
Who’s Winning So Far? Let’s look at the scorecard. And before I show you the statistics, let’s just say…it ain’t looking so good. Round One: Medical School 50% of medical students experience burnout and 10% experience suicidal ideation during medical school. CHESTER COUNTY
suffering from symptomatic burnout Burnout is waging a constant, invisible, soul-eroding battle with our health care providers. Physicians engage this enemy every single day and research shows one third of us end up among the walking wounded. It is time to share the research proven tools to tip the odds in the favor of engagement, fulfillment, and career satisfaction for our men and women “in the trenches” of modern medical practice.
Organizational Prevention Measures Many of the negative consequences of physician burnout have direct bottom-line implications for provider organizations. Any decrease in physician burnout should produce measurable increases in quality of care and patient satisfaction in addition to lower malpractice rates and physician and staff turnover. Each of these effects of physician burnout reduction would be expected to create sizeable increases in profits. There is a natural place for physician burnout prevention at the organizational level. Recent research shows us what that might look like. • State an organizational intention to value, track, and support physician well being • Institute regular monitoring for physician burnout amongst providers • Create CME programs teaching the Personal Burnout Prevention Measures • Provide time and funding for physician support meetings • Provide leadership skills training • Support flexibility in work hours • Create specific programs to support physicians
Victory in This Burnout Battle Would Make Everyone a Winner • The Physician • Their Patients • Their Family • Their Staff and Wider Organization • Even the Payor Dike Drummond, MD, is an executive coach, trainer, and consultant on physician burnout. Learn more at his website www.TheHappyMD.com.
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PAMED Legislative Update
Pennsylvania Medical Society Quarterly Legislative Update By Scot Chadwick
s is often the case at the start of a fresh two-year term of the General Assembly, there isn’t much to report in the form of newly enacted legislation. In fact, an April 2 search of the legislature’s website for statutes enacted so far this year reveals “no records found.” Don’t be fooled, though. There is a lot going on, and much of it is health care-related. Following are some key early developments in what promises to be an interesting year, as Pennsylvania’s new Democrat governor, Tom Wolf, interacts with conservative Republican majorities in the state House and Senate.
2015-2016 State Budget Pennsylvania’s annual budget process began with a proposed spending and revenue plan delivered by the governor in an address to a joint session of the General Assembly on March 3, and those expecting Gov. Wolf to offer an initiative very different from those of his Republican predecessor were not disappointed. Overall, Wolf’s proposal would increase state spending by 2.7 percent (actually more than 8 percent if you include education spending), to be paid for with a variety of tax increases, including a raise in the state income tax from 3.07 percent to 3.7 percent, and a boost in the sales tax from 6 percent to 6.6 percent. The sales tax would also be expanded to include many services, though physician/patient office encounters are excluded. Wolf’s proposal offers $8.5 million to expand the state’s loan forgiveness program for primary care physicians,
more than doubling the current appropriation. He also recommends that the program be moved from the Department of Health to the Pennsylvania Higher Education Assistance Agency, commonly referred to as PHEAA. Other significant health care items include a $2.5 million increase for behavioral health services and a $5 million increase to the Department of Drug and Alcohol Programs (DDAP) to address heroin and opioid addiction. PAMED works closely with DDAP on drug abuse issues. The budget proposal also contains $3.8 million to reopen closed state health centers; $3 million for health care innovation, to fund a multi-payer payment and health delivery system transformation; and $100,000 for a new registry to compile health data from people living in Marcellus Shale drilling areas. PAMED supports the establishment of such a registry. Importantly, the budget appropriates $2.147 million to the Achieving Better Care by Monitoring All Prescriptions (ABC-MAP) program. That’s the official name for the newly enacted statewide controlled substance database. The database is supposed to be up and running by June 30 of this year, but that timetable has been jeopardized by a lack of funding in the current year state budget. Additionally, the budget contains $2.7 million to continue the operation of the Pennsylvania Health Care Cost Containment Council (HC4), which was unfunded in the current year budget but continues to operate under a gubernatorial executive order. While it is encouraging to see so many proposed health care-related spending increases, it must be noted that Pennsylvania’s state constitution requires revenues to match spending, and House and Senate Republican leaders have reacted negatively to Gov. Wolf’s recommended tax increases. House and Senate budget hearings have now been completed, and work will soon begin on crafting the new revenue and spending plan, which is due by the end of the fiscal year on June 30.
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2/11/15 5:18 PM
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Medical Marijuana Legislation on Center Stage
Legislation to legalize medical marijuana didn’t make it to the governor’s desk last year, dying in the state House after receiving Senate approval. However, Sen. Mike Folmer (R-Lebanon County) has reintroduced the measure, now Senate Bill 3, and it has already been the subject of House and Senate public hearings this year. PAMED testified at the hearings, repeating our position that the FDA should relax marijuana’s status as a Schedule I drug to facilitate testing of a substance that seems to have some promise in treating children with epileptic seizure disorders, nausea in cancer patients, and other conditions. PAMED also believes the state should fund pilot studies that the Department of Health laid the groundwork for last year. However, until solid research results are in hand, the Society believes legalization would be premature. Looking at the bill’s specific provisions, there are a number of reasons for concern. The bill’s scope is very broad, and goes well beyond the legalization of cannabidiol, the non-psychoactive component of marijuana that seems to help some children with seizure disorders. SB 3 would also legalize THC, the psychoactive component of marijuana, to treat cancer, epilepsy and seizures, ALS, cachexia/wasting syndrome, Parkinson’s disease, traumatic brain injury and post-concussion syndrome, multiple sclerosis, Spinocerebellara Ataxia (SCA), post-traumatic stress disorder, severe fibromyalgia, and any other condition authorized by the Department of State. This is despite a review in the February 2015 Journal of Developmental & Behavioral Pediatrics, the official journal of the Society for Developmental and Behavioral Pediatrics, stating that a growing body of evidence links cannabis
to “long-term and potentially irreversible physical, neurocognitive, psychiatric, and psychosocial adverse outcomes.” The bill would permit the medical use of marijuana edibles, presumably including THC-laced brownies and candy bars, raising concern over the risk of diversion and unintended harm. This has been a problem in states that have legalized medical marijuana, as evidenced by a 2011 study in Colorado that concluded that “diversion of medical marijuana is common among adolescents in substance treatment.” The bill would authorize up to 65 growers and another 65 processors, far more than would seem necessary to provide marijuana-based products to a defined subset of patients with specifically enumerated conditions. Further, this creates more than 4,000 possible ways a specific medical marijuana product could get from grower to processor to dispenser, raising questions about product consistency. The bill would permit physicians, CRNPs, podiatrists, nurse midwives, and physician assistants to all “recommend” medical marijuana to patients, the antithesis of a go-slow, cautious approach warranted by legislation legalizing a Schedule I, non-FDA approved substance. Yet another problem relates to physician liability. The bill provides that the commonwealth can’t be held liable for any deleterious outcomes resulting from the medical use of cannabis by a registered patient, which makes sense given the paucity of scientific evidence supporting the safety and efficacy of medical marijuana. However, no similar protection is given to health care practitioners who will actually “recommend” non-FDA approved marijuana concoctions to their patients. Despite these concerns, Senate approval is again expected early this year. House action on the legislation is less certain.
Naturopathic Licensure Bill Advances House Bill 516, which would provide for the licensure of naturopaths and grant them a formal scope of practice, was recently approved by the House Professional Licensure Committee. The bill would permit licensed naturopaths to independently prevent, diagnose, and treat human health conditions, injuries, and diseases. They would be able to order and perform physical and laboratory examinations, and utilize invasive routes of administration for their tests and treatments that include “oral, nasal, auricular, ocular, rectal, vaginal, transdermal, intradermal, subcutaneous, and intramuscular.” PAMED opposes the bill for several reasons. The level of credibility that state licensure establishes could be misleading to the average Pennsylvanian by implying that naturopathy is equivalent to mainstream medicine. “Naturopathic medicine” is defined in HB 516 as “a system of primary health care.” Patients may see unproven and possibly unsafe treatments by “naturopathic doctors” as a substitute for conventional medical care. If there is doubt about whether the bill allows naturopaths to perform a particular test or treatment, the question would likely be resolved in their favor, as Section 102 (4) specifically calls for the act to be “liberally construed.” Additionally, there is no requirement in HB 516 that naturopaths collaborate with or refer complicated medical cases to a physician. The bill would also create logistical headaches for the state. Fewer than 100 naturopaths would qualify for licensure under this bill, requiring the State Board of Medicine to establish and maintain the necessary infrastructure for a mere handful of people. The vast majority of Pennsylvania naturopaths would remain unlicensed after the bill is enacted, adding confusion and providing little, if any, protection to the general public. The committee improved the bill slightly by deleting language that would have authorized licensed naturopaths to order diagnostic imaging studies, though that change is insufficient to warrant a change in PAMED’s opposition. Scot Chadwick is legislative counsel, state legislative affairs for the Pennsylvania Medical Society.
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Anti-Thrombin Agents Blessing or a Curse? BY ZARSHAWN AND MIAN JAN
n array of drugs has come up in the market in the last few years that can make it confusing, not just for patients, but also for health care personnel. In a two-part series, we will clarify and explain these drugs, their benefits, their mechanism of action, and their side effects. The first part will cover anticoagulants and the second part will examine antiplatelet agents. Figure 1 provides both the trade and generic names of these agents; it is important to recognize both.
Figure 1: Oral Anti-thrombin Agents
Mechanism of Action These drugs work on the coagulation cascade. Warfarin, which was the only oral anticoagulant available to us until recently, acts mainly on factor VIIa and IXa and can thus be reversed by Vitamin K. Warfarin was initially used as a rat poison, until its benefit as an anticoagulant was discovered and the drug was approved in 1954. Newer oral anticoagulants act mainly against factor Xa (Rivaroxaban, Apixaban, and Edoxaban) and against factor IIa or thrombin (Dabigatran).
Figure 2: Mechanism of Action
Need for Anticoagulation in Atrial Fibrillation Atrial Fibrillation (AF) is the most common arrhythmia seen in the Western Hemisphere. More than 3 million people suffer from AF in the United States alone, and a quarter of the population will suffer from AF at some point in their lifetime. It is more common in males than in females, as well as more common in whites than in blacks. The most devastating complication of AF is stroke, and as you can see in figure 4, the stroke rate is 6 times greater than the general population and is especially
Figure 3: Prevalence of Atrial Fibrillation CHESTER COUNTY
Jan & Jan
increased in rheumatic AF and in the elderly. Not only is the annual risk of stroke increased to 23.5% in patients with AF over the age of 80, but AF can also result in cardiomyopathy and congestive heart failure. Cost in quality of life is immeasurable. The latest guidelines from the American Heart Association recommend that anticoagulation be based on CHA2DS2-VASc score. The old CHA2DS score is no longer recommended. (See figure 5.) The current recommendation is that everyone with a CHA2DS2-VASc score of 2 or more should be anticoagulated with Warfarin or the newer agents. A score of 1 is a gray area, but if the patient has cardiovascular risks, the preference should be anticoagulation. Use of aspirin as an anticoagulant is discouraged and benefits of aspirin as anticoagulants minimized.
Figure 4: Risks of Atrial Fibrillation
Characteristics and Trials of Anticoagulants Warfarin has been very effective in prevention of stroke in AF if used appropriately. As you can see in figure 6, the meta-analysis of six trials shows favorable outcomes in patients taking Warfarin. Unfortunately, in the real world, the goal of INR is reached only in 65% of patients. Due to this factor, as well as the need for multiple blood testing and adverse side effects, it is not an ideal anticoagulant. The newer drugs compare well with Warfarin (see figure 7). The differences, including no need for blood testing and a need for renal clearance in new oral anticoagulants (NOACs), are shown in figure 8.
Figure 5: CHA2DS2-VASc
Figure 6:Warfarin Trials
Figure 8: Comparison Figure 7: NOACs CHESTER COUNTY
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In head-to-head trials, NOACs fared better on several levels. The trials that resulted in approval of NOACs are listed in figure 9. RE-LY was the trial for Dabigatran, ROCKET AF for Rivaroxaban, and ARISTOTLE for Apixaban. As you can see in figure 10, all three NOACs were better at preventing stroke than Warfarin. The only instance where Warfarin appeared comparable was when Dabigatran was used in a smaller dose. Similarly, mortality rates were better for the NOACs (figure 11). Even the bleeding risk was generally lower for the NOACs (figure 12).
Figure 10: Prevention of Stroke
Figure 11: Mortality
Figure 12: Reducing the Bleeding Risk
Jan & Jan
Risks of NOACs As with any other drug, there are risks associated with NOACs. Bleeding remains a major issue, especially since there is no antidote currently available. Trials are in the works to find an antidote to NOACs. Another instance of concern is renal failure, since these drugs are eliminated via the kidney and renal function needs to be monitored closely. If the patient is on NOACs and needs a surgical procedure, we need to be careful, particularly if the patient has renal failure. We have summarized in figure 13 how to deal with such a situation. If one remembers NOACs’ half-life and renal clearance, it becomes easier to use these drugs (figure 14). Since NOACs are shorter acting, if renal function is normal, holding them for 24-36 hours suffices.
Figure 13: Practical Considerations 1 Zarshawn Jan is a first-year medical student at Drexel Medical School, who wrote this article under the guidance of Mian A. Jan, MD, an interventional cardiologist practicing in Chester County.
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Figure 14: Practical Consideration 2 In summary, NOACs are useful additions to our armamentarium against AF and stroke. Recently they have also been approved for pulmonary embolism and deep vein thrombosis. In comparison with the previous gold standard of Warfarin, they are more effective, need less monitoring, require less blood testing, and cause less bleeding, specifically devastating intra-cranial bleeding. While the cost is high, it should reduce as the competition increases.
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The Art of Chester County
The Art of
Chester County BY BRUCE A. COLLEY, DO
lthough her oeuvre is art that reflects her love and respect of the Indians of the Americas, Maria de los Angeles Morales is a Chester County artist who grew up in Chester County and was educated at Immaculata University. Her works, usually using a gouache medium, reflect the heritage of the North, South, and Central Native American. A Taino Indian descendant from Puerto Rico, Maria has had her works featured in exhibitions throughout the United States and the Caribbean. She is well known in the Southeastern Pennsylvania art community and has taught and studied with many prominent local artists. While not focused on the “traditional” Chester County themes and settings of a “Brandywine artist,” Maria has reached beyond our “forty miles girdled round” and captures with obvious pride the color, design, and most clearly the character of the American Indian culture. Enjoy and revel in her breathtaking works featured here.
They Came to Say, “Hello”! American Indians love and prize the hummingbird. They believe that it is the eyes of the Creator and his messenger on earth and that it brings powerful healing and good fortune medicine. In my painting, I brought three of the special little creatures to bless the young mother and her baby, whom she will now consider to have received a special blessing.
“Sunset at Chinle, Arizona.” The sunsets in the deserts of the Southwest are truly spectacular. They inspired this painting when I was in Chinle taking a workshop with a well-known Navajo Indian artist friend. The immense space, and the effects that the changing light and colors have on the earth, mountains, and mesas, is an artist’s awesome dream environment. “At the Flower Market.” Women selling flowers is a familiar sight in Latin American markets. Their wares and the clothing they wear create a feast of colors that makes their poverty radiate with dignity. This painting was inspired by these magnificent women I have seen.
“Morning Prayers at Rancho de Taos Church.” St. Francis of Assisi Church is in Rancho de Taos, New Mexico. I have visited this impressive adobe building many times, and its massive walls and simple lines inspire me spiritually and artistically. In this painting I show what a scene might have looked like after the Spanish priests brought Catholicism to the Pueblo Indians. The Indians took up Christianity, but today they still also adhere to their own spiritual beliefs. Bruce A. Colley, DO, is vice president of the Chester County Medical Society. CHESTER COUNTY
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The 2015 OIG Work Plan:
What Exactly Is It, and Why Are Physicians Always So Interested? BY MARY ELLEN CORUM
he Office of Inspector General (OIG) has the task of protecting the integrity of Department of Health and Human Services (HHS) programs. It is an enforcement agency and has oversight of more than 300 HHS programs, of which Medicare and Medicaid are the largest. Its job is to detect and prevent fraud, waste, and abuse; identify opportunities to improve program efficiency and effectiveness; and hold accountable those who violate federal laws. The OIG carries out its work mainly through the use of audits and investigations. As part of its ongoing objectives, the OIG has stated that reducing waste in Medicare Parts A and B and ensuring quality in nursing home care, hospice care, and home and community-based care, is among the top management challenges for the Department. It will examine the safeguards in place to ensure medical necessity, patient safety, and quality of care, looking to identify any integrity gaps or breaches. Patient access to care, including access to durable medical equipment, prosthetics, orthotics, and supplies, and the effect of competitive bidding program will be reviewed. In order to focus on these broader objectives, every year the OIG releases its work plan, which identifies the areas of health care on which the agency will focus its fight against fraud and abuse in Medicare and Medicaid. New projects are revealed, as well as projects that will be carried over or continued from previous years’ work plans.
The 2015 Work Plan added just three new project areas. They are: • Hospital wage data used to calculate Medicare payments – Determine whether there are appropriate controls in place for the collection and reporting of wage data, to ensure that only eligible services and compensation are included in the wage data reported. • Adverse events in post-acute care – Examine adverse events and temporary harm events to identify contributing factors, the extent to which the events were preventable, and the associated costs to Medicare. • Independent clinical laboratory billing requirements – Medicare is the single largest payer of lab services, and the fact that lab spending has increased by almost 30 percent in a five-year period from 2005 and 2010 has got the attention of the OIG. It will use 13 measures to indicate possible questionable billing practices. Here are some of the projects that have been carried over or extended from previous work plan years: • New inpatient admission criteria – A review will be done to determine the impact of new inpatient admission criteria on hospital billing, Medicare payments, and beneficiary copayments. The review will also report billing variations among hospitals.
• Medicare oversight of provider-based status – Provider-based status allows facilities owned and operated by hospitals to bill as hospital outpatient departments. This can result in higher payments for the facilities, and increased beneficiary coinsurance liabilities. The OIG wants to determine whether provider-based facilities meet the Centers for Medicare and Medicaid Services’ criteria.
of issues and services addressed in the OIG Work Plan. Who wouldn’t find this scrutiny rather intimidating? The work plan does, however, provide a map of sorts that can make the challenge of navigating the world according to Medicare a bit less daunting. Mary Ellen Corum is director of practice support at the Pennsylvania Medical Society.
• Comparison of provider-based and free-standing clinics – Medicare payments for physician office visits in provider-based clinics and free-standing clinics will be compared to determine the difference in payments. • Oversight of hospital privileging – Determine how hospitals assess medical staff candidates prior to granting initial privileges, including verification of credentials and review of the National Practitioner Databank. Medicare requires participating hospitals have a medical staff that operates under bylaws approved by the governing body.
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• Part B services during nursing home stays – Congress directed OIG to monitor Part B billing for abuse during non-Part A stays to ensure that no excessive services are provided. Several broad categories of services, such as foot care, will be examined. • Ophthalmologists – inappropriate and questionable billing – Driven by the fact that in 2010, Medicare allowed more than $6.8 billion for services provided by ophthalmologists. Claims data will be reviewed to identify “potentially inappropriate and questionable billing” for ophthalmology services during 2012.
Letters to the Editor: If you would like to respond to an item you read in Chester County Medicine, or suggest additional content, please submit a message to
• Imaging services – payments for practice expenses – A review of Medicare Part B payments for imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. The focus will be on the practice expense components, including the equipment utilization rate.
email@example.com with “Letter to the Editor” as the subject. Your message will be read and considered by the editor, and may appear in a future issue of the magazine.
It is no wonder that physicians have an interest in the OIG Work Plan each year. Look at the wide range
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Working With Rare Diseases Anne Macek, MD, FAAP
“When you hear hoofbeats, think of horses, not zebras”
is a commonplace, if not wearisome, adage in medicine. It is my great privilege to work with the zebras. Back in 1987, I became a clinical researcher and nearly 20 years later joined a contract research organization (CRO) to work with pharmaceutical and biopharma companies to develop protocols and monitor patient safety in clinical trials. Occasionally, an opportunity came along to develop a program for a rare disease. The FDA defines rare diseases/ disorders as those that affect fewer than 200,000 people in the U.S., or that affect more than 200,000 persons but are not expected to recover the costs of developing and marketing a treatment drug. The FDA confers orphan status to drugs and biologics that are intended for the safe and effective treatment of these disorders. In recent years, being part of a team to develop a life-changing treatment became more matter-of-course. Disorders such as cystic fibrosis and epidermolysis bullosa
(EB) quickly became passions for researchers almost as much as the dedicated physicians who manage patients with these conditions. EB is known as “the worst disease you’ve never heard of.” There is no treatment or cure. Nonprofit, donor-supported organizations such as debRA, which supports those affected by EB, provide information, resources, and funding for research. EB is a genetic connective tissue disorder, characterized by extremely fragile skin. It is associated with blistering, intense itching, pain, deformity, and even blindness. The cost of specialized wound care bandages can be upwards of $10,000/month and is not reimbursable. Last year debRA provided more than $400,000 in supplies such as bandages and ointment to nearly 150 families with EB in the United States. Cystic fibrosis (CF) is an inherited disorder that mainly affects the lungs and digestive system. The genetic mutation leads to thickened secretions, infections, CFrelated diabetes, and ultimately respiratory failure resulting in early death. Thanks to the efforts of The Cystic Fibrosis Foundation and its supporters, all 50 states require newborn screening for CF. Ten years ago, mandatory testing was in place for just 5 states. With the advent of new treatments, the quality of life in CF patients has improved dramatically and many patients live into their
40s and beyond. Back in the 1950s, patients were not expected to survive long enough to attend elementary school. The Vertex drug, Kalydeco, was the first drug approved for CF that treats the underlying cause. Forbes called Kalydeco the most important new drug of 2012. Since its approval, there are more CF drugs in the pipeline that specifically target other known CF mutations. While CF is a relatively high profile rare disease, the reality is that CF affects only 70,000 patients worldwide; 30,000 of these patients are in the U.S. The nonprofit organizations for most rare diseases are strong fundraisers for research, taking matters into their own hands in order to raise capital for new drugs and testing in patients. When Kalydeco was approved, it had been “fast-tracked” and became one of the fastest FDAapproved drugs in U.S. history. About the same time, the FDA added a breakthrough therapy designation for drugs in development. This new designation expedites
the development and review of drugs for serious or lifethreatening conditions that provide meaningful therapeutic benefit over available therapies. Scioderm’s drug, Zorblisa, has been granted orphan drug designation as well as breakthrough designation by the FDA. It shows great promise for the treatment of serious skin lesions of epidermolysis bullosa and will be the first drug to receive FDA approval for EB. With ongoing hard work and commitment to developing cures and treatments, patients affected with devastating rare disorders have real hope for living full, meaningful, and productive lives. For further information on rare diseases, go to the website of The National Organization of Rare Disorders at https:// www.rarediseases.org/. Anne Macek, MD, FAAP, completed her pediatric residency at Thomas Jefferson University Hospital in Philadelphia and is a senior medical director at Theorem Clinical Research, a contract research organization.
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Chester County Health Department: Who We Are and What We Do BY KIMBERLY E. STONE, MD, MPH, FAAP
want to take this opportunity to introduce myself to Chester County Medical Society members and provide an overview of the Health Department’s services and my role within it. I attended medical school at the University of Cincinnati and completed my pediatric residency at Cincinnati Children’s Hospital and Medical Center. After several years in practice, I completed an academic medicine fellowship and received my master’s degree in public health from Johns Hopkins University. I have the privilege of serving as the medical advisor for all the important services the health department provides to Chester County residents, which allows me to use my clinical skills as well as my public health expertise. Under the direction of Jeanne Casner, MPH, PMP, the Health Department’s mission is to “provide personal and environmental health services to residents and visitors so that they may grow, live, and work in healthy and safe
communities.” Within the Health Department are three bureaus: 1. The Bureau of Personal Health Services provides: a. Consultation on suspected tuberculosis disease and latent tuberculosis infection, with clinical care and medication provided at no cost to the patient b. Routine immunizations for uninsured and underinsured persons, and community and school influenza vaccination clinics c. Free and confidential testing for HIV, chlamydia, gonorrhea and syphilis, with treatment provided at no cost for chlamydia, gonorrhea, and syphilis d. Nurse home visiting programs for expectant and new mothers e. Nutritional education, breastfeeding support, and healthy food supplements for expectant mothers and young children through the Women’s Infants and Children (WIC) program
f. Surveillance for emerging infections, vaccine preventable illness, and other communicable diseases g. Investigation of disease outbreaks to determine possible sources h. Guidance for the general public, health care providers, and institutions regarding communicable disease prevention and outbreak control i. Support for preparedness efforts with syndromic surveillance and bioterrorism agent expertise 2. The Bureau of Environmental Health Services provides: a. Food-borne illness and institutional outbreak investigations and control b. Restaurant and food handling inspections, licensing, and training c. Inspections and permits for well and septic systems d. Mobile home park inspections e. Guidance and inspections for pool facilities f. Vector control programs, such as mosquito surveillance for West Nile virus 3. Operating within the Bureau of Administrative Services, the Chronic Disease and Injury Prevention Program’s team
of health educators provides: a. Outreach and education at schools, community health fairs, and group events b. Blood pressure and cholesterol screenings c. Balance and exercise training for older adults with the “Matter of Balance” Program d. Coordination of National Public Health Week activities It is my hope that you will utilize the Health Department as a resource and that you will not hesitate to contact us with any questions. Please visit our website at www.chesco.org/health for more information. You can also find a link to our website on the Chester County Medical Society website. I look forward to working with all of you to make Chester County an even safer, healthier place to live. Kimberly E. Stone, MD, MPH, FAAP, is the public health physician for the Chester County Health Department. Contact Dr. Stone at 610-344-6230 or firstname.lastname@example.org.
At Advanced Hearing Care, we take a patient-focused and clinical approach to audiology and hearing loss. Did you know that: • There is a direct correlation between hearing loss & diabetes • Researchers have found a link between age-related hearing loss and cognitive decline • Relationships, self-image, and social life greatly improve with hearing loss treatment • 90 percent of hearing losses can be effectively treated with hearing aids Joan D’Alessandro, Au.D. Annette Peppard, Au.D. Kelly Flaherty, Au.D. Paoli • 30 S Valley Rd, Ste 206
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Website Explains Process for Obtaining Your Mcare Refund
ast fall’s Mcare settlement (http://www.pamedsoc.org/ MainMenuCategories/Laws-Politics/Analysis/LawsAnalysis/Mcare/Mcare-Settlement.html) requires that $200 million be returned to physicians, hospitals, and other health care providers. This includes $139 million in refunds for prior assessment overpayments for 2009, 2010, 2011, 2012, and 2014. • • • •
to request these assignment agreement forms is now available on the Mcare website. The www.McareRefund.org website that PAMED created was designed to give physicians and medical practices the proper information to help them understand these scenarios and make the best decision. PAMED also has a webinar on www.McareRefund.org that provides an overview of the Mcare refund process.
Who is eligible to receive refunds? How are refunds calculated? Are physicians required to remit their refund to another person or entity that paid the assessment, such as a medical practice or hospital? What should physicians and medical practices do over the next few months to protect their interests?
These are some of the questions the Pennsylvania Medical Society (PAMED) attempted to answer in a new website, www.McareRefund.org, which debuted April 1. The first round of refund checks is tentatively scheduled to be sent to physicians in the first quarter of 2016. But to ensure that they make informed decisions and receive payment of refunds that they are entitled to keep, physicians need to understand several possible scenarios and actions that could arise from those scenarios. For example, a person or entity that paid the assessment for the physician may make a claim on that refund. The claim period has started and runs through Aug. 19. Physicians will be notified of a claim through the mail— tentatively scheduled for the fall of 2015—and will be directed to a website where they must choose whether a claimed refund should be paid to them or have Mcare pay the claimant. A person or entity that paid your refund also may ask you to fill out an assignment agreement if it did not make a claim on the refund. Medical practices and other assessment payors are permitted to begin asking for assignment agreements once they obtain the required forms from Mcare. The form CHESTER COUNTY
Ask a Physician: If you have any medical questions for a physician member of the Chester County Medical Society, please submit an inquiry to
email@example.com with “Ask a Physician” as the subject. Your question will be forwarded to a physician and may be featured with an answer in a future issue of the magazine.
150787 BF CC Medicine Ad.indd 1
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CCMS Membership: Resources You Need Building Better Practices and Stronger Communities One Member at a Time
PAMED and Chester County Medical Society (CCMS) membership supports you and your community in many ways. Membership in both Societies provides an indispensable resource for information, continuing education, distance learning, professional contact, and networking. PAMED offers practice management courses and refreshers on patient care. As leadership development is hard to find, PAMED presents webinars, online courses, conferences, and seminars for the benefit of its physician members. PAMED advocacy has an inside track on legislative and executive proposals on need-to-know issues so we can keep members like you fully informed. CCMS works collaboratively with PAMED, but its focus is on the local Chester County community. Some specific benefits of membership in CCMS include: • An opportunity to sign up for the PAMED “Find a Physician” program to promote your practice • Representation with local legislators • An annual meeting which provides you with the opportunity to impact your Society’s activities and goals • A legislative dinner, known as “The Clam Bake,” where you can meet with local legislators in an informal setting • An automatic subscription to Chester County Medicine magazine, the Society’s new twist on its longtime quarterly publication, and • Access to DocBookMD®, an exclusive HIPAA-secure messaging application for smart phone and tablet devices.
For additional information about becoming a PAMED and CCMS member, visit http://www.pamedsoc.org/membership and click “Join PAMED,” email firstname.lastname@example.org, or call ( (717) 909-2684.
To renew your current membership, visit http://www.pamedsoc.org/membership and click “Renew your membership.” Membership is available only for physicians licensed to practice in Pennsylvania.
APPLICATION ___________________________________ County Medical Society (You may choose to be a member of the county in which you either live or work.) 777 East Park Drive, PO Box 8820, Harrisburg, PA 17105-8820 717-558-7750 (Phone) 717-558-7840 (Fax) Full Name (Print): ___________________________________________________________________________________ Last
Email Address: ____________________________________________
For mailing, please use: Office Address Home Address
Area Code & Phone Number
Area Code & Phone Number Area Code & Phone Number
Preferred Communication: Email Fax Mail
BIOGRAPHICAL DATA Gender: Male Female EDUCATION
Date of Birth: ____________ Spouseʼs Name:
BEGIN DATE END DATE
FOR RESIDENCY & FELLOWSHIP, YOU MUST GIVE ACTUAL OR PROJECTED ENDING MONTH & YEAR BEGIN DATE END DATE Residency__________________________________________________________________ Fellowships_________________________________________________________________ License: PA No. Date Issued
__________ -_________ __________ -_________
PROFESSIONAL DATA Present Type of Practice (Check Appropriately): Owner of Physician Practice Group Name ___________________________________________________ Employed by Hospital/Health System Employed by Physician(s) Group Name ___________________________________________________ Employed by Industry or Government Independent Contractor Other (specify) _________________________________________________ Specialty: Within the last 5 years, have you been convicted of a felony crime or is your license to practice medicine actively suspended or revoked? If yes, please provide full information. ___________________________________________________________
___________________________________________________________ ___________________________________________________________ DATE RETURN TO: ATTENTION:
SIGNATURE Pennsylvania Medical Society Member Services
QUESTIONS? Call (800) 228-7823
717-558-7840 777 East Park Drive PO Box 8820 Harrisburg, PA 17105-8820
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To publi new CC sh photos of physicia MS membe r ns, p digital lease submit c op admin @chest ies to ercms.o rg
Membership News & Announcements
Members in the News
Robert P. Denitzio, a family physician, is among the first of 121 physicians in the country to receive board certification following successful passing of the new Integrative Medicine Board Certification Exam created by the American Board of Integrative Medicine. Dr. Denitzio is a member of the Jennersville Regional Hospital medical staff and is the principal provider for Family Medicine Specialists of Jennersville. “By blending traditional family medicine with proven treatments outside western medicine, I can offer my patients a unique and comprehensive medical experience,” says Dr. Denitzio, who has been a family physician for more than 30 years. We would like your help in touting the accomplishments of Chester County physicians. If you receive an award or certification or have other good news to share, please submit it to email@example.com.
Frontline Groups Frontline Groups with 100 percent membership in CCMS are the backbone of the society. We are thankful for their total commitment to CCMS. This list reflects the Frontline Groups as of April 13, 2014.
Academic Urology-West Chester Brandywine Gastroenterology Associates Ltd.
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Cardiology Consultants of Philadelphia-Main Line Cardiology Consultants of Philadelphia-Paoli Cardiology Consultants of Philadelphia-West Chester
The annual Chester County Medical Society Clam Bake is an opportunity for the legislators and physicians of Chester County to discuss current medical policy issues and enjoy a casual sumptuous dinner.
Chester County Eye Care Associates PC Chester County Otolaryngology & Allergy Associates Clinical Renal Associates-Exton Devon Family Practice LLP Family Practice Associates of West Grove
Join us Friday, September 11, 2015 6:00 pm - 9:00 pm
Gateway Endocrinology Associates
At the beautiful Radley Run Country Club Clubhouse Dining Room https://www.radleyruncountryclub.com Refreshments and hors d’oeuvres will be served on the patio at 6:00 pm, followed by a delicious buffet of clams, filet mignon, shrimp, crab, tilapia, chicken, and fabulous desserts. Mark your calendar now and watch for registration information soon.
Gateway Myers Squire & Limpert
Gateway Family Practice Downingtown Gateway Internal Medicine of West Chester Gateway Medical Colonial Family Practice Great Valley Medical Associates PC Levin Luminais Chronister Eye Associates Main Line Dermatology Medical Inpatient Care Associates Paoli Hematology Oncology Associates PC Plastic & Reconstructive Surgery of Chester County PC Village Family Medicine West Chester GI Associates PC 34
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Chester County Medicine is a publication of the Chester County Medical Society (CCMS). The Chester County Medical Society’s mission has evol...
Published on May 30, 2015
Chester County Medicine is a publication of the Chester County Medical Society (CCMS). The Chester County Medical Society’s mission has evol...