THE ART of Chester County WORKS OF
William Robinson “Rob” McIlvaine
F E AT U R E D O N PA G E 2 0
CHESTER FROM DualINONE-SIZE-FITS-ALL RAASCOUNTY Blockade: HEALTHCARE
Irrational Exuberance Quelled bySODIUM Clinical Trial Results RESTRICTION: A TIME-HONORED DOGMA OR Medical Marijuana AN EVIDENCE-BASED PURSUIT?
Everything’s better at the lake. Welcome to the most comprehensive outpatient complex in the region – now with advanced cancer care – located right in the Brinton Lake shopping district on Route 1 in Glen Mills. Over 25 medical specialties, plus the latest imaging technologies, a surgery center, sleep center and endoscopy center. One-stop shopping now includes one-stop caring. • Asthma and Allergy
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• Family Medicine
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Learn more at CrozerAtTheLake.org.
We’re 5 hospitals, 2,600 doctors and nurses, and 6,800 caring people with 1 vision. Crozer-Keystone. Something to feel good about.
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Gateway Medical Associates, in Chester and now Delaware County, has been serving our community since 1996. Gateway strives to provide the highest quality primary and specialty care with a focus on our patientsâ&#x20AC;&#x2122; wellbeing and health.
Our 43 physicians and nurse practitioners provide quality care from any of our 10 convenient locations throughout the Counties.
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Gynecologic Oncology. Right here. For more than 20 years, Waleed Shalaby, M.D., Ph.D., has provided compassionate care to women with gynecological cancer. Should you ever need his care, he will remain focused on you from diagnosis, through treatment, and thereafter. His patient-centered approach helped him become 2013’s corecipient of the prestigious Press Ganey® Guardian of Excellence Award for Patient Satisfaction. Dr. Shalaby’s services include: • Consultation for suspected or known gynecologic tumors • Advanced robotic-assisted surgery • Genetics counseling and cancer risk assessment Most major insurance plans are accepted. For referrals or specific questions, please contact our cancer care coordinator at 610-983-1530.
Waleed Shalaby, M.D., Ph.D. Gynecologic Oncology
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Advanced Medical Homecare Supplies has been serving home medical equipment and respiratory supply needs for ten years. Physicians and customers know they can count on AMHS, your full-service home medical equipment provider committed to serving YOU. • CPAP Equipment and Supplies (MediCare Contracted Provider) • Oxygen
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See our online catalog at www.advancedmedicalpa.com Or, come visit our new showroom. Serving the local Philadelphia tri-state area since 2005. To Place an Order Call 610-524-1510 1025 Andrew Drive, Suite 150, West Chester, PA 19380
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2013-2016 CCMS OFFICERS President Winslow W. Murdoch, MD
President-Elect Mian A. Jan, MD, FACC
Vice President Bruce A. Colley, DO
Secretary David E. Bobman, MD
Treasurer Liza P. Jodry, MD
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 email@example.com
14 Medical Marijuana
THE ART of Chester County
Features 12 Dual RAAS Blockade: Irrational Exuberance Quelled by Clinical Trial Results 14 Commentary: Medical Marijuana 15 The Importance of Adding Fiber to Your Diet 16 Physician Revalidation Requirements — Avoiding Disruption to Reimbursement
Physician Revalidation Requirements
18 Collection Strategies Help PhysicianPatient Relationship, Protect Bottom Line 24 Case Study: Woman With Cardiac Arrest and Prolonged Coma Secondary to Hypoxic Encephalopathy Caused by Viral Myocarditis 29 The Birth and Death of a Legal/ Medical Footnote
In Every Issue
30 PMSLIC Transitioning Policyholders to NORCAL
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32 CCMS Membership
President’s Message PAMED Legislative Update The Art of Chester County Hospital Profile Membership News & Announcements
34 Snapshot of the Health of County Residents
Chester County Medicine is published by Hoffmann Publishing Group, Inc. Reading, PA I HoffmannPublishing.com I 610.685.0914 I for advertising information: firstname.lastname@example.org
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y wife, who works for an academic institution, received an invitation to a national Summit for Healthcare Innovation in Philadelphia that touted it would integrate ALL of the “stakeholders” in health care. “MedCity CONVERGE provides the most accurate picture of the future of medical innovation by gathering decisionmakers from every sector to debate the challenges and opportunities facing the industry,” declared the meeting’s marketing material. “This national, executive-level summit gathers leaders from health systems, payers, medical device, pharma and digital health/ health IT to join with entrepreneurs, government leaders, investors, and other key stakeholders to see the latest innovations and create, through their conversations, truly actionable intelligence on where the innovation opportunities are right now.” The agenda included how to best leverage big data, work on tiered care,
goods and services, how to maintain market share in narrow clinically integrated networks based on cost control versus “outcomes,” and how to position stakeholder institutions to thrive in the rapidly evolving health care environment. “At CONVERGE, you get the whole picture, because all sectors are represented: Hospitals, Pharma, Startups, Venture Capital, Digital Health, Mobile, Biotech, Payers, Health IT, Medical Devices and ACOs,” organizers said. Am I confused, naïve, ignorant, just plain simple, or all of the above? Conspicuously absent was any mention of patients, nurses, and medical office staff, not to mention…physicians. My wife wrote to the conference coordinator and asked specifically why physicians were not asked to attend the meeting. She was told that they no longer reach out to physicians because in the past invited doctors had been unable to take time away from caring for patients to attend the all-day, midweek conference. It seems to me that the current “stakeholders” view technology, big data, and care through the lens of institutionalized population management, apps, and wearable technology. Perhaps those things will play a part in the future
of health care. But it seems that patient care is considered a commoditized service, where no one entity takes real ownership of a patient’s journey. Plug and play parts can be created into a protocol that will correctly and more profitably benefit the majority of the patients and therefore, be more easily measured and managed. Startups that can create ways to help with the patient experience will be critical in the next era of health care. Innovation to augment our care is welcome. Leaving providers out of the conversation is not. Institutional protocol is a good base that prevents mistakes in the 90% of cases that are routine. Protocol flies the “airplane of patient safety” into the side of the mountain consistently about 10% of the time. Breaking protocol in order to provide individualized attention to the unique patient has become increasingly harder to do, as institutions gather increasing control and power. There may be new technologies that can help, but again, shouldn’t we be a part of that conversation? The patient is THE primary stakeholder in health care. Their primary interactions are with primary care providers in their community, or, in the case of severe, or advanced chronic
disease, their specialist colleagues and staff. As physicians, our responsibilities go beyond the exam room. When a patient consults us in distress, emotional or physical, we rely on our decades of training to provide help and comfort. When our entire patient population is in distress, it remains our responsibility to provide care and comfort, yet we are not trained for this part of our responsibility, so we largely shy away and leave it to “the stakeholders.” The rubber meets the road whenever the medical office staff and/or physician interact with a patient. Trust must be established, continuity of care must be protected, and individualized care must be implemented when it is appropriate. Counter viewpoints need to be conveyed to institutional players. How can innovation happen without the input of the providers who ultimately care for patients? Resources must be allocated to the actual delivery of care where it occurs, not in a board meeting or conference of institutional players trying to profit on margins or startups, but at the core of the patient-doctor-staff interaction. Neither our patients nor we are considered stakeholders in the currently evolving “new era” of medical care. It is our duty as professionals to organize the primary stakeholders— ourselves and our patients. If we don’t collaborate by adding our voice to those of our patients, colleagues, and industry then others will speak for us as we are in absentia. We will lose our place at the table, because we are not there to speak for those in our charge and ourselves. I have spoken up by becoming active in county and state organized medical societies and am encouraged by the hard work and dedication of involved colleagues. I’m also attempting to be involved in the local entrepreneurial health care community, and hope to invite participants to share their ideas with us as providers. You will be hearing more on this issue, as I hope to connect innovators with providers. There really is quite a lot going on behind the scenes to be excited about in health care as physician stakeholders, but engaged members have dwindled, so our voices are fading. I invite you to come along for the ride.
Surviving Cancer in Style “At the most difficult time in my life Jude and Therese were there to give my life some normalcy. I didn’t know the first thing about hair or wigs when I met Therese. She was a wealth of knowledge. She helped me find the wig and hairpieces that fit my lifestyle: something for work, something for the pool, something for when I exercised. It gave my husband and me peace of mind. He says, ‘You look just as beautiful; it’s like you never lost your hair!’ I am so thankful for Jude Plum Salon—a bright spot at a dark time in my life.” Alice D., Cancer Survivor Shown wearing her wig
Winslow W. Murdoch, MD, practices family medicine in West Chester. He is president of the Chester County Medical Society. Contact Dr. Murdoch at email@example.com.
Call for your free consultation
610.527.1770 821 W. Lancaster Avenue Bryn Mawr, PA 19010
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PAMED Legislative Update
The past few months have seen a flurry of activity, as lawmakers rushed to finish as much of the 2013-2014 session’s work as possible before breaking for the summer. Traditionally, few controversial issues are addressed in the fall of the second year of a two-year term, as most House and Senate members are focused on their reelection efforts and the November 4 general election. Following are highlights of recent legislative and regulatory actions.
Pennsylvania Medical Society Quarterly Legislative Update BY SCOT CHADWICK
egislators struggled to address the Commonwealth’s ailing fiscal health in passing Pennsylvania’s annual state budget. Revenues for the 2013-2014 fiscal year badly lagged projections due to a slower than expected economic recovery, and the problem was exacerbated by the need to significantly increase contributions to our underfunded state pension system. The latter concern is serious enough that all three major credit rating agencies have threatened to lower the state’s credit rating. Nevertheless, lawmakers patched together a nonew-taxes spending plan for the coming year, based in part on highly optimistic future revenue projections. Despite concern that legislators did not address pension system reform, Governor Tom Corbett signed the budget bill into law on July 10.
Regulation of Tanning Salons Culminating years of hard work by PAMED and its allies, on May 6, 2014, Governor Corbett signed a new law banning use of tanning facilities by minors under the age of 17 and requiring parental consent for 17-yearolds. The law (formerly HB 1259, now Act 41) also requires: • Tanning facilities to post warning signs on the premises and keep records for three years • Customers to sign a written warning statement prior to tanning • Tanning devices to meet federal and state standards • Employees of tanning facilities to have training in both the use of the devices and recognition of customer skin types.
There have been several versions of tanning bills over the years supported by the Pennsylvania Medical Society (PAMED), the Pennsylvania Academy of Dermatology and Dermatologic Surgery, and the Pennsylvania Chapter of the American Academy of Pediatrics. In past sessions tanning legislation would pass the Senate but stall in the House. However, persistence has paid off, and the law went into effect on July 5, 2014.
Ask a Physician: If you have any medical questions for a physician member of the Chester County Medical Society, please submit an inquiry to
Medical Liability Lawsuit Filings Remain Below Pre-Reform Levels Despite a slight uptick in the number of 2013 medical malpractice filings, lawsuit abuse reforms that were adopted in 2002 appear to be having a positive impact to weed out meritless lawsuits. According to the Administrative Office of Pennsylvania Courts (AOPC), the latest filings show a 43.4 percent decline from the “base years” of 2000 to 2002. Specifically, the AOPC credits the elimination of venue shopping and requiring a certificate of merit. The Pennsylvania Medical Society led the fight for these changes, and our prediction that they would cause a significant reduction in unnecessary lawsuits has been proven accurate. However, while Pennsylvania physicians can be
firstname.lastname@example.org 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.
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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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The Department will also be directed to cooperate with the Pennsylvania Game Commission, the Department of Conservation and Natural Resources, and the Department of Education to ensure that the information is widely disseminated to the general public, as well as to school administrators, school nurses, faculty and staff, parents, guardians, and students. The Pennsylvania Medical Society has long supported legislation calling for the state to take a more active role in information gathering and public education regarding Lyme disease. Unfortunately, earlier versions of the legislation also contained problematic language statutorily endorsing long-term antibiotic therapy, a controversial treatment protocol rejected by the CDC, which ultimately doomed those bills to failure. However, the new law does not contain that highly contentious provision, and the Society is pleased with the bill’s enactment.
justifiably pleased with the results of the Society’s hardwon reforms, more remains to be done. The AOPC points out that 77 percent of jury verdicts in 2013 went to the defense. In other words, personal injury lawyers are still taking too many cases to trial that do not involve physician negligence. The Pennsylvania Medical Society has a robust, ongoing tort reform agenda that includes caps on pain and suffering awards, limits on plaintiffs’ attorney fees, increased liability protection for physicians who provide emergency care, strengthening the Certificate of Merit court rule, and closing the loophole in the expert witness requirements.
Lyme Disease Bill Signed Into Law Lyme disease is the most commonly reported vectorborne illness in the United States, and according to the Centers for Disease Control and Prevention (CDC), in 2012 it was also the country’s seventh most common nationally notifiable disease, despite the fact that 95 percent of the cases are reported from just 13 states. Pennsylvania sits at the top of that unfortunate baker’s dozen, joined only by Massachusetts as states with more than 5,000 confirmed or likely cases in 2012. Senate Bill 177, signed into law by Governor Corbett on June 29, 2014, will establish a task force in the Department of Health to make recommendations to the Department regarding a wide range of surveillance, prevention, information collecting, and education measures. The Department will be charged with the task of developing a program of general public and health care professional information and education regarding Lyme disease, along with an active tick collection, testing, surveillance, and communication program.
Down Syndrome Bill Reaches Governor’s Desk In June, the state House and Senate continued a troubling trend of passing well-meaning legislation that intrudes into the physician-patient relationship. If signed by the Governor, House Bill 2111 will require a health care practitioner that administers, or causes to be administered, a test for Down syndrome to an expectant or new parent to, upon receiving a positive test result, provide the expectant or new parent with educational information made available by the Department of Health.
The Pennsylvania Medical Society has consistently opposed this and other legislation that strips a physician of the ability to use his or her best clinical judgment in treating individual patients, each of whom may have unique challenges or health issues. This bill forces a physician to use one-size-fits-all, state-issued material that may not be appropriate for every patient.
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
email@example.com with â&#x20AC;&#x153;Letter to the Editorâ&#x20AC;? as the subject. Your message will be read and considered by the editor, and may appear in a future issue of the magazine.
Opioid Legislation on Hold Until Fall While major progress has been made on two important initiatives intended to address the opioid abuse crisis, both ran into last-minute snags during the late June budget crunch, and final passage will likely not occur until the fall. Efforts to enact legislation establishing a statewide controlled substance database are close to bearing fruit, though a couple of issues remain to be resolved. As reported earlier, the House of Representatives passed House Bill 1694 on Oct. 21, 2013, by a vote of 191-7, and on May 6, 2014, the Senate passed its own version, Senate Bill 1180, 47-2. It now seems clear that the Senate bill will be the measure that reaches the finish line, and for a while it looked like the bill would reach the governorâ&#x20AC;&#x2122;s desk in June. However, a proposed House amendment to the Senate bill allowing non-addictive, rarely-abused drugs to be excluded from the database met unexpected last-minute resistance, leading to a decision to try to work things out over the summer. Also awaiting final action in September is legislation providing Good Samaritan protection to persons aiding the victim of a drug overdose. Senate Bill 1164 also contains important provisions authorizing the prescribing of Naloxone to first responders like policemen and firefighters, as well as to friends and family members of persons at risk of experiencing a drug overdose. The bill is in position to be approved quickly, but apparently got tangled up in the June state budget negotiations and will likely not be considered until September. Scot Chadwick is legislative counsel, state legislative affairs for the Pennsylvania Medical Society. CHESTER COUNTY
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Dual RAAS Blockade: Irrational Exuberance Quelled by Clinical Trial Results BY MICHAEL LATTANZIO, DO
enin-angiotensin aldosterone system (RAAS) blockade in patients with established heart or kidney disease provides an approximate 20% relative risk reduction in disease progression, cardiovascular, and/or renal endpoints. Many physicians suspected that more complete blockade of the RAAS with the implementation of dual RAAS blockade would confer additive renal and/or cardiovascular benefit. Emerging clinical data has failed to substantiate the cardiovascular and renal benefits of dual RAAS blockade, particularly in individuals with renal disease. Moreover, the use of dual RAAS blockade has been associated with significant safety issues, particularly hyperkalemia, hypotension, and acute renal failure. These findings have dampened the fervor surrounding the use of dual RAAS blockade to achieve superior outcomes over monotherapy. In the ONTARGET trial, the combination of ACE inhibitor and ARB in patients with diabetes or vascular disease failed to show reduction in cardiovascular outcomes, and was associated with increased risk of hypotension, syncope, and renal dysfunction.1 Similarly, the ALTITUDE trial showed no reduction in cardiovascular or renal endpoints among individuals with diabetic kidney disease on dual RAAS blockade.2 This trial was halted due to an increased incidence of hyperkalemia, hypotension, and stroke in the treatment arm. Lastly, the VA NEPHRON-D trial, which examined the effect of ARB plus ACE inhibitor in diabetic nephropathy, demonstrated no renal advantage of dual RAAS blockade over monotherapy. This study also was terminated prematurely due to excess risk of hyperkalemia and renal failure in the treatment arm.3
Despite significant excitement regarding the utilization of dual RAAS blockade to achieve superior renal and/or cardiovascular outcomes, emerging data do not support this clinical practice, particularly in renal disease. In individuals with heart failure, the efficacy of dual RAAS blockade to reduce hospitalization is evident, but this will have to be weighed against the potential for safety issues. Further studies are required to determine whether different combinations of the four available RAAS blocking agents available will produce stereotypical results, particularly in individuals with and without renal disease and heart failure. For now, more circumspect use of dual RAAS blockade appears to be warranted. References Mann JF, Schmieder RE, McQueen M, et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet 2008;372:547-53.
Parving HH, Brenner B, McMurray J et al. Cardiorenal end points in a trial of aliskiren for type 2 diabetes. New England Journal of Medicine 2012;367:2204-2213.
Fried LF, Duckworth W, Zhang JH, et al. Design of combination angiotensin receptor blocker and angiotensinconverting enzyme inhibitor for treatment of diabetic nephropathy (VA NEPHRON-D). Clinical Journal of the American Society of Nephrology: CJASN 2009;4:361-8.
Michael Lattanzio, DO, is a clinical nephrologist and hypertension specialist with Clinical Renal Associates of Chester County.
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BY JON SHAPIRO, MD
recent trip to the Federation of State Physician Health Programs Annual Conference, in Denver, highlighted some of the controversy surrounding the legalization of marijuana. It has raised several complex issues. I endorse the American Society of Addiction Medicine’s policy on medical marijuana. Marijuana is not a standardized product. It has not been adequately studied as a treatment for the many indications for which it is recommended. Also smoking is an unhealthy delivery system. In states with medical marijuana, physicians do not prescribe it in a specific fashion but rather give the patients a certificate that allows them to use any dose they choose. There is some consensus in the medical field that marijuana is not good for growing brains. Studies have suggested stunted intellect and emotional growth in young people who use large amounts of marijuana on a regular basis. The use of cannabis, similar to the use of alcohol, should be restricted to adults. The safe operation of motor vehicles is extremely important. Mothers Against Drunk Driving has been an exceptionally influential and informative group, no doubt saving countless lives on our highways. The correlation between blood THC level (the active chemical fraction of marijuana) and performance is quite complex. It is difficult to set a safe level of THC for driving or other critical functions. In the addiction field we frequently refer to the common final chemical nature pathway of a variety of substances in the brain. People in recovery are advised to steer clear of all moodaltering substances, including marijuana, to avoid triggering urges and relapse. Never forget the law of unintended consequences. Colorado is reporting an increase in THC poisoning. The new marijuana is much stronger than the classic weed of the 1970s so adults are showing up in emergency rooms with anxiety and other symptoms of overdose. There is also concern that candy and pastries laced with THC could be eaten accidentally by children. Research with airline pilots has demonstrated that marijuana can reduce performance. Importantly, test pilots were unaware of their own temporary impairment. Until
safe levels of marijuana usage are determined, its use must be prohibited in people in critical positions. A zero tolerance policy should be advocated for transportation workers and health care workers. What is at issue for us here is not the public policy of legalization of marijuana but rather maintenance of public safety. Marijuana use should be disallowed for young people, for recovering addicts, and for those in whom we entrust our lives. This article is the opinion of Jon Shapiro, MD, who serves as Physicians’ Health Programs’ medical director. He can be reached at php-foundation@ pamedsoc.org. The PHP is a program of the Foundation of the Pennsylvania Medical Society that has restored careers, families, and confidence by helping more than 3,000 physicians seek and receive the recovery care that enables them to remain a vibrant part of the physician workforce.
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The Importance of Adding Fiber to Your Diet BY A. GERALD FROST, MD, FASCR
any health problems can be prevented or treated by the addition of fiber to your regular diet and thereby “normalizing” bowel function. In certain circumstances, people experiencing diarrhea and those with constipation can benefit from fiber as can those with “regular” bowel habits. The addition of fiber to the diet has been shown to lower serum cholesterol, decrease the cramps and pain associated with irritable bowel syndrome (or so-called “spastic colitis”), prevent the development of diverticulosis and diverticulitis, and perhaps, even prevent colon cancer. The addition of fiber to the diet can also prevent the development of anal fissures and decrease or prevent the development of symptoms from hemorrhoids and brim irritation. The proper amount of fiber in the digestive tract makes it easier for the
intestines to function properly. As an indication of how fiber works, try this: place one finger from your left hand in the palm of your right hand and try to squeeze it as hard as you can. Now, place three fingers from your left hand in the palm of your right hand and squeeze. Notice how much easier it is to squeeze by adding more “bulk.” This shows how adding more fiber to your diet works for your intestines. I recommend people get 30 – 40 grams of fiber each day. The amount of fiber required differs for each person, but the goal is to have soft, wellformed, somewhat bulky stools that are easy to pass. It is also important to consume enough fluid along with the fiber to create the proper stool consistency. If your stools are too hard, add fluid; if too loose, add fiber. There are many foods that are high in fiber per serving, such as beets, beans, peas, sweet potatoes,
figs, blackberries, pears, raspberries, strawberries, whole grain breads, and bran cereals. If you find you have trouble adding high fiber foods to your diet, I often recommend supplements like Benifiber, FiberCon, and Konsyl. Remember, your goal should be to always have “regular” bowel movements, so keep eating fiber to maximize its many health benefits. If you have any questions about how fiber can impact your overall health, or to make an appointment with Dr. Frost, call 610-983-1715. A. Gerald Frost, MD, a boardcertified colon and rectal surgeon and a fellow of the American Society of Colon and Rectal Surgeons, is a member of the medical staff at Phoenixville Hospital.
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Physician Revalidation Requirements – Avoiding Disruption to Reimbursement BY LARA BROOKS
evalidation, the process by which the Centers for Medicare and Medicaid Services (CMS) requires a physician to certify the accuracy of his or her existing enrollment information, can be a new and confusing process. With the passage of the Affordable Care Act (ACA), revalidation requires physicians to be screened under new program integrity rules. Complying with these requests within the specified time is crucial to avoid deactivation of billing privileges. Here’s what you need to know about Medicare and Medicaid revalidation to avoid disruption to your reimbursement.
Medicare Revalidation Medicare requires revalidation every five years, but CMS may also perform “off-cycle” revalidations under certain circumstances. The revalidation letter will be mailed in a colored envelope to the physician’s practice address and/ or the pay to address. Do not submit a revalidation application unless specifically requested by Medicare. Upon receipt of the request to revalidate, you have 60 days from the
postmark date of the letter to submit complete enrollment information using one of the following methods • Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) – This system, accessible at https://pecos.cms.hhs. gov/pecos/login.do, allows you to review information currently on file, upload supporting documentation, and electronically sign and submit your revalidation application. • Paper application form – To revalidate by paper, download the appropriate and current CMS-855 Medicare Enrollment Application and mail the completed application and all required supporting documentation to Novitas Solutions. The requests are issued by NPI; thus a group practice may have multiple enrollments that must be revalidated. While CMS has instructed Medicare carriers to work with physicians to ensure compliance (e.g., calling a physician that fails to respond to a revalidation request), physicians should seek out with diligence revalidation requests to prevent deactivation and disruption of reimbursement.
Physicians should review the CMS website at www.cms.gov/Medicare/ Provider-Enrollment-and-Certification/ MedicareProviderSupEnroll/ Revalidations.html for a list of providers/suppliers by NPI number to see if a revalidation request has been sent. The Provider Enrollment Inquiry Tool, available on CMS’ website at www.novitas-solutions.com/webcenter/ content/conn/UCM_Repository/ uuid/dDocName:00004864, provides the status history of all enrollment applications submitted to Medicare. The Pennsylvania Medical Society strongly encourages physicians to utilize this tool for tracking enrollment applications. If there is a discrepancy with the application, requests for additional information from Medicare may be sent to an email address if provided on the application. CMS began the process of revalidating physicians and group practices that were enrolled in Medicare prior to March 25, 2011. Medicare will continue to send revalidation notices on an intermittent and regular basis until all affected physicians revalidate their information with CMS by March 2015.
Medicaid Revalidation The ACA also requires the Department of Public Welfare (DPW) to validate all new physicians and revalidate all currently enrolled physicians by March 16, 2016, and at least every five years thereafter. In order to do this, DPW is requiring that all physicians re-enroll by submitting a fully completed Pennsylvania PROMISe ™ Provider Enrollment Application, along with any required additional documentation for every active and current service location. As of May 2014, only 18 percent of Medicaid physicians revalidated their enrollment, with over 83,884 service locations set to expire in March 2016. Unlike Medicare which notifies physicians when it’s time to revalidate enrollment, the onus is on the physician to initiate this process. While March 24, 2016, might sound far away, physicians should complete the process as soon as possible for several reasons:
Coach Chaney knew who to trust for the win. When Hall of Fame basketball coach John Chaney needed treatment for complications related to diabetes, he knew where to turn. The caring staff at Chestnut Hill Hospital jumped into action. After treatment, Coach Chaney was able to return to his daily activities, giving high fives along the way. If you have a problem with wounds that won’t heal, lack of circulation or similar health issues, talk to your primary care physician about a referral.
8835 Germantown Avenue Philadelphia, PA 19118 215-248-8601
1. March 24, 2016, is not the deadline by which DPW has to receive your application. It’s the deadline by which your application must be processed and in the system.
Our physicians treat a variety of wounds, including: Diabetic foot wounds Venous ulcers • Arterial ulcers Surgical and pressure-related wounds Osteomyelitis • Radiation injury/necrosis Necrotizing infections
2. DPW expects longer wait times for approvals. 3. Don’t wait for a written notice. DPW has confirmed that providers will not receive written notices. It’s imperative that physicians submit applications immediately to avoid disruptions in claim payment as all service locations that are not revalidated will expire. Physicians also are reminded of the ongoing requirement to inform DPW of any changes, including changes of direct or indirect ownership and controlling interest of 5 percent or greater, contact information changes (including email), address changes, closed or invalid service locations, or any other change to the information provided on their enrollment record that would otherwise render the information in their current provider file inaccurate. All provider letters and portal login screens will indicate your next revalidation due date. Verify this information on the DPW provider portal for each 13-digit logon at each service location. Information about this helpful tool can be found on DPW’s website at www.dpw.state.pa.us/cs/ groups/webcontent/documents/communication/p_034770. pdf.
Hyperbaric oxygen therapy is available.
John Chaney Retired Hall of Fame Basketball Coach, Temple University
John Scanlon, DPM Co-Director, Comprehensive Center for Wound Healing
Lara Brooks is associate director of practice economics and payer relations for the Pennsylvania Medical Society. John Scanlon, DPM, is a Member of the Medical Staff at Chestnut Hill Hospital.
6/23/14 12:20 PM
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Collection Strategies Help Physician-Patient Relationship, Protect Bottom Line BY CAROL BISHOP
ollecting money from patients is one of those necessary things that few physicians or their staffs are comfortable doing. But practices must have a good process in place to collect deductibles, co-payments, and co-insurances if they want to continue to offer quality health care. When communicated clearly and respectfully to patients, these processes may also help avoid negative impacts on the physician-patient relationship and damage to the practice and/or physician’s reputation. Practices should take a step back and examine their current procedures—from how patients check in to patient billing and collections.
Clearly Communicating Policies and Procedures With Patients The first steps in creating this process should include finding a reliable system for checking eligibility, accurately estimating the patient’s financial obligation, and reviewing the estimate with the patients prior to their appointment or when they check in. When a patient knows upfront the estimated financial obligation, he or she is more likely to pay all or some of the bill at the time of service. To ensure accuracy, staff must collect and enter demographic and insurance information correctly at time of check in. The best practice is to verify coverage and the applicable cost share amounts (i.e., co-payment, deductible, and co-insurance).
Collection Strategies The bottom line: Health care costs money. With payments from patients for services provided poised to make up a larger and far more critical percentage of providers’ total revenue, bad debt can no longer be viewed as simply a cost of doing business. It now has the potential to damage your practice. For many practices, it’s a change in thinking.
Practices need to ensure that the policies and procedures that are in place are doing everything possible to prevent balances from becoming delinquent, such as: • Collecting payment (e.g., co-payment, co-insurance, deductible) prior to services being provided • Increasing the pace of collections to include reducing the number of days between when a bill is sent and when payment is due. There is no better time to collect than when the patient is already at the office. This will help to avoid wasting more time and money for billing patients later. Even if a patient is not able to pay in full, the opportunity for patients to pay a portion of their bill or set up a payment arrangement with automatic withdrawals is one that is becoming more prevalent. Practices should also: • Implement a solid financial and billing policy detailing expectations for charging, billing, and collection of accounts receivable. • Educate patients, especially new patients, on their financial responsibilities and on their billing policies and procedures. This will encourage compliance. Some examples are office brochures, welcome letters, and websites. The information should include the insurance companies the practice participates with as well as policies for collecting co-payments, deductibles, co-insurances, as well as payments for noncovered services. Information should also be included on the practice’s process for filing claims, credit cards that are accepted, the process and timing for sending out patient statements, when payment is due, and the policy for turning balances over to a collection agency. • Review financial policies annually, especially due to the ever-changing rules of private and public health insurance carriers. • Ensure that office staff is fully knowledgeable of
the policies and procedures, as well of any changes that may be made to the financial policy. • Train front office staff to double-check for past due balances on the patient account and consider reminding the patients of such balance. • Consider payment plans. The patient may be more inclined to make a payment or pay the balance if this option is available. Find more tools, valuable information, and suggested strategies from the Pennsylvania Medical Society (PAMED) at www.pamedsoc.org/collections.
Hard to Collect Balances For those hard to collect balances, practices should follow their protocols listed in their financial policy and procedure manual, such as phone calls, late payment notices, and the process for placing patients on payment plans. The practices’ physicians should also be fully aware of the financial policies and procedures, because many times physicians want to know who may be sent to a collection agency. Some practices find it very difficult to pursue patients who owe the practice money or who fail to pay their co-payments, deductibles, co-insurances, or past due balances at time of service. However, it is important to keep in mind that the physician has provided important services to the patient and deserves to be paid for such services. When the patient claims he or she cannot pay a balance due, the practice should do their due diligence to work out a payment arrangement that is comfortable for both parties. For those patients who simply refuse to pay their balance, this should be handled in accordance with the practice’s financial policy. It must be understood that health care costs money. If the patient is truly in difficult circumstances, the practice’s willingness to work with the patient will show patient loyalty and goodwill.
Changing Your Thinking on Patient Collections, Medical Practice Insider www.medicalpracticeinsider.com/best-practices/changing-yourthinking-patient-collections How to Clearly Communicate Patients’ Financial Obligations, Medical Practice Insider www.medicalpracticeinsider.com/best-practices/how-clearlycommunicate-patients-financial-obligations Paying a Visit to the Doctor: Current Financial Protections for Medicare Patients When Receiving Physician Services, Kaiser Family Foundation http://kff.org/medicare/issue-brief/paying-a-visit-to-the-doctorcurrent-financial-protections-for-medicare-patients-whenreceiving-physician-services/ Carol Bishop is associate director of practice economics and payer relations at the Pennsylvania Medical Society.
References Collection Protocols for the Medical Practice, PAMED www.pamedsoc.org/collectionprotocols Patient Liquidity at Time of Service Big New Problem for Providers, Insurers, Managed Care www.managedcaremag.com/archives/2014/3/patientliquidity-time-service-big-new-problem-providers-insurers Higher Copayments and Deductibles Delay Medical Care, A Common Problem for Americans, Managed Care www.managedcaremag.com/archives/1001/1001. downstream.html
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The Art of Chester County
The Art of Chester County BY BRUCE A. COLLEY, DO
illiam Robinson “Rob” McIlvaine, 1948—2012, came from an original Chester County family who are well known in the Exton-Downingtown area. They were among the first to farm the rich soils of the central Chester Valley. A part of the Baby Boomer generation, Rob was an accomplished film maker, writer, and to his neighbors and friends –the artist. He was a contemporary of other Chester County artists such as Peter Sculthorpe and Jamie Wyeth, who are known for their artistic renderings of Chester County landscapes and structures such as barns and bridges. Rob was admired for his ability to capture “faces,” whether human or animal, and personal objects that radiated the personality of the owner. Rob’s unfortunate passing left many faces unrendered by his skilled eyes and hands.
Flock of Sheep done in 1993 of his neighbor’s flock
Bruce A. Colley, DO, is vice president of the Chester County Medical Society.
Mary C. Howse, depiction of Mrs. Howse, a grand lady of Exton who dedicated her life to the education of the children of West Whiteland Township
Dog and Tulip, a colorful rendering of the dog of Rob’s daughter
Shoes, Rob’s worn hiking boots Women and Child, painted in the 1960s in Japan where Rob was stationed as a Navy corpsman
Dog and Barn, rendering of a friend’s dog
Flowers in a Tree, a study of color and form
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CHESTER COUNTY HOSPITAL:
Quality Care for Cardiac Patients
hester County Hospital’s implementation of specific quality improvement measures outlined by the American Heart Association for the treatment of patients who suffer severe heart attacks has been recognized. The hospital earned the Mission: Lifeline® Silver Receiving Quality Achievement Award. Each year in the United States, approximately 250,000 people have a STEMI, or ST-segment elevation myocardial infarction, caused by a complete blockage of blood flow to the heart. To prevent death, doctors must immediately restore blood flow, either by surgically opening the blocked vessel or by administering a clot-busting medication. The American Heart Association’s Mission: Lifeline program helps hospitals, emergency medical services, and communities improve treatment response times for people suffering a STEMI. The goal is to streamline systems of care to get heart attack patients from the first 911 call to hospital treatment as quickly as possible.
“Chester County Hospital is dedicated to improving the quality of care for our patients who suffer a heart attack, and the American Heart Association’s Mission: Lifeline program is helping us accomplish that goal through internationally respected clinical guidelines,” said Timothy Boyek, MD, Medical Director, Interventional Cardiology, Chester County Hospital. “We are pleased to be recognized for our dedication and achievements in cardiac care, and I am very proud of our team.” Chester County Hospital earned the award by meeting specific criteria and standards of performance for the quick and appropriate treatment of STEMI patients to open the blocked artery. Before patients are discharged, they are started on aggressive risk reduction therapies such as cholesterol-lowering drugs, aspirin, ACE inhibitors, and betablockers. If needed, they receive smoking cessation counseling. Eligible hospitals must adhere to these measures at a set level for a designated period to receive the awards.
The hospital’s Medic 91 paramedic service also received recognition, earning the American Heart Association’s Mission: Lifeline® EMS Bronze for its commitment and success in implementing specific quality improvement measures for the treatment of patients who suffer a STEMI. Emergency Medical System providers are vital to the success of Mission: Lifeline. EMS agencies provide education in STEMI identification and access to 12-lead ECG machines and follow protocols derived from American Heart Association/American College of Cardiology guidelines. The correct tools and training allow EMS providers to rapidly identify the STEMI, promptly notify the medical center, and trigger an early response from the awaiting hospital personnel. Agencies that receive the Mission: Lifeline Bronze award have demonstrated at least 75 percent compliance for each required achievement measure for three months (one quarter), and treated at least four STEMI patients for the year.
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Case Study: Woman with Cardiac Arrest and Prolonged Coma Secondary to Hypoxic Encephalopathy Caused by Viral Myocarditis BY M. KOURESCH JAN AND MIAN A. JAN, MD
43-year-old Caucasian female was brought to the emergency room following a cardiopulmonary arrest witnessed by her husband who then began cardiopulmonary resuscitation and called emergency medical services. The paramedics found the patient in full arrest and the rhythm on the monitor was found to be ventricular fibrillation. They started the advanced life support protocol and shocked her a few times. The patient did not regain any stable rhythm and required cardiopulmonary resuscitation and oxygenation via mechanical intubation throughout the drive to the emergency room. During the 37 minutes that the patient did not have stable rhythm or hemodynamics, she received constant chest compressions and oxygenation via endotracheal tube. In the emergency room she was again defibrillated and a broad complex rhythm surfaced. The patient was placed on a respirator.
diminished. Laboratory data – CT head unenhanced: unremarkable. X-ray chest: Infilitrate in right upper lobe. CT chest: Upper lobe opacities; likely aspiration. Atelectasis over bases bilaterally. No evidence of pulmonary embolism. CBC - Hemoglobin: 11.8 g/dL, WBC: 9.90 K/uL (48% lymphocytes) Renal Panel – Na: 138 mmol/L, K: 3.1 mmol/L, Cl: 102 mmol/L, Cr: 1.18 mg/dL, Anion Gap: 20 mmol/L (n=2-12) Liver Panel – LDH: 403 IU/L, ALT : 148 IU/L, AST: 132 IU/L, Total Bilirubin: 0.3 mg/dL, Alkaline Phosphatase: 57 IU/L Cardiac Markers – Triponin I: 0.14 ng/mL (n=<0.08), CPK: 912 IU/L (CKMB: 39.8 ng/mL with a relative index of 4.4), Lactate 14.4 mmol/L (n=0.5-2.2) ABG –d pH: 6.97, pCO2: 55 mmHg, pO2: 130 mmHg, HCO3-: 12.7 mmol/L (on respirator)
History and Exam Results Essentials of the patient’s history, obtained from her husband, were unremarkable. She had no allergies and was not taking any medication. The patient even had dinner with friends the night before without issue. The patient is married, is a housewife with two young children, and has no prior history of drug, alcohol, or nicotine abuse. There is no significant family history of premature heart disease. There is no family history of sudden death. A review of systems was also unremarkable other than the fact that in recent days the family has been suffering from upper respiratory symptoms that they felt could be flu. Physical exam: Vital signs – BP was initially unrecordable; after adding epinephrine and dopamine, the BP came up to 100 systolic. Pulse was 96. General – Patient is intubated and nonresponsive. Head – Normocephalic without trauma. Eyes – Pupils nonreactive to light. Extraocular muscles could not be checked. Fundoscopic exam showed no pathology. Neck – Supple. Cardiovascular – PMI in 5th space. Both heart sounds are audible. No murmurs, rubs, or gallops. CNS – Patient was comatose at time of exam. Extremeties – No pedal edema. Distal pulses were CHESTER COUNTY
Initial Course During Hospitalization Our working diagnosis in the absence of intracranial lesion and pulmonary embolism was ventricular fibrillation likely secondary to non-ST elevation myocardial infarction or acute cardiomyopathy with development of hypoxic encephalopathy secondary to prolonged hemodynamic instability and pneumonia secondary to aspiration. The rise in liver enzymes was likely related to hemodynamic compromise from diminished flow secondary to shock. We corrected the electrolyte imbalance and kept the patient’s blood pressure in an acceptable range with ionotropic agents. Broad spectrum antibiotics were started for likely aspiration pneumonia. We took the patient from the emergency room to the cath lab where the patient was having runs of ventricular tachycardia. We stopped the dopamine because we felt the ionotropic agent might be causing myocardial irritability. We also started the patient on IV amioderone drip; boluses had already been given earlier. We had spoken to the family regarding the possibility of hypothermia treatment to combat prolonged hypoxia to the brain. Using Seldinger technique a hypothermia quatro catheter was placed in her right femoral vein. We also left an arterial line and a large bore central venous catheter in place for close monitoring of hemodynamic status. 24
Jan & Jan
The patient was admitted to ICU and was quickly cooled to 33 and 33.5 degrees Celsius. Portable echo was performed at bedside which showed severe LV dysfunction and ejection fraction of 31%.
Initial echo revealed dilated left ventricle and severe LV dysfunction with a calculated ejection fraction of 31%.
Remainder of Hospital Stay After 24 hours of hypothermia, the patient was gradually rewarmed. In the next few days, she started responding to physical and then verbal stimuli. Her mental faculties gradually improved. Her hemodynamic status returned to normal as did her labs. She was treated with ACE inhibitors and carvedilol as per American Heart Association recommendations for cardiomyopathy. A PEG feeding tube was also placed. A repeat echo showed slight improvement of the LV function. The patient was transferred to a rehabilitation hospital in stable condition. In view of her history of ventricular fibrillation arrest, a life vest was placed on transfer to rehabilitation hospital with plans of placing an AICD if her LV function did not improve. The patient continued to show improvement in her neuro status and subsequently had an AICD implanted since her ejection fraction had not improved beyond 40%. A year later the patient has completely regained her mental capacities and enjoying a full life with her family. She is off almost all of her medications and her heart function has returned to normal. continued on next page
Echo six months later; almost normal LV function and size. A consult was obtained with neurology and the initial evaluation was: “Patient shows evidence of significant anoxic encephalopathy with persistence of some brain stem reflexes. At the present time, it is hard to make any prognostication until such a time that she is extubated and seen whether or not she can speak or how much and how much comprehension she has. It is very likely that her neurological functionality would be compromised, and therefore the prognosis is guarded at this time.” A portable electroencephalogram was done in ICU which showed generalized slow activity indicative of generalized brain dysfunction compatible with anoxic encephalopathy. Workup during next few days revealed: CRP – 38.7 mg/L WBC – 21.12 K/uL Parvovirus B19 IgG antibody – 6.23 IV (n=<0.89), IgM: 0.13 IV CMV IgM – <8 IV Mycoplasma – 0.24 U/L Coxsackie B Virus Type 6 – 1:40 (n=<1:10) Echo virus – <1:10 Adenovirus AB IgG – 2.11 Units (n=<0.89) Legionella – Negative Lipid profile – Cholesterol: 80 mg/dL, Triglycerides: 46 mg/dL, LDL: 27 mg/dL
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See examples of our photography www.PamHeslerPhoto.com/business.html Schedule a phone or in-person appointment to talk about your practice needs and how we can help. firstname.lastname@example.org | 484.356.4016 25
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Discussion In summary, we have presented a case of out of hospital cardiac arrest with prolonged hypoxic encephalopathy most likely caused by viral cardiomyopathy. Viral infection of the heart is relatively common and usually of little consequence. It can, however, lead to substantial cardiac damage and severe acute heart failure. It can also evolve into a progressive syndrome of chronic heart failure. Acute myocarditis can present in various ways; it may present as sudden death, as in our patient, or a more chronic process.
Etiology Myocarditis can be initiated by several different agents including parasites, protozoa, and fungi, but the most common cause is usually viral in nature. The Coxsackie B virus is most often implicated in viral myocarditis, which was likely the case in this patient. Other viruses such as adenovirus, influenza, herpes, CMV, Epstein-Barr, mumps, rubella, and HIV can also cause myocarditis.
Clinical Manifestation The majority of patients may remain asymptomatic or have non-specific symptoms such as upper respiratory flu-like symptoms, chest pain, fever, and general malaise. Our patient likely had antecedent flu-like syndrome but presented with a clinical syndrome mimicking acute myocardial infarction and sudden death.
Laboratory Data EKG has non-specific findings that include intraventricular conduction delay, bundle branch block, ST-T wave abnormalities, and ventricular tachyarrhythmias. Our patient presented with most of the aforementioned findings. First EKG showed PVCs, incomplete left bundle branch block and non-specific ST-T wave abnormalities.
Pathogenesis A complex immune and viral mediated mechanism likely caused the cardiac damage. After viral invasion of the myocardium, the first wave of infiltrating immune cells consist of natural killer (NK) cells that are thought to be cardioprotective and limit virus replication. This infiltration is accompanied by production of various cytokines, including IL-1B, TNF-a, y interferon, and IL-2B. There’s convincing data showing a detrimental effect of TNF-a in myocarditis. A vasoconstrictor substance endothelin may play a role in the pathogenesis of myocarditis. The T-cells are also involved in the process and play an important role in both viral clearance and immune mediated cardiac damage. A nitric oxide may also be involved in the equation. The virus itself can result in focal necrosis of myocytes and contributes towards the detrimental process. Biopsy finding in a patient with viral mycarditis showing lymphocyte infilitration and myocyte necrosis. Copyright © 2009 Mayo Foundation for Medical Education and Research. Schultz JC, Cooper LC, Rihal CS. Diagnosis and Treatment of Viral Myocarditis. Mayo Clin Proc. 2009;6(11):1001–1009.
EKG later during admission revealed narrower complexes and non-specific ST-T wave abnormalities.
Jan & Jan
Recent EKG showing near normal configuration.
Although the pathophysiology can be immune, immunosuppressive agents have not shown any benefit. For patients like ours who presented in cardiogenic shock, it is crucial to maintain oxygenation and hemodynamic stability. This can be achieved with mechanical intubation, IV ionotropes, intraortic balloon pump, and even LVAD. Treatment of congestive heart itself follows American Heart Association recommendations of ACE inhibitors, beta-blockers, diuretics, and spironolactone. Some data suggest that immune globulins may also be useful.
Blood tests show elevated CRP and WBC count and rise in antibody titers, all of which was present in our case. Echocardiography is helpful but myocarditis maybe segmental since the process maybe focal in nature and thus mimic regional ischemic damage. LV dimensions are usually not increased in the acute phase of myocarditis. Again, these findings were also seen in our patient. Cardiac biopsy can show inflammatory infiltrates with degeneration of myocytes and help exclude other causes. However, the management is not altered and biopsy is usually not indicated.
Prognosis Presentation can be fulminant or non-fulminant and surprisingly even though the fulminant cases have higher initial mortality they do better if they survive the inciting event, as was the case with our patient. Early recognition and treatment of fulminant myocarditis and aggressive hemodynamic support reflects a better prognosis. The myocarditis treatment trial, currently the largest clinical study to evaluate prognosis of myocarditis, shows 20% mortality at 1 year, and 56% mortality rate at 3 years.
continued on next page
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Jan & Jan
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Hypothermia and Hypoxic Encephalopathy
Quattro Hypothermia Catheter
Hypothermia is considered the goldstandard by which the body can protect the brain. Targeted temperature management (TTM) is now used in many major hospitals to minimize neurological injury after cardiac arrest. Several trials have shown that even when the temperature was reduced using cold rags there was still an improvement in outcomes. The newer trials using hypothermia catheters have shown significantly better outcomes in patients surviving out-of-hospital cardiac arrest, especially if rhythm was shockable as was the case in our patient. In patients who do not have a shockable rhythm, benefit was more limited. Pathophysiology of cerebral injury after successful resuscitated cardiac arrest is currently thought to be multifactorial. The initial damage is directly related to the time elapsed from the onset of cardiac arrest to return of spontaneous circulation. Cerebral anoxia not only causes the death of cerebral tissue and neurons but also primes the brain for further injury during the reperfusion phase. Experimental and clinical evidence have shown neuroprotective effect of hypothermia by acting on multiple deleterious pathways. A Barthel Index score (0 score = Totally Dependent, 100 score = Fully Independent) has been used to assess improvement of function and TMH was associated with an increased odds ratio of good neurological outcome with adjusted odds ratio of 1.90, 95 confidence interval: 1.18 to 3.06. Our patient reached a Barthel score of 100 and complete recovery.
Hypothermia Catheter in situ.
M. Kouresch Jan, primary author and researcher of the case study, is beginning his fourth year at Drexel Medical School. He collaborated on the article with Mian A. Jan, MD, an interventional cardiologist at Chester County Hospital.
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The Birth and Death of a Legal/Medical Footnote BY ROBERT HOFFMAN
his is a story about a footnote. Chester County Medicine readers know footnotes from medical professional journal articles they read or write. Lawyers know them too; court opinions and legal writing generally are littered with footnotes. In a few cases, the footnotes in Court opinions achieve greater prominence even than the cases in which they appear. Many law review articles have been written about what lawyers refer to as “Carolene Products footnote 4,” from a 1938 Supreme Court decision on the obscure topic of the constitutionality of a federal law prohibiting “filled milk” from being shipped in interstate commerce. This article is about a footnote in a 1990 decision of the Pennsylvania Supreme Court titled DiMarco v. Lynch HomesChester County, Inc. The case, and the footnote, are about physicians. The footnote stood out because it was unusually mean-spirited and medically very wrong. Here is the story of the life and death of that footnote. DiMarco concerned a Chester County patient with Hepatitis B who alleged that her physicians, Leonard Guinta, DO, and Lawrence Alwine, DO, had told her that it was safe to resume sexual activity after an inappropriately short interval. Mr. DiMarco, the patient’s partner, sued the physicians after becoming infected with Hepatitis B. The Supreme Court held that if those were the facts, the physician could be liable to the partner even though the partner was not the patient. DiMarco was the first Pennsylvania Supreme Court decision, and an important one, imposing a physician’s liability to a non-patient. Since then, many cases have cited it. At issue in this tale is DiMarco footnote 4, written on behalf of four Pennsylvania Supreme Court justices and appended to the last sentence in the Court’s majority opinion. It was thus the Court’s very last words on Mr. DiMarco’s rights. Justice Rolf Larsen (later impeached and removed from the bench for various offenses) wrote:
The physician who fails to properly inform his or her patient about the communicability of the disease that the patient has contracted or to which the patient has been exposed should be at least as culpable as the hacker who unleashes a virus that spreads from computer to computer destroying computer programs and files as it travels. Computer hackers are subject to criminal sanctions and civil sanctions. We can at least assess civil sanctions where a physician’s action or inaction causes the spread of death and disease. It’s a pretty ugly footnote, off-base, mean and wrong. From the mid-1990s through the recent past, I represented the Pennsylvania Medical Society as amicus curiae (Latin for “friend of the court”) in a series of cases in which DiMarco was a relevant precedent. I came across the footnote and it irked me. I had represented many physicians and spoken with many more. I had married one. Some had quality of care or other issues, but none seemed remotely a sociopath. It seemed a sure thing that the physicians whose advice led to Mr. DiMarco’s contracting Hepatitis B, even assuming it happened as alleged, didn’t do so deliberately so as to spread the disease and cause harm. In short, the comparison of a physician to a computer hacker reflected a view of physicians that was inconsistent with everything I knew about physicians. It’s bad enough when a court gets the medicine wrong, as happens, but this seemed to be an entirely different order of wrongheadedness about physicians in general. The implicit notion that the physician defendants were lucky they weren’t facing criminal charges was over the top. A judge who thought the analogy apt, as four justices apparently did, was unlikely to rule in a physician’s favor in much of anything. But doing something about the footnote seemed all but impossible; there is really no available process to get a Court to change
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PMSLIC Transitioning Policyholders to NORCAL
or more than 35 years, PMSLIC Insurance Company, now a wholly owned subsidiary of NORCAL Mutual Insurance Company, has served the medical community with the promise of providing the highest quality products and services. Continuing in this spirit, NORCAL Mutual is integrating its subsidiaries and undergoing a strategic expansion to become one national mutual insurance company to provide policyholders greater services and resources as well as increased options. New offerings will include information and network security and administrative defense insurance. Beginning August 1, PMSLIC policyholders will transition to NORCAL Mutual at their next renewal. Policyholders will continue to receive the same exceptional level of personal service and attention that has been a hallmark, and will also work with the same service teams. “We will be notifying each of our policyholders of any potential changes to their coverage as they approach their renewal period and will endeavor to make this conversion as seamless as possible for our policyholders,” the company stated in an announcement. With the transition to NORCAL Mutual, policyholders will be offered coverage with a newly filed policy that enhances existing offerings. As members of a mutual company, policyholders will have the right to vote in the election of the NORCAL Mutual board of directors and share in any dividends. “We are very excited about this next phase of our growth,” the announcement stated. “Our company is dedicated now more than ever to serving our policyholders, and to providing the protection and peace of mind they have come to expect.”
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language it uses in an opinion. Then, in 2011, I was writing yet another amicus brief for the Medical Society in the Pennsylvania Supreme Court in another DiMarco type case, called Seebold v. Prison Health Services, Inc. I decided to take a shot at the footnote and see what would happen. Seebold focused on whether prison physicians were liable to prison guards who had assertedly contracted MRSA from prisoners whom the physicians had either misdiagnosed (assertedly as flea bites) or failed to order be quarantined. My Supreme Court brief necessarily discussed how DiMarco affected the decision in this case and, as I did so, I addressed the footnote. Doing so was a little off the point, but it was part of criticizing DiMarco as a precedent, and the Medical Society’s general counsel said, “OK.” I wrote: Finally, Justice Larson’s majority opinion ends with a discussion that, the Medical Society respectfully submits, reflects a view of physicians that is unduly harsh and entirely inapt: it compares a physician who misdiagnoses a communi cable disease to a “hacker who unleashes a virus that spreads from computer to computer destroying computer programs and files as it travels.” The latter, Justice Larson noted, were subject to criminal and civil sanctions, and physicians “should be at least as culpable.” A computer hacker intends to harm others; physicians, even when they err, do not. No physician misdiagnoses MRSA (or makes any other error) with the intent that the patient, and those the patient comes into contact with, will suffer. In most cases, the condition that the physician failed to diagnose was not as apparent at that time as it became in hindsight. In December 2012, the Supreme Court issued a lengthy and thoughtful decision in Seebold, ruling in the physician’s favor. Much to my delight and surprise, the Court also righted the wrong inflicted by the footnote. Justice Thomas Saylor, on behalf of five justices, wrote a new footnote that relegated DiMarco footnote 4 to the ash heap, as follows: As an aside, the Medical Society finds a broad-scale analogy drawn by the DiMarco Court between a negligent medical professional and a computer hacker … to be particularly unjustified and unfortunate. See Brief for Amicus Pa. Med. Soc’y at 23-24 (“A computer hacker intends to harm others; physicians when they err, do not.”). We agree with the Medical Society on this point and, accordingly, disapprove this particular comment from DiMarco. Needless to say, I like the new footnote – Seebold footnote 11 —a whole lot better. Editor’s Note: A more legally oriented version of this article appeared in the March-April, 2014 edition of The Pennsylvania Lawyer magazine.
Robert Hoffman is an attorney with Eckert Seamans Cherin & Mellot, LLC. Based in Harrisburg, he concentrates his practice on health law and general civil litigation, as well as counseling on health law regulatory, licensing, and contract issues.
Membership News & Announcements
Members in the News Grant Hubbard, last year’s winner of the CCMS scholarship, has been
To publ i new CC sh photos of MS m physici ans, pl ember ease su digi bmit admin tal copies to @chest ercms.o rg
accepted to Drexel Medical School in the Fall 2014 entering class. The scholarship is given in memory of CCMS Founder William Darlington, MD. 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. Cardiology Consultants of Philadelphia-Main Line Cardiology Consultants of Philadelphia-Paoli
The annual CCMS Clam Bake gives Chester County physicians and legislators an opportunity to share a casual evening of excellent food and conversation
Cardiology Consultants of Philadelphia-West Chester
Join Us Friday, September 12, 2014 6:00 pm – 9:00 pm Radley Run Country Club Clubhouse Dining Room $45.00 per person for CCMS members and guests; $60.00 for non-members and guests
Chester County Otolaryngology & Allergy Associates Clinical Renal Associates-Exton Devon Family Practice LLP Gateway Family Practice Downingtown Gateway Medical Colonial Family Practice Great Valley Medical Associates PC Levin Luminais Chronister Eye Associates Main Line Dermatology Main Line Gastroenterology Associates
Medical Inpatient Care Associates Paoli Hematology Oncology Associates PC Plastic & Reconstructive Surgery of Chester County PC Village Family Medicine Wade Townend Pediatric Associates West Chester GI Associates PC
Refreshments and hors d’oeuvres will be served on the patio at 6:00 pm, followed by a delicious buffet of filet mignon, shrimp, crab, tilapia, chicken, mouth-watering desserts…and yes…clams!
To make your reservation, contact firstname.lastname@example.org
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CCMS Membership: Resources You Need Building
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 email@example.com, 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: ____________ Spouse’s 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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Snapshot of the Health of County Residents Demographic Median Age of the Population % Population Aged 65 and Over % Population With Income Below Poverty Level Population Population Per Square Mile Birth Rate Per 1,000 Population
Data 39.0 13.1 6.1 503,897 (247,522 females; 256,375 males) 671.4 11.1
Reported Incidence and Average Annual Rate Per 100,000 for Select Notifiable Diseases Disease Chlamydia Lyme Disease Gonorrhea Salmonellosis Hepatitis B (Chronic) Varicella Giardiasis Pertussis Rabies (Animals) Tuberculosis
Total 2,573 2,395 539 272 118 118 95 73 65 23
Rate 171.3 159.5 35.9 18.1 7.9 7.9 6.3 4.9 N/A 1.5
Major Causes of Death, Number and Average Annual Age-Adjusted Death Rate Per 100,000 Cause Heart Diseases Cancer Stroke Chronic Lower Respiratory Disease Accidents Alzheimerâ&#x20AC;&#x2122;s Disease Diabetes Mellitus Nephritis/Nephrosis Influenza/Pneumonia Septicemia
Total 2,707 2,649 532 478 451 330 173 220 205 169
Rate 164.8 163.3 32.9 30.3 29.1 20.2 10.5 13.7 12.7 10.5
Source: Pennsylvania and County Health Profiles 2013, Pennsylvania Department of Health Bureau of Health Statistics and Research CHESTER COUNTY
EXCELLENCE. ONE OF THE TOP IN THE NATION. RIGHT HERE.
By focusing on quality care for patients and doing what’s right, we have received national recognition. The Joint Commission recognizes Brandywine Hospital* with the distinction of 2012 Top Performer on Key Quality Measures® for attaining and sustaining excellence in the following measure sets: Heart Attack, Heart Failure, Pneumonia and Surgical Care. So what does this recognition in using evidence-based care mean for you? Peace of mind in knowing that our local care is among the top in the nation. Find out more at BrandywineHospital.com.
It’s better at Brandywine. *Coatesville Hospital Corporation d/b/a Brandywine Hospital
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PMSLIC is committed to its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. For more information contact your agent, or call Laurie Bush at PMSLIC at 800-445-1212, ext. 5558 or email firstname.lastname@example.org. Or visit www.pmslic.com/start for a premium estimate.
A NorcAl Group compANy
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