Medical record Fall 2013

Medical Record AUTUMN 2013

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t h e

B e r k s

C o u n t y

M e d i c a l

S o c i e t y

Tomorrow’s Doctors: Are We Training Them Today?

Tomorrow’s Doctors.......................................................8 Dental Disease: Medical/Dental Collaboration..24

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Treating Cancer Faster, with More Versatility, and Better Results

Medical Record

of the Berks County Medical Society

A Quarterly Publication

To provide news and opinion to support professional growth and personal connections within the Berks County Medical Society community.

The Berks County Medical Record

Lucy J. Cairns, MD, Editor Editorial Board

D. Michael Baxter, MD Emma Singh, RPh, MD Betsy Ostermiller Bruce Weidman

Berks County Medical Society Officers

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Pamela Q. Taffera, DO, MBA, President Kristen Sandel, MD , President-Elect

D. Michael Baxter, MD, Chair, Executive Council Michael Haas, MD, Treasurer Andrew Waxler, MD, Secretary William C. Finneran III, MD, Immediate Past President Bruce R. Weidman, Executive Director

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Berks County Medical Society, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610 Phone: 610.375.6555 | Fax: 610.375.6535 | Email: info@berkscms.org

The opinions expressed in these pages are those of the individual authors and not necessarily those of the Berks 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 Berks County Medical Society.

Manuscripts offered for publication and other correspondence should be sent to 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. The editorial board reserves the right to reject and/or alter submitted material before publication.

All manuscripts and letters should be typed double-spaced on standard 8 1/2"x11" stationery.

The Berks County Medical Record (ISSN #0736-7333) is published four times a year in March, June, September, and December by the Berks County Medical Society, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. Subscription $50.00 per year. Periodicals postage paid at Reading, PA, and at additional mailing offices. POSTMASTER: Please send address changes to the Berks County Medical Record, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610.

readinghealth.org | N-Building | Ground Floor | 484-628-8067

BECOME A MEMBER TODAY!

AUTUMN 2013

Go to our website at

www.berkscms.org

and click on “Join Now” Cover Photo by Lucy J. Cairns,MD

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A President’s Message An Message from the President

Tomorrow’s Doctors: Are We Training Them Today?

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FAQ’s on Exchanges, Market Reforms and Medicaid

By Lucy J. Cairns,MD

By Jessica Dean, Employee Benefit Consultant

14 Pennsylvania Physician’s Health Care Program

By Kelly Royer

24

Dental Disease: Why Medical/Dental Collaboration

By Dr. Eve Kimball, MD

Departments: Editor’s Comments................................................................................................................................................................ 4 President’s Note.................................................................................................................................................................... 6 Legislative and Regulatory Updates..................................................................................................................................... 18 Members in the News......................................................................................................................................................... 30 Alliance Update.................................................................................................................................................................. 34 BCMSA Events Calendar..................................................................................................................................................... 35 Department of Family Medicine Lecture Series Fall 2013..................................................................................................... 36

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EDITOR’S COMMENTS

Lucy J. Cairns, MD, Editor

T

he feature article I wrote for this edition of the Record involves predictions about the future. Not the near future, like next week or next year, but looking ahead 10 years and more. Many experts in forecasting future workforce needs are predicting that a dire shortage of physicians is in store for our country—somewhere between 90,000 and 130,000 too few doctors.. In response to these predictions, American medical schools have undertaken a significant expansion and new schools are coming online.

A bottleneck is developing, however, at the point where M.D. and D.O. seniors set about planning the next step required to becoming fully qualified: post-graduate residency training.

The federal government, through provisions in the Medicare program, is by far the major source of funding for Graduate Medical Education (GME), and in 1997 legislation was passed which capped the number of such residency positions at the 1996 level. Thus, the worsening bottleneck, as an increasing number of graduates of U.S. medical schools compete for these positions with each other and with U.S. and non-U.S. graduates of foreign medical schools.

Meanwhile, the U.S. population is growing, aging, developing more obesity and other chronic health conditions, and hopefully will soon have wider health insurance coverage.

Given the current economic and political climate, Congressional action that would increase spending is about as likely as my winning the next Powerball lottery (although I admit to dreaming that both of these happenings will one day come to pass). So what will the future look like?

Will people insured by Medicare and Medical Assistance

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be standing in line behind people with insurance that reimburses providers at a better rate? Will over-worked doctors burn out from the stress of trying to care for too many people, exacerbating the shortage?

Predicting the future requires making assumptions, because no one knows exactly what is going to happen. As the disclaimer for every mutual fund states, “past performance is no guarantee of future returns.” There are many unknowns when it comes to predicting future demand for physician services. Will aging physicians actually retire at the rate indicated in surveys? Will the planned shift from the pay-for-volume model to the pay-for-value model of physician payment translate into fewer office visits per patient? How much of the increased demand for health care will be shifted to Physician Assistants and Nurse Practitioners? Will the team-based model of primary care reduce the demands on physicians or increase them?

One thing that does seem certain is that physicians will continue to face a rapidly-changing environment. Adapting to new practice arrangements and new payment models will be very challenging. Physicians need to be pro-active and serve in leadership roles in the organizations implementing these changes or risk becoming less and less able to provide care in the manner we believe is best for our patients.

PAMED and the Berks County Medical Society are the means by which we can support one another and work together to achieve the best outcomes for ourselves and our patients.

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presidents message

Pamela Q. Taffera, D.O., MBA

A

s 2013 draws to a close, it is a strange year to reflect upon. This is a time in which we have only started to realize that the reform needed in healthcare is not “health insurance reform,” but instead, “healthcare delivery reform.” We continue to face the challenges of implementing the Affordable Care Act, repealing the SGR, understanding the consequences of a government “shut down”, and facing the fiscal cliff…again. This is also a time where our state of the art medical schools increasingly fill seats with bright young aspiring medical students, but graduate medical education programs cannot offer enough training positions for these doctors. Negotiation between the ACGME and AOA for a unified match came to a screeching halt, and as of 2015, residents graduating from AOA programs that are not dually or ACGME accredited will not be welcome to apply to ACGME fellowships. Further, within our graduate medical education programs, we struggle to deliver the finest medical training available amidst work hour rules and lack of funding. As I face my colleagues, family medicine residents, and medical students each day, I struggle to offer them an explanation for our system’s failure to meet the needs of patients and healthcare providers alike. In times like these, where one may feel hopeless, I can only offer hope and optimism, as it is ingrained in my personality.

I remain full of energy to bound out of bed each day and meet these challenges. I get to (not have to!) work, each day, with the most amazing students, residents, physicians, nurses, case managers, physical and occupational therapists, pharmacists… and patients. It is the patients and young physicians who remind me most of the blessings of our profession in medicine. It is the docs who take time out of their days to show my residents their “firsts” (first STEMI, first central line, first C-section, first newborn, first end of life discussion…) who inspire me to be an educator like my mentors before me. It is the hard working poor of our

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community who desperately need healthcare services and the physicians who offer amazing care (without taking into account a patient’s ability to pay for services), who remind me why I chose this career path. And after spending my last 7 years in Berks County, it is the folks of this beautiful area that remind me why I am thrilled to hang a shingle and call it home.

Your incoming president, Dr. Kristen Sandel, offers leadership, wisdom, and experience like our county medical society has never before experienced.

As I exit my presidency of the Berks County Medical Society, I look to 2014 with excitement and anticipation of a better year to come. Your incoming president, Dr. Kristen Sandel, offers leadership, wisdom, and experience like our county medical society has never before experienced. Under her leadership, I expect the BCMS will go places it never has before and be represented at PAMED with dignity and honor throughout the changes and crises our healthcare system is facing.

In this challenging time I am reminded from my Jesuit education at The University of Scranton, “To whom much is given, much is expected” (Luke, 12:48). I will dedicate my career to providing quality care to the patients of our community and to educating and mentoring young physicians, with hopes that they too will be inspired to call Berks County home.

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Tomorrow’s Doctors: Are We Training Them Today?

By Lucy J. Cairns, MD

Background Every once in a while, an influential report warns of an impending shortage or surplus of physicians in the U.S. When this occurs, policymakers tend to take note and then take action to prevent the crisis. The reports (plus one piece of legislation) that have had a major impact on the number of physicians trained in the U.S. are as follows:

1959 The Bane Report (“Physicians for a Growing America”). This report was generated by the Surgeon General’s Consultant Group on medical education at a time when the U.S. economy and population were booming. It forecast a huge shortage of physicians and recommended federal subsidies for medical education.

Result: Federal and state funds began flowing to medical schools, and the number of students graduating from U.S. schools doubled between 1965 and 1980. In 1980, the aggregate entering class for allopathic schools numbered 18,200.

1980 The Graduate Medical Education National Advisory Committee issued a report warning of an impending doctor glut and recommended reduced government support for medical education.

Result: Allopathic medical school enrollment flattened.

The aggregate entering class of 2011 numbered 18,655 – just 455 more students than in 1980

1997 The Balanced Budget Act of 1997 was designed to produce a balanced federal budget by 2002. Among the provisions aimed at reining in the growth of Medicare spending was one which capped the number of medical residency positions Medicare would support via Direct Medical Education payments. The cap was set at the number of such positions reported at the end of 1996.

Result: Since the Medicare program was (and still is) the major source of funding for Graduate Medical Education, the number of residency positions available has been fairly stagnant for 15 years.

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2006 American Association of Medical Colleges (AAMC) called for a 30% increase in U.S. allopathic medical school enrollment in response to a looming physician shortage.

Result: Both allopathic (MD) and osteopathic (DO) medical schools began increasing class size and new schools have opened while others are being planned.

The size of the entering class for MD schools is expected to reach the 30% increase mark (compared to the 2002 baseline) by 2017. When the expansion of osteopathic education is factored in, the total increase compared to 2002 is projected to be 44%.

Fig. 1 Aggregate First-Year Enrollment for Entire U.S.

Fig. 2 Entering Medical School Class (PCOM figures are for the Philadelphia campus only) The Graduate Medical Education Squeeze An increased number of medical school graduates, however, does not automatically generate an increased number of fully trained, practicing physicians. In order to be granted a license to practice, medical school graduates must successfully complete post-graduate residency training (GME). And with the number of residency slots available increasing at a much slower pace than medical school enrollment, the number of doctors available to fill future needs will continue to fall short. In addition, more and more graduating medical students will fail to obtain

the training necessary a license to practice. Centralized “match” programs are the processes by which graduates rank the GME programs they prefer, the programs rank the candidates they prefer, and a computer algorithm maximizes the outcome for both.

2013 Residency Match Results

1. NRMP (National Resident Matching Program) for ACGME-accredited GME programs. This is the program that matches most medical school graduates with a PGY-1 (Post-Graduate Year 1) position. Those eligible to participate include: Senior students in U.S. allopathic and osteopathic medical schools (U.S. Grads) U.S. citizen graduates of international medical schools (U.S. IMGs) Certified non-U.S. graduates of international medical schools (Non-U.S. IMGs) Other (previous U.S. Grads, 5th Pathway students, Canadian med school grads)

In 2013 there were 26,392 PGY-1 positions and 2,779 PGY-2 positions available through NRMP. Type of Participant

Number of Participants

% Successfully Matched

U.S. MD

17,487

93.7%

U.S. DO

2,677

75.4%

U.S. IMG

5,095

53.1%

Non-U.S. IMG

7,568

47.6%

2. AOA Match (American Osteopathic Association) for OCGME-accredited programs. This is the osteopathic equivalent of the NRMP, and MD graduates are eligible to participate. The AOA website gives the following information regarding the results of the 2013 Match:

Positions funded: Positions filled:

2900 1891

The number of DO graduates in 2013 was not provided, but this figure has been increasing every year recently, and in 2012 there were 4,458 graduates of U.S. osteopathic medical schools.

At the end of Match Day 2013, 1,097 U.S. MD seniors had not obtained a PGY-1 position. Of these, 595 obtained positions during the week following the Main Match.

In the final analysis, 97% of U.S. senior MD students were successful in the 2013 Match, down from 98.5% in 2012.

The number of students graduating from U.S. medical

schools and the number of U.S. citizens attending medical school outside the U.S. has been growing for years, and this trend is expected to continue. Without significant expansion of opportunities for Graduate Medical Education, more and more Americans with a medical education will be blocked from completing their training and from providing care. And since U.S. citizen graduates tend to be more successful obtaining GME positions than non-U.S. International Medical Graduates, it is likely that fewer and fewer IMGs will enter U.S. training programs.

Fewer IMGs could exacerbate the existing shortage of physicians in primary care specialties, since historically IMGs train in primary care at twice the rate of U.S. graduates. In addition, access to health care in rural and other underserved areas would very likely become even more problematic than it is today, since many IMGs practice in such areas in exchange for visa waivers which allow them to remain in the U.S. at the completion of their training.

Should We Really be Worried?

If the U.S. has really been heading into a worsening physician shortage for the last 7 years, why is the number of residency positions given direct support under Medicare still capped at the 1996 level? First, consider that lifting this cap would require Congressional action—action that would result in increased government spending. Second, not all who have the ear of policymakers agree that increasing the supply of physicians is necessary or even desirable.

Yes, We Are In Trouble!

• Aging population: 35% increase in number over 65 y.o. projected between 2010 and 2020.

• Retiring Baby Boomer physicians: almost 1/3 of all physicians practicing in 2010 expected to retire by 2020. Some are likely to limit their work hours as they approach retirement.

• Expansion of health insurance under the Affordable Care Act • Increasing numbers with chronic disease(s): obesity epidemic, diabetes, heart disease …

• Decreased “work effort” on the part of women physicians and younger physicians, who are making up a larger and larger component of the physician supply.

These physicians are placing more importance on work/life balance than prior generations.

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• Decreased productivity of employed physicians: the recent rapid shift from private practice to employment tends to alter productivity incentives.

• Decreasing proportion of physician graduates entering full-time clinical practice

An article published in the Nov/Dec 2012 issue of the Annals of Family Medicine projected the demand for primary care physicians for 2010-2025 taking into account implementation of the Affordable Care Act. Using 2008 data on demand for office-based primary care, the authors concluded that the U.S. will need an additional 52,000 primary care doctors by 2025: 33,000 needed to accommodate population growth; 10,000 in response to the aging of our population; and 8,000 due to expansion of insurance coverage. Without immediate changes in undergraduate and graduate medical education and improved incentives for choosing a career in primary care, the U.S. will not produce the physicians we need.

A specialty physician shortage of almost equal magnitude has been predicted by the Council on Graduate Medical Education, many of the national medical specialty organizations, and Dr. Richard Cooper, among others.

No, We Are Not Facing a Physician Shortage!

• Shift away from volume-based physician payment system and toward value-based reimbursement model is expected to reduce unnecessary” care.

• Team-based care models, such as the Patient-Centered Medical Home, may allow each physician to cover more patients through involvement of Physician Assistants, Nurse Practitioners, and other team members.

• Improved communication using technology could reduce the need for office visits.

• “Increasing the number of physicians will make our health care system worse, not better.”

The preceding quote is taken from The Dartmouth Atlas of Health Care website. The Dartmouth Atlas Project is a series of publications, based on Medicare data, which examine geographic variations in health care utilization.

The Robert Wood Johnson Foundation provides major financial support for the Project, and its analyses carry weight with policymakers. The basic reason given for concluding that more doctors would be bad for health care is that regions of the country with more physicians have increased spending on care without achieving better quality of care, better access to care, or better health outcomes. Therefore, increasing the supply of physicians would add to the cost of the system without yielding any benefit.

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Among those who disagree with this conclusion of the Dartmouth Atlas Project is Dr. Richard Cooper, an oncologist who is Director of the Center for the Future of the Healthcare Workforce at New York Institute of Technology and a Senior Fellow in the Leonard Davis Institute of Health Economics at the University of Pennsylvania. His analysis of the same Medicare data leads him to conclude that most of the geographic variation in health care utilization is explained by the geographic distribution of poverty and the increased burden of illness that accompanies poverty. In July 2013 the Institute of Medicine released a report examining this issue titled Variation in Health Care Spending: Target Decision Making, Not Geography. The committee of experts who authored this report concluded that the primary determinant of geographic variability in health care spending on the Medicare population is variation in the utilization of post-acute care services (skilled nursing facilities, in-patient rehabilitation, home health care, hospice care, and long-term acute care).

What Does the Future Hold?

The Future of Graduate Medical Education Prospects for increased federal support for GME: • H.R. 1201 “Training Tomorrow’s Doctors Today Act”

Introduced by Allyson Schwartz (D-PA) and Aaron

Schock (R-Ill) and referred to the Health

Subcommittee of the Energy & Commerce

Committee and to the House Ways & Means

Committee in March 2013. This bill would amend

Medicare legislation to increase the residency

positions supported by 3,000 per year for each of

5 years. It contains provisions to prioritize

primary care training.

• H.R. 1180 “Resident Physician Shortage

Reduction Act 2013”

Introduced by Joseph Crowley (D-NY) and

referred to same committees as H.R.1201. It

would also increase the number of supported

residency positions by 15,000 over a 5-year period.

• S. 577 “Resident Physician Shortage Reduction Act 2013”

Introduced by Sen. Bill Nelson (D-FL) in March

2013 with provisions similar to the House bills.

According to the government transparency website GovTrack.us, these bills have between 0% and 1% chance of being enacted. Although Rep. Allyson Schwartz is the only Representative from Pennsylvania to sign on to H.R. 1201, Rep. Jim Gerlach has indicated he would support this bill. In a position statement supplied by his press

secretary, Kori Walter, on September 13, Mr. Gerlach further stated: “I believe that GME is a critical linchpin for our teaching hospitals in Pennsylvania to ensure our children will have the expert physicians and medical professionals to care for them in the future.”

Senator Bob Casey is a co-sponsor of S. 577. In response to my request for his position on this bill, Senator Pat Toomey’s comments included: “ … Medicare … plays an integral role in training future physicians through the GME program. Last year alone, this program helped 70 Pennsylvania teaching hospitals train over 7,000 medical residents and interns. … All areas of government spending must be carefully examined so that we can put our nation on a path toward fiscal solvency.” Senator Toomey did not specifically address S. 577.

Berks County Implications

Graduate Medical Education Dr. David George (VP of Academic Affairs and Chief Academic Officer) reports that Reading Health System has recently increased the number of GME positions in its Internal Medicine and Family Medicine programs, has just added a program in General Surgery for PCOM as well as a Podiatry program, and has plans to begin an Emergency Medicine residency within the next few years.

The system is also developing its capacity to serve as a clinical training site for Physician Assistant and Nurse Practitioner students.

Reading Health System is absorbing most of the cost of this expansion in GME as a matter of necessity. Dr. George cites many reasons for this investment in training future

health care professionals, including a recent analysis suggesting a need for a substantial number of new doctors to replace those that plan to retire soon and to serve the needs of a growing Berks County population. Physicians who train locally are more likely to remain in Berks County.

St. Joseph Medical Center supports 7 residents per year in a Family Medicine Residency program accredited by the American Osteopathic Association. There are currently no plans for expansion.

Comments from Berks County Physician Recruiters

John Gleason (Executive Director, Digestive Disease Associates): This group of gastroenterologists has grown from 5 members to 14 over the 12 years he has been with them. Most new recruits were identified through personal contacts by current members, or were contacted without resorting to outside physician recruiters. Mr. Gleason attributes their successful recruiting to factors which include a great group of doctors to work with, an excellent facility to work in, and a good community in which to raise a family.

Valerie DeVine (Berks Cardiologists): She has been recruiting physicians to Berks County for 13 years and offered the comment that, while there are many factors which affect the process, “…recruiting efforts have become very competitive with starting salaries and years to partnership.”

Kenneth (Nick) Nichols (Reading Health System): Mr. Nichols began recruiting medical staff for RHS in 2007. He has experienced a change in recent years, with particular challenges in recruiting the following specialties:

• Neurosurgery – especially the subspecialties

• Neurology – general and subspecialties

• Trauma/Critical Care Surgeons

• Dermatology In addition, he points to shortages in Family Medicine, General Internal Medicine, Geriatrics, and Wound Care.

Julie A. Rumbold (HR Business Partner, St. Joseph Medical Center): Ms. Rumbold recently attended a meeting of the Association of Physician Staff Recruiters. One of the speakers quoted a projected physician shortage of 130,600 by 2025, and mention was made of the fact that demand for family physicians is increasing faster than the supply.

Continued on Page 12

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Parting Thought If those who predict a worsening shortage of physicians turn out to be correct, and the doctors of the future are not able to meet all of the demand for their services, who is likely to end up with the “short end of the stick?” The groups most likely to have trouble finding a doctor, and to be at risk of not receiving necessary care at the right time, are those with no insurance or insurance which pays doctors relatively poorly (such as Medicare and Medical Assistance).

Dr. Arthur M. Feldman, the Executive Dean of Temple Univ. School of Medicine and Chief Academic Officer of Temple Univ. Health System, commented for this story on the fact that federal funding for GME has been reduced each year recently, despite years of active lobbying by teaching hospitals on the need for expansion of GME. He also pointed out that academic medical institutions are simultaneously facing cuts in funding for their research mission. Sequestration, for example, forced the National Institutes of Health to make a 5.1% across-the-board reduction to all its programs, including medical research grants, earlier this year. An additional 18% cut to the ECOP_BCMR_HalfPgHoriz_FINAL_Layout 1 4/2/13 10:37 AM Page 1

arm of government which funds the NIH was approved earlier this year by the House Appropriations Committee for the 2014 budget.

Unfortunately, the most likely scenario would seem to be inaction or further reductions in public support for physician training until a public outcry occurs in response to difficulty accessing physician care. The problem is that there will be a lag time of many years between taking the first steps to create more GME opportunities and any significant increase in the number of practicing physicians. The prudent course would be to heed the warnings and act now to relieve the bottleneck created by the federal cap on support for residency training. n

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Pennsylvania’s Physicians Health Program KERRY ROYER

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he Physicians’ Health Programs (PHP), a program of The Foundation of the Pennsylvania Medical Society, provides support and advocacy to physicians struggling with addiction or physical or mental challenges.

The program also offers information and support to families of impaired physicians and encourages their involvement in the physician recovery process. The PHP is funded by grants and contributions from physicians, hospitals, and others interested in physician health issues.

The PHP began as a volunteer-based impaired physician program in 1970. Physician volunteers handled the casework, with assistance from a part-time Pennsylvania Medical Society staff member. In the 1980s, the Medical Society responded to the growing need for services by hiring a medical director and case managers.

Since then, the program has grown significantly in reputation and in services.

It is now one of the largest and most fully developed physicians’ health programs in the country. The PHP has a cooperative working relationship with the State Board of Medicine, State Board of Osteopathic Medicine, Pennsylvania Medical Society, and are contracted by the Pennsylvania Dental Society to assist all licensed dental professionals.

Many hospitals, medical staffs, and managed care organizations in Pennsylvania use the services offered by the PHP.

Educational Programs and Materials PHP staff is available to give presentations upon request to medical students, residents, medical staffs or hospital administrations, county medical societies, and others 14 | MEDICAL RECORD

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interested in learning more about impairment issues. Staff will tailor a presentation to address an organization’s issues.

Some areas of concern might include:

• What Constitutes Impairment and How to Recognize It • Signs and Symptoms of Addiction in Health Care Professionals • Addiction and Depression • Establishing a Physicians’ Health Committee for Your Hospital

“Since then, the program has grown significantly in reputation and in services. It is now one of the largest and most fully developed physicians’ health programs in the country.”

Physicians’ Health Programs Case Study Mike, an internal medicine resident, was referred to the Pennsylvania Physicians’ Health Programs because a colleague cared enough about him to reach out for help.

When Mike arrived at the hospital with alcohol on his breath, the hospital Physician Health Committee contacted the PHP with the name of a potential referral. They placed him on administrative leave and informed him of the need to contact the PHP within five days.

Mike contacted the PHP and spoke with our case manager about completing an evaluation, all the while, denying there was any problem. A PHP representative informed Mike that he was referred because there was concern about his behavior in the hospital. Colleagues reported tardiness, sloppiness and “partying” at night. Like many individuals who are addicted, Mike didn’t see the effects of his alcoholism as interfering with his ability to practice medicine. He also did not see the toll it was taking on him personally.

The PHP evaluation included collateral contacts, toxicology screens, and other testing measures performed to

determine if there was a diagnosis. PHP determined that Mike met the criteria for a diagnosis of alcohol dependence.

The PHP medical director informed Mike that inpatient treatment would be the most appropriate and provided him several PHP-approved treatment centers from which to choose. After completing ten weeks of treatment, Mike presented to the PHP office and signed a five-year monitoring agreement that included individual and group therapy, toxicology and Phosphatidylethanol (PEth) testing, 12-step meeting attendance, quarterly reports from a peer and workplace monitor and monthly check-in calls to the PHP office.

Mike eventually admitted that treatment was probably the best thing that he had done for himself. He felt that he got his life back and it was so much better than before.

He appreciated that the PHP was there for him and he was able to obtain advocacy that he was compliant with his agreement and was safe and sober to continue to practice medicine.

The PHP has assisted over 2,000 physicians since 1985 to “enjoy life without drugs or alcohol” and continue to be successful physicians. n

FOR FURTHER READING

The Effects of the Balanced Budget Act of 1997 on Graduate Medical Education. A COGME Review, March 2000.

Association of American Medical Colleges, Workforce Data and Reports at www.aamc.org/data/

Council on Graduate Medical Education. Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 20002020. Washington, D.C.: US Department of Health and Human Services, Health Resources and Services Administration; 2005.

The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. December 2008. U.S. Department of HHS.

Cooper, RA. It’s Time to Address the Problem of Physician Shortages: Graduate Medical Education is the Key. Ann Surgery.

2007; Vol 246 No 4: 527-534.

National Resident Matching Program at www.nrmp.org American Association of Osteopathic Colleges at: www.aacom.org American Osteopathic Association at: www.osteopathic.org

The Dartmouth Atlas of Health Care at: www.dartmouthatlas.org American Academy of Pediatric Dentists: www.aapd.org P h o ne M onda y - T hursda y 7 : 3 0 a . m . to 5 p. m .

( 8 6 6 ) 7 4 7 - 2 2 5 5 or ( 7 1 7 ) 5 5 8 - 7 8 1 9 E-mail

php - foundation @ pamedsoc . org A ddress

P hysicians ’ H ealth P rograms 7 7 7 E ast P ark D rive P. O . B o x 8 8 2 0

H arrisburg , P A 1 7 1 0 5 - 8 8 2 0

PA Dental Association – www.padental.org

Dentists accepting Medicaid – www.InsureKidsNow.gov “My Waters Fluoride” for fluoride concentration in tap water anywhere in the US – apps.nccd.cdc.gov/MWF/Index.asp AAP Website for Parents – www.healthychildren.org Bright Futures in Practice: Oral Health www.brightfutures.org/oralhealth/pdf/index.html

National Head Start Oral Health Resources: http://eclkc.ohs.acf. hhs.gov/hslc/tta-system/health/health/oralhealth Information re fluoride water laws: http://www.fluidlaw.org

Pew Foundation: www.pewfoundation.org - up to date advocacy information MEDICAL RECORD

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LEGISLATIVE AND REGULATORY UPDATES From: J. Scot Chadwick, V i c e P r e s i d e n t, G o v e r n m e n t a l Aff a i r s ———————— Amy C. Green, Ass o c i a t e D i r e c t o r , G o v e r n m e n t a l Aff a i r s P e n n s y l va n i a M e d i c a l S o c i e t y

LEGISLATIVE AND REGULATORY UPDATE ith the enactment of the annual state budget on June 30 the General Assembly has recessed for the balance of the summer, and is not scheduled to return to Harrisburg until September 23. A busy fall is anticipated, though the legislative appetite for controversial issues will wane as the year winds down and members start gearing up for next year’s elections in their newly reapportioned districts.

W

Following is a status report on key legislative and regulatory activities in Harrisburg.

LEGISLATIVE UPDATE

2013-2014 State Budget On June 30th Governor Corbett signed the 2013-2014 state budget, marking the third consecutive year during his administration that the annual spending plan was completed on time. The $28.4 billion budget represents a 2.3 percent increase over the prior fiscal year.

While the budget was finalized in a timely manner, the legislature failed to address three major priorities of the Governor: tackling PA’s transportation infrastructure needs, liquor privatization, and pension reform. All three issues remain unresolved, at least until the return of the General Assembly in late September. Medicaid expansion also remains unresolved as language within the Welfare Code requiring Governor Corbett to move forward with an expansion of Medicaid under the Affordable Care Act was stripped by the House.

Following is a breakdown of the budget elements that will be of most interest to physicians and health care providers.

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Department of Education One of the main budget priorities was education, although not much was done to repair the large cuts from FY12-13.

The new budget provides an additional $6.5 million for the safe school initiative to provide grants to schools to address violence and promote safety awareness. Basic Education will see an additional $123 million, and Accountability Block Grants supporting full-day kindergarten and other early childhood programs remain level-funded at $100 million.

The budget provides flat‐funding to the community colleges, the State System of Higher Education, and the majority of the funding for Penn State, the University of Pittsburgh, and Temple University. The Academic Medical Center line item within the Department of Public Welfare that supports medical schools received a $4.2 million increase, bringing appropriations to approximately $17 million.

Physician Practice Plans that support Drexel University, Thomas Jefferson, and University of Pennsylvania will also see an increase of $1.1 million, bringing funding levels to approximately $9.1 million.

Department of Health

This year’s final budget allocates approximately $195 million to the Department of Health, representing a 2.9 percent increase from FY12-13. While diabetes programs, regional poison control centers, trauma program coordination, epilepsy support services, and bio-technology research line items were cut in the governor’s original proposal, these funds have either been restored or increased within the final budget.

Unfortunately, the Department did not receive the additional funding for the medical school loan repayment program and residency slots proposed by Governor Corbett in February.

Originally, the governor proposed a $1 million increase under the primary health care practitioner line item for loan repayment programs, and $4 million to expand primary care focused on underserved areas. Primary care residency slots were also set to be expanded by 10 this year. While the Department still received an additional $4 million for community-based health care, no additional funding for loan repayment or residency slots was provided. However, we have been told that the Department will look into different alternatives.

Lastly, funding for state health care centers is even less than the governor’s proposal which assumed a plan to consolidate the state’s 60 health centers into 36. A total of 73 layoffs, including 26 community health nurses, are anticipated.

Department of Public Welfare There is continuous growth in Medical Assistance (MA) spending with 2.2 million Pennsylvanians on MA and 70,000 providers.

A major initiative last year was the expansion of HealthChoices in 42 counties. This progression moved approximately 400,000 MA recipients into the program, which now encompasses all 67 counties.

There are a total of three different funding sources that pay for health care including the capitation line item that funds managed care, and outpatient/inpatient line items that fund the fee-for-service system. The capitation line item to help fund managed care organizations received an 8.4 percent increase, bringing levels to approximately $3.9 billion, which also includes a rate increase of over 2 percent for the state’s managed care health providers. The increase in funding for medical assistance capitation is largely offset by corresponding decreases in inpatient and outpatient costs. MA Inpatient appropriations that help fund reimbursement rates to hospitals, supplemental payments, Medicare Part A, and HIT incentive grants are funded at $124 million, an overall decrease of approximately 54 percent from the 2012-13 levels. MA Outpatient appropriations that help fund primary health care and preventative services for MA recipients, Disproportionate Share Hospital payments, and Medicare Part B payments are funded at $311 million, representing a decrease of 31 percent.

Below is a chart that illustrates the state funds for Medical Assistance.

Department/Appropriation (amounts in thousands)

FY12-13 Available

Governor’s Proposed Budget FY13-14

State Budget FY13-14

Difference ($) Change FY12-13 vs. FY13-14

Difference (%) Change FY12-13 vs. FY13-14

MA – Outpatient (physicians and other providers)

450,835

369,311

369,311

(140,265)

-31.1%

MA – Inpatient

268,112

121,719

124,095

(144,017)

-53.7%

3,631,373

3,830,192

3,935,020

303,647

8.4%

3,681

3,681

6,681

3,000

81.5%

MA – Long-term Care

770,903

844,284

838,528

67,625

8.8%

MA – Home & Community Based Services

184,500

200,199

143,812

(40,688)

-22.1%

MA – Hospital-Based Burn Centers

3,782

3,782

3,782

0

0.0%

MA – Critical Access Hospitals

4,076

3,576

6,776

2,700

66.2%

MA – Trauma Centers

8,656

8,656

8,656

0

0.0%

MA – Academic Medical Centers

12,618

12,831

16,831

4,213

33.4%

MA – Physician Practice Plans

7,937

6,545

9,071

1,134

14.3%

MA – Transportation

67,142

76,179

72,799

5,657

8.4%

MA – Capitation MA – Obstetrics & Neonatal

Insurance Department The final budget includes an additional $9.5 million for the Children’s Health Insurance Program (CHIP), and a $3.8 million increase to the Children’s Health Insurance Administration. This is $4 million less than the Governor’s original budget proposal.

Overall, the Department received a total of approximately $118 million, representing a 3.8 percent decrease in total funds.

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Apology Sooner or later all tort reform initiatives have to pass through the Senate Judiciary Committee, where Chairman Stewart Greenleaf (R-Montgomery) buries them. That problem has been solved this session, at least for PAMED’s apology bill. Senator Pat Vance (R-Cumberland) shrewdly attached the measure to a bill (SB 379) extending the life of the CHIP program, which was referred instead to the Senate Banking and Insurance Committee, chaired by tort reform champion Don White (R-Indiana). Senator White’s committee promptly approved the measure, and the Senate subsequently passed it 50-0. The House Judiciary Committee gave its stamp of approval in late June, and a House vote is anticipated early this fall. The bill would make physician apologies and other benevolent gestures (except outright admissions of fault or negligence) to patients after a poor outcome inadmissible by plaintiffs in medical liability lawsuits.

Mcare

Pursuant to Act 13 of 2002, this spring Insurance Commissioner Michael Consedine will examine the financial health of the state’s primary liability insurance carriers this spring to determine their capacity to begin selling physicians and hospitals $750,000 in coverage, rather than today’s coverage level of $500,000. Previously, on July 29, 2011, Commissioner Consedine ruled that the primary insurance limits would NOT be increased for the next two years. Now it is time to repeat the exercise. A positive finding will cause the primary limits to rise to $750,000 next January, with a corresponding reduction in Mcare coverage from its current $500,000 level to $250,000. A negative finding will keep primary and Mcare insurance at current levels for another two years, when the process would again be repeated.

An increase in the primary limits would result in a significant rise in out-of-pocket liability insurance costs for physicians unless accompanied by transition relief. PAMED supports the phase-out of the Mcare Fund, but only in a manner that does not impose the cost of retiring the Fund’s $1.3 billion unfunded liability on the state’s physicians, and has so notified state officials. Some in the Corbett administration have strongly suggested that Commissioner Consedine will order the primary limits raised. Others have suggested that may not happen.

HAP, which wants to eliminate the Fund at any cost, has advocated legislation to raise the primary limits by $100,000 to $600,000, using the current Mcare “surplus,” estimated at 20 | MEDICAL RECORD

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$130 million, to offset the increased out-of-pocket costs for providers. The HAP proposal would then freeze the limits at this new, higher level and use future surpluses to reduce the following year’s assessment. In the event that a single year surplus of $75 million or more is realized, the primary limits would be raised by another $100,000, with the large surplus again helping to offset increased out-of-pocket costs for physicians. PAMED has been studying this proposal. The Insurance Department retained Price Waterhouse to run numbers on what this proposal and other possible phaseout scenarios might look like, and Representative Glen Grell (R-Cumberland) is drafting legislation to move the proposal forward if stakeholders approve. However, HAP has now disavowed its own proposal because of the likelihood that it would never result in the ultimate elimination of the Mcare Fund. Rather, HAP is now working with the Mcare Fund to get numbers from Price Waterhouse on different scenarios that would ultimately end the Fund. None of these scenarios provide for any state funding to offset the increased cost, and would result in providers paying off the entire unfunded liability. PAMED opposes any such arrangement, and continues to work toward a satisfactory solution.

In the meantime, we have aggressively lobbied the Corbett administration to maintain the status quo for the next two years, and are optimistic that we will get a favorable decision from the Insurance Commissioner in the near future.

PAMED is coordinating its examination of this issue with the Pennsylvania Orthopaedic Society and other stakeholders.

Supreme Court Data on 2012 Liability Lawsuit Filings On June 4, 2013, the Pennsylvania Supreme Court released state court system data on medical liability lawsuit filings and verdicts for 2012 that show a “decline in the number of filings in Pennsylvania, continuing a spiraling trend seen in eight of the last 10 years since the systematic collection of the statistics began.”

The 2012 data show the statewide total number of medical liability filings and the number and amount of jury and non-jury verdicts. There were 1,508 filings in 2012, down considerably from 2011, and representing a 44.8 percent decline from the base years of 2000-2002, the three years immediately preceding the enactment of the Act 13 liability reforms. Case filings were 2,903 (2002), 1,712 (2003), 1,817 (2004), 1,700 (2005), 1,693 (2006) 1,617 (2007), 1,602 (2008) 1,533 (2009), 1491 (2010), and 1675 (2011).

Prompt Credentialing In the last session, Representative Bryan Cutler (R-Lancaster) introduced House Bill 1551, PAMED’s prompt credentialing legislation. A similar bill, Senate Bill 1224, was introduced by Senator Gene Yaw (R-Lycoming) on October 18, 2011. These bills were intended to eliminate the unnecessary delays that frequently occur when physicians apply to be credentialed by various health insurers.

Under the bills, insurers would have to notify applicants of the status of their application for credentialing within five business days after receipt, including their intention to continue the process and an itemization of any missing items. Insurers would have 60 days to act on a completed application, and physicians would be eligible for reimbursement within 15 calendar days from the postmarked date on the application.

From that point until the credentialing process is complete, health insurers would reimburse physicians based on their fee schedule rates applicable to nonparticipating physicians.

If the physician applicant is a member of a medical group practice currently contracted with the health insurer he or she will be reimbursed at the group’s contracted rate.

A health insurer would be required to accept the CAQH’s Provider Credentialing Application when submitted by a physician for participation in the health insurer’s provider panel.

On November 30, 2011, the House Insurance Committee held a public hearing on the bill, at which PAMED testified.

Committee members and staff expressed considerable interest in the proposal, and PAMED spent much of the last year responding to members’ questions and objections raised by payers.

As a result of input received last year, we have redrafted the legislation to address outstanding issues, and will be reintroducing the House and Senate bills shortly.

Regulation of Tanning Salons

Last session Senate Bill 349, which would regulate the state’s tanning facilities and set age limits for who can use them, was approved by the Senate by a vote of 48-1. The bill later cleared the House Health Committee on December 5, 2011, but was never considered by the full House. This session it appears that this much needed legislation will cross the finish line. In June the House passed a strong

tanning bill 153-37, and the Senate is likely to follow suit before the end of the year. PAMED strongly supports this legislation.

Fair Contracting

Once again PAMED is seeking enactment of legislation to level the playing field between physicians and payers. Last session PAMED supported House Bill 1763, legislation intended to closely track expired court settlements known as the Love settlements. However, the bill received harsh treatment during a November 2011 House Insurance Committee public hearing, which, as expected, generated considerable opposition from the Blues. This session, PAMED will draft new legislation focusing on our core concerns and addressing payer objections.

Deemed

Status

In an effort to jumpstart a long overdue update of Pennsylvania’s hospital regulations, the Hospital and Healthsystem Association of Pennsylvania (HAP) is attempting to bypass the lack of regulatory action via the legislative route.

Last session House Bill 1570, introduced by Representative Doug Reichley (R-Lehigh), provided that facilities or specialized health care services accredited by a national accrediting organization approved by the Centers for Medicare and Medicaid Services (CMS) would be deemed to meet state licensure requirements and would be entitled to a license issued by the Department of Health (DOH). This would allow them to ignore inconsistent state licensing requirements.

PAMED was, and remains, sympathetic to HAP’s desire to modernize the state hospital regulations, and indeed, supports such an endeavor. However, the blanket erasure of some significant state patient and physician protections through deemed status, is a major concern. Importantly, the bill as introduced would have eliminated state regulations that ensure the protection of physician-led hospital medical staffs.

HAP and PAMED worked to address those concerns, and that process produced an agreement on all issues, an agreement that was endorsed by DOH and Rep. Matt Baker, who chairs the House Health Committee. However, a number of nonphysician provider groups saw the bill as an opportunity to expand their role and scope of practice in a hospital setting.

This and other complications resulted in a scuttling of the bill at the end of the session.

In the new session PAMED has worked with DOH and other stakeholders to craft language that reduces the likelihood MEDICAL RECORD

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of an assault on the bill by mid-level provider groups.

While the language ultimately settled on by the Corbett administration isn’t as “tight” as we would like, DOH has issued a letter reassuring us that its interpretation of the legislation addresses our concerns. HAP has also sent a letter stating that they accept that interpretation. That language is contained in House Bill 1190, which passed the House and Senate in June and was signed into law by Governor Corbett as Act 60 of 2013.

The Department of Health is initiating a series of meetings with key stakeholders to discuss implementation of the new law, and PAMED is actively participating in that process.

Controlled Substance Database (CSDB)

Last session Representative Gene DiGirolomo (R-Bucks) introduced House Bill 1651, legislation intended to improve the Commonwealth’s ability to enable informed and responsible prescribing and dispensing of controlled substances and to reduce diversion and misuse of such drugs in an efficient and cost-effective manner that will not impede the appropriate medical utilization of licit controlled substances.

PAMED supports the creation of a CSDB, but had a number of concerns with the bill as drafted, including the lack of legal protection for physicians who opt not to use the database, and overly broad language permitting law enforcement personnel to surf the data looking for fraud.

PAMED worked with Rep. DiGirolomo and key stakeholders to address these concerns, and ultimately a vastly improved version of the bill was approved by the House Human Services Committee. Unfortunately the bill went no farther.

However, PAMED’s “Pills for Ills, Not Thrills” campaign has generated significant support for a CSDB in the governor’s office and legislature, and we are optimistic that a good bill can be enacted this year.

LEGISLATIVE UPDATE

State Board of Medicine Vacancies At its May, 2011 meeting, the PAMED Board of Trustees approved a process to be used to identify PAMEDrecommended candidates to fill future vacancies on the State Board of Medicine (SBOM). That process directs the Executive Committee to utilize specified suggested criteria to identify and ultimately select qualified candidates that PAMED will recommend for consideration by the Governor.

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A total of five names were provided for the Executive Committee to review, and all names were selected for formal submission to the Governor’s office. On June 6, 2013, Governor Corbett announced the appointments of Drs. Brod and Heine to the Board, along with Sukh Dev Sharma, MD, a PAMED member from Erie. None of Governor Corbett’s nominees were confirmed by the Senate before the General Assembly recessed for the summer, which results in the current members whose terms are expiring. The Senate is not scheduled to return until September 23, 2013.

Drs. Brod and Sharma were nominated to replace Drs. Freeman and Rose, and with Dr. Heine named to replace Dr. Schwartz, no one was named by Governor Corbett to replace Dr. Agrawal, whose second term is expiring. Additionally, on July 3, 2013, PAMED member Carrie L. DeLone, MD was confirmed by the Senate as Pennsylvania’s new Physician General, replacing Dr. Ostroff and entitling her to the seat he filled on the Board. Dr. DeLone is the wife of Board member Bret DeLone, MD, and Dr. Bret DeLone has now resigned from the Board for obvious reasons. The end result is that there are still two Board vacancies to be filled, those of Dr. Agrawal and Dr. Bret DeLone. PAMED will be working to fill the vacancies with the individuals on the list we provided to the Governor’s office several months ago.

State Board of Pharmacy: Compounding

The outbreak of meningitis at the New England Compounding Center has sparked a large initiative among many states and the FDA on the issue of compounding. Staff and members at the Pharmacy Board attended a meeting held by the FDA and discussed what states are seeking to do through regulation and ways in which the FDA can tighten its rules. Many individuals from other states requested for a consistent definition of compounding/compounding pharmacy.

The State Board of Pharmacy is currently developing draft language within regulation to address issues of compounding. A revised draft of the regulation has been distributed in August to stakeholders for review. PAMED is currently reviewing the regulation and will provide comments for suggestions and/or revisions. One issue in question is whether the regulatory language provides for compounding in batches to fill orders for “office stock”.

There is language for anticipatory compounding, but it appears to be utilized before the receipt of a valid patientspecific prescription. The Society has participated in all discussions and will continue to monitor this regulation as it progresses.

State Board of Pharmacy: Collaborative Drug Therapy Management A review of the regulatory package indicates that the proposed regulation largely follows the language found in Act 29 of 2010; however, there are several areas of concern that we felt merit consideration from the Pharmacy Board.

Essentially, this regulation extends management of drug therapy to all pharmacists (it was only in institutional settings until the Act was amended in 2010), and must enter into a collaborative agreement with a physician.

In June, PAMED submitted comments to the Pharmacy Board with several recommendations. These recommendations are as follows:

1. Controlled substances should be excluded in drug therapy management.

2. Collaborative agreements should be approved and filed with the relevant physician licensing board.

3. Authorizing physicians should have access to pharmacist records for regular review.

4. Changes in drug therapy should be notified to the physician in 48 hours or less.

5. Consider workload limitations on pharmacists performing drug therapy management.

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State Board of Medicine: Prescribing

While the Board already had in place a regulation to provide safeguards for physicians prescribing, administering and dispensing controlled substances, the Board failed to address and provide similar safeguards related to non-controlled prescription drugs. Requiring the same safeguards for non-controlled prescription drugs would be unnecessary and overly burdensome because most noncontrolled prescription drugs, such as antibiotics, are used very safely and are not drugs of abuse themselves or used in association with drugs of abuse. The Board identified three non-controlled drugs—Carisoprodol, Butalbital and Tramadol—with sufficiently similar propensities for abuse or use in combination with drugs of abuse to controlled substances, and for which there are numerous cases reported of fatal overdose, to warrant placing additional requirements on physicians who prescribe, administer and dispense these drugs. On June 22, 2013, this regulation became final upon publication in the PA Bulletin. n

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DENTAL DISEASE: WHY MEDICAL/DENTAL COLLABORATION EVE KIMBALL, MD

Case History RM was a 22 month old male hospitalized for four days on the pediatric floor of a local hospital. The following findings were noted: • Streptococcus viridans sepsis positive blood culture and spinal fluid • Past history of staphylococcal cellulitis of scapula at 18 months of age • Teeth look like upside down ice cream cones but are normal in color except for 1 mm brown spots on upper incisors and left upper molar • 5 sippy cups half full of water + juice are scattered around his hospital room • Family history reveals that his Mother lost all of her teeth when braces were applied as a teenager.

• Family has well water without fluoride • ECG is normal as is ultrasound of the heart • MRI reveals a left temporal abscess • He is currently happily playing and angry that he is in isolation!

Where did his infection come from? His teeth. Strep viridans is oral flora. When the brain abscess was diagnosed he was transferred to Children’s Hospital of Philadelphia where the dental resident made the diagnosis of NEMO

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syndrome (x-linked variant of ectodermal dysplasia (thus the conical teeth) with a systemic immune deficiency syndrome. He was discharged and given an appointment for 8 months hence to have his teeth repaired in Philadelphia.

This was “moved up” (after much time spent in advocacy by several physicians and a dental resident!) 4 months. We all knew that by then his teeth would be totally decayed (the 1 mm lesions were now 3 mm!).

Local anesthesiologists were uncomfortable putting him to sleep for our local pediatric dentist because of his brain abscess. In consultation with a pediatric dentist we painted fluoride varnish on his teeth every two weeks, his parents brushed twice daily with a small smear of fluoride toothpaste (which he swallowed), and sippy cups between meals contained only plain water. The caries remained stable until his teeth were repaired at CHOP four months later. He is now 6 years old and his teeth are all intact!

There are no signs of fluorosis in his teeth. He is now able to receive his dental care locally. His mother has NONE of her permanent teeth – she lost all of them when braces were applied – she is a carrier of his disease.

Why Oral Health for Medical Professionals

This case illustrates that: 1. Access to dental care, especially for children on Medicaid, is difficult at best even with good advocacy.

The case of 12 year old Deamonte Driver in 2007 in Maryland is another example - he died of his infection (after $250,000 of medical treatment and hospitalization).

2. Much of dental caries is preventable (35-85%).

Fluoride at a dose of 0.05 mg/kg/day works to prevent early childhood caries (ECC), the most common infectious disease of childhood and is also useful in the treatment of this disorder.

3. Juice in sippy cups (or water “flavored” with juice) is a major cause of a current epidemic of Early Childhood Caries that crosses socioeconomic lines.

4. Teeth must be looked at by physicians as we examine the oral cavity.

5. Twice daily brushing with fluoride toothpaste and flossing daily works!

Many physicians regard the teeth as the province of dentists.

Yet we are frequently the first to identify carious teeth.

People avoid going for dental care because of fear, finances, or the perception that care is not needed unless they hurt.

A 2012 study in Florida Emergency Rooms demonstrated the presence of dental caries in many persons seeking ECU care. Diabetic control is impossible in the presence of dental disease. And the list goes on. The cost of treatment of dental disease is huge. Dental insurance coverage for adults

is not mandated and frequently not purchased because it is seen as low priority.

So first, insurance: The ACA mandates basic preventive dental coverage and care of dental disease for children but not for adults. PA Medicaid covers children for preventive and restorative services. Unfortunately, for adults in PA, it only covers two preventive visits per year, tooth extraction, and one set of dentures. (However in many other states it doesn’t even cover that!) Private dental insurance is available for both children and adults to purchase.

Unfortunately it is seen as unnecessary by many.

• We can talk to our patients about the importance of care of their teeth and encourage them to obtain dental care.

• When we see dental cavities we can make the call to their dentist from our office.

Second, prevention: Important action steps are: • Dental visits every 6-12 months, depending upon risk factors, for cleaning and plaque removal and filling of decayed teeth.

• Brushing twice daily with a SMEAR of fluoride toothpaste (“just a dot, not a lot” for those under two) – spit don’t rinse after brushing (children can swallow that amount of toothpaste without harm).

• Fluoridated water now contains 0.7 ppm fluoride (down from 1.2 ppm). The concentration was reduced because of the widespread prevalence and use of fluoridated toothpaste and fluoride in foods processed with fluoridated water.

The recommended dose of fluoride for prevention of decay in children is 0.05mg/kg of body weight/day. For a 10 kg one year old – recommended dose is 0.5 mg per day, so brushing twice daily = 0.2 mg + water added to make 24 ounces from powdered formula = 0.2 mg totaling 0.4 mg.

To this might be added the other 0.1 mg from fluoridated water in other foods. Thus even if the child swallows the toothpaste, the recommended intake of fluoride for promotion of oral health will not be exceeded. Note: children’s fluoridated flavored toothpaste contains the same concentration of fluoride as adult toothpaste. Children’s “training toothpaste” contains no fluoride. Be vigilant to supervise children brushing teeth and applying toothpaste to the brush since children love to eat their toothpaste and toxicity is possible from swallowing larger amounts than a “smear”. No “noodle or ribbon” please!

Third, sippy cups: Sippy cups are convenient and (unfortunately) not likely to go away. Water is frequently

placed in sippy cups between meals because it is a convenient way to have water available to children. To entice drinking, juice is frequently added. This bathes the teeth in sugar all day long. It takes the saliva ~20+ minutes to neutralize the acid produced by bacteria breaking down sugar in the mouth, so if constant doses of sugar are presented, even though small, the acid produced by the bacteria eats away the soft enamel of childhood teeth and early childhood caries – first white spots, then brown spots, and finally “tooth rot” are produced. An additional side effect of the sugar is the triggering of habits resulting in the epidemic of obesity that we are currently experiencing. So by encouraging “only water between meals” we can go a long way toward the prevention of TWO diseases • Only (fluoridated) tap water in both sippy cups and adult cups between meals.

Fourth, medical personnel looking at teeth: In the course of our day, clinicians and our staff look at the mouth of almost every patient that we see. But we look past the teeth to the back of the mouth. A superficial examination of the teeth and gums in both children and adults can reveal clues to disease. For example, in diabetics, periodontal disease is a frequent cause of failure to control diabetes and begins in adolescence. It is documented that 65 year olds with their original teeth have fewer health problems than those who have or have had dental disease resulting in removal of teeth. From 37.3% (non-hispanic white high income children) to 70.5% (Mexican American low income children) of five year olds in the US in 2000 had evidence of decay when examined.

• Look for decay, periodontal disease, and oral lesions every time you look in the mouth.

Fifth, medical/dental collaboration: Find several dentists that you know provide excellent care, make a list with addresses and phone numbers to give to your patients, and encourage them to see the dentist regularly. Develop a relationship with them so that if you have a patient with MEDICAL RECORD

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a problem, you can call them for advice (free CME!) and encourage bidirectional communication. You’ll be amazed at the improvement in care this provides for our patients.

I recently received a call from a dentist about one of our patients. He was frustrated because the child had been scheduled for oral rehab under sedation and the Father had called to cancel the appointment and said that the child didn’t want to do it now so he was going to wait. The family was Indian and well known to one of our pediatricians.

She called and discovered that the Mother had committed suicide two weeks before and that was why the Father cancelled the oral rehab appointment. She was able to help the Father understand the importance of the procedure to the child’s well being and health and the appointment was rescheduled. This is but one of many examples that we have found when a collaborative relationship exists between medical (physicians, NPs, PAs) and dental professionals (dentists, hygienists).

• Open communication with dentists who do care based on clinical guidelines and will accept your patients Sixth, brush and floss: Brushing twice daily with fluoride toothpaste upon arising and at bedtime provides topical fluoride to bind with the hydroxyapatite in enamel to form the harder compound fluoroapatite that is more resistant to decay. Flossing wherever the teeth touch is also recommended at least once per day. Brushing alone without toothpaste provides some removal of the plaque but does not provide the fluoride to assist with decay prevention.

• Brush twice daily with a smear of fluoridated toothpaste and spit, don’t rinse, afterwards. Floss at least once daily.

And finally, for a free one hour in office “Lunch and Learn” session contact Bonnie Magliochetti at hthc@paaap.org taught by a pediatrician and a dentist or a dental hygienist.

What’s Happening in Pennsylvania?

There are many collaborative efforts that have begun with enthusiasm across the Commonwealth.

• The PA Coalition for Oral Health is revisiting it’s mission and goals to focus on oral health policy in the Commonwealth.

• PA Head Start has received a DentaQuest grant in conjunction with the state of Massachusetts to focus on access to care and follow-up treatment beginning with cutting the first tooth. They have formed the Healthy Smiles Task Force to bring together people across the state.

A “Connect the Dots” initiative will educate dentists to see one year olds, and “Cavity Free Kids” curriculum has been 26 | MEDICAL RECORD

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taught to more than 250 attendees across the state to use to educate parents in Head Start classrooms.

• PA Association of Community Health Centers has received a DentaQuest grant to build Medical/Dental Collaboration in their member centers and improve access to care.

• Healthy Teeth, Healthy Children: A Medical/Dental Collaborative was formed at the PA Chapter of the American Academy of Pediatrics with a grant from the DentaQuest Foundation to focus on Access to Care, Oral Health Literacy, and Medical Dental Collaboration.

They have: - Developed the Educating Practices In Their Community (EPIC) Oral Health training and a pediatrician and a dentist or hygienist present it in primary care offices free of charge to teach Oral Health Risk Assessment, Examination of the teeth, Fluoride Varnish Application, Education of families about etiology of caries and prevention, and Referral to dental home.

- Revised the Early Childhood Educators Learning System Oral Health Curriculum and provided 400 scholarships for educators to take the module and receive credit.

- Produced a low literacy poster in Spanish and English and a poster about fluoride varnish in English for medical offices.

- Developed a survey of primary care residencies across the state is currently to determine best practices for integrating oral health into their curriculum.

- Implementation of oral health into the medical student curriculum is in progress spearheaded by Dr. Olapeju Simoyan at Commonwealth Medical School in Scranton.

They hope to provide assistance with best practices to programs who wish help.

- Begun creation of an interactive web based map for the state containing Head Start locations, Dentists who accept Medicaid, and Primary Care Physicians trained / who apply fluoride varnish.

• Oral Health is already a part of Physician Assistant curriculum in PA. • Local efforts include the Green County Task Force, Temple Kornberg School of Dentistry Pediatric Dentistry program and Extended Function Dental Assistant program, AmeriHealth Caritas Foundation Annual Medical/Dental Collaboration Seminars, Mission of Mercy Event, St Joseph Mobile Van, UPMC Pediatric Residency Oral Health Integration, Kid’s Smiles, Healthy Smiles, Achieva Oral Health for Special Needs Children, and so many others.

So What Can YOU Do?

• Look at teeth – everyone, all the time • Refer to and communicate with dentists specifically and with explanation and followup to be sure it is accomplished just like you would with any other consultant!

• Refer children within 6 months of first tooth eruption, persons with special abilities immediately when first tooth erupts-they should go at least every 6 months for care • Only plain water between meals and in sippy cups • Learn from the many free curricula available: - Smiles for Life – www.smilesforlifeoralhealth.org 8 hours free CME - Protecting All Children’s Teeth (PACT) www.aap.org/oralhealth 11 hours free CME - National Maternal & Child Oral Health (MCOH) Resource Center – www.mchoralhealth.org free CME and practice resources and toolkits - Other practice resources – www.aap.org/oralhealth Practice toolkit and education • Other helpful resources: - American Academy of Pediatric Dentists – www.aapd.org - list of pediatric dentists in your area - PA Dental Association – www.padental.org - Dentists accepting Medicaid – www.InsureKidsNow.govo If you have comments or additional stories to share, please email me at: ekimball@aacpp.com or call 610-372-9222 ext 927. n

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FAQs on Exchanges, Market Reforms and Medicaid

By Jessica Dean,z

T

he Affordable Care Act (ACA), which was enacted on March 23, 2010, includes significant changes related to health care coverage. Among other things, the ACA calls for the creation of state-based Affordable Health Insurance Exchanges (Exchanges) to facilitate the purchase of insurance, requires insurers to comply with a new set of market reforms and expands the Medicaid program.

On Dec. 10, 2012, the Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) issued Frequently Asked Questions (FAQs) http://www.cms.gov/cciio/index.html to answer questions regarding the implementation of the Exchanges and the Medicaid expansion.

MEDICAID EXPANSION

The ACA calls for a nationwide expansion of Medicaid eligibility, set to begin in 2014. Under the expansion, nearly all adults under 65 with family incomes of up to 133 percent of the federal poverty level (FPL) would qualify for Medicaid.

Originally, the ACA required states to comply with the new Medicaid eligibility requirements, or risk losing their federal funding. The Supreme Court’s ruling in the ACA case, however, limited the federal government’s ability to penalize states that don’t comply, effectively making the expansion optional. Even if they choose not to expand their Medicaid program, states will continue to receive their standard federal contributions for individuals who were already eligible for Medicaid coverage in their state.

States are not under a deadline for deciding to expand Medicaid and can drop out of the expansion program later if they participate initially.

Federal Matching Funds

For states that implement the Medicaid expansion, the federal government will cover 100 percent of the cost of the first three years of the expansion (2014-2016), gradually phasing down to a 90 percent share. The FAQs clarify that states must fully expand Medicaid eligibility up to 28 | MEDICAL RECORD

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133 percent of the FPL to receive the 100 percent federal matching funds. This means that states that implement partial Medicaid expansions (that is, expansions to less than 133 percent of the FPL) will not receive the full federal funding.

The FAQs note that states do have the option of implementing a partial Medicaid expansion. However, any partial expansion would be subject to the regular federal matching rate (that is, the federal match that states received before the expansion). Additionally, HHS intends to allow states significant discretion as to the “benchmark” benefit plans they will offer the Medicaid expansion population, as long as they cover the 10 categories of essential health benefits. States will also have some control over the cost sharing they will impose, particularly for recipients with incomes above 100 percent of the FPL. Effect of the Supreme Court Ruling

The FAQs further clarify that the Supreme Court ruling releases the states only from the Medicaid expansion requirement. States must still coordinate Medicaid eligibility with the exchanges if they wish to stay in the Medicaid program. They must also convert their income eligibility standards for most groups to the modified adjusted gross income (MAGI) standard used for premium tax credit eligibility.

HEALTH INSURANCE EXCHANGES

The ACA also requires each state to have an Exchange to provide a competitive marketplace where individuals and small businesses will be able to purchase private health insurance coverage. The Exchanges are scheduled to be operational by Jan. 1, 2014, with enrollment expected to begin on Oct. 1, 2013. States have three options with

respect to their Exchanges. A state may: Establish its own state-based Exchange;

• Have HHS operate a federally facilitated

Exchange (FFE) for its residents; or

• Partner with HHS so that some FFE Exchange

functions can be performed by the state.

State-based and State Partnership Exchanges

States that intend to pursue a state-based Exchange or a state partnership Exchange must submit a short declaration letter and an Exchange blueprint to HHS for approval. In November 2012, HHS extended the deadline for states to submit this notification and blueprint to:

• Dec. 14, 2012, for states that intend to establish

their own Exchange; or

• Feb. 15, 2013, for states that would like to partner

with HHS to establish an Exchange.

deadline beyond the current date. Additionally, the FAQs outline federal funding that is available to states that establish a state-based or state partnership exchange, and describe a federal data hub that states will be permitted to use, free of charge for exchange, Medicaid and Children’s Health Insurance Program (CHIP) activity.

“The FAQs clarify that HHS will not further extend the deadline beyond the current date.”

Federally Facilitated Exchanges HHS will operate federally facilitated Exchanges in each state that does not move forward with implementing its own Exchange or select the partnership model. The FAQs state that HHS intends to work with these states to preserve the traditional responsibilities of state insurance departments when establishing FFEs. HHS plans to coordinate with the states to take advantage of regulatory efficiencies, such as relying on states with effective rate review programs for rate review of qualified health plans.

The FAQs also reiterate that the FFEs will be funded through monthly user fees. Although HHS previously proposed that the rate for these fees will be 3.5 percent of the premium, the FAQs note that this rate may be adjusted to take into account state-based Exchange rates.

OTHER TOPICS

The FAQs address a number of other topics that states have expressed concern about, including, but not limited to: • Bridge Plans – The FAQs endorse a “Medicaid bridge plan” that states could use to ease the transition for consumers out of Medicaid or CHIP coverage. A bridge plan would be certified as a Medicaid managed care plan, but could continue to offer coverage through a single insurer and provider network to households transitioning out of Medicaid, or that have children in Medicaid or CHIP and adults in the Exchange.

The FAQs clarify that HHS will not further extend the

• The Navigator Program – The FAQs also describe in greater detail how the navigator program will work.

Navigators are organizations, or in some instances individuals, that will receive grants from the Exchanges to educate and assist consumers to better understand their insurance options. n MEDICAL RECORD

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MEMBERS IN THE NEWS Ron d. nutting, Md Reading Hospital Names First Director of Medical Affairs

BRENT J. WAGNER. MD Elected Vice Chairman of the Board of the Reading Health System EDUCATION Earned a bachelor’s degree in chemistry from Lafayette College in Easton; earned a medical degree from Thomas Jefferson University, Philadelphia. He did his radiology residency at the Wilford Hall Medical Center in San Antonio.

PROFESSIONAL BACKGROUND Ten years in the Air Force Medical Corp, finishing in the Department of Radiologic Pathology at the Armed Forces Institute of Pathology in Washington. He moved to Reading in 1998, joining West Reading Radiology Associates.

He was president of Reading Hospital medical staff in 2010-12. He is a member of the Reading Health System and Reading Hospital Boards, 2010 through present; and president West Reading Radiology Associates 2006 through present.

MOST REWARDING AND CHALLENGING ASPECTS OF RADIOLOGY “It’s being part of a team that brings together parts of a very complicated system to deliver cost-effective care that expects high quality in a safe environment. This is not ‘new’ but it currently has-a greater emphasis and an increasingly robust underpinning of organizational culture.

ON HIS NEW ROLE AS VICE CHAIRMAN OF THE READING HOSPITAL “The challenges that will face health care organizations over the next five to 10 years (and beyond) create an imperative for focus on the mission (‘high quality patient care’) while optimizing these cooperative relationships.

We have had a history of truly excellent board leadership at Reading Hospital, but I think the need for integration, particularly with the medical staff, creates an opportunity to engage physicians at multiple levels. I am honored to have been selected to serve in this role.”

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Ron D. Nutting, MD, of Wyomissing, has been appointed Director of Medical Affairs at Reading Hospital. effective immediately.

In this newly created position within the Chief Medical Officer’s Division Dr. Nutting supports the delivery of high quality patient care through ongoing development of a professional environment for physicians focused on interdisciplinary collaboration and resource utilization with a dual goal of enhancing clinical outcomes and patient satisfaction.

Dr. Nutting had most recently served as Reading Hospital’s Chief of Cardiothoracic Surgery, a position held for three years. He had joined Reading Hospital’s Medical Staff in 1991 as surgeon in the section of cardiothoracic surgery.

Before relocating to Berks County, he had been chief of cardiothoracic surgery with Fitzsimmons Army Medical Center in Aurora, Colorado, and served in Iraq and Saudi Arabia as chief of surgery with the 93rd evacuation Hospital during Operation Desert Shield and Storm.

Dr. Nutting is a founding member and past treasurer of the Delaware Valley STS Quality Improvement Initiative. a physician-managed organization involving cardiac surgeons and data managers from 32 hospitals in three states. He is also a past president and current member of the executive council of the Eastem Thoracic Surgical Society, a physician group focused on supporting the dissemination of scientific knowledge in this field.

An honors graduate of the University of Illinois, he earned his medical degree from Northwestern University School of Medicine. His postgraduate medical experience included a categorical surgical internship at Walter Reed Army Medical Center, general surgery residency at Letterman Army Medical Center, and a cardlothoracic surgery residency at Walter Reed Army Medical Center.

Dr. Nutting is certified by both the American Board of Surgery and the American Board of Thoracic Surgery, and is a Fellow in the American College of Surgeons. n

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PAGODA EVENT re c a p

O

n August 1st, the Berks County Medical Society and the Young Physician Section of the Pennsylvania Medical Society co-sponsored an event at the Pagoda for young physicians as well as physicians new to the Reading area. Attendees were able to meet with current members of the medical society as well as mingle with each other in the relaxed atmosphere at of one of the most recognizable and historic buildings in Reading. In addition to the fabulous views from Mount Penn, they were also treated to an educational history lesson about the building by representatives of The Foundation for the Reading Pagoda. n

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He has interned at the Equal Employment Opportunity Commission in Washington, D.C. and for Fox News legal analyst and best-selling author, Lis Wiehl. Prior to coming to Berks County, David was a law clerk for Judge Steven Davis of the National Labor Relations Board.

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ALLIANCE UPDATE

of our county’s parks. Interested patients and families may continue to buy a tree as a way to say thank you to a physician who has impacted their lives.

KATHY ROGERS B C M S A Preside n t

While writing my President’s Letter for our Alliance Yearbook and website, I took a minute to reflect on my experience in the Berks County Medical Society Alliance and what also to take a good look at all of the wonderful things that our members do together and for the good of our county.

When I first moved to Berks County for my husband’s job four years ago, I knew almost no one in the area. When I was invited to an Alliance New Member Coffee, I wasn’t sure what to expect, especially since I was pregnant with my second child and toting a toddler along with me into the meeting. What a wonderful, warm and interesting group of people welcomed me to the meeting and to the area! I was so taken with this friendly group that I paid my membership dues on the spot, although I really had little idea of what the Alliance was all about or what these women did.

Through the meetings and community events, I have come to see what the dedicated members of the Berks County Medical Society Alliance offer to each other and to our community. Through our scholarships we assist those who are planning to work in a health-related field. In fact, by raising over $13,000 last year through our Holiday card fundraiser, we were able to provide seven $1000 scholarships to students studying in Berks County.

With the remaining funds we were able to provide philanthropic donations to many diverse groups in Berks County, including the Children’s Dyslexia Center, Western Berks Free Medical Clinic, Reach Out and Read, Aaron’s Acres, Berks Youth in Action, IM Able Foundation, Girls on the Run, Breast Cancer Support Services, and Berks Women in Crisis. The BCMSA was honored to be able to give back to all these amazing organizations which give so much to those in Berks County.

Through Doctor’s Grove we help families and patients honor local physicians. Last year this existing, but almost forgotten, program was revitalized. Eighteen trees were planted to honor local physicians, as well as beautify one 34 | MEDICAL RECORD

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Our Heath Project has become a well-respected source of CEU’s for local educators and school nurses, and a valuable source of information for parents and students in our community. Last year’s Health in Balance Series focused on Autism and was well attended and highly praised by attendees. This year’s topic will be on Social Media and how it affects today’s school-aged children and teens.

“Our Health Project has become a well-respected source of CEU’s for local educators and school nurses, and a valuable source of information for parents and students in our community.”

While mentioning all of the ways that we donate to our community, it is important to acknowledge that members of the BCMSA also serve as volunteers to our local chapter of Meals on Wheels. How lucky we are to have caring individuals who give their time to this important community service.

Our Alliance is gearing up for another great year of meetings, fundraising and philanthropy. Some of the speakers lined up for meetings include Dr. Aparna Mele of Digestive Disease Associates, Ltd. speaking about digestive health, Tim Daley of the local chapter of Habitat for Humanity, informing us about what is involved in their organization, and George Balthasar of Windsor Garden Design speaking about gardening. In the spring our Health Project will be about the very concerning and relevant topic of social media and its effects on our children and teens.

So, after four years as a member, I now understand what the BCMSA is all about. I have learned that the Alliance is about community- educating, serving, giving, and recognizing those who deserve and need it. It is also about friendship, kindness, volunteerism and generosity. I am thrilled to be part of such a fantastic organization, and honored to be this year’s President. Here’s to another wonderful year, and I hope to see you at some of our meetings and events! n

BCMSA SCHEDULE OF EVENTS

Berks County Medical Society’s

HEALTH TALK Schedule of Events November 6, 2013 9:15 am Fall General Mtg. Host: Kelly O’Shea Speaker: Tim Daley, Habitat for Humanity December 11, 2013 (snow date Dec 12) Host: Lisa Geyer

9:00 am 10:00 am

Board Meeting Holiday Brunch

February 12, 2014 9:00 am Board Meeting Host: Gretchen Platt 10:00 am Second New Member Coffee March 20, 2014 9:15 am Mtg Host: Lisa Banco Speaker: George Balthasar, Gardening

Spring General

April 24, 2014 BCMS Office

Board Meeting

April 10, 2014

Tune in to Health Talk Live on WEEU radio to hear live community conversations about health topics with members and guests of the Berks County Medical Society!

Join the discussion every Wednesday evening from 6 to 7pm when the Berks County Medical Society presents “Health Talk.” It’s your chance to call and chat with many of the region’s leading health care practitioners! Take a look at the Berks County Medical Society’s website, BerksCMS.org, for more information.

FOr Live call in: (610) 374-8800 or 1-800-323-8800 to participate.

Hosts include: Dr. John Dethoff (pictured) Dr. Chuck Barbera Dr. Andy Waxler Dr. Bill Finneran Dr. Margaret Wilkins Dr. Pam Taffera

Health Project: Social Media 9:15 am

May 8, 2014 11:30 am Installation Luncheon

If you or someone you know is interested in finding out more about our organization please visit our website at www.berkscmsa.org. Also be sure to “Like” us on Facebook!

PLEASE SUPPORT THE BCMSA Just a reminder that during the fall months we will be sending out our Holiday card donation requests. As it is our only fundraising campaign, please donate generously so that we can continue to support local charities and students in our community. Thank you for your support in the past!

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Department of Family Medicine Lecture Series FALL 2013

October 11 DSM V – Implications for Improved Psychiatric Diagnosis and Treatment Colin Good, MD, Chair, Department of Psychiatry Muhammad Raza, MD, Medical Director, Adolescent Partial Program Reading Hospital

October 18 Teen Pregnancy in Berks County: The Physician/Nurse Role in Prevention Nadine Smet-Weiss, MA, Director of Policy & Program Development Co-county Wellness Services Sheila Bressler, Berks County CASSP Coordinator Berks County Mental Health/Developmental Disability Program Rebecca Hartman, Doctoral Candidate in Community Leadership Alvernia University October 25 No Conference (Residency In-training Exam) November 1 Friday’s Child Lecture Series – To Eat or Not to Eat: Medical and Behavioral Approach to Feeding Problems in Children Douglas Field, MD Keith Williams, PhD Penn State Children’s Hospital November 8 Emerging Infectious Diseases/Influenza Update 2013 Robert Jones, DO Chair, Section of Infectious Disease, Department of Medicine Reading Hospital

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November 15 Improving Diagnosis and Care of the Fibromyalgia Patient David George, MD, VP of Academic Affairs Reading Health Physician Network November 22 Childhood Immunizations Update, Robert Cordes III, DO Children’s’ Clinic of Wyomissing November 29 No Conference

December 6 Friday’s Child Lecture Series – It Takes a Team – The Modern Management of Kids with Cleft Lip and Palate Donald Mackay, MD, FACS, FAAP Thomas Samson, MD Penn State Milton S. Hershey Medical Center December 13 What’s New (and Old) in Contraception Kristine Leaman, MD, FACOG, NCPM Reading Health Physician Network – All About Women

December 20 Everything You Always Wanted to Know About the New Anticoagulant/Antiplatelet Drugs Eric Elgin, MD, FACC Cardiology Associates of West Reading

* CME and AAFP credits have been applied for. Approval is pending.

* Presentations may meet PSRM criteria as outlined by ACT 13 for Patient Safety Credit for CME as approved by the Pennsylvania Medical Society. All PSRM credit is recorded and self-reported by the physician.

All lectures will be held in the Reading Hospital Conference Center, Rooms 1 and 2 at 8:00 a.m. unless otherwise noted.

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