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March Issue 2019

Inside This Issue

Physician Trends to Watch in 2019 By Jennifer Larson Merritt Hawkins


Texas A&M Simulates Disaster to Train Students in Emergency Response See pg. 11

INDEX Financial Forecast............. pg.3 Legal Matters........................ pg.4 Oncology Research......... pg.5 Technology............................ pg.6 Healthy Heart....................... pg.8

Time for a Talk About Vaping? See pg. 12

o one can say definitively what’s going to happen with the practice of medicine this year. Yet industry experts expect some ongoing trends and other phenomena have the potential to affect how healthcare is provided both now and in the future. They will also affect how individual physicians go about their jobs. Check out these healthcare trends, technology advances and disruptions that may change the way you work in 2019 and beyond. 8 healthcare trends to watch this year 1. Burnout will continue to be a problem. Not surprisingly, experts forecast physician burnout as an ongoing problem in 2019. In fact, a new report from the Massachusetts Medical Society, the Massachusetts Health & Hospital Association, and the Harvard T.H. Chan School of Public Health calls it a “public health crisis.” The 2018 Survey of America’s Physicians, conducted by Merritt Hawkins on behalf of The Physicians Foundation, found that 78 percent of physicians sometimes, often or always have feelings of burnout. The burnout rate is higher for female physicians than for males; 84.8 percent vs. 74.1 percent. Burnout and job dissatisfaction can cause physicians to cut back on hours or get out of direct patient care altogether, which affects patient access and puts additional strain on clinicians who remain. 2. Doctors will join start-ups. Looking for something new—really new? This could be the year you join some of your colleagues in finding a start-up that could use your skills and education. Preventive medicine physician Sylvie Stacy, MD, MPH, has been watching as job postings for physicians with start-ups have grown, often in the digital health arena. “Since many

of the technologies are so closely intertwined with healthcare delivery and disease management, there will be an increasing need for physicians,” she predicted. 3. More states will join the Interstate Medical Licensure Compact. It just got easier to practice medicine in multiple states. Michigan became the 25th state to enact the Interstate Medical Licensure Compact (IMLC) on December 31, when the

Industry experts expect some ongoing trends and other phenomena have the potential to affect how healthcare is provided both now and in the future. state’s governor signed the legislation. The District of Columbia and Guam also participate in the compact, bringing the total participants to 27. That number could grow again in 2019, as the Federation of State Medical Boards reports that Kentucky,

New Mexico, and South Carolina are considering an initiative to join the compact. 4. Consolidations will continue. A growing number of physician practices have been sold to larger healthcare systems in recent years, and consolidations, mergers and acquisitions will continue in 2019. When this happens, some physicians may feel relieved to relinquish the burden of practice management, while others are less excited about losing their independence. “We are seeing many venture capital firms purchasing physician groups along with larger health systems,” said Shawn Yates, director of healthcare product management for Ontario Systems. “This will drive out the smaller physician groups and force them to change their focus and develop partnerships.” 5. More emphasis will be placed on interprofessional collaboration. Team-based care models aren’t going away. “With greater emphasis on holistic care known as patient-centered care for the last few years, it will be paramount going forward,” predicted Ankita Sagar, MD, MPH, a primary care physician with Northwell Health. see Physician Trends... page 12


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Financial Outlook Succession Planning for Solo and Group Medical Practices By Reed Tinsley, CPA CVA, CFP, CHBC


hether you are a solo practicing physician or a member in a larger group practice, it’s wise to begin thinking about your business succession plan. I have found in my consulting practice that many physicians seem to wait until the last minute to address the issue of succession. With advanced planning however, you can come to a financially beneficial conclusion and ease the transition of ownership. Solo Physician Practices Individual physicians must pursue the future of their practice with intensity and thoughtfulness. The good news is that the extra effort can have a direct effect on the financial rewards of succession planning. This process requires realistic evaluation of your financial needs and the emotional effect of passing the practice on to a new physician versus simply closing it. Typically, individual physicians have three basic options for succession planning:

1. Slow down gradually and close the practice when the financial rewards are no longer worth the effort, selling the equipment for a nominal value. 2. Maintain a full-time schedule until the day of retirement and then sell the practice to a single recruited successor or a potential buyer. 3. Recruit a successor early, build the practice until it can support two physicians, and then sell the remaining half of this new multi physician practice to a third physician. The timetable for each of these three basic options depends on how long it takes to recruit a successor (or find a buyer for the practice), if one is needed. The first option, which doesn’t require a successor physician, is the quickest. Winding down and closing the practice will result in a decline in compensation and, ultimately, a nominal sale price. If you happen to find

an eager buyer while you are winding down the practice, you can simply shift to a variation of the second strategy, selling the practice to a single successor upon retirement. Selling the practice to one physician produces a fair market value practice purchase. There is reduced compensation during the transition period because your one physician practice must support the income of two physicians. The timetable for the second option varies based on whether you are recruiting your successor from a resident or fellowship program or recruiting a physician that is already in practice. The third option requires not only recruitment of two physicians, but also enough time between those recruitments to successfully build a practice to accommodate additional physicians, so it takes twice as long as the second option. If you decide to pursue an option that involves selling to a third-party, you should obtain a practice valuation from an experienced financial/practice valuation advisor as a first step. This

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gives you a realistic expectation and a basis for negotiations that can’t be dismissed as simply a personal opinion of your own practice’s value. Finally, use other area resources. Discuss your plans with the hospital or hospitals at which you practice, for example. Hospitals in underserved areas need to maintain physicians. Hospitals in competitive markets need to maintain or build their physician and patient bases. Larger Group Practices Established multiphysician practices typically have succession plans that are driven by the opposing interests of the entering and exiting owners, who might be shareholders, see Financial 14

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Legal Matters Out-Of-Network Providers Rejoice: The 8th Circuit Condemns the Practice of Cross-Plan Offsetting By Ebad Khan, JD

Polsinelli, PC


fter over a year of waiting, the Eight Circuit Court of Appeals aligned itself with the Department of Labor by concurring that the practice of Cross-Plan Offsetting orchestrated by many commercial health insurance companies, and in this case United Healthcare, to recover erroneously overpaid claims from out-of-network health care providers is not only a violation of the terms of a self-funded benefit plan, but may also trigger additional liabilities for commercial health insurers and plan sponsors and administrators of self-funded benefit plans under ERISA. Though the practice is shrouded

in complexities, generally speaking, Cross-Plan Offsetting is a practice commercial payors employ to recover overpayments made to out-of-network providers by withholding the overpaid amount from subsequent payments to be made to the same out-of-network provider. This is done by commercial payors regardless of the fact that the overpayment may have been made by one plan and the offset is taken from a payment to be made by a completely different plan. In Peterson v. UnitedHealth Group, Inc., the Eight Circuit determined that: (i) nothing in a self-funded plan’s plan documents even comes close to authorizing United Healthcare to engage in Cross-Plan Offsetting; (ii) even the broad authority granted to United Healthcare to administer a self-funded benefit plan does not permit it to engage in this practice; (iii) Cross-Plan Offsetting is in tension with the fiduciary duties of a commercial health insurer acting

as a third-party claims administrator (TPA) of a self-funded benefit plan and the fiduciary duties of a plan sponsor because it may amount to failing to pay a benefit owed to a beneficiary under one plan in order to recover money for the benefit of another plan; and (iv) Cross-Plan Offsetting may constitute a transfer of money from one plan to another in violation of ERISA’s “exclusive purpose” requirement. Though this practice is likely permitted between providers who are contracted with commercial payors, those providers who are not contracted with commercial payors (i.e. out-of-network providers) that have overpayments made to them, erroneous or otherwise, that are offset against future payments owed to them, likely have recourse as a result of the Eight Circuit’s ruling. Commercial payors have been orchestrating this practice for many years, and for some, as long as a decade. This translates to many out-of-network providers losing out on a substantial amount of money that should have otherwise been paid to them. As a result of this ruling, the Eight Circuit has now opened the door to out-of-network providers to take

action against commercial payors in hopes to collect money that may have been unlawfully offset against them. Furthermore, if commercial payers are currently still offsetting overpayments against out-of-network providers, this case provides an avenue to those providers to put a stop to this harmful practice against them. Although the Eight Circuit’s decision is not controlling precedent in the Fifth Circuit, the Circuit in which Texas is located, this case may likely be considered as persuasive authority by courts and fact-finders in Texas and nationwide. By taking action against commercial payers to collect offset money or, at the very least, to put a stop to this practice, providers can not only take better control of their patient accounts but make commercial payers think twice about the ramifications of potentially engaging in any suspect practices in the future. 


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Austin Medical Times

Oncology Research Three Ways to Cut Your Cancer Risk and Take Back Your Health By Punit Chadha, M.D., Texas Oncology–South Austin


very year we see advancements and promising trends in diagnosing and treating cancer. Already this year, we learned that the death rate from cancer in the U.S. declined steadily over the past 25 years – 27 percent from 1991 to 2016 – according to the reporting from the American Cancer Society (ACS). It’s a hopeful development attributed largely to reductions in smoking, advances in early detection, and treatment breakthroughs. While we can’t control everything about our health, the World Health Organization reports that 30 to 50 percent of all cancers may be preventable. That means there are steps you can take to improve your overall health – and to beat cancer before you have it.

•Be mindful of nutrition and diet and exercise. While cancer deaths overall are declining, obesity-related cancer deaths are on the rise and Texas is leading the way. According to the new ACS data, Texas has the highest rate of cancers due to excess body weight (EBW), with at least one of every 17 cancers in the U.S. attributable to EBW. Managing your weight, eating a balanced diet, and maintaining regular physical activity are all factors in protecting your body. A lifestyle that includes a well-balanced diet full of nutrients that lower the risk of disease is also important for overall well-being and critical to both preventing and fighting cancer. •Eliminate smoking and tobacco use. In its 2019 report, the ACS cites lung cancer as a major cancer type and one of the top three cancers diagnosed in both men and women. Research consistently shows that smoking cessation is paramount to lung health, and smokers who quit are more likely to live a healthier and longer life, while greatly decreasing lung cancer

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risk. Smoking-related deaths represent 80 percent of lung cancer mortalities. Options for reducing and eliminating tobacco use include nicotine replacements such as patches, gum, inhalers, sprays, and lozenges – as well as resources and tips for starting your cessation journey. Talk to your primary care physician about how to quit, or contact the Quitline, a hotline supported by the Texas Department of State Health Services, by calling 1-877-937-7848. •Limit alcohol consumption. While the link between smoking and cancer is common knowledge, patients are sometimes surprised to hear that limiting alcohol consumption also is a significant factor in preventing the disease. Alcohol use is linked to mouth, throat, larynx, pharynx, esophagus, liver, colon, rectum, and breast cancers. Alcohol affects the body’s ability to absorb nutrients, damages body tissue, raises levels of estrogen, which can lead to breast cancer, and contributes to weight gain. When combined with other factors, such as smoking, the risk of cancer is significantly higher. To decrease this risk, it is recommended that men should limit intake to two drinks per day, and women to one

drink a day. As a society, we’re making huge strides in the fight against cancer, but there is much work to be done. While the medical community continues to focus on diagnosis and treatment, you can do your part one small step at a time by taking charge of your own prevention strategy. It’s about making progress, not perfection, and I am encouraged by the recent statistics that show how far we’ve come in reducing cancer-related deaths. Across the Texas Oncology network, we’re proud to celebrate these victories. Punit Chadha, M.D., is a medical oncologist at Texas Oncology– South Austin, 4101 James Casey Street, Suite 100, in Austin, Texas. For more information, visit TexasOncology. com.

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New Technology Your Advantage in a Changing Health Care Market By Mark Johnson President, Xtrii


he competitive forces in health care continue to grow. Physicians continue to feel the squeeze of lower reimbursements as their operations costs and complexities increase. Entrepreneurial companies have moved into key service areas, such as radiology, lab services, outpatient surgery centers, and other areas that were historically prime revenue sources for hospitals and large health care organizations. National health care organizations are expanding and moving into new markets and threatening local providers. Innovative companies such as Amazon and Google that have an impressive track record of transforming industries, have stated their plans to enter the health care market. In addition to those market

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will occur in the health care industry. Turning challenges into opportunities: • A better customer experience: Rethink the old practices and create a more frictionless customer experience. Eliminate the paper nightmare, make it easier for patients to get a timely appointment, provide secure, easy access to the patient’s health information, improve patient engagement, and look for innovative ways to stand out by providing a better experience. Properly rethinking your processes and applying the right technology can provide the solution. • Better leverage the experts: Practitioners and smaller organizations can’t afford to hire employees for every need. Leverage the growing trend of hiring seasoned experts to provide that niche expertise as needed. For example, you know you need the right technology guidance for key decisions but can’t afford to a

hire a full-time Chief Technology changes, Digital Transformation is Officer. Instead, engage a highlyoccurring in every market, including accomplished, health care healthcare, and will create major shifts technology expert on an as needed in the health care industry. Even with basis. You get a better fit, a higher these huge changes in motion, some caliber of expertise, and typically traditional health care organizations the savings is more than $100,000 will continue to stick their head in a year. the sand and continue with their old ways and the status quo. By the time • David vs. Goliath: How do small organizations compete with the these market laggards realize the massive organizations? Too many massive impact, if will be too late and health care organizations tend to they will struggle to survive. Digital be slow moving market-laggards Transformation leaders will reshape that often get bogged down in a healthcare and become the new market series of committee meetings and leaders. internal politics. Be more strategic, We have already seen this nimble, decisive, and timely transformation in the retail industry, than your competitors, and fully with malls and storefronts being leverage technology opportunities closed, previously dominant brands and digital transformation to your like Sears, JCPenney, Kmart and others advantage. are now struggling to survive, and more innovative players like Amazon are dominating. The same transformation see New 14

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Healthy Heart Cycling is Good for Your Heart Health By Joel Rice Executive Director American Heart Association


he American Heart Association and American Stroke Association are encouraging people to use cycling to help get brain and heart healthy all while raising critical dollars to support our lifesaving work. You can be a part of the excitement by participating in the first ever CycleNationTM Austin event which will be happening in May! During this stationary cycling event, CycleNationTM teams of up to eight individuals work together to keep their team’s bike spinning for two hours while enjoying music, encouragement from cycling instructors and inspiring heart and stroke mission moments from the AHA/ASA. Heart disease and stroke are the number one and number five killers of all Americans. Austin is a cycling city and many of the initiatives

throughout our community encourage cycling instead of driving. For instance, Bike Austin –, is a strong proponent of the power of biking and they envision “Central Texas as a place where everyone recognizes and embraces the benefits of cycling, whether they ride or not, and where cycling is a common aspect of daily life for everyone.” Did you know that cycling 20 miles a week can reduce the risk of heart disease by 50 percent? And that cyclists on average live two years longer than non-cyclists and take 15 percent fewer days off work? The American Heart Association’s research shows that cyclists are less likely to be obese, have high cholesterol or high blood pressure. People who bike regularly have a 25 percent lower risk of developing heart disease. And as little as 30 minutes of biking a week could protect from coronary artery disease. An adult cyclist typically has a level of fitness equivalent to someone 10 years younger, and active commuting

that incorporates cycling and walking is associated with an overall 11 percent reduction in cardiovascular risk. With this new event in the vibrant, health-focused Austin community we hope to gather all those cycling enthusiasts to come participate in two hours of hard-hitting stationary biking all to support funding toward the reduction of deaths from cardiovascular and stroke diseases. Grab a few of your favorite friends and create a team! The minimum team fundraising goal per bike is $1,000. If you want to go at it alone and ride the entire time then break away from the pack and raise $1,000 and do our

individual challenge. I’ll be on a bike and I hope you’ll join myself and my team. The event is on May 18th and kicks off at 9AM at the Amy Donovan Plaza/Domain. We want you to help us ignite a health revolution in our community that will create awareness for stroke and heart disease. Bikes are reserved, and space is limited, so sign up early at cyclenation. org/Austin . This LIVE event includes live music, family-friendly activities, and more! CycleNationTM is nationally sponsored by Amgen Cardiovascular and is locally sponsored by Transamerica.

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Dell Medical School, Episcopal Health Foundation Join Forces to Advance Health Beyond the Clinic


ell Medical School at The University of Texas at Austin and Houston-based Episcopal Health Foundation have announced a partnership to discover and advance health interventions outside of clinical settings that address underlying, nonmedical causes of poor health. The program’s goal is to transform the most promising efforts into successful cost-effective initiatives that measurably improve health. Research shows that as much as 80-90 percent of our health is determined by nonmedical factors such as smoking, access to healthy food, housing and transportation — also known as social d eter m i n a nt s of health. That means only 10-20 percent of our health relates directly to health care, where the vast majority of health-focused dollars are spent. “We know that nonmedical drivers play an outsized role in influencing health outcomes, but that’s not where we are investing resources,” said Mini Kahlon, Ph.D., Dell Med’s vice dean for the health ecosystem and associate professor of population health. “This strategic partnership addresses that imbalance by bringing ideas together with expertise and funding to drive better health outcomes, particularly for those who are underinsured and uninsured.” Supported by a $2.6 million investment from the Episcopal Health Foundation, Dell Med’s new program, Factor Health, will: • Solicit innovative proposals from organizations working to advance nonmedical drivers of health (initially in Austin and Travis County, followed by expansion to include Harris and other counties). • Invest to improve the proposals over several months by leveraging expertise from across the country to raise the chances of improving health outcomes. • Provide funding for two years to the programs most likely to be

fundable by long-term health care payers. • Match the most viable programs with longer-term payers to ensure scalability and financial sustainability. “The startling reality is that we’re spending our health resources almost exclusively on medical care, but we’re not getting better health. Medical care alone isn’t enough to keep many Texans healthy because it doesn’t address the root causes of poor health,” said Elena Marks, president and CEO of the Episcopal H e a l t h F o u n d at io n. “ M a n y innovative organizations are already reaching beyond clinics to tackle these nonmedical drivers of health, but it’s a challenge to find health care payers to support them. This effort works to find solutions that work outside the exam room and are proved to be cost-effective and lead to better health.” Collaborating with health payers is another critical priority of this partnership. “Beyond improving health, a key component of this collaboration involves identifying measurable outcomes and economic models that are of interest to health care payers, while also helping the payers better understand the value created,” said Elizabeth Jacobs, M.D., chief of primary care and value-based health at Dell Med. “We are looking to bring all of the right players together to quickly prove effective and sustainable models that can be replicated elsewhere.” Although there is no set criteria regarding the type of organization or business that can apply, organizers say they expect interest from those with a history of delivering value and services to historically underserved groups and from groups with a proven track record of delivering results in relevant areas such as transportation, housing, see 12



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Texas Cardiac Arrhythmia Institute at St. David’s Medical Center first in U.S. to treat patient in study to evaluate balloon ablation catheter for treating Atrial Fibrillation


he Texas Cardiac Arrhythmia Institute (TCAI) at St. David’s Medical Center recently performed the first procedure in the U.S. using the new HELIOSTAR Multi-electrode Radiofrequency (RF) Balloon Ablation Catheter as part of the STELLAR study. The study is designed to evaluate the safety and effectiveness of the catheter in treating intermittent atrial fibrillation (A Fib), the most common type of irregular heartbeat. Rodney Horton, M.D., an electrophysiologist at TCAI, treated the first patient in the study with Andrea Natale, M.D.,

F.A.C.C., F.H.R.S., F.E.S.C., executive medical director at TCAI. “The new balloon catheter could potentially make it easier and faster to isolate the pulmonary veins in order to treat A Fib,” Dr. Horton said. “It is unique because it conforms to any pulmonary vein anatomy and allows us to control electrodes individually to deliver tailored energy during ablation.” The HELIOSTAR RF Balloon Ablation Catheter has 10 electrodes, which allow electrophysiologists to deliver different levels of energy depending on the tissue during lesion creation. In

addition, the balloon design makes it possible to isolate pulmonary veins with a single application of RF energy. “The catheter design has the potential to overcome the limitations of current balloon ablation catheters,” Dr. Natale said. “Current balloon-based technologies often require the use of multiple sizes of balloons, which carries risk and can be time consuming. This system has one balloon that can adjust to whatever size is required, resulting in shorter procedure times.” Up to 640 patients in as many as 40 clinical sites worldwide will be enrolled in the STELLAR study. It is estimated that 33 million

people worldwide are living with A Fib, which can lead to blood clots, stroke, heart failure and other heart-related complications. Texas Cardiac Arrhythmia Institute (TCAI) at St. David’s Medical Center is one of the world’s preeminent centers dedicated to the latest treatment advances for correcting abnormal heart rhythms such as Atrial Fibrillation (A Fib). The center is led by Executive Medical Director Andrea Natale, M.D., a world-renowned expert in the field. Natale is at the forefront of advancing treatment for A Fib, leading numerous clinical trials and participating in the development of new technologies and procedures.


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Texas A&M Simulates Disaster to Train Students in Emergency Response By Mary Leigh Meyer


he Texas A&M University Health Science Center conducted Disaster Day, the largest student-led interprofessional emergency response simulation in the country today. Started by the Texas A&M College of Nursing and now in its 11th year, the event is designed to give future health care and public health professionals experience working together in a disaster scenario. The one-day event, which is carefully planned and executed by Texas A&M Health Science Center students, with oversight from a faculty and staff steering committee, provides students with critical life-saving skills required in disaster situations. Not only are participants better prepared to respond in real-life emergencies, but they also learn vital skills to practice collaboratively. The event is held at Texas A&M Engineering Extension Service’s (TEEX) Brayton Fire Training Field and Disaster City, a 52-acre mock city that serves as a training facility for our nation’s emergency responders. A new scenario is selected each year and kept secret until event day to provide the realism of an unexpected situation. Last year’s event was a train crash, and this year’s event simulated a chemical explosion and building collapse where nearly 600 students from the Texas A&M College of Medicine,

College of Nursing, Irma Lerma Rangel College of Pharmacy, School of Public Health and the College of Veterinary Medicine & Biomedical Sciences engaged in triage at the disaster site, patient care at a mock field hospital and disaster management and simulation oversight at Disaster City’s Emergency Operations Training Center. The students had to react to mass “injuries,” with volunteers in makeup portraying victims with various degrees of wounds, from cuts to compound fractures. The volunteers mimicked panicked patients as they screamed, cried and pleaded for help. At the end of each exercise, instructors and other observers critiqued student teams on their strategy and communication to help improve their skills for a real-life disaster. “Disaster Day is one of the most transformational interprofessional education exercises at Texas A&M, where students from the Health Science Center and College of Veterinary Medicine and Biomedical Sciences— and for the first time this year, the Corps of Cadets—come together for effective management of an emergency situation,” said Carrie L. Byington ’85, MD, vice chancellor for health services at The Texas A&M University System, senior vice president of the Health Science Center and dean of the College

Live Well Age Well Steps You Can Take to Prevent Falls By Chelsea Couch Texas Health and Human Services Commission


reventing falls is one of the best ways older adults can maintain their health and independence. Falls are a leading cause of fatal and non-fatal injuries for seniors and can seriously affect one’s health and quality of life. One in four Americans 65 or older will have a fall each year, according to the National Council on Aging. “Age, and especially advanced age of 85 years and older, is a major risk factor for falling, and falling once is a risk factor for multiple falls,” said Marcia

Ory, professor and director of the Center for Population Health & Aging at Texas A&M University. Area agencies on aging offer a variety of evidence-based programs, including a Matter of Balance, which is designed to increase physical activity and reduce falls and the fear of falling. To learn about the evidence-based programs offered at the AAA, call 855-252-9240. The impact of a fall can affect you in a variety of ways. It’s not just the physical injuries that can hurt quality of life. The psychological effects can slow you down too. “Every 11 seconds an

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of Medicine. “We are grateful to our system partner TEEX for providing this premier facility for our students to learn in a realistic, hands-on envi ron ment, where emergency r e s p o n s e professionals from Students seen here in emergency response scenario. across the nation at the College of Nursing. regularly train.” “When health sciences students train During the simulation, students along side each other, they directly either act as providers or emergency management officials. As each team see the value that each discipline is is interprofessional, students can gain bringing to the table,” added Christine a greater perspective on how different Kaunas, MPH, executive director health professions collaborate. In of interprofessional education and collaboration with all of the people and research. “We see that team-based, groups required to make an event of emergency response training provides this scale happen, the Health Science for better and safer health outcomes.” These students act as first Center’s Office of Interprofessional Education & Research leads the responders during emergency situations committee that guides the production across the country after they graduate, of Disaster Day, as its function is to which makes the training provided by promote and support collaboration Disaster Day irreplaceable. “Training for emergency across health disciplines. situations is imperative,” said Corey “Although part of our students’ education occurs in the same room Authement, College of Nursing student and the same simulated experience as and training director for this year’s students in other professions, what we Disaster Day. “When you have multiple really want to do is change the way our groups responding to an incident, the graduates think about team medicine interprofessional aspect really comes and how they approach and embrace into play. This interprofessional the concept of the team approach,” said training is important to be able to Regina Bentley, EdD, MSN, RN, CNE, respond appropriately in the future.” Nicole Mancuso, a graduate assistant vice chancellor for health services at The Texas A&M University System and clinical associate professor see Emergency 14

older adult goes to the emergency room due to a fall, and every 19 minutes an older adult dies from a fall,” said Carol Zernial, executive director of the WellMed Charitable Foundation. “Quality of life for older adults is impacted by both the fear of falling and the actual experience of falling, and someone who falls is more likely to lose some of their independence.” The good news is that there are steps that can be taken to prevent a fall from occurring. “A first step is knowing that falls are preventable — and not an inevitable part of aging,” Ory said. Follow these steps to prevent falls: • Talk with your primary care physician. Zernial encourages people to “ask a physician to do a

falls risk assessment.” The “Timed Up and Go test is an easy way to assess” the likelihood of a fall, she said. • Review your medications. Medications can increase the risk of falling. Periodically reviewing see Live 12 March 2019

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Austin Medical Times

Time for a Talk About Vaping? By Patrick Wascovich


ith new findings that show an unprecedented jump in nicotine-containing electronic cigarette usage among teens, many parents wonder how best to approach the topic. “The important thing is to have a nonemotional action that has consequence for the using adolescent,” says psychiatrist Dr. David Atkinson, an addiction specialist at UT Southwestern Medical Center. “Action is more important than explanation, and emotion can actually be counterproductive. Parents should destroy the device the teen is vaping with, flush all of the nicotine that they have, and let their child know that will be

Physician Trends Continued from page 1

(RELATED: 5 Things Doctors Can Learn from Nurses) 6. We’ll feel the Amazon and Apple effect. Keep an eye out for changes that may develop from Amazon’s entrance into the healthcare arena, Yates added. Amazon has already purchased an internet pharmacy, launched its own private label brand of OTC healthcare products called Basic Care, and collaborated with J.P.


Continued from page 9 education and food. Examples of initiatives that could receive support through the

Live Well

Continued from page 11 medications with a physician or pharmacist could help identify potential side effects that could increase the risk of a fall. “Ask if a change in medication may increase dizziness and could be a fall risk,” said Zernial. • Enroll in a falls prevention March 2019

their action in the future should it recur.” Dr. Atkinson says that discovering bad behavior by your teen calls for an educative and strategic tact. First, concerned parents need to educate themselves about vaping devices, which are easier to hide and can resemble computer flash drives. “Parents should familiarize themselves with the packaging from pods and other nicotine tanks, and I believe that a teen’s cash flow should be watched carefully,” Dr. Atkinson says. “There’s also send-out tests for metabolites that detect whether they are vaping or smoking combustible [regular] cigarettes.” New data from

Morgan and Berkshire Hathaway to establish an employer health coalition. And watch for more innovations in mobile fitness apps and chronic disease management; Apple has hired about 50 physicians in recent months as the tech giant expands their reach into healthcare, too. 7. The ACA’s future hangs in the balance. In December 2018, a federal judge in Texas ruled that the Affordable Care Act was unconstitutional. But a group of attorneys general appealed the ruling, which could eventually send the landmark healthcare legislation to the Supreme Court again. The Texas

Centers for Disease Control and Prevention found that more than 1 in 4 high school students and about 1 in 14 middle school students in 2018 had used a tobacco product in the past 30 days. This was a considerable increase from 2017, which was driven by an increase in e-cigarette use. E-cigarette use increased from 11.7 to 20.8 percent among high school students and from 3.3 to 4.9 percent among middle school students from 2017 to 2018. A National Institutes of Health-supported study found that twice as many high school students used e-cigarettes last year compared with 2017, and 1 in every 5 participating seniors reported having vaped nicotine at

judge has allowed the law to remain in effect while under appeal. “If the ACA loses its appeal, this could affect the care of millions of people around the country due to lack of protection for pre-existing conditions, coverage for basic healthcare and screening needs, and decreased funding for Medicaid plans,” said Sagar. “This would be practice-changing because as a physician caring for patients with Medicaid and complex illnesses, I see many patients requiring these protections.” 8. Telemedicine opportunities will expand. Last year, the Centers

least once in the previous month – the largest single-year increase in the University of Michigan-based survey’s 44-year history, surpassing a mid-1970s surge in marijuana smoking. The same report found that marijuana usage has largely remained level over the past few years and that more teens are saying “No” to many other illegal and harmful substances, including alcohol, cigarettes, cocaine, LSD, ecstasy, heroin, and opioid pills.

for Medicare and Medicaid Services (CMS) proposed adding more services to its list of Medicare-approved telehealth services for reimbursement. (Learn more about the five new Current Procedural Terminology (CPT) codes and other information included in the final version of the 2019 Physician Fee Schedule and Quality Payment Program.) CMS could do that again in 2019, which would enable providers to receive reimbursement for services using virtual technology. It’s easier to provide services via telemedicine if you’re getting paid to offer them.

program include an affordable housing organization providing wraparound services to support health at home, an entity delivering nonmedical diabetes prevention services such as diet and exercise coaching, or a group addressing

loneliness and social isolation through exercise and community building. As the program evolves, a select number of proposals will enter a consultation phase. During this time, a customized team of experts will

provide guidance on ways to improve interventions to ensure sustainable funding and maximize opportunities for overall success.

program. Participating in an exercise program can decrease the risk of a fall. “Engaging in physical activity that helps improve strength and balance is a great way to reduce the risk of falling,” said Ory. • Get regular vision and hearing checkups. Eyes and ears are important to balance. Getting regular vision and hearing checkups can help identify and

correct potential issues that may increase the risk of falling. • Check your home. Assess your home and remove potential tripping hazards, like rugs or items stacked on the floor. Consider low-cost home modifications that remove tripping hazards, improve lighting, and make stairs and restrooms safer. “Texas has a variety of resources to help seniors address

falls,” said Chelsea Couch, Texercise program coordinator for the Texas Health and Human Services Commission. “The HHS Texercise initiative has resources that promotes regular physical activity, including balance exercises. Texans 45 and older can order a free copy of the Texercise handbook at or call 1-800-889-8595.” 

Austin Medical Times

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March 2019

Page 14

Financial Outlook Continued from page 3

partners, or LLC members. Consider the following: 1. Buy-in and buy-out. Entering physicians seek the lowest possible buy-in and exiting physicians want the highest possible buy-out. That is not to say that either seeks an unfair deal, just that they have opposing interests. Therefore, structuring a reasonable buy-in and buy-out is critically important and often difficult in today’s healthcare environment. The biggest issue here has to do with assigning a value to practice goodwill. Does the practice have value in excess of its net assets? 2. Malpractice insurance. If a practice’s professional liability

New Technology

Continued from page 6 Keys to success: Take the right actions now. The lost time and expenses incurred for the wrong plan of action can be devasting. Taking no action will be even more devasting. Success starts with tapping the right expertise and leadership. Know your strengths and engage the right subject matter expert to guide you through these changing times and augment

Emergency Response

Continued from page 11 of the College of Nursing, can attest to this. She was working in a Las Vegas emergency room during the mass shooting on the Las Vegas strip in October 2017. “It was probably the worst thing I have ever seen in my life, and I hope I never have to see it again,” Mancuso said. She credits her training at the college and involvement in Disaster Day for teaching her how to appropriately triage and treat patients in mass casualty scenarios. “Having the knowledge of triaging really helped to know who needs more time from me and who is okay in comparison. What I learned at the college built my initial skills to become an emergency room nurse.” This year, emergency response professionals from both Germany and England traveled to observe the scenario and gain insight into how they could bring some of the concepts back to their countries. Members of the March 2019

Austin Medical Times

insurance is claims-made insurance, then the exit plans must include payment of the malpractice tail. Some insurance companies waive the tail in the event of the physician’s retirement. If this issue is not addressed, there could be significant dispute among the physicians because the tail cost is rising along with malpractice premiums in general. Both the practice and the physician must be aware of the potential for uninsured liability if the tail is not purchased. 3. Restrictive covenants. Practice departures that are real retirements do not usually raise restrictive covenant issues. Physician practice owners should not pay practice buyouts to physicians who leave or retire only to set up competing

practices. This issue must be covered in the transition documents. 4. Real estate. Practices that lease offices from third parties may not be confronted with this issue. However, real estate investment is often a component of a physician practice and is usually not part of the professional corporation that serves as the practice entity. If the ownership is linked to the practice, then a buy-out provision in the transition plan should be included. If not, then the remaining physicians must be prepared to deal with the real estate owners as independent third-party owners.

your business. While you may be the top medical expert in your field, don’t go it alone and make the mistake of trying to be the expert for everything. Missteps can very costly, and it’s vital to know when you should tap a local technology expert, a marketing expert or other professionals to ensure you are making the right investments and are executing the optimal plan. Health care is going through a time of significant change, and digital transformation will cause the pace and impact to increase. Be a transformation

leader and take the right, decisive actions to turn these changes into your advantage. Mark Johnson is a global technology leader that has advised and led the top healthcare organizations for more than 30 years. He currently serves as President of Xtrii, To see more of Mark’s technology tips and insights, visit

Texas State Guard also participated, training members of the Texas A&M Corps of Cadets in extraction procedures for the “injured.” H-E-B’s director of emergency preparedness, Justen Noakes, led a team from their headquarters in San Antonio. His staff served breakfast and lunch to simulation participants from their mobile cooking facility, one of the several H-E-B deploys during real disasters such as Hurricane Harvey. “Disaster Day is a unique opportunity for students to gain firsthand experience in emergency response, conducting duties that are usually entrusted to health care and emergency officials,” Kaunas added. “With interprofessional collaboration, hundreds of students understand how they can conduct disaster response when lives are at stake while building critical thinking and teamwork abilities.” “Often health care providers compartamentalize themselves— they identify as nurses, as physicians as pharmacists as public health professionals—and do not

communicate with each other,” added Charles Borrego, College of Nursing student and incident commander of this year’s Disaster Day. “So starting an interprofessional education early in the learning process helps to break down the compartments and open lines of communication.” Creating an event of this magnitude necessitates a great amount of support. Generous sponsors for the one-day mock disaster included the colleges of medicine, nursing, pharmacy and public health, the Association of Former Students and H-E-B. “I am so proud of all the students, faculty and staff who plan and execute these extraordinary scenarios each year with the goal of providing transformational education to our health students,” Texas A&M University President Michael K. Young said. “It is experiences like this that ensure our graduates who go on to careers in the health field are well prepared for its many challenges and rewards.”

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Profile for Rick Delarosa

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Bringing Healthcare News to the Forefront

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Bringing Healthcare News to the Forefront