March Issue 2018
Inside This Issue
Top Five Cancer Trend in 2018 See pg.10
INDEX Mental Health...................... pg.3 Oncology Research......... pg.4 Financial Forecast………… pg.5 Pharmacy Corner.............. pg.6 Healthy Heart....................... pg.8
Baylor Scott & White Partners with World Golf Championships – Dell Technologies See pg. 12
Gainsharing Guidance: Clarification on Cost-Savings Arrangements
By Marissa R. Urban, JD and Gabriel Scott, JD Polsinelli, PC
he Office of Inspector General of the U.S. Department of Health and Human Services (“OIG”) recently posted the first advisory opinion interpreting a gainsharing arrangement since recent amendments to the Civil Monetary Penalties Law (CMP) limited CMP’s prohibition on gainsharing arrangements to only those involving reductions or limits in medically necessary services, rather than all services. In Advisory Opinion 17-09 (the “Opinion”), the OIG analyzes a gainsharing arrangement (the “Arrangement”) between a non-profit hospital (“Hospital”) and spinal surgeons (“Neurosurgeons”) in a multispecialty physician practice (“Group”) under which Hospital pays Group a share of cost savings associated with adhering to guidelines on the proper use (and reduction in unnecessary use) of bone morphogenetic protein and use of standardized products during surgeries. Cost savings are calculated based on comparing historic out-of-pocket costs (“Base Year”) to current costs. The Opinion states that the OIG will not impose sanctions in connection with the Arrangement under the CMP or the Anti- Kickback Statute (“AKS”), even though the Arrangement implicates both laws. The Opinion discusses several factors that reduce the risk under the CMP and AKS and that industry players may consider in structuring future gainsharing arrangements. Gainsharing CMP – The OIG states that the Arrangement implicates
the Gainsharing CMP because Neurosurgeons may be incentivized to reduce or limit medically necessary services in exchange for cost savings. However, the OIG states that while it cannot opine on whether the Arrangement reduces only medically unnecessary services, it finds that Hospital monitoring and the methodology used to develop the cost-saving recommendations reduces the risk of unlawful reductions in care. AKS – The OIG states that the Arrangement implicates the AKS because remuneration flows indirectly from Hospital to Neurosurgeons under the Arrangement, which may induce or reward referrals. However, the OIG found the following safeguards, among others, to mitigate referral incentives: • Cost-saving amounts are capped based on, among other things, Base Year surgeries performed for Federal health care program beneficiaries and are distributed on a per capita basis • The Arrangement monitors current patient mix against historic patient mix to prevent and identify cherry-picking of patients to increase cost savings
• Preferred products were selected, and associated use guidelines developed, for the Arrangement based on U.S. Food and Drug Administration guidelines and a evidence-based medical review by Neurosurgeons • Cost-savings are calculated based on actual, verifiable cost savings attributable to the Arrangement and the use recommendations • Neurosurgeons continue to make patient-by-patient determinations as to the best product • The Arrangement is limited to Group Neurosurgeons only The Arrangement also includes a number of facts not addressed in prior gainsharing arrangements approved by the OIG. First, the Arrangement does not prohibit participants from increasing referrals to Hospital, although referral increases are capped at Base Year amounts. Second, patients must receive written notice of the Arrangement (and compensation relationship) prior to admission, where possible. It is unclear whether this feature
see Gainsharing... page 16
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Mental Health Building and Breaking Connections: How Neuronal Networks Influence Alcoholism The Urge to Drink May Be ‘Turned On,’ Offering Clues About How To Turn It Off By Christina Sumners
he About 15.1 million American adults have alcohol use disorder, meaning they cannot stop drinking despite adverse consequences—in other words, they have what is commonly referred to as alcoholism. Although it has been known that alterations in the connections between neurons in the brain likely play a role in alcohol dependence and other addictions, the cause-and-effect between these brain alterations and behavior has been less clear. Now, Texas A&M research indicates that alcohol-seeking behavior may be induced by altering the strength of connections between particular neurons, according to recent results published in the journal Nature Neuroscience. “We found that by applying a long-term potentiation protocol to animal models, we could directly induce a persistent change in their
drinking behavior,” said Jun Wang, MD, PhD, assistant professor at the Texas A&M College of Medicine and lead author of the study. Long-term potentiation is thought to be the basis of all learning and memory. It is the strengthening of synapses — the connections between neurons — based on sustained patterns of activity. In some cases, the strengthening may be facilitated by alcohol consumption — but Wang and his colleagues found a way around that. Wang and his team mimicked the effect of alcohol with optogenetics, in which specially implanted proteins sensitive to light can be rapidly turned on and off within the brain. This process stimulates neuronal activity and essentially recreates the learning and memory that comes from actually performing an activity. Either way, it results in changes to the strength of synapses. But what is more exciting, Wang and his team were able to
Jun Wang, MD, PhD, assistant professor at the Texas A&M College of Medicine
reverse the alcohol-mediated synaptic strengthening by reversing the process. They did so with the opposite of long-term potentiation — what they call long-term depression — and decreased drinking behavior. These changes affected particular neurons called D1, which Wang’s earlier research indicated could tell the brain to keep drinking. He calls them the ‘go’ neurons. Other neurons, called D2, do the opposite, and when they are activated, they give the signal to stop drinking. “Our results provide pretty solid evidence that there is indeed a cause-and-effect relationship between the long-term synaptic changes and
alcohol-seeking behavior,” Wang said. “Essentially, when brain changes are reversed, an individual may not want to drink for a long time.” Although using this exact process in a human brain wouldn’t be feasible now, the results indicate possible targets for drugs or other therapies in the future. “Ultimately, our long-term goal is a cure for alcoholism, and possibly for other addictions as well,” Wang said. “We think these results that help us better understand how the brain works are an important step toward that goal.”
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Oncology Research Neoantigens and Immune Checkpoint Blockade By Jorge Augusto Borin Scutti, PhD Austin Medical Times
tarting with the comprehension that cancer is a genetic disease, the design of personalized molecularly targeted therapies, seems a rational step to endeavor. Resistance to several of these therapeutic agents such as Vemurafenib, Imatinib, Nilotinib, Erlotinib, and Trastuzumab is the main issues focused on current cancer research. Transformed cells that may express, for instance, high levels of BRAF mutations, BCR-ABL, EGFR, and HER2 must be discerned from nontransformed cells. Through natural selection transformed cells, submitted to molecularly targeted therapies, have learned to escape from these therapies. Alterations in the drug target, activation of pro-survival pathways and
ineffective induction of cell death are some examples. Consequently, there is a critical demand to develop new therapies for cancer treatment. The role of the immune system and its importance in conferring protection against transformed cells have been extensively discussed in the last decade. As the results from the last ten yearsâ€™ attest, cancer immunotherapy is the best strategy to restore the activity of the immune system and unleash its potential to destroy cancer cells in cancer patients. The absence of an immunocompetent system revealed the increase in the susceptibility to carcinogens induced in spontaneous cancer. The genetic landscape of the antigens that allow the immune system to discriminate between cancer cells from non-transformed cells remains unclear. Not all antigens can elicit an effective immune response. A tumor rejection is defined by how satisfactory an immune response can act against a specific tumor antigen and how this response would impact
on tumor growth. Deep-sequencing and DNA libraries have profoundly contributed to cancer immunology and immunotherapy, mainly by the characterization of neoantigens that arise from tumor-specific mutations. As cancer cells divide, they accumulate mutations that result in altered or novel peptide sequences specific to the tumor cell. Distinguished as neoantigens, these tumor-specific antigens could be the key to developing successful cancer therapies. The exome-based cancer (a genomic technique for sequencing
all of the protein-coding genes in a genome) is, indeed, a crucial approach to determine the T cell reactivity against cancer neoantigens. Preclinical models provided the original evidence for the cancer-exome based method that could be used to identify neoantigens and interrogate about the T cell reactivity and consequently an immune response against that
see Oncology...page 16
Austin Medical Times
Financial Forecast Summary of the New Tax Law – Individual Tax By Reed Tinsley CPA, CVA, CFP, CHBC
n 12/20/17, both the House and Senate passed H.R. 1-commonly referred to as the Tax Cuts and Jobs Act (TCJA). The President then signed it in to law. Hailed as the largest major tax reform in over three decades, the TCJA contains a whole host of tax provisions that impact individuals and businesses. With a few rare exceptions, the provisions of the TCJA affect 2018 tax returns. However, now is the time to become familiar with this massive and groundbreaking act. The following is a summary of the provisions in the new law affection individual taxpayers. New Tax Rates and Brackets. For tax years 2018-2025, seven tax brackets apply for individuals: 10%, 12%, 22%, 24%, 32%, 35%, and 37%. Kiddie Tax Modified. Under pre-TCJA law, pursuant to the “kiddie tax” provisions, the net unearned income of a child was taxed at the
Standard Deduction Increased. Under pre-TCJA law, for 2018, the standard deduction amounts were to be: $6,500 for single individuals and married individuals filing separately, $9,550 for heads of household, and $13,000 for married individuals filing jointly (including surviving spouses). Additional standard deductions may be claimed by taxpayers who are elderly or blind. For tax years 2018-2025, the standard deduction is increased to $24,000 for married individuals filing a joint return, $18,000 for head-of-household filers, and $12,000 for all other taxpayers, adjusted for inflation in tax years after 2018. No changes are made to the current-law additional standard deduction for the elderly and blind. State and Local Tax Deduction Limited. For tax years 2018-2025, a taxpayer’s itemized deduction for state and local taxes is limited to $10,000 ($5,000 for a married taxpayer filing a separate return) of the aggregate
THE STRENGTH TO HEAL and get back to what I love about family medicine parents’ tax rates if the parents’ tax rates were higher than the tax rates of the child. The remainder of the child’s taxable income [i.e., earned income, plus unearned income up to $2,100 (for 2018), less the child’s standard deduction] was taxed at the child’s rates. For tax years 2018-2025, the taxable income of a child attributable to earned income is taxed under the rates for single individuals, and taxable income of a child attributable to net unearned income is taxed according to the brackets applicable to trusts and estates. Personal Exemption Deduction Eliminated. Under pre-TCJA law, the deduction for each personal exemption was $4,150 for 2018, subject to a phaseout for higher earners. For tax years 2018-2025, the deduction for personal exemptions is eliminated.
of (1) state and local property taxes and (2) state and local income taxes. The provision also includes a rule stating that an individual may not claim an itemized deduction in 2017 on a pre-payment of income tax for a future tax year in order to avoid the dollar limitation applicable for tax years beginning after 2017. To prepay property taxes however, the tax has to be “assessed” before January 1, 2018. Mortgage and Home Equity Indebtedness Interest Deduction Limited. Under pre-TCJA law, taxpayers could deduct as an itemized deduction qualified residence interest, which included interest paid on a mortgage secured by a principal residence or a second residence. The
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see Financial Forecast...page 16
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Pharmacy Corner The Review of Diabetes By Abimbola Farinde, PharmD Austin Medical Times
n America, type II diabetes is highly regarded as a chronic and debilitating condition that can progress over time, if not managed appropriately by the individual who is diagnosed with the condition. At times, lack of proper knowledge or awareness about the condition can produce the negative consequences of the condition. According to the American Diabetes Association, it was reported that 29.1 million Americans or 9.3% of the population had diabetes in 2012, and about 1.4 million Americans are diagnosed with new cases of diabetes each year. The prevalence of diabetes continues to grow and it is becoming recognized as a major public health issue that warrants greater attention to be placed on appropriate lifelong management and adequate control of symptoms. Along with adults, children
and adolescents are increasingly becoming diagnosed with the endocrine disorder which can be attributed to a myriad of reasons. Approximately 208,000 Americans under the age of 20 are estimated to have been diagnosed with diabetes so this places an additional layer of urgency to this issue. In order to effectively curtail the development of diabetes many Americans are being instructed by healthcare professionals to take the both the initiative and the initial steps towards changing their lifestyle habits and behaviors. Some of the recommended changes can include eating habits and seek to engage in more physical activities and adopt a less sedentary lifestyle. The movement away from the sedentary lifestyle and unhealthy eating habits are considered to be effective but practical methods for keeping the symptoms and progression of diabetes at bay. It has become customary for many individuals to be counseled on these two areas of diabetes management. Since diabetes is considered to be a progressive condition, lifestyle interventions are recognized as
first line interventions for management but this may not work for every single person. If this becomes the case there are certain individuals that have to resort to other treatment options that can include medication initiation. The advent of oral medications (i.e., first generation agents, second generation agents, non sulfonylurea secretagogue (glinide therapy), alpha-glucosidase inhibitor therapy, and biguanide therapy, thiazolidinedione therapy and insulin therapy, have become mainstays for the management of diabetes for many Americans. In those cases where patients have reached their limit with the use of oral hypoglycemis agents they can generally revert to the use of insulin therapies ranging
from rapid acting to long acting agents depending on the type of management that is needed. . With each year newer agents, potentially those with an innovative method for addressing diabetes are released unto the market and these provide additional options for patients who might have failed to achieve their therapeutic goals with the existing medications. With proper management and ongoing care individuals who are diagnosed with diabetes are able to achieve and maintain a good quality of life for many years to come through the proper management of the symptoms that can be associated with the disorder.ď ľ
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Healthy Heart Break Up With Sodium By Joel Rice, Executive Director of the American Heart Association – Austin Chapter
odium is essential for life. It’s regulated in the body by your kidneys and it helps control your body’s fluid balance. It also helps send nerve impulses and affects muscle function. But when there’s extra sodium in your bloodstream, it pulls water into your blood vessels, increasing the total volume inside your blood vessels and raising your blood pressure. Over time, high blood pressure may injure the blood vessel walls, speed the build-up of plaque that can block blood flow, and tire out the heart by forcing it to work harder to pump blood through the body. High blood pressure, called “the silent killer”, is a leading risk factor heart disease and stroke. The American Heart Association recommends no more than 2,300 milligrams (mgs) a day and
an ideal limit of no more than 1,500 mg per day for most adults. Cutting back to no more than 2,400 milligrams a day will significantly improve blood pressure and heart health. How Can I Reduce Sodium In My Diet? The fact is that more than 75 percent of the sodium Americans eat comes from processed, prepackaged and restaurant foods – not from your salt shaker! At the grocery store, look for the American Heart Association’s Heart-Check mark for certified foods that meet nutrition requirements. Choose packaged and prepared foods carefully by comparing labels. Pick fresh or frozen poultry that hasn’t been injected with a sodium solution (check the fine print on the packaging for terms like “broth,” “saline” or “sodium solution.”). and choose canned vegetables labeled “no salt added.” When cooking at home, use onions, garlic, herbs, spices, citrus juices and vinegars in place of some or all of the salt to add flavor to your food. Draining and rinsing canned beans
and vegetables can reduce the sodium by up to 40 percent. At restaurants, don’t be shy! Ask for your dish to be made without extra salt. Taste your food before adding salt. And watch out for foods described using the words pickled, brined, barbecued, cured, smoked, broth, au jus, soy sauce, miso, or teriyaki sauce: these tend to be high in sodium. Finally, visit sodiumbreakup. heart.org to take action today and help make America’s stores, restaurants, schools, and industries heart-healthier. More and more Americans are saying that their food is too salty and they want action to reduce sodium. Robust, clear
science backs this consumer demand for less sodium in the food supply. The American Heart Association is Encouraging manufacturers to reduce the amount of sodium in the food supply and advocating for more healthy foods, like fruits and vegetables, to be available and accessible. You can join our growing community by encouraging significant changes in the food industry and in government policy. Visit sodiumbreakup.heart.org to learn more and Break Up With Sodium!
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Austin Medical Times
Top Five Cancer Trends in 2018 By Kathryn Hudson, M.D., Texas Oncology—Austin Central
ew developments in cancer care provide more options and optimism for the 120,000 Texans diagnosed each year with cancer. Texas Oncology physicians have identified the following top cancer trends for 2018: 1. Toppling Cancer Type and Location Ten years ago, we looked at cancer primarily by the subtype location, be it breast, lung, melanoma, or colon cancer. Today, we better understand distinct molecular pathways, enabling us to target and personalize treatment plans regardless of the cancer location. Five years ago, we conducted testing for only a handful of cancer factors. Now we test for more than 50 genetic markers to make evidence-based decisions on the best treatment options. Patients appreciate that we’re
treating their tumor rather than just a generic cancer. 2. Reducing Chemotherapy Although chemotherapy remains a primary way we treat cancer, innovations based on studying gene mutations within the cancer are an exciting trend. Through recent advances in molecular biology and immunotherapy – which uses the body’s immune system to fight cancer – personalized treatment can be more effective and less toxic than chemotherapy. Precision in radiation technology has advanced dramatically, targeting tumors without harming healthy tissue. Now, in some metastatic stage IV cancer patients, we can use stereotactic body radiation therapy (SBRT) and immunotherapy to achieve long-term control and possibly cure of disease. 3. Using Big Data With many thousands of patients under its care, Texas Oncology uses big data to glean powerful insights and discoveries, such as better understanding of genetic risk, new approaches to therapeutics, and trends in healthy living post-treatment. Oncology is a
highly evidence-based specialty, and cancer data are critical to treatment planning, which involves a careful balance of effectiveness, toxicity, and cost. For more than a decade, we have participated in evidence-based pathways, using cancer data to improve outcomes. We use vast amounts of information on patient illnesses, Medicare data on services, and as well as total cost of care. We analyze patient outcomes, hospitalizations, and ER visits to help us identify opportunities
to change care delivery to improve outcomes and patient experience. 4. Surviving and Thriving Better screening and treatment means more survivors who can enjoy better quality of life after cancer. Treatment breakthroughs that are less toxic mean fewer near and long-term side effects. Earlier detection and genetic testing provide better understanding of cancer risk and the opportunity to treat cancer sooner, with greater success. Also, see Cancer Trends... page 18
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Access to nutritious food is essential for a healthy, thriving community. Learn about how we’re leading the fight against hunger at centraltexasfoodbank.org. March 2018
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Baylor Scott & White Health Partners with the World Golf Championships-Dell Technologies Match Play as Preferred Healthcare Provider
he World Golf Championships-Dell Technologies Match Play is teaming up with Baylor Scott & White Health, the largest not-for-profit healthcare system in Texas. The pair announced an agreement for the system to become the preferred healthcare provider of the WGC-Dell Technologies Match Play. The tournament, set to return to Austin Country Club March 21-25, will draw the top talent in the game and their fans. “We’re honored to be part of this exciting event, happening right here in our community,” said Jay Fox, president, Baylor Scott & White – Austin/Round Rock Region. “Golf requires precision, commitment and focus—the same
attributes you want in a medical team.” Baylor Scott & White will provide medical services for players and spectators of the WGC-Dell Technologies Match Play. Baylor Scott & White also will provide two conveniently located comfort zones, where fans can receive first aid and sunscreen throughout the tournament. “We’re pleased to begin this relationship with Baylor Scott & White and grateful to have their support in taking care of our players and spectators’ medical needs at this year’s tournament,” said Executive Director Jordan Uppleger. “The WGC-Dell
Technologies Match Play has donated over $2.1 million to charity since moving to Austin and a major cog in that has been the continued local support of partners like Baylor Scott & White.” Baylor Scott & White has grown its Austin area presence to 30 primary care clinics spanning Travis, Williamson, and Hays counties, and four area medical centers to provide care for Central Texans. The system’s high-quality, integrated care delivery
model focused on patient-centered care includes a single electronic medical record, interactive consumer applications that give patients access to their health information, virtual check-in capabilities for convenience, and interactive screen displays during patient visits that enable greater communication with providers. With only six weeks before the World Golf Championships-Dell see Baylor Scott & White... page 18
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Providing Advanced Care for Critically Injured Patients, Closer to Home
eton Medical Center Hays (SMCH) has received designation from Texas Department of State Health Services as an Advanced Level III Adult Trauma Facility. This means many traumatic injuries including injuries from automobile crashes, falls, or other serious events can be treated closer to home. “Seton is committed to improving this community’s health and well-being,” said Neal Kelley, RN, Vice President and Chief Operating Officer of SMCH. Seton is part of Ascension, the largest nonprofit health system in the U.S. and the world’s largest Catholic health system. “This designation shows our
a $14M maternity and women’s services expansion. Providing advanced care When a trauma strikes, getting the right care at the right time is critical. As a Level III Trauma Center, SMCH’s expert team of emergency medicine physicians, surgeons, anesthesiologists, radiologists and other health care professionals are specially equipped to offer a full spectrum of medical and surgical care. “Trauma is a leading cause of death in people ages one – 44,” said Fausto Meza, MD, MPA, Vice President Medical Affairs at SMCH. “Access to high-quality trauma care in our area
commitment to providing life-saving care patients can trust.” The hospital began operating as an adult Level III trauma center in March 2017 and is moving toward Level II capabilities in Fall 2018. This designation is part of a continued commitment to grow with the community’s needs, providing convenient access to quality care: In January 2017, the world-class pediatric emergency care of Dell Children’s Medical Center of Central Texas expanded to SMCH. In June, SMCH marked its accomplishment of 100 heart surgeries in one year, a milestone credited to the addition of heart surgeon Jeffrey McNeil, MD In July, SMCH surgeons began using the state-of-the art-technology of Firefly Fluorescence Imaging with the da Vinci® Xi™ robotic arm system creating enhanced visualization and mobility, resulting in less pain, less blood loss, shorter hospital stays and minimal scarring In November 2017, SMCH opened a new 30-bed surgical unit, expanding the hospital from 112 beds to a 142-bed care site. Other exciting developments on the horizon for 2018 include a new wound care clinic, wellness center and
can mean the difference between life and death.” If a higher level of care is needed, Level I trauma care is available right here in Austin. Dell Seton Medical Center at The University of Texas is home to our region’s only anticipated Level I Trauma Center for adults and Dell Children’s Medical Center of Central Texas remains the only Pediatric Level I Trauma Center in Central Texas, providing the most advanced care for the most severely injured patients. Meeting stringent standards The accreditation process involves an extensive on-site survey and a comprehensive program review. To gain the official Level III designation, SMCH had to meet a range of stringent standards including the ability to provide: ∙∙ Prompt assessment, resuscitation, surgery, intensive care and stabilization of injured patients ∙∙ 24-hour immediate coverage by emergency medicine physicians and the prompt availability of general surgeons and anesthesiologists ∙∙ Back-up care for rural and community hospitals ∙∙ Continued education of the nursing and allied health personnel or the trauma team
Austin Medical Times
Untimely Immune Cell Clocks May Contribute to Obesity and Diabetes in Shift Workers Texas A&M Researchers Discover the Effects of Shift Work on Immune Cell Clocks May Lead to Metabolic Disorders By Christina Sumners
bout 15 million Americans don’t have a typical nine-to-five workday, and many of these—nurses, firefighters and flight attendants, among many other professions—may see their schedule change drastically one week to the next. As a result, these shift workers’ biological clocks, which keep track of the time of day, cannot keep accurate time, potentially making the negative effects of a high fat diet on metabolic disorders even more pronounced, according to new research published in The FASEB Journal. “It’s been difficult to tease apart cause and effect in this situation, because when sleep is disrupted, eating habits tend to be altered as well,” said David Earnest, PhD, professor at the Texas A&M College of Medicine’s
Department of Neuroscience and Experimental Therapeutics and lead author of the article. “However, using animal models, we were able to show here that it really was alterations of biological clock timekeeping that caused these effects.” Biological clocks are located in virtually all cells in the body, controlling circadian rhythms, the 24-hour cycles that regulate the timing of sleepiness, hunger and many other physiological processes, including inflammation and metabolism. Earnest’s earlier research indicated that when the internal clock is completely disrupted—meaning it can’t keep time at all—there is a cascade of problems, especially to how the immune cells mediate inflammation. The current research indicates that shift work has similar effects on immune cell clocks and their inflammatory
responses. Earnest and his team, including Robert S. Chapkin, PhD, Texas A&M Distinguished Professor and deputy director of the Center for Translational Environmental Health Research, and
Robert Alaniz, PhD, research assistant professor at the Texas A&M College of Medicine, used a model of shift work
and whole grains ∙∙ Including lean proteins such as poultry and fish, along with beans, eggs, and nuts ∙∙ Minimizing saturated fats, trans fats, salt (sodium), and added sugars
diet. Don’t be fooled by the name. The DASH diet can work for you even if you aren’t diagnosed with hypertension. This program supports the total diet approach by encouraging Americans to choose nutrient-dense foods and beverages, while reducing intake of saturated fats, trans fats, added sugars, and sodium.
see Shift Workers...page 18
Total Diet Approach to Healthy Eating By Denise Hernandez, MS, RD, LD Austin Medical Times
any Americans struggle with understanding what healthy eating is. The reason for this can be attributed to the endless amounts of information circulating social media and on the internet. Most times, these sources share information that is either in its preliminary stage of research or just outright false. The truth is that eating right doesn’t have to be complicated. Following the Total Diet Approach to Healthy Living is a good start. This approach includes at it’s foundation physical activity and a balanced, variety of nutrient-rich foods. Its defined as everything a person eats averaged over time and includes all the foods and beverages that offer nutrients and energy (calories).
W h y is this approach recommended? Simply because it is based on sound nutrition research. It’s also known that a large number of Americans do not meet the basic recommendations based on the Dietary Guideli nes for A mer ic a n s. T he statistics show that 82% don’t want to give up foods they like in order to eat healthier. They also show that 68% percent don’t eat fruits and vegetables at least twice per day. When it comes to physical activity, 36% of Americans state they have no time for physical activity. You can start shifting to healthier food and beverage choices by following the recommendations from the Dietary Guidelines for Americans, such as:
∙∙ Emphasizing fruit, vegetables,
If a program works best for you, consider following the DASH (Dietary Approaches to Stop Hypertension)
Austin Medical Times
Continued from page 1 affected the OIG’s decision to approve the Arrangement. The OIG does not identify patient notice as a factor in reducing the Arrangement’s fraud and abuse risk; nor has the OIG addressed patient notice in other gainsharing advisory opinions (e.g., Advisory Opinion 12-22). Third, while the Opinion does not state that Hospital’s
cost-saving opportunities specifically affect medically unnecessary items or services only, the OIG notes that the recommendations are reasonable and cites to Hospital’s certification that medically necessary services would not be reduced. Entities engaging in or considering such arrangements should consider whether arrangements
reduce, or create incentives to reduce, medically necessary items or services. It is unclear whether the industry can expect additional advisory opinions regarding gainsharing arrangements, particularly given the limited number of advisory opinions recently issued by the OIG. However, the Opinion may provide useful insight into how the OIG
may address gainsharing arrangements going forward and identifies potential safeguards that providers may use to mitigate risk in structuring these arrangements, which may increase in use as more provider payment arrangements involve cost-saving distributions.
pancreas and prostate cancers, which occasionally have, one mutation per megabase. That could explain why the effectiveness of the immune checkpoint blockade is not impressive in those tumors that have few somatic mutations and consequently a poor neoantigen repertoire. Such evidence together with assumptions about the tumor microenvironment, immune privilege and the expression of negative immune checkpoints lead to an insufficient T cell activity and
consequently cancer progression. Several groups are trying to develop novel approaches so that the effect of the immune checkpoint blockade could be augmented in patients with few somatic mutations. To this end, the researchers are focusing their attention on the mechanisms involved in the antitumor response. Preclinical models suggest that an effective antitumor response is obtained when Ipilimumab and Nivolumab induce lymphocyte responses to neoantigens expressed on
the individual tumor. If so, a therapeutic approach could be the combination of the immune checkpoint blockade with peptide vaccines. Since the majority of mutations are patient-specific, this new approach could lead the way favoring personalized immunotherapy, combining immune checkpoint blockade with cancer vaccines containing a cocktail of peptides corresponding to neoantigens known to be expressed in a given patient’s tumor cells.
services, or any trade or business where the principal asset of such trade or business is the reputation or skill of one or more of its employees or owners, or which involves the performance of services that consist of investing and investment management trading, or dealing in securities, partnership interests, or commodities. Alimony Deduction by Payor and Income Inclusion by Payee Repealed. For any divorce or separation agreement executed after 2018, or executed before that date but modified after it (if the modification expressly provides that the new amendments apply), alimony and separate maintenance payments are not deductible by the payor spouse and are not included in the income of the payee spouse. Moving Expense Deduction and Reimbursements Eliminated. For tax years 2018-2025, the deduction for moving expenses and the income exclusion for qualified moving expense reimbursements is eliminated, except for members of the Armed Forces on active duty (and their spouses and dependents) who move pursuant to a military order and incident to a permanent change of station. Child Tax Credit Increased.
For tax years 2018-2025, the child tax credit is increased from $1,000 to $2,000 per qualifying child under the age of 17, and other changes are made to phase-outs and refundability during this same period. Nonchild Dependents. A $500 nonrefundable credit is provided for certain nonchild dependents. Estate and Gift Tax Retained with Increased Exemption Amount. Under pre-TCJA law, the first $5 million (as adjusted for inflation in years after 2011) of transferred property was exempt from estate and gift tax. For estates of decedents dying and gifts made in 2018, this “basic exclusion amount” was $5.6 million ($11.2 million for a married couple). For estates of decedents dying and gifts made after 2017 and before 2026, the TCJA doubles the base estate and gift tax exemption amount from $5 million to $10 million. The $10 million amount is indexed for inflation occurring after 2011 and is expected to be approximately $11.2 million in 2018 ($22.4 million per married couple). example.
Continued from page 4 particular cancer type. One of the reasons why the immune checkpoint blockade, especially by anti-CTLA-4 and anti-PD1, successfully work on melanoma and lung cancer patients is due to the potential formation of a neoantigen repertoire Melanoma and lung cancer cells have a mutational rate above ten somatic mutations per megabase (Mb) of encoding DNA, unlike astrocytoma, thyroid, medulloblastoma, neuroblastoma, glioblastoma, myeloma, ovary, thyroid,
Financial Forecast Continued from page 5 underlying mortgage loans could represent acquisition indebtedness of up to $1 million, plus home equity indebtedness of up to $100,000. For tax years 2018-2025, the deduction for interest on home equity indebtedness is eliminated and the deduction for mortgage interest is limited to underlying indebtedness of up to $750,000 ($375,000 for married taxpayers filing separately), The new lower limit doesn’t apply to any acquisition indebtedness incurred before 12/15/17. Charitable Contribution Deduction Limitation Increased. For contributions made in tax years after 2017, the 50% limitation for cash contributions to public charities and certain private foundations is increased to 60%. Charitable Contribution Deduction for College Athletic Seating Rights Eliminated. For tax years after 2017, no charitable deduction will be allowed for any payment to an institution of higher education in exchange for the right to purchase tickets or seating at an athletic event. Casualty and Theft Loss Deduction Eliminated. For tax years 2018-2025, the personal casualty and theft loss deduction is eliminated, March 2018
except for personal casualty losses incurred in a federally-declared disaster area. New Deduction for Business Income from Pass-through Entities and Sole Proprietorships. For tax years 2018-2025, an individual generally may deduct 20% of qualified business income from a partnership, S corporation, or sole proprietorship, as well as 20% of aggregate qualified Real Estate Investment Trust (REIT) dividends, qualified cooperative dividends, and qualified publicly traded partnership income. The 20% deduction is not allowed in computing Adjusted Gross Income (AGI), but rather is allowed as a deduction reducing taxable income. A limitation based on W-2 wages paid is phased in for married filing joint taxpayers with taxable income of $315,000 or more ($157,500 for other individuals). A disallowance of the deduction with respect to specified service trades or businesses also is phased in above these threshold amounts of taxable income. A specified service trade or business means any trade or business involving the performance of services in the fields of health, law, consulting, athletics, financial services, brokerage
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Warm cookies, baked-to-order, delivered to your door. cookiedelivery.com
Austin Medical Times
Continued from page 10 more people are quitting or avoiding smoking, leading to significantly lower lung cancer deaths. We believe that survivorship begins at diagnosis. That’s why we create a treatment plan for every patient, outlining all care options using evidence-based research. We guide patients and family members through every part of the treatment process, including post-treatment and adjusting to a new life as a cancer survivor. 5. Increasing Patient Power In 2018, cancer patients are more
involved in their treatment decisions than ever. Baby Boomers and succeeding generations have more access to information and tend to conduct their own cancer research. We encourage patients to discuss their goals and values with their doctors early and throughout treatment. Texas Oncology’s detailed treatment plans include the type and stage of cancer, the purpose and goal of treatment, and information on drugs and any side effects. Patients are free to share the plan with family and friends so
that everyone sharing in their cancer journey is informed. We are excited about promising trends in cancer that enable us to innovate with more effective treatments that lead to better outcomes and quality of life for patients during and after treatment. Kathryn Hudson, M.D., Texas Oncology is a medical oncologist at Texas Oncology—Austin Central, 6204 Balcones Drive in Austin, Texas.
Continued from page 12
exciting tournaments on golf’s calendar as one in a series of four World Golf Championships events sanctioned and organized by the operational committee of the International Federation of PGA Tours, which includes the Asian Tour, European Tour, Japan Golf Tour, PGA TOUR, PGA Tour of Australasia and Sunshine Tour. The WGC-Dell Technologies Match Play field annually consists of the very best players from
around the world from all Tours and traditionally features nearly all of the top 64 in the world. Since its inception, the WGC-Dell Technologies Match Play has generated more than $17 million for charity, with the tournament announcing in early October that the 2017 edition raised over $1.1 million for five Austin-based charities.
Senior Designer Jamie Farquhar-Rizzo Web Development Lorenzo Morales
Writers Jorge Augusto Borin Scutti, PhD Denise Hernandez MS,RD,LD Office: 512-203-3987 For Advertising advertising@medicaltimesnews. com Editor email@example.com
Continued from page 15
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in which cycles were reversed every five days. “The body just can’t keep up with that kind of disruption,” Earnest said. “The same effects are likely true any time there is a routine change in schedule, like what we call ‘social jet lag,’ where people stay up late on the weekends and then have to shift back to an earlier schedule during the week for work or school.” Although the study focused on immune cells, the implications go far beyond fighting off invading pathogens.
Editor Sharon Pennington
Distribution Brad Jander
Baylor Scott & White Technologies Match Play kicks off, defending champion Dustin Johnson remains the No. 1 player in the world and will be back in the field in Austin in March. Only the top 64 in the world rankings as of March 12 are guaranteed qualification for the WGC-Dell Technologies Match Play. As of now, Three former Texas Longhorns – Jordan Spieth, Jhonattan Vegas and Dylan Frittelli – would be qualified for the field if it were set today. The 2018 WGC-Dell Technologies Match Play, the third of four World Golf Championships events during the 2017-18 season, returns to Austin for the third consecutive year March 21-25. The WGC-Dell Technologies Match Play is one of the most elite and
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Instead, altering our internal clocks exacerbates inflammatory responses that lead to the development of metabolic disease, including obesity and diabetes. Related research in his lab has indicated that shift workers may be at higher risk of severe stroke. Compounding the problem may be what people partying or working at night choose to eat. Fatty foods can cause the clock to lag further behind normal time, imposing mistimed cycles on many body processes.
These results indicate possible ways to reduce inflammation and help shift workers avoid some of the metabolic effects of their schedules. “We hope that we can find therapeutics to cancel out some of the problems caused by circadian rhythm disturbances,” Earnest said. “There are many people who are required to function well on irregular cycles, and if we can find a way to cut down the inflammation this causes, we may be able to minimize the long-term effects.”
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Austin Medical Times
FACE FEEL PUFFY?
On average, American adults eat more than 3,400 milligrams of sodium daily – more than double the American Heart Association’s recommended limit.
JEANS FIT TIGHTER? 3500
weeks you can:
• Change your sodium palate &
• Start enjoying foods with less sodium • Reduce bloating
Servings Per Container 4 Amount Per Serving
Calories 310 Calories from Fat 100 % Daily Value*
Sodium 560mg Cholesterol 118g Total Fat 15g Saturated Fat 2.6g Trans Fat 1g Cholesterol 118g Sodium 560mg Total Carbohydrate 12g Dietary Fiber 1g
28% 39% 21% 17%
2000 1500 1000 500
recommended sodium intake
IN ONLY Nutrition Facts Serving Size 5 oz. (144g)
mg average sodium intake
Learning to read & understand food labels can help you make healthier choices.
21 DAYS heartcheckmark.org Look for the HeartCheck mark to find products that can help you make smarter choices about the foods you eat.
39% 28% 4% 4%
WEEK ONE Breads & Rolls
Cold Cuts & Cured Meats
WEEK TWO Pizza
• Look for lower sodium items • Track your sodium consumption • Log how much sodium you’ve shaved out of your diet
• If you do eat pizza, make it one with less cheese & meats • Add veggies to your pizza instead • Use fresh poultry rather than fried, canned or processed
KNOW THE SALTY 6 Common foods that may be loaded with excess sodium: 1 2 3 4 5 6
Breads & Rolls Cold Cuts & Cured Meats Pizza Poultry Soup Sandwiches
Choose wisely, read nutrition labels & watch portion control.
WEEK THREE Soups
• One cup of chicken noodle soup can have up to 940 mg of sodium • Check labels & try lower sodium varieties • Use lower sodium meats, cheeses & condiments & plenty of vegetables to build healthier sandwiches
Austin Medical Times
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