C olorado E dition | N ovember 2011
The Growing Need for “Safety Net” Care Community Health Centers Like Peak Vista Strive to Fill Care Gaps
ALSO INSIDE THIS EDITION Medical Marijuana – Where Do We Stand? By Kenneth Finn, MD
Check-Up for Your Financial Health: An Interview With Jeff Jensen, CIMA, AIF
CLINICAL FEATURES Trauma Medicine: Centura’s Trauma Program IMAGING: Y-90 Radioembolization-New Hope for Liver Cancer
Conte n ts colorado edition | november 2011
From The Medical Voyce CEO
Y-90 Radioembolization Offers New Hope To Patients With Liver Cancer
L E G I S L AT I O N
Potential Impacts of New Federal Policies on Provider Reimbursement Rates
C OV E R F E AT U R E
The Growing Need for “Safety Net” Care
Community Health Centers like Peak Vista Strive to Fill Care Gaps
C L I N I C A L F E AT U R E : R AD I O L O G Y & I M A G I N G
• Top Five Challenges With ICD-10 • New Guideline Helps Providers in Preventing Rx Drug Abuse
R E V E N U E C YC L E : M ANA G E M E N T
What Small to Medium-Sized Practices Should Look For When Outsourcing Their RCM And Billing
F I NAN C I A L & I N V E S T M E N T M ANA G E M E N T
A Check-Up For Your Financial Health
O P - E D : M E D I C I NA L M A R I J UANA
CLINICAL GUIDELINES BY H e a lth T e a m W or k s
Medical Marijuana: Where Do We Stand?
Guidelines For Geriatric Resuscitation After Trauma Should Include Lactate
What’s Going On Here?
New Palliative Care Guidelines Assist Primary Care Providers C L I N I C A L F E AT U R E : T R AU M A
FROM THE DEAN: university of colorado denver-anschtz medical campus
Welcome to the inaugural edition of Medical Voyce, The Magazine – a business and clinical news journal for Colorado physicians, health care executives and administrators. This publication is complimentary and is circulated throughout the entire state to all licensed physicians, so enjoy reading this state-focused edition from thought leaders and subject matter experts in the realms of business, law, risk management, accounting, clinical and academic medicine, and a myriad of other topics. Having served the medical establishment in Colorado for nearly eight years as a three-time awardwinning publisher for M.D. News, it was time for a change and after receiving nearly 1,000 e-mails from Colorado providers, we’ve decided to expand our multimedia platforms to bring you this new publication.
D i r k R. H o b b s , CEO M ed i c a l V o y ce , LLC
The magazine complements our public and professional Web domains and our efforts with several component medical societies in Colorado, as well as key leaders at the medical schools, healthcare advocacy groups, and within all our health systems. Our cover features are free editorial profiles focusing on key events or topics that have a wide-ranging impact on our health delivery system here in Colorado. For example, this first edition takes a look inside Peak Vista Community Health Centers – the safety net health system in Southern Colorado and how it is poised to deal with the challenges it faces in the ever-evolving world of reform. We’ll bring you content from Colorado’s best and brightest business leaders each month, who will present bite-sized exposés into their areas of expertise for your benefit. Topics will range from in-practice business issues, to personal finance, health reform, practice redesign, physician employment and those matters that occur outside of practice. Our clinical departments will showcase the intellectual property of Colorado’s world-class network of clinical professionals in all modalities and specialties of medicine and behavioral health. We welcome all agencies and health systems to present their service lines to educate the state’s referring physicians on resources available to their patients. Additionally, we’re pleased to present clinical guidelines from HealthTeamWorks along with other chronic disease treatment and management topics – all for your professional curiosity and edification. Article submissions: As long as it is relevant to Colorado medicine and healthcare, we can discuss placement of your content. Got a new building or campus? Got new equipment or a new physician on staff? Or how about a new technique or procedure? Virtually all aspects of the business are welcome so long as we are informing and educating. Op-eds are welcome too – just have a look at our Medical Marijuana discussion inside! A word about Medical Voyce Multimedia: Our organization now spans three bordering states (CO, WY and NM), and we just added South Carolina. We have more than 10,000 providers in our system using dozens of our services. Chances are, your professional profile is on our public domain, http://www.medicalvoyce.com. Check it out and if you want to change anything, you can – just call your local medical society and they will tell you how. It was their gift to you! Also, any story that appears in our magazine can automatically appear on our Web domains and social media platforms (optional), so prospective patients can see your work as well. Welcome to the powerful world of “collaborative drip marketing”! Get the word out about what you’re doing to improve health via our many media outlets. It’s how you can stay in front of patients too. Well, that’s enough for our first edition. Enjoy your free magazine and as always, this is a very personal endeavor for our team. We want you to engage and respect our efforts and to use this publication as a resource you can count on. So tell us what you want and need and we’ll find it. Submit your inquiry or request to: firstname.lastname@example.org or call me personally, 719.884.1184, extension 1. I’d love to talk with you.
To your success,
Dirk R. Hobbs Chief Executive Officer & Executive Publisher Medical Voyce Sciences & Multimedia, LLC
Medical Voyce Magazine Colorado Edition Executive Publisher: Dirk R. Hobbs Medical Direction: Bhaktasharan C. Patel, MD Senior Medical Editor: Jeanne Davant Graphics, Layout & Design: Marta Podkul Printing Consultant: Marcum Group Media Contributing Writers: Charles W. Mains, MD; Kenneth Finn, MD; Steven Wegert, MD; Richard Krugman, MD; HealthTeamWorks; and Robert Semro State Sales Executive: Dianne Tantillo Medical Voyce Sciences & Multimedia, LLC Chief Executive Officer: Dirk R. Hobbs Chief Operating Officer: Scott W. Casey Chief Medical Officer: Buck C. Patel, MD Associate Medical Director: Sheldon Ravin, MD EVP Communications: Kim Ronkin EVP SEO Services: Greg Walthour Director of Web Services: Winn Jewitt Ask-My-Doc VP Development: Abhay Natu Ask-My-Doc Project Manager: Arun Raval Territory Managing Director, NM: Michele Sequiera Territory Managing Director, NM: Michael Westphal Medical Voyce Magazine is published by Medical Voyce Sciences & Multimedia, LLC 422 West Bijou Street Colorado Springs, CO 80905 Phone: 719.884.1184 | Fax: 719.884.1189 Email: email@example.com Web: http://www.medicalvoyce.com To advertise, reprint, or submit sponsored content in Medical Voyce, contact Dianne Tantillo at Dianne.Tantillo@medicalvoyce.com or 720.878.6008 â€“ or firstname.lastname@example.org Copyright 2011 ÂŠ Medical Voyce Multimedia, LLC POSTMASTER: Use form 3579 to 422 West Bijou Street-Colorado Springs, CO 80905.
Every attempt is made to ensure accuracy of published materials. Medical Voyce cannot be held responsible for the opinions, facts, or ideas expressed by its authors or contributors.
L e g i s l at i o n
Potential Impacts of New Federal Policies on Provider Reimbursement Rates Robert Semro, Health Policy Analyst - The Bell Policy Center
Provider reimbursement rates have been or may be affected by a number of federal policies, laws and proposals.
Broadly speaking, the policy areas break down this way: • Sustainable Growth Rate (SGR) – This is the formula for determining Medicare reimbursement rates. In theory, it requires reimbursement reductions should spending per Medicare beneficiary increase faster than the rate of growth in GDP, but since it was included in the Balanced Budget Act of 1997, Congress has chosen not to execute the SGR recommendations on twelve separate occasions due to the size of cuts that the formula would have required. If SGR cuts were to be put into effect on Jan. 1, 2012, when the latest postponement runs out, Medicare providers would face a rate reduction of 29.4%. These cuts will almost certainly not be implemented, however, because of the potential damage this would inflict on the Medicare program. The real question is whether there is any possibility of creating a permanent fix, a replacement for SGR. The new Temporary Joint Select Committee on Deficit Reduction, or “super committee,” is one possible mechanism, but a replacement would add an additional $297.5 billion to the current budget deficit. As an alternative, the President’s FY2012 budget proposal postpones implementation of the SGR adjustments for another two years and pays for the delay with other offsets to the Medicare program. • The President’s Debt and Deficit Reduction Proposal – This proposal was released in mid-September. It specifically targets provider reimbursement as part of a larger plan to reduce public health care spending by $248 billion for Medicare and $73 billion for Medicaid over 10 years.
Specific proposals include:
R o b e r t S em r o
• Reductions in some Medicare special payments; reductions in payments to SNFs, LTCHs, IRFs and home health; realignment of Medicare drug policies that would save about $135 billion; imposition of a new blended Medicaid payment formula that would reduce funding to states; and a new limit on Medicaid provider taxes that could be levied by states. While it is unlikely that this proposal will become law as currently structured, it does identify potential provider reductions that would be acceptable to the administration. • The Budget Control Act of 2011 – This law, which arose out of the recent debt ceiling debate, has already imposed roughly $917 billion in broad budget cuts over the next 10 years. It also created the deficit-reduction “super committee.” This committee is charged with reducing the nation’s deficit by an additional $1.5 trillion or more over the next 10 years. That work is in progress and could include provider-rate adjustments. If the committee cannot reach agreement on at least $1.2 trillion in deficit reduction by November 23, the difference will be subject to across-the-board reductions, including cuts in Medicare payments to providers and insurance plans. Those cuts would be limited to two percent of such payments in any year. Adjustments would be limited to Medicare payments to Medicare Advantage plans, Part D (prescription drug) plans and providers including but not limited to hospitals and physicians. • The Affordable Care Act (ACA) – The new health care reform law affects provider reimbursement in several ways.
Provider Bonuses: This provision would provide a 10% reimbursement bonus to primary-care practitioners and general surgeons who practice in health professional
7 shortage areas through the end of 2015. Additionally, Medicaid payments to primary care physicians would not be lower than the Medicare fee schedule from 2013-2014.
Reductions to Medicare Payment Updates: The most significant reimbursement adjustment in the ACA would reduce annual Medicare payment updates to 15 services, including in-patient hospital, home health, skilled-nursing facility, hospice and other Medicare providers. Some of these adjustments were implemented in 2010. The ACA will also apply a new “productivity adjustment” beginning in calendar, fiscal or rate year 2012, as appropriate. The Congressional Budget Office (CBO) has argued that unlike other segments of the private sector, current annual update payment formulas overstated cost increases to providers because they did not account for productivity increases. Productivity adjustments would not apply to physicians. The CBO projects a total reduction of $156 billion over the next 10 years, while the CMS actuary projects $233 billion.
Reductions to DSH Payments: Another provision of the ACA will reduce Disproportionate Share Hospital (DSH) payment spending by $18 billion over the next 10 years. Beginning in 2014, Medicare DSH payments will be
reduced by 75% and adjusted upward over time according to the percent of the population uninsured and the amount of uncompensated care provided. Medicaid DSH payment reductions will be phased in starting in 2014, with the largest reductions targeted from 2018-2020. The largest DSH reductions will apply to states with the lowest number of uninsured.
IPAB: Finally, the ACA could impact reimbursement through its creation of an Independent Payment Advisory Board (IPAB). The IPAB would be required to submit proposals to Congress that would reduce per capita growth in Medicare spending if that spending were to exceed a targeted growth rate. If Congress rejects the IPAB recommendations without proposing alternatives that achieve the spending targets, then the recommendations of the IPAB would be implemented. Since the IPAB is prevented from making any recommendations that would ration care, increase premiums or cost-sharing, raise taxes, restrict benefits or modify Medicare eligibility, it is likely that provider reimbursement reductions will be considered. The first IPAB recommendation report to Congress must be delivered in 2014. The recommendations themselves would be implemented the following year.
A bout T he B ell P olicy C e n ter : Research – Advocacy – Opportunity: The Bell Policy Center believes Colorado should be a state of opportunity - a place where all people can build better lives for themselves and their families. Opportunity motivates effort, unleashes the talents of individuals, feeds a dynamic economy and stimulates creativity and invention. Turning this vision into a reality is the mission of the Bell Policy Center. You can reach the Bell Policy Center: 1905 Sherman St., Suite 900, Denver, Colorado 80203. (303) 297-0456 Metro Denver (866) 283-8051 Toll-free in Colorado (303) 297-0460 Fax www.bellpolicy.org
F e at u r e
The Growing Need for “Safety Net” Care Community Health Centers like Peak Vista Strive to Fill Care Gaps By Jeanne Davant, Senior Medical Writer
Community health centers serve a vital purpose in Colorado. They provide medical and dental care, lab and pharmacy services, and behavioral health care to hundreds of thousands of patients who otherwise do not have access to health care, and their role is expanding.
Peak Vista is the largest safety net organization in the state outside the Denver metro area, with 19 health centers in the populous Pikes Peak region. Medical Voyce asked Peak Vista’s leaders to share their perspectives on the significance and impact of their organization and the challenges of the future.
“We’re growing as fast as possible to meet the needs, and yet the needs are still growing,” says Pamela McManus, President and CEO of Peak Vista Community Health Centers, which is based in Colorado Springs. Peak Vista is one of 15 community health organizations that form the backbone of the “safety net” system in Colorado.
Safety Nets’ Growing Role
H e a lth C e n ters According to the Colorado Community Health Network’s 2011 Economic Impact Analysis, community health centers significantly impact health care in Colorado. They: Provide health care homes to more than 500,000 people • Provide comprehensive primary care • Help patients manage chronic conditions • Reduce the rate of emergency room visits, hospital readmissions and preventable hospitalizations.
In addition, community health centers have a significant impact on economic development. They: •
Generated more than 3,000 full-time jobs in 2010 and provided jobs for more than 6,500 Colorado residents • Are among the largest employers in many communities • Support local economies through purchase of goods and services • Act as economic incubators, attracting investment, residents and other businesses to their communities.
Since its founding in 1971, there has rarely been a year when Peak Vista has not grown. But the economic downturn that started in 2008 has spurred extraordinary growth at Peak Vista and all of the state’s safety net providers. Peak Vista serves more than 63,000 people. Between 2007 and 2010, the number of patients served increased by 5,700, and the number of visits increased by 44,000. Peak Vista has opened or expanded half a dozen facilities, including a new Senior Health Center in 2010, and the number of providers has increased from 56 to 82. Perhaps the most telling statistic, though, is that Peak Vista’s waiting list, which had only a few hundred patients in 2007, now tops 8,000. “The overall need exceeds the 8,000 on our waiting list,” McManus says. “There are still people in our community who are going to emergency rooms for primary care. I believe that 8,000 number is just a small part of the people who need primary health care.” Adults ages 19 to 65 have the greatest need for safety net services, McManus says. Many statewide programs give priority to children, whereas adults may be working one or more jobs with no benefits or have had their hours and/or benefits cut. Parents may sacrifice their own care in favor of getting care for their children. “These are people who make just enough to get through to the next paycheck,” she says. “When they get sick or think about preventive care, it’s something that’s not in the budget.” “That means Peak Vista’s providers are seeing patients
P a me l a M c M a n u s , CEO
“We’re growing as fast as possible to meet the needs, and yet the needs are still growing.”
“That means Peak Vista’s providers are seeing patients who are sicker and have more health issues than those who have received regular care.” M i ch a e l W e l ch , DO, VP M ed i c a l & D e n ta l
who are sicker and have more health issues than those who have received regular care,” says Dr. Michael Welch, D.O., Vice President of Medical and Dental at Peak Vista. “This leads to more clinical work when you initially see these patients,” he says. “It’s much more labor-intensive to get them medically up to speed than if you see someone transferring care from one provider to another.” Several studies have concluded that medically underserved people have poorer health and die sooner because of lack of access to primary care, Dr. Welch notes. One nationwide study showed that 123 people a day die because they lack health insurance and found a 40% increased risk of death among the uninsured. In Colorado, five people die every three days because they lack access to primary care. Rapid increases in the cost of health insurance and the growing number of people in high-deductible plans also factor into the safety net equation. Colorado is among states with the highest percentage of high-deductible plans; with 9.2% of under-65 adults enrolled, Colorado’s numbers are exceeded only by Vermont and Minnesota. Peak Vista certainly is not alone in running at capacity. Organizations like the Open Bible and Mission medical clinics and S.E.T. Family Medical Clinics are vital parts of the Pikes Peak region’s safety net, and they, too are feeling the pressure of growing need. “Despite all of our safety net centers, our local ERs are the two busiest in the state,” Dr. Welch says. “The underserved certainly are contributing to that.”
Economic Impact and Economies of Scale In an April 2011 report, the National Conference of State Legislatures, a research organization, estimated that community health centers save the health care system between $9.9 billion and $17.6 billion each year, provide
143,000 jobs and generate $12.6 billion in economic activity. The same publication highlighted Peak Vista’s new Senior Health Center and noted that community health centers are a cost-effective way to deliver services. The primary care setting is much less expensive than having patients seen at the ER and saves the whole community those costs, McManus says. Part of that comes from savings in uninsured use of resources. “After adjusting for all factors, patients that go to a community health center save about one-third of ER visits and one-third of admissions and readmissions,” she says. Peak Vista’s 2010 payroll amounted to $22 million, but the organization’s 500-plus employees have an economic impact beyond their numbers. Using the Implan economic model, a software program that calculates economic generation, the Colorado Community Health Network calculated that Peak Vista created a total of 669 jobs and had a total economic impact on the community of $43 million. “Of course, Peak Vista can’t do what we do alone,” says McManus, who chairs the Community Health Partnership, a non-profit that supports collaboration and coordination of care. “What Peak Vista does for the community is a highly collaborative effort among the safety net organizations with large assistance from both hospitals, private practice physicians, the El Paso County Department of Health and Human Services, and the El Paso County Medical Society.” The partnerships bring together more than 20 organizations, including several large private practices. Coordination and collaboration enable economies of scale and synergies. “We’re all working toward meeting the need,” she says. “We work hard to try not to duplicate but to fill the gaps and to look at resources and options. That’s important because every time there is duplication, it means someone else does not get care.”
10 An example of the benefits of collaboration is a program designed to reduce ER use by people who lack primary care. Peak Vista outreach workers embedded in the Emergency Departments of both Colorado Springs hospitals interview patients - identified by ED physicians - who could or should have been seen in a primary care setting, for example, a patient undergoing a diabetic crisis. “Our staff talks to them about the importance of primary care and sets up an appointment,” McManus says. The effort started as a pilot program focusing on Medicaid patients, but McManus hopes it will grow to encompass others in need as well.
Future Challenges “We’ve maintained our growth with a focus on the medical home concept and quality measures,” McManus says. “We wanted to grow in a smart way. We’ve utilized technology when we could—we were one of the early adopters of Electronic Health Records (EHR) in 2006. That gave us the data to track care and provide continuity of care.” Peak Vista’s strategic plan calls for doubling its capacity in the next five years, “with the assumption this is what will have to happen in order to meet the need,” McManus says. That growth will occur within an environment in which payment methods are changing and regulatory review is increasing. One of the greatest challenges for all safety net organizations will be continuing to both provide needed services and assure quality. The Affordable Care Act (ACA) has enabled Peak Vista to obtain some additional short-term funding for expansion, Dr. Welch says.
“More importantly, moving forward in time, if the ACA is implemented as currently defined, we expect it to increase the number of people covered by Medicaid. That means that many of the patients we currently see who are uninsured but don’t qualify for Medicaid will qualify in 2014, and the number of uninsured patients we’re caring for should drop.” Nevertheless, support from the community, from individual and corporate donations to volunteers, will remain a mainstay of community health centers’ ability to serve and grow. The dollar value of services donated to Peak Vista increased from $8.6 million in 2007 to $13.6 million in 2010. A large piece of that is from local volunteer physicians. “This community has been very supportive, and their support makes a big difference,” McManus says. “What we’re concerned about is that there is already the perception that if the ACA happens, everyone will be covered,” Dr. Welch says. “That is not the case. The ACA is not designed to cover everyone. But in a world where it is perceived that everyone is covered, I would be concerned that donations would drastically drop. If payment reform occurs as expected, and you add the ‘everyone is covered’ component, that would have a negative impact on our ability to continue to take care of people who don’t have coverage.” Even more important to the Pikes Peak region is the question of the ownership of Memorial Health System, says Dr. Welch, who is a member of the Task Force studying the issue. While the pros and cons of that question are beyond the scope of this article, “that issue is not about the current leadership, but the ultimate ownership,” Dr. Welch says. “I see that as the greatest challenge regarding safety net care and health care delivery in general.”
Peak Vista serves more than 63,000 people. Between 2007 and 2010, the number of patients served increased by 5,700 and the number of visits increased by 44,000. Peak Vista has opened or expanded half a dozen facilities, including a new Senior Health Center (left) in 2010, and the number of providers has increased from 56 to 82. P a me l a M c M a n u s , CEO
Clinical Guidelines p r e s e n t e d b y
H e a lt h T e a m W o r k s
New Palliative Care Guideline Assists Primary Care Providers
By lisa schneck, msj, and thea carruth, mph
People say that they want to die at home, but 60-80 percent die in some kind of healthcare facility. Pain and symptom control are essential, but 70 percent of outpatients with advanced cancer have moderate to severe pain.
• • • • •
Palliative care seeks to address these issues. It joins the patient, medical professionals and the family in a partnership to optimize quality of life for the sick individual and his/her loved ones by anticipating, preventing and treating their suffering. Palliative care throughout the continuum of illness should address physical, intellectual, emotional, social, and spiritual needs, facilitating patient autonomy as well as access to information and choice.
How the guideline was developed
A new clinical guideline on palliative care is now available free from HealthTeamWorks, formerly the Colorado Clinical Guidelines Collaborative. This two-page, easyto-use reference is intended for — but not limited to — primary care providers. As with all HealthTeamWorks guidelines, it is not meant to replace a clinician’s judgment or establish a standard of care.
Palliative care can begin in primary care setting
Ideally, palliative care begins at diagnosis of a potentially life-limiting illness, and can be delivered in conjunction with curative or disease-modifying treatment. Although granted sub-specialty status by the American Medical Association in 2006, palliative care can begin in the primary care setting. Its twin pillars are identifying goals of care and managing pain and symptoms, both of which are ongoing processes ideally suited to initiation and coordination by primary care. Importantly, the guideline provides indicators for referral to specialtylevel palliative care or hospice. The guideline defines palliative care and its role in the trajectory of various life-limiting conditions, differentiating between palliative care and hospice care. It suggests trigger questions that providers can use, adapt and revisit throughout the progress of illness to address the major foci of palliative care:
Advance care planning; Pain and symptom management; Emotional-social-spiritual needs and challenges; Caregiver burden; and Coping with decline and eventual death.
HealthTeamWorks convened a guideline development committee comprising physicians, advanced-practice nurses, and professionals in behavioral science, health communication and social work. Eleven Colorado organizations were represented, including private practices, hospitals, hospices, the University of Colorado and healthcare insurers. The committee identified existing evidence-based guidelines and conducted a literature review on palliative care. Its members determined the key issues that providers need to know to deliver appropriate care, decided what is not now being done that could make the most difference to improve care, and built the guideline around those issues. Following HealthTeamWorks’ usual procedure, a focus group of primary care physicians reviewed the guideline draft and made suggestions. The revised guideline was then reviewed by the HealthTeamWorks board of directors and membership. After further revisions, a final draft went to the HealthTeamWorks board and membership for final approval. The result: a carefully crafted, up-to-date clinical tool, rigorously vetted by healthcare professionals, published in a user-friendly form in hard copy and online. The HealthTeamWorks website also provides a beginning palliative-care tool set for care-givers at www.healthteamworks.org/guidelines/palliativecare.html.
S ources (1) Field MJ, Casel CK, eds. Approaching Death; Improving Care at the End of Life. Washington, DC: National Academy Press; 1997. (2) Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994; 330:592-596.
C l i n i c a l F e at u r e t r a u m a
Guidelines For Geriatric Resuscitation After Trauma Should Include Lactate By Charles W. Mains, MD
A bstr a ct
Are current guidelines for resuscitative management after trauma adequately addressing the senior population?
In Centura Healthâ€™s experience, the major causes of morbidity and mortality in elderly trauma patients (>65) are: under-triage to trauma centers; underrecognition that seemingly minor mechanism can result in major injury; and under-resuscitation of occult hypoperfusion.
It is no secret that geriatric patients respond to trauma and shock differently than their younger counterparts due to the presence of co-morbid conditions, decreased physiologic reserve, elasticity of the vascular system, and concomitant medication use. Falling from standing height is the most common mechanism of injury in the elderly population, often resulting in hip and rib fractures that can place these patients at significant risk. The unique characteristics of the geriatric patient often result in under-evaluation and less than optimal resuscitation. Recent studies show that an elevated lactate is indicative of severe injury and mortality in all trauma patients, and is a strong prognostic indicator in patients older than 55 years. Centura Health, the stateâ€™s largest health care provider, invites the physician-reader to explore the hypothesis that better indicators exist in identifying severe injury in older trauma patients. When every second counts, this expertise and experience can be a matter of life and death. Factors In Evaluating Patient Trauma Elderly patients constitute the fastest growing segment of the U.S. population, with estimates that those age 85 and older will number 15 million by 2025 (1). The decreased physiologic reserve of aging is well known. Factors include: reduced cardiovascular reserve degenerative musculoskeletal disease; renal impairment; reduced chest wall compliance and pulmonary reserve; decreased neurologic reserve; protein-calorie malnutrition; co-morbid illnesses; and confounding medications (2).
C h a r l e s W. M a i n s , MD
During hypoperfusion, lactate is produced in excess of its rate of metabolism, resulting in elevated blood lactate levels. The amount of lactate produced is believed to correlate with the total oxygen debt, the magnitude of hypoperfusion, and the severity of shock. Venous lactate is an accessible, accurate, validated measurement, and the use of an up-front lactate may increase the accuracy of recognizing occult hypoperfusion and shock (3-5). Recent studies have shown that an elevated lactate is indicative of severe injury and mortality in all trauma patients, and is a strong prognostic indicator in patients older than 55 years (6-9). Moreover, Martin et al. determined that current triage criteria using systolic blood pressure (SBP) and heart rate (HR) are inadequate when applied to elderly trauma patients (10).
13 Venous Lactate vs. Vital Signs Charles W. Mains, MD, Kristin Salottolo, MPH, Pamela Bourg, RN, MS, FAEN, Patrick Offner, MD, MPH, and David Bar-Or, MD, at St. Anthony Hospital, Lakewood, Colo., hypothesized that venous lactate would have better predictive ability than hypotension, tachycardia, and elevated shock index in the geriatric trauma population. That study, entitled “Venous Lactate is a better predictor of mortality than traditional vital signs in the geriatric trauma population,” was presented at the American Association for the Surgery of Trauma (AAST) on Sept. 14, 2011. It has been submitted for publication to the Journal of the American College of Surgeons. St. Anthony Hospital conducted a retrospective study of 1,053 geriatric trauma patients admitted under a new geriatric protocol from Jan. 1, 2009, through Sept. 30, 2010. The protocol provided for venous lactate determination and trauma surgery consultation on all admitted trauma patients age 65 or older. Patients with elevated lactate had aggressive volume resuscitation and serial lactate determinations.
Results of the Study are Summarized Here
There were 1,053 geriatric trauma patients with an overall mortality rate of 3.32%. Mortality was not significantly different in patients with abnormal vs. normal TVS (2.50% vs. 3.30%, p=100). However, mortality was significantly greater in patients with an elevated vs. normal lactate (10.76% vs. 2.34%, p<0.001). The area under the ROC was better for lactate (AUC: 0.70) compared with SBP (AUC: 0.53), heart rate (AUC: 0.52), and SI (AUC: 0.52), p<0.05 for all comparisons. After adjustment, lactate predicted mortality (OR: 2.71, p=0.04), whereas abnormal TVS (OR: 0.31, p=0.29) and SI ≥ 1 (OR: 1.31, p= 0.75) did not. The conclusion is as follows: The association between abnormal vital signs and mortality was negligible in geriatric patients, while an elevated lactate increased the odds of mortality approximately threefold. Geriatric resuscitation guidelines should incorporate an admission lactate to ensure adequate triage and monitor resuscitation. The Centura Health Trauma System is implementing a geriatric guideline at participating trauma centers that calls for initial and serial lactates on all >65-yearold admitted trauma patients. Trauma service
consultation is instituted within six hours for geriatric patients with normal lactates and urgently for those with elevated lactate requiring resuscitation from occult hypoperfusion. After partial implementation, preliminary results show trends toward reduced mortality and a reduction in geriatric patient length of stay. For further information or opportunities to participate in the project, contact: Trauma Services at St. Anthony Hospital, Pam Bourg, pamelabourg@ centura.org or 720.321.0605.
1. U.S Census Bureau Interim Projections by age, sex and race. Internet release March 2004 2. Menaker J, and Scalea TM. Crit Care Med 2010, vol38, no9(suppl); 452-459 3. Eastridge BJ, Salinas J, McManus JG, et al. (2007). Hypotension begins at 110mm HgL redefining “hypotension” with data. Journal of Trauma, 291-297 discussion 297-299 4. Jansen TC, v. B. (2008). The prognostic value of blood lactate levels relative to that of vital signs in the pre-hospital setting: a pilot study. Crit Care, 160 5. Lavery RF, L. D. (2000). The utility of venous lactate to triage injured patients in the trauma center. J Am Coll Surg, 656-664 6. Martin JT, A. F. (2010). ‘Normal’ vital signs belie occult hypoperfusion in geriatric trauma patients. Am Surg, 65-69 7. Paladino L, S. R. (2008). The utility of base deficit and arterial lactate in differentiating major from minor injury in trauma patients with normal vital signs. Resuscitation, 363-368 8. Schulman AM, C. J. (2002). Young versus old: factors affecting mortality after blunt traumatic injury. AM Surg, 942-947; discussion 947-948 Vandromme MJ, G. R. (2010). Lactate is a better 9. predictor than systolic blood pressure for determining blood requirement and mortality: could prehospital measures improve trauma triage? J AM Coll Surg, 861-867, 867-8691 Zarzaur BL, C. M. (2010). Identifying life10. threatening shock in the older injured patient: an analysis of the National Trauma Data Bank. Journal of Trauma, 1134-1138
C l i n i c a l F e at u r e r a d i o l o g y & i m a g i n g
Y-90 Radioembolization Offers New Hope To Patients With Liver Cancer By steven wegert, MD, Radiology Imaging Consultants
Interventional radiologists at Memorial Hospital are treating liver cancer patients with yttrium-90 (Y-90) radioembolization, an outpatient procedure that targets tumors with a high dose of radiation while sparing healthy liver tissue. For patients with Hepatocellular Carcinoma (HCC) or liver tumors from metastatic colorectal carcinoma, Y-90 radioembolization is “an exciting form of therapy that’s very well tolerated by the patient and can prolong the time to progression and survival,” says Dr. Steven Wegert, one of two radiologists at Radiology & Imaging Consultants, P.C., trained to do the procedure at Memorial. While it is considered palliative and not a cure, recent studies suggest the procedure is very effective compared with chemoembolization. It causes less pain to the patient, has a low toxicity profile and low complication rate, and can downstage a patient to allow resection or transplant. “One of the benefits of Y90 is that it does not preclude future therapy,” Dr. Wegert says. If an HCC patient is awaiting a transplant, Y-90 treatment can halt progression of the disease. For a patient with metastatic colorectal cancer, “Y-90 offers an excellent alternative if there has been no response with conventional first and second-line therapy,” he says. A multidisciplinary team at Memorial, including interventional radiologists in the RIC group, evaluates patients to determine suitability for the procedure. Two weeks prior to performing radioembolization, an angiogram is taken to map the patient’s blood supply, identify vessels that communicate from the liver to the gut, and block them with coils. During the procedure, the radiologist implants microspheres containing the radioactive isotope Y-90 through a tiny catheter inserted from the groin into the liver. A smaller catheter is then advanced to the artery supplying the liver tumor, targeting it directly.
S t eve n W e g e r t , MD
The tiny spheres lodge at the periphery of the lesion, where growth occurs, causing cell damage and death, and tumor shrinkage. Other areas of the liver are spared. This can even be done in patients who have a blockage of the portal vein. Adverse events after treatment may include fatigue, which can be managed with steroids; mild pain or discomfort; fever; and night sweats related to tumor necrosis. A CT scan one month post-procedure is performed to assess response to treatment. Y-90 radioembolization “is an excellent tool in the armamentarium of those fighting liver cancer,” Dr. Wegert says. Radiology & Imaging Consultants is a multispecialty radiology group based in Colorado Springs. Its board certified radiologists specialize in minimally invasive therapies, pediatric radiology, digital mammography, musculoskeletal imaging, neuroradiology, PET, CT and MRI scans.
R efere n ces Gulec S et al. “Safety and efficacy of Y-90 microsphere treatment in patients with primary and metastatic liver cancer: The tumor selectivity of the treatment as a function of tumor to liver flow ratio.” J Transl Med. 2007; 5:15 Kennedy A et al. Resin 909Y-Microsphere Brachytherapy for Unresectable Colorectal Liver Metastases: Modern USA Experience. Int J Radiat Oncol Biol Phys 2006; 65:412-425 Sharma R et al. FOXFIRE: A Phase III Clinical Trial of Chemo-radioembolisation as First-line Treatment of Liver Metastases in Patients with Colorectal Cancer. Clinical Oncol 2008; 20:261-263 van Hazel G et al. Treatment of Fluorouracil-Refractory Patients With Liver Metastases From Colorectal Cancer by Using Yttrium-90 Resin Microspheres Plus Concomitant Irinotecan Chemotherapy. J Clinical Oncol 2009; 27
Top Five Challenges With ICD-10 1. Resourcing the transition
The ICD-10 transition will require significant investment of time and money to ensure that all systems that use and record diagnosis data are updated to comply. It will be a complex and painstaking process, and many are worried about the costs involved.
The amount of time trainees can devote to learning the ins and outs of ICD-10 is a concern, as well as the expertise of the trainers. One of the more daunting issues is the depth of training needed to make sure all stakeholders understand how ICD-10 works and how to accurately submit claims to payers.
3. Maintaining two coding systems
Private payers, such as worker’s compensation plans, are not required to change to ICD-10. Therefore, providers could have to maintain both coding systems, depending on payers’ strategies.
4. Sustaining momentum
Most physician incentive programs use reporting based on CPT and ICD-9 codes. To continue correct submission, systems collecting data for incentive programs need to support ICD-10. Updating systems and ensuring that long-term reporting continues smoothly during the transition will be a concern.
5. Avoiding payment delays
Training physicians to code accurately, making sure that codes are entered correctly in billing systems and depending on payers to efficiently review claims under ICD-10 are all likely to lead to delays in payment.
New Guideline Helps Providers In Preventing Rx Drug Abuse Prescription medications relieve all sorts of ills, but they are increasingly being abused for recreation or addiction. In 2002, the National Survey on Drug Use and Health reported that an estimated 29.6 million Americans had
used pain relievers non-medically; by 2005, the number had risen to 32.7 million. (1) In 2009, 45 percent of the nearly 4.6 million drug-related emergency room visits nationwide were attributed to abuse of pharmaceuticals. (2) The Drug Abuse Warning Network estimates that of the 2.1 million drug abuse visits, 27.1 percent involved non-medical use of medications.(3) Prescription drug abuse means taking a prescription medication that is not prescribed for you, or taking it for reasons or in dosages other than as prescribed. Abuse of prescription drugs can produce serious health effects, including addiction. Commonly abused classes of prescription medications include opioids, central nervous system depressants and stimulants. HealthTeamWorks has just released a new clinical guideline supplement on prescription drug abuse prevention [http:// healthteamworks-media.precis5.com/sbirt-rx-abusesupplement] to assist primary care providers and others. The supplement is part of the SBIRT program (Screening, Brief Intervention and Referral to Treatment) that we offer to healthcare organizations free of charge. SBIRT Colorado partners with HealthTeamWorks to work directly with primary care throughout the state to integrate the Alcohol and Substance Use Screening Guideline into clinical practice. The supplement includes screening questions, responsible opioid prescribing, behavioral health considerations, tips for patients and care-givers and resources for prescribers. Printed front and back on an 8 ½ x 11 inch page, the supplement, like all HealthTeamWorks guidelines, is concise and easy to use in the clinical setting. HealthTeamWorks’ clinical guidelines and supplements are available for free download healthteamworks.org/ guidelines/guidelines.html. To ask questions about our guidelines, e-mail email@example.com or call 720-297-1681.
S ources 1. Maxwell JC. Trends in the abuse of prescription drugs. The Center for Excellence in Drug Epidemiology, the Gulf Coast Addiction Technology Transfer Center, the University of Texas at Austin. http://www. utexas.edu/research/cswr/gcattc/documents/PrescriptionTrends_Web.pdf, accessed Sept. 20, 2011. 2. National Institute on Drug Abuse. NIDA InfoFacts: Drug-Related Hospital Emergency Room Visits. http://drugabuse.gov/infofacts/HospitalVisits.html, accessed Sept. 20, 2011. 3. Ibid.
R e v e n u e C yc l e m a n a g e m e n t
What Small to Medium-Sized Practices Should Look For When Outsourcing Their RCM And Billing an interview with daniel karpel, mba, mha, and ceo of peak medical management
G e n er a l
i n form a tio n :
Daniel Karpel, MBA, MHA Medical Revenue Cycle Management (Billing/Collection), Practice Management and Consulting, Healthcare Finance, Regulatory Compliance, Strategic Planning and Marketing Peak Medical Management, LLC 155 Printers Parkway, Suite 100 Colorado Springs, CO 80910 719-578-1162 • www.peak-medical.com
How long have you and your organization been serving physicians and their practices in this region? I have been working with physicians for 15 years in various capacities, including practice administrator for a large radiology group. I recognized a critical shortage of sophisticated revenue cycle management services for small and medium sized practices in Colorado Springs, and formed Peak Medical Management in early 2005.
What core business services does your organization offer physicians and their practices?
To do an effective job of medical billing, you have to manage the full revenue cycle, starting from the time the patient calls for an appointment. Everything you do from then until payment is received and a claim fully adjudicated is the revenue cycle and needs specific attention. That’s what I do. We are now also channel partners with Optum Insight’s Caretracker EMR and now offer a fully integrated practice management, EMR and revenue cycle management system.
Explain one or two common mistakes practices or individuals make in regards to medical billing, which could be avoided with some sound counsel or knowledge.
D a n i e l K a r pe l , CEO
The biggest mistake is lack of full awareness of what their revenue stream should be. There’s a fundamental lack of understanding of how the system works and how their services turn into revenue. Sometimes physicians put off or are unwilling to seek help or make the investment to understand their business operation. That’s understandable—physicians want to practice good medicine, and with limited resources they often can’t afford to have expert business help in their offices. But by not fully addressing their business operation, substantial amounts of money may be getting left on the table.
Regarding those issues, what advice and/or resources, would you offer them on these topics that would empower them? From a business perspective, what we do is help you reconcile the demands of owning a small business with the integrity of your clinical practice. We start with a thorough evaluation to determine the reality of what the practice should be earning. As for services: We are an extension of your office; we consider ourselves your billing department and we’re here to optimize your revenue stream. We also assist practices in keeping up with the rapid regulatory changes. We also help with strategic planning: Do you have a vision for your practice now and into the future? If you do, how do we get you there?
Name some common misperceptions or outright objections about your profession that you’ve heard, and how would you debunk those myths or overcome those objections? What distinguishes one billing company from another is integrity, the level of services, and their experience and professionalism. It’s important to investigate the background of the company, the ownership, and the people who are in charge so you really understand with whom you’re working.
In the current health care climate, what overarching business philosophy or advice with regard to your specific business discipline, would you encourage physicians to adopt, and why? In my experience, good doctors want to practice good medicine. Maintain your focus on clinical excellence and integrity because whether it’s the patient or the payor, it’s a buyer’s market out there and will become increasingly so for the foreseeable future. As such, and as with any other business, your success will largely be determined by the quality of the service you provide. However, perception is reality and the quality of your business operation will increasingly impact your patients’ perception of your service – when your patients know your billing department better than they know you, it’s time to evaluate.
In your estimation, what is one thing that needs to happen to improve the health care system in America?
Rather than providing the resources necessary to mitigate barriers and bottlenecks that increasingly hinder physicians’ ability to practice good medicine, we seem to be stripping them of resources while asking for more. First things first, let’s remove these obstacles and get out of the way of our physicians and allied clinical professionals.
Please provide some professional & personal data below: • Organizational affiliation: Peak Medical Management, LLC • Organizational service offerings: Billing and accounts receivable; coding & documentation; denial management; payment followup; customized financial reporting; payor contracting; practice management consulting; strategic planning & marketing. • Education and training: University of Michigan, B.S. biology and history; Georgia State University, M.B.A., M.H.A. Professional Affiliations and Special Accolades: • Medical Group Management Association, Colorado and national chapters; Radiology Business Management Association; Healthcare Billing and Management Association.
G e n er a l
i n form a tio n :
Good doctors just want to practice good medicine; unfortunately, most doctors find themselves spending too much time and emotional energy worrying about their business. The mission of my business is to provide confidence and assurance to physicians trying to reconcile the demands of owning a small business with the integrity of their clinical practice.
Financial & Investment m a n a g e m e n t
A Check-Up For Your Financial Health Jeff L. jensen, senior vp wealth management, morgan stanley
A bout Jeff Jensen is a Senior Vice President - Wealth Management, Senior Investment Management Consultant, and Corporate Retirement Director and founder of The Jensen Group at Morgan Stanley Smith Barney. Jeff, along with his team, is a highly regarded advisor working with medical professionals for their financial planning and retirement needs. Jeff holds a number of professional designations including the Certified Investment Management Analyst (CIMA) and Accredited Investment Fiduciary (AIF) designations. Recently, we had a chance to sit down with Jeff and discuss his “Financial Check-up for Healthcare Professionals.”
M V: What is a “Financial Check-up for Healthcare Professionals?” Jeff Jensen: Just like an annual physical with a doctor, a Financial Check-up is an evaluation of your retirement plan and overall financial picture to make sure you are in “good financial health.” With medical professionals encountering higher costs to provide services, uncertainty in the healthcare marketplace and lower reimbursements from payors, they face greater financial risks in their practices and have less time to practice medicine. A Financial Check-up helps you balance some of this uncertainty and provide protection for your assets. MV: What is involved in a Financial Check- up? JJ: The Jensen Group begins a Financial Check-up by looking at the five key areas that need to be reviewed for all group retirement plans. Those areas are plan design, plan administration, mutual fund selection and monitoring, fiduciary responsibilities, and education. We look at all of these areas to help make the plan fully compliant and working effectively for our clients - this is our job. After doctors we work with see what we can do to improve their retirement plans, many ask us to help with their personal Financial Check-up. MV: Could you explain the five retirement plan components you review as a part of the Financial Check-up?
JJ: There is a lot of detail in each of the components. At the highest level, we look at plan design to help optimize plan performance. This allows us to reduce the employer cost in the plan and direct more money to the medical professionals who are the business owners. MV: What type of cost savings do you generally see with plan design changes? JJ: When I work with a group of doctors on plan design, more often than not we can help find between 20 to 25% of hard cost savings. This money can be directed back to the doctors allowing them to increase their contributions to the retirement plan without additional cost. MV: Let’s look at the other areas of the Financial Check-up you provide. JJ: We work on plan administration making sure there is transparency that fees are fully disclosed and issues of plan compliance are being addressed. We work with the group to make sure the mutual funds they select are highly rated and have a reasonable fee. We then help monitor the fund performance to assist the practice in finding a match for the plan using top quintile fund managers in all asset classes. MV: We’ve heard a lot about fiduciary responsibilities lately; how do you help with that?
J e f f L. J e n s e n
JJ: We have put together a fiduciary audit notebook that we use with all of our clients to help them with their fiduciary responsibilities. The notebook gives you a road map of the materials you need for your plan and it helps you collect all of that information in one place so that you are never struggling to find the documents you might need. We would be happy to share that notebook with any of your readers. They can email ann.marie.ries@ mssb.com or call 719.577.6333. MV: It’s great that you help the plan administrators but do you educate the employees who participate in a plan? JJ: Everyone promises education but few deliver on that promise. We offer one-on-one meetings for all plan participants, which often helps increase the number of employees participating in a plan and increases an employee’s deferral. And many times an employee’s spouse will come to the one-on-one meeting to understand how their retirement can work for them. MV: Jeff, this is a lot of information to absorb in a short period of time. Can we count on getting more detail from you in the future? JJ: You definitely can. Look for future articles with detail about each of the components of a Financial Check-up for Healthcare Professionals. Jeff Jensen can be reached by e-mail at firstname.lastname@example.org or by phone at 719.577.6333. While you are waiting for Jeff’s future articles in Medical Voyce, check his website for timely information about your Financial Health. http://fa.smithbarney.com/jensen_group/. Tax laws are complex and subject to change. MSSB does not provide tax or legal advice and we are not “fiduciaries” (under ERISA, the Internal Revenue Code or otherwise) unless otherwise agreed to in writing. Individuals are urged to consult their tax or legal advisors before establishing a retirement plan and to understand the tax, ERISA and related consequences of any investments made under such plan.
Op-ed m e d i c i n a l m a r i j ua n a
M edical Marijuana: Where D o W e S tand ? By kenneth Finn, MD
S umm a ry This is a topic of debate recently and physicians in general may not be completely aware of some of the particular issues making this topic more complicated. Although its history is long, there are several events worth noting. The history of marijuana dates back thousands of years to China, where its seeds were used as food and textiles were made of hemp. It was described in a Chinese medical compendium as early as 2737 BC. Emir of the Ottoman Empire makes the first edict against eating hashish or smoking cannabis in 1378. In colonial America, it was grown as a source of fiber (hemp). In 1798, Napolean declared prohibition on marijuana after noticing much of the Egyptian lower class were habitual smokers (the more things change, the more they remain the same). In 1868, Egypt was the first modern country to outlaw cannabis ingestion. Hashish was made illegally in Turkey in 1890. The Marijuana Tax Act in 1937 made it illegal to transfer cannabis throughout the US except for medical or industrial use, which usually brought expensive excise tax and detailed logs as a requirement. In 1970, The Controlled Substance Act classified cannabis as a Schedule I medication with high abuse potential, no medical use, and was felt not to be safe. In 1975, the FDA established the Compassionate Use Program for medical marijuana for glaucoma, multiple sclerosis, and cancer. Dronabinol (Marinol) is a synthetic THC manufactured and placed into Schedule II by the DEA in 1986. November 4, 2000, Colorado voters passed Amendment 20, designed for â€œcompassionate careâ€?. This article is based upon the most recent DEA Position on Marijuana published January 2011 and the FDA Statement published April 20, 2006. Within the bodies of these documents are the references to which a bulk of the information presented here is based. There is also information to be presented that is directly from the Colorado Department of Public Health and Environment from the latest data of July 31, 2011. Most of this article will be referring to inhaled or smoked marijuana.
K e n n e t h F i n n , MD
Ingested forms will not be discussed as ingesting forms of marijuana was only noted to cause slower and sometimes less predictable effects. Marijuana has been categorized under Schedule I of the Controlled Substances Act, meaning there is a high potential for abuse, has no accepted medicinal value in treatment in the United States, and there is a general lack of accepted safety for its use even under medical supervision. According to the National Institute of Health, marijuana is defined as a dry, shredded mix of flowers, stems, seeds, and leaves of the hemp plant Cannabis sativa. It is the most commonly abused illegal drug in the United States. Abusing marijuana can result in problems with memory, learning, and social behavior. It can interfere with family, school, work, and other activities. There are more than 400 compounds derived from the Cannabis sativa plant with 60 different compounds described to have activity on the cannabinergic system. Isolation of its main constituent, delta-9 tetrahydrocannabinol (THC, which is felt to be the most psychoactive) and discovery of the endocannabinoid system (CB1 and CB2 receptors) has made it possible to study how this chemical works. CB1 is present throughout the central nervous system including the hippocampus, amygdyla, cortex, basal ganglia, cerebellum, and spinal cord and this distribution may account for the behavior effects of cannabinoids. CB2 is located peripherally in the spleen and macrophages and is linked to the immune system. Marijuana smoke contains 50-70% more carcinogenic hydrocarbons than tobacco smoke and is inhaled more deeply and held in the lungs much longer than tobacco smoke (National Institute on Drug Abuse, National Institutes of Health). The link to cancer has not been proven at this time, however, it is logical
21 to consider that there would be one given the above information and what is know about inhaled tobacco smoke. The only FDA approved drug that contains the synthetic form of THC is Marinol. It is in pill form, and is used to relieve nausea and vomiting associated with chemotherapy for cancer patients and to assist with appetite loss in AIDS patients. Sativex is an oromucosal spray for the treatment of spasticity due to Multiple Sclerosis approved in Canada and more recently in the United Kingdom. It contains THC and cannabidiol but unlike smoked marijuana removes contaminants, which reduces intoxicating effects, and is administered in a set dosage. “Medical” marijuana has not met the standards of a modern medicine: quality, safety, and efficacy. There is no standard composition or dosage, no prescribing information, no quality control, no accountability for the product, no safety regulation, no way to measure efficacy and no insurance coverage. Science should determine what medicine truly is, not public opinion.
The DEA position statement nicely outlines the history of legalization efforts across the country, which will not be reiterated here due to its length. The concern, however, lies in the failure of these efforts across the country. Many of the co-authors of legislation in several states have expressed disappointment with how, what was designed to be good, has failed and now new problems are arising. Some believe that many people have “medicinalized” their recreational use. Profits are going under reported and many dispensaries are evading taxes (California State Board of Equalization, 2008). Up to one half of the illegal street marijuana is being grown under the protection of the state’s medical marijuana program (Director of the Oregon State Police Drug Enforcement Section, April 2010). There are increased home invasion robberies and more violence. There is a higher percentage of young people referred to adolescent substance abuse programs with marijuana problems. More aggressive behavior, social isolation, poor choices, and young adults without licenses getting pot from caregivers whose plants yield enough supply to support sales on the side (Denver Post, Dr. Christian Thurstone, February 2010).
Glaucoma is the number one cause of blindness world wide. In 1992, the American Academy of Ophthalmology’s Committee on Drugs found no verifiable evidence that use of marijuana is safe or effective in the treatment of glaucoma. In 1997, the National Eye Institute reported there were no studies that demonstrated marijuana can safely or effectively lower intraocular pressure any more than the variety of drugs on the market. This was reviewed again in 2009 and the position has not changed. In 1999, the Institute of Medicine reported that although intraocular pressure can be reduced by using cannabinoids, the effect is too short lived and requires high doses (1012 joints per 24 hours to maintain lowered intraocular pressure during the day).
In Colorado treatment centers, clinicians are treating more teens for marijuana addiction since the state legalized marijuana for medical use. At the Denver Health Medical Center, treatment for referrals has tripled with 83% of teens that smoke pot daily obtaining their marijuana from a medical marijuana patient (White Mountain Independent, January 2011). A study by the Associated Press of doctors prescribing “medical” marijuana to patients in California found that beyond having a medical license, there is no necessary training, familiarity of the scientific literature on marijuana’s reported benefits and side effects, and no special certification. In California, nearly 25% of prescribing physicians had blemished records at the State Board. Even Rolling Stone Magazine reported on abuses of California’s law in an article February 7, 2007. In most states with voter approved “medical” marijuana laws, the number of cardholders has increased substantially. In Montana, the number of cardholders increased from 2,900 to 15,000 between 2009 and 2011 with an increase of dispensaries from 900 to 5,000 during this time. With that comes more crime. There has been a significant increase in teenage marijuana use and the Chemical Awareness/Responsive Education Coordinator felt the “kids are using it as medication so they don’t have to deal with adolescence” (Great Falls Tribune, May 2010). Cannabis caravans are being organized to provide marijuana throughout the state and one physician was found by the Montana Medical Board
22 to have prescribed 150 marijuana cards in 14.5 hours: a patient every six minutes. In this time there is no conceivable way to obtain a comprehensive history and physical and provide an assessment and plan (MSNBC June 2010, Matt Volz). Similar problems are occurring in other states such as California (LA Times, November and December 2009, NPR, February 2010). Closer to home in Colorado, dispensaries began to proliferate in 2009 despite Amendment 20 passing in November 2000. Colorado recently has been the first state to regulate production of “medical” marijuana (seed to sale). Currently, there is no way to verify the product a person is purchasing is what is advertised. Given marijuana is not approved as a medicine and not regulated by the FDA, nor is it a legitimate crop overseen by the US Department of Agriculture, there are no guidelines currently available. According to the Colorado Medical Marijuana Registry, as of July 31, 2011, there had been over 151,000 applications for “medical” marijuana cards and over 127,000 cardholders. Sixty-eight percent are male and the average age is 41. More than 1,100 physicians have signed for patients in Colorado. Apparently the vast majority of prescriptions were written by 15 physicians, a third of which have had admonishments by the Colorado Board of Medical Examiners. El Paso County had nearly 15,000 cardholders. In Colorado, 94% of cardholders were written cards for severe pain, despite the lack of medical science to support its use in that condition. In 1999, the International Association for the Study of Pain outlined much of the basic mechanisms of cannabinoidinduced analgesia but concluded that “their potential therapeutic use continues to be limited by their side effect profile” and further study was recommended. In Colorado, only two percent were written for cancer and one percent for HIV/AIDS, some of the medical conditions that actually have FDA approval. What are the dangers of marijuana? Marijuana today is more potent that it was in the 1970’s. The average amount of THC in seized samples has reached over 10% compared to an average of just under four percent in 1983. Science has shown that marijuana can produce adverse physical, mental, emotional, and behavioral changes and contrary to public belief, addiction. Newer forms are being created with up to 30% THC. (Office of National Drug Control Policy Press Release, April 2007 and May 2009). Mental health issues related to marijuana use are on the rise. The Center for Substance Abuse Research at the University of Maryland noted in January 2008 that
“students who had used cannabis five times or more in the past year reported problems related to their cannabis use, such as concentration problems (40%), regularly putting themselves in physical danger (24%), and driving after using marijuana (19%). On the subject of teens, depression and marijuana use, the Office of National Drug Control Policy noted in May 2008 that depressed teens are two times as likely to use marijuana and other illicit drugs, are more that two times as likely to abuse or become dependent on marijuana, and marijuana can worsen depression and lead to more serious mental illness such as schizophrenia, anxiety, and even suicide. Teens who smoke marijuana at least once a month are two times more likely to have suicidal thoughts. Australian researchers reported that long-term, heavy cannabis use may be associated with structural abnormalities in areas of the brain that govern memory, emotion, and aggression. Brain scans showed the hippocampus was 12% smaller and the amygdale seven percent smaller in men who smoked at least five marijuana cigarettes a day for 10 years. A two year study by the National Cannabis Prevention and Information Centre at the University of New South Wales in Sydney reported cannabis users can be as aggressive as crystal methamphetamine users and 12% were considered a suicide risk. The Journal of the American Academy of Child and Adolescent Psychiatry in March 2008 noted that “prenatal marijuana exposure has a significant effect on school-age intelligence”. The Canadian Journal of Psychiatry reflects that cannabis use can trigger schizophrenia in people already vulnerable to the mental illness (August 2006). Memory, speed of thinking, and other cognitive abilities get worse over time with marijuana use according to a study published May 2006 in Neurology, the scientific journal of the American Academy of Neurology. Long term marijuana users trying to quit report withdrawal symptoms including irritability, sleeplessness, decreased appetite, and drug craving, making it difficult to remain abstinent. These symptoms begin about a day after cessation, peak at 2-3 days, and subside within 1-2 weeks following drug cessation (Journal of Substance Abuse Treatment, March 2008). A study from the National Institute of Drug Abuse found that people who smoked marijuana had changes in cerebral blood flow even after a month of not smoking, with pulsatile index (PI) values higher than people with chronic hypertension and diabetes, suggesting that smoking marijuana may lead to small vessel ischemic disease and its consequences. There are several other studies to support this. Read the rest in the December issue of Medical Voyce.
D e a n university of colorado
denver - anschutz medical campus
What’s Going On Here? by Richard D. Krugman, MD
Dear Colleague, I spent the weekend in Illinois accompanying my spouse, who was attending a major reunion. It was a terrific weekend, and one of the highlights was a really wonderful video cataloging the history of the class created by none other than John Sladek, PhD, (Professor, Neurology, Pediatrics and Neuroscience), who graduated the same year as Mary did. Being there meant that I missed several things this weekend. One was the Carousel of Hope – an annual fundraiser for the Children’s Diabetes Foundation at Denver. I am told it was a great event, which honored Georgeanna Klingensmith, MD, (Professor, Pediatrics), for her years of service to children with Type 1 Diabetes. Judy and Charlie McNeil also were honored – she is President of the Guild of the Children’s Diabetes Foundation and they both are longtime supporters of the Barbara Davis Center. I also had to miss the inaugural 1st Saturday for Seniors event. This was the first of a series of community outreach efforts by Robert Schwartz, MD, and the Center on Aging. The first lecture, given by Kerry Hildreth, MD (Instructor, Geriatrics), was about dementia and mild cognitive impairment. This series is aimed at seniors and their care providers. The next two lectures will cover polypharmacy (on 11/5) and depression (on 12/3). The schedule for the next few months is available on the Geriatric Medicine web site. The only dinner out last week for me was with twodozen of our alumni from the Classes of 1947, 1952, 1957, 1962, 1967 up through 2002. They are planning their Class reunions for May of next year. It was an enthusiastic group and it was good to see so many of them engaged in bringing their classmates to the new campus. Last week’s email was so full that I delayed mentioning two important events regarding women’s health. The Frontiers in Pregnancy Research Symposium, sponsored by our OB/GYN Department and the March of Dimes, brought in state and national experts. We also had the Center for Women’s Health Research Day, at which I introduced Nanette Santoro, MD, (Professor and Chair, OB/GYN), who gave the keynote address. This was followed by a poster session with 44 presentations,
r i ch a r d d . k r u g m a n , md
bringing together researchers from all the professional schools here reflecting the tremendous groundswell of interest and support in Women’s Health on campus. We have launched the search for a Director of the Center for Bioethics and Humanities. Fred Grover, MD, Chair of Surgery, is heading the committee. And Pat Moritz, RN, PhD, FAAN, has announced that she will be stepping down from her position as Dean of the College of Nursing. Pat and her colleagues have been good partners for all of us on the campus (as well as on the previous campus). The Provost will form a search committee sometime relatively soon, I suspect. And while we are talking searches, we have a candidate in for Surgery Chair this week (Richard Schulick, MD, from Johns Hopkins) and two more candidates for Dean of the Colorado School of Public Health. The St. Geme dinner is Thursday night, which makes it another opportunity for a four-dinner-out week. On a more serious note (than my dinner habits), I had a note from the staff at Ethics Point. Apparently, a group of students from the Anschutz Medical Campus were riding public transportation recently and talked about patients by first name while discussing their health information. Someone heard this and contacted the Ethics Point hotline (on the Office of Regulatory Compliance web page). We don’t know which students or which school and it really doesn’t matter. All of us need to be really careful about patient confidentiality, wherever we are and whomever we’re with. Congratulations to Melissa Wright, PhD, a fourth-year medical student (in the Medical Scientist Training Program), for being selected for the Joseph W. St. Geme Jr., MD, Medical Student Award. Her mentor, Angeles Ribera, PhD, said about Melissa, “Ms. Wright excelled during her PhD years ... Her scientific maturity and drive indicate that she will without any doubt continue to be a major player in the field of developmental neurobiology.” The award goes to a student interested in a career in academic pediatrics. With warm regards, Richard D. Krugman, MD Vice Chancellor for Health Affairs and Dean, School of Medicine
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Medical Voyce Magazine - Colorado Edition for November 2011. A Clinical and Business Journal for Colorado Phycisians. Copyright © 2011 Medic...
Published on Oct 28, 2011
Medical Voyce Magazine - Colorado Edition for November 2011. A Clinical and Business Journal for Colorado Phycisians. Copyright © 2011 Medic...