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On Rounds Physician Spotlight Dr. Christy Valentine Rising Phoenix
From the devastation of a barrage of hurricanes arose a phoenix, bringing renewed hope to New Orleans residents facing the upcoming storm season. Lessons learned from Hurricanes Katrina, Gustav and Isaac spurred local physician Christy Valentine to create PhoenixLink Solutions, an online portal for patients and physicians to stay connected during disasters ... page 3
Louisiana Hospitals Seek Funding Protection By TED GRIGGS
Each year, for the past five years, Louisiana’s hospitals have gone to the Jindal administration and the state Legislature and asked for Medicaid funding help. And each year, the cash-strapped state government’s answer has been more cuts, roughly $260 million, or 26 percent, since 2009. But this year, the Legislature overwhelmingly approved two measures that will let voters decide whether hospitals can put up the money to draw down federal funds for Medicaid. Hospitals and their supporters say the bills will help stabilize funding through constitutional protections. Opponents, who included the non-partisan Public Affairs Research Council and the liberal Louisiana Budget Project and Gov. Bobby Jindal’s administration, say constitutional protection means the state will have even less flexibility in budgeting matters. Opponents argued that if voters approve the amendments, higher education will suffer because it (CONTINUED ON PAGE 5)
A program for younger breast cancer survivors in Louisiana By BARBARA mCCoNNELL
What do Angelina Jolie and 2013 Miss America Pageant contestant, Allyn Rose have in common? They are young, beautiful, and both have elected to have bilateral mastectomies without an actual diagnosis of breast cancer due to a combination of family history and possession of the BRCA-1 gene mutation. And that has put the younger breast cancer patient in the center of a national news frenzy and increased public curiosity. People don’t always think about a young woman developing the disease, especially since both incidence and mortality rates increase exponentially with age, with the median age being 61 years at time of diagnosis. The younger patient has unique priorities from an older woman including: bearing and nursing children, body image, jug-
Conference Offers PAD, CLI Solutions Fourteen years ago, when Dr. Craig M. Walker organized the first New Cardiovascular Horizons conference, he had a number of goals ... page 6 Britney Temple, fitness trainer and SurviveDAT! audience
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T E N N E S S E E
T E X A S
Dr. Christy Valentine Rising Phoenix
By LISA HANCHEy
From the devastation of a barrage of hurricanes arose a phoenix, bringing renewed hope to New Orleans residents facing the upcoming storm season. Lessons learned from Hurricanes Katrina, Gustav and Isaac spurred local physician Christy Valentine to create PhoenixLink Solutions, an online portal for patients and physicians to stay connected during disasters. Shortly after Hurricane Katrina hit in 2005, Valentine incorporated her practice, Valentine Medical Center. But, she was unable to open an office right away. “It took some time to get it up and running with the conditions in our area,” she recalled. A couple of months after the storm, she gave birth to a daughter, Phoenix, who became her glimmer of hope during the chaotic recovery period. “She just helped in the whole healing process,” Valentine said. “She was a great gift.” In 2007, Valentine opened her first location in Belle Chase with a complete electronic medical records system. A year later, Hurricane Gustav delivered another destructive blow to Belle Chase. Valentine’s office building sustained a major loss, sparking her to develop a hurricane
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plan. Before Hurricane Isaac hit in August, 2012, her staff started preparing – packing up and labeling computers, office machines and lab equipment and placing them in a central room up off of the ground. Unfortunately, when the storm made landfall, strong winds blew off the roof. Torrential rains ravaged inside, completely destroying the contents. Fortunately, Valentine found an alternate location nearby, allowing her to maintain her patient base and continue serving the area. Last August, Valentine opened a second location in New Orleans. “Having an awesome team that I work with, everybody just really pitched in and we pulled it all back together,” she said. During these emergencies, Valentine’s office had a difficult time communicating with displaced patients. This
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motivated Valentine to take action. “Having an electronic office, I keep my patients’ information safe and secure,” she said. “We originally had a server-based electronic records system, and I had to evacuate the server twice. So, what I recognized was that the patients’ information was all safe, but we had no way to connect with the patients when they evacuated.” So, on June 1, the first day of hurricane season, Valentine launched PhoenixLink Solutions, a brand new online health information system. Named after Valentine’s daughter, PhoenixLink allows patients to access all of their medical records, including immunizations, tests, prescriptions and physician information, from any Internet connection. The HIPAAcompliant system also creates a forum for physicians to post their updated contact information during emergency situations. “I’m so excited about it, because it is really something that I think will empower the people in our area,” she said. “Every part of our nation has something that happens, whether it is a tornado, fire or hurricane. So, knowing that you are able to have access to your information and maintain some sort of control in a truly chaotic time will bring a level of peace. And then, if you have to evacuate, you’ll have access to your medical records and can give the information to the provider in your new location.” Being reared in a storm-prone area obviously impacted the New Orleans-bred Valentine. The first in her family to become a doctor, Valentine was inspired by her parents’ care of her autistic brother, Darrell. “Growing up in a home with him, I really appreciated the things that my parents did to keep order in the house,”
she said. “He still had to listen; he still had to do his chores. It just fascinated me.” After graduating from Ursuline Academy, Valentine attended college at Xavier University of Louisiana. She remained in New Orleans for her medical studies, beginning at LSU for medical school followed by Tulane University for residency. Her specialties are in internal medicine and pediatrics. “I like the fact that I can have a patient from birth through childhood and adolescence, and totally see the transition of that individual,” she explained. “I love being able to see entire families, and I have a lot of families where I see the mom, dad, children, aunt, uncle and the grandparents. I just love the fact that you have one place where the whole family can get service and really help make healthy choices in their lives.” When not juggling her two offices, Valentine enjoys spending time with seven-year-old Phoenix and fiancé, Saton Wilson. The couple is planning a February wedding. In her off time, Valentine indulges in her favorite activity – fishing. “I love to fish,” she said. “I love going out and catching redfish. I would do that all of time, especially growing up with my family. I love the whole, you know, waking up before the break of dawn to get out there. It makes you appreciate how beautiful our city is.”
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JULY 2013 • 3
Tapping into Hospice and Palliative Medicine PCPs benefit from services of underutilized specialty By LyNNE JETER
Not long ago, hospice referrals for end-of-life care were typically made only a few weeks before the patient’s death. Now, good hospice referrals are made six months to a year in advance to allow time for patients and their families to transition to the final phase of life. Palliative care comes in sooner for patients suffering from serious illness, with specialists having the advantage of focusing on the patient, not the disease. “Just about any patient with a serious, life-limiting illness can benefit from palliative care,” said Robert Lehmberg, MD, FACS, assistant professor of hospice and palliative medicine at the University of Arkansas for Medical Sciences (UAMS). “It improves the patient’s quality – and sometimes length – Dr. Robert of life.” Lehmberg Hospice is definitely underutilized in the United States, said Derrick O’Connell, RN, MBA, chief quality officer for Esse Health, a St. Louis-based practice group with nearly 100 Derrick O’Connell physicians and specialists. “There are barriers to hospice because of the inability to confront mortality as a psycho-social issue,” he said, “and barriers within the medical community to refer patients to hospice because physicians and their teams may feel they’ve failed in the medical management of a patient.” Miguel A. Paniagua, MD, FACP, concurs. Because so many great technological advances in medicine have been made, he said a patient’s treating physician may view their death as failure. O’Connell, a former hospice manager, said the emerging Patient Dr. Miguel A. Centered Medical Home Paniagua
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(PCMH) model has a mechanism in place to assist primary care providers (PCPs) with the transition of patients to hospice and palliative care. “Primary care providers and their teams can facilitate the documentation of advanced directives for each patient,” he explained. “Each patient is counseled on choices in the event of a life-ending medical condition or event. It’s important when provider teams recognize that the patient is nearing the end of their life cycle and can begin the patient-centered collaboration for appropriate end-of-life care with a statement like: ‘there’s nothing more medicine can do for you. We’d like to refer you to hospice care because they’re experts at keeping you comfortable at end-of-life care and can enable you to die with dignity.’” Paniagua, associate professor and director of the Department of Internal Medicine Residency Program at Saint Louis University (SLU) School of Medicine in Missouri, said a smooth transition is easier when the primary care provider (PCP) team clearly communicates the endof-life plan with patients. “We similarly teach many high-tech and high-reimbursing procedures in medicine, but in my view, the most delicate and nuanced procedure we can teach and learn is the bedside conversation about goals of care and treatment planning,” he said. “Like any procedure in medicine, there are effective and ineffective ways of doing it. Unfortunately, not enough emphasis is placed on teaching and learning this procedure, which leads to much variability in the way it’s delivered, as well as providers’ discomfort and unease with doing it.” Paniagua also noted that mainstream media’s sensationalized coverage of euthanasia and physician-assisted suicide issues
Outside the Box When it was established 25 years ago, the American Academy of Hospice and Palliative Medicine (AAHPM) had 250 charter members. Now, the professional organization has 5,000 members. Yet even though four of five larger U.S. hospitals now have palliative care programs, and consultations for the specialty have spiked, new growth isn’t keeping pace with the coming demand. New hurdles hinder progress – a rapidly aging baby boomer generation coupled with the existing senior population, continued segmentation of care, and limited funding for specialty training programs. AAHPM leaders recently proposed a solution to the specialty shortage problem: Timothy E. Quill, MD, FACP, and Amy P. Abernethy, MD, FACP, president and president-elect of the AAHPM, respectively, suggested reserving palliative medicine physicians for more challenging cases, while also increasing the palliative skills of primary care providers (PCPs) and specialists who see patients daily. Using their model, PCPs would receive appropriate education to address management of pain and other symptoms and other basic palliative care needs. Palliative medicine physicians would be called in to manage difficult-to-treat pain, complicated depression, anxiety and grief and other more complex needs. SOURCE: AAHPM.
has hindered progress in the advancement of the specialty and public perception. “In reality, (euthanasia and physician-assisted suicide) is such a miniscule practice, and in only three states,” he emphasized. “But my view is that too often patients feel they have no other way out of their suffering. More often than not, we providers don’t do an adequate job providing palliative care to most of the suffering.” Lehmberg, who switched specialties to hospice and palliative medicine after a neck injury prevented him from continuing his nearly 30-year plastic surgery practice, said the most common misperceptions about the specialty are the differences between palliative care and hospice, and getting the team involved early
Palliative v. Hospice Care Palliative care: • provides comfort and relief from pain and other distressing symptoms; • is meant to neither hasten nor postpone death; •integrates the psychological and spiritual aspects of patient care; • affirms life while regarding dying as a normal process; • assists patients in living as actively as possible until death; • helps the family cope during the patient’s illness; • uses a specialized team approach including physician, nursing, chaplaincy and social work; and • is provided in conjunction with therapeutic treatments such as chemotherapy and radiation. Hospice: • focuses on caring, comfort and dignity at end of life; • provides relief from pain and other distressing symptoms; • is meant to neither hasten nor postpone death; • integrates the psychological and spiritual aspects of patient care; • helps the family cope with the patient’s end of life and their own bereavement • uses a specialized team approach including physician, nursing, chaplaincy and social work.
enough to “truly assist the patients, their families and the treating physicians.” “Most people, physicians included, think of us only in terms of hospice and end of life,” said Lehmberg. “However, palliative care improves the quality of life of patients and their families with lifethreatening conditions through the prevention and relief of suffering, and also the treatment of pain and other problems – physical, psychosocial and spiritual.” Palliative care may be extremely helpful to physicians and patients in conjunction with therapeutic treatments, such as chemotherapy and radiation, said Lehmberg, noting that requests for hospice and palliative care consultations for the UAMS Department of Hematology and Oncology has increased significantly – from 400 in 2007 to more than 2,200 estimated this year. “As evidenced by our program growth, an awareness of the role of palliative care is increasing,” he said. “Still, I’d like to continue to contribute to a better understanding of our subspecialty and how we can help. Once a patient has been diagnosed with a life-threatening illness, it’s really never too early to involve a multi-disciplinary palliative care team.” Palliative care transitions to hospice care when the illness progresses to the point that therapeutic treatments are no longer applicable, explained Lehmberg. “In palliative care, an experienced team is best at fitting in with the primary medical approach, not rivaling it,” said Lehmberg. “As consultants, the palliative care team … complements the treatment and care provided by the primary physicians.”
The Move to DNP
Nurses embrace advanced degree program to address the increasingly complex healthcare practice environment By CINDy SANDERS
In October 2004, member schools of the American Association of Colleges of Nursing (AACN) voted to endorse the organization’s position statement calling for the transition of the level of preparation needed for advance practice nursing from the master’s degree to the doctorate level by 2015 through the addition of the DNP — Doctor of Nursing Practice. “Will we have all of our APRN programs transition to DNP by the 2015 deadline? Probably not … but we will have a critical mass that are,” said Jane Kirschling, PhD, RN, FAAN, dean of the School of Nursing for the University of Maryland who serves as 2012-2014 board president for AACN. “I feel like we’ve reached the tipping point,” she added. Indeed, the growth of DNP programs nationwide has been remarkable. By spring 2013, programs existed in 40 states and the DisDr. Jane Kirschling trict of Columbia. “We are extremely pleased that we currently have 217 Doctor of Nursing Practice programs up and running in the United States. If you go back to 2004, we only had seven programs,” Kirschling noted. “In addition, we have 97 new programs under development.” She
added enrollment has jumped from 170 DNP students in 2004 to 11,575 last year. Rooted in the desire to deliver the highest quality of care in the practice setting, Kirschling said the addition of the DNP was consistent with what is happening in other healthcare disciplines including pharmacy, audiology and physical therapy. Grounded in evidence-based practice, she said the hope is that these doctoral-prepared nurses will take existing discoveries and more rapidly drive that knowledge to the bedside. Additionally, she said the degree is anticipated to prepare these nurses to provide leadership in an increasingly multifaceted healthcare environment. “What I project we’ll see with time as we graduate more from the DNP program is they will actually partner with PhD nurses to create some really interesting synergy to solve really difficult clinical issues and to solve them in a quicker timeline that directly impacts patient care,” stated Kirschling. The reason for the DNP movement is multifactorial. In addition to aligning with other health profession disciplines that offer a clinical doctorate, Kirschling said the degree also recognizes the complexity of the nation’s evolving healthcare delivery system. The number of hours and amount of academic work required to become an advanced practice registered nurse pro-
PhD vs. DNP Jane Kirschling, PhD, RN, FAAN, president of the American Association of Colleges of Nursing, said the addition of the Doctor of Nursing Practice (DNP) degree was the clinical complement to the long-standing Doctor of Philosophy (PhD) or Doctor of Nursing Science (DNSc) degrees, which prepare students for scientific research. The PhD, she noted, “is really intended to prepare the next generation of scientists for new discovery so they are generating new knowledge for the discipline.” In addition to an interest in a nursing faculty career with a research component, Kirschling said it was fairly common for nurse executives to obtain a PhD as they sought to increase leadership roles. With the addition of the DNP, nurses now have two terminal degree tracks from which to choose — research and practice. The newer DNP quickly overtook PhD and DNSc programs in terms of the number being offered across the country. Currently, there are 131 researchfocused programs in the U.S. The number of research doctoral programs grew from 103 to 131 between 2006 and 2012. During that same time period, DNP programs grew from 20 to 217. As the field looks to increase the number of doctoral-prepared nurses, the good news is enrollment is up in both research-based and practice-based doctorate programs, although the newer DNP degree has seen much more rapid growth as more academic institutions have begun offering the option. Between 2004 and 2012, the number of students enrolled in DNP programs increased from 170 to 11,575. The number of students seeking a PhD in nursing grew from 3,439 to 5,110 during the same timeframe.
vided another impetus behind the DNP movement, Kirschling noted. Nursing had already moved to increase and expand practical knowledge in APRN master’s programming. Where many master’s degrees in other fields require 30-36 credit hours, the four recognized APRN master’s programs — Nurse Practitioner, Clinical Nurse Specialist, Nurse Anesthetist, and Nurse Midwife — already required a minimum of 40-55 credit hours. With the
newer doctoral degree, students need, on average, 80 credit hours in the baccalaureate to DNP program and an additional 39 credits in the master’s to DNP path. “Healthcare in the county has changed dramatically,” Kirschling concluded. “The depths of knowledge and the skill set any provider needs have just increased over time. We, as a discipline, felt it was critical that our graduates be prepared to meet the demands of the future.”
Louisiana Hospitals Seek Funding Protection, continued from page 1 will be the only other major, unprotected chunk of the budget left. John Matessino, president and chief executive officer of the Louisiana Hospital Association, said he knew the bills had a good chance of passing but the amount of backing was something of a stunner. “Are we surprised at the overwhelming majority we got? I’d be lying if I said I wasn’t,” Matessino said. However, Matessino said hospitals and nursing homes did a good job of lobbying their respective legislators. And the providers made legislators’ decision easier by offering a solution – putting up their own money to draw down the federal match for Medicaid – rather than asking for more funding, he said. Polls showing members of the public understood the impact that Medicare and Medicaid funding cuts have on hospitals and the state’s economy also helped influence legislators. “When you cut Medicaid and Medicare, insured people and employers make up the difference. It’s almost like a hidden tax,” Matessino said. One bill allows the hospitals to pool their money for their share of the Medicaid match. The bill limits cuts to Medicaid payments and requires a vote of the legislature to do so. The second bill sets a floor on Medicaid patient payments to nursing homes, pharmacies and intermediate care facilities, or institutions for the developmentally disabled. Cuts to those payments would also require a vote by legislators. Matessino said the fiscal picture for healthcare providers was not good heading into the session. The Medicaid programs that hospitals and the state have relied on in the past, such as the disproportionate share-hospital and upper payment limit funds, have questionable futures, he said. The hospitals had to figure out a way to get a more stable funding stream and reimbursement rate. “We’re not trying to leapfrog over the Medicare rates or anything like that,” Matessino said. “We’re just trying to get a little bit closer to where those are … so it puts hospitals in a better position to be able to provide care to everyone.”
Right now, the larger non-state, nonrural hospitals, like those in Baton Rouge and Lafayette, get paid about 60 cents on the dollar for the cost of treating Medicaid patients, Matessino said. “If and when Medicaid expansion comes in, that could paint a pretty red cloud over a hospital, and physicians for that matter,” Matessino said. Until now, the state Department of Health and Hospitals, with the governor’s approval, has set Medicaid payments. But the amendments, if passed, mean DHH couldn’t cut rates without legislators’ approval. Matessino said Gov. Jindal’s position against new fees, taxes or assessments is well-known. The proposed constitutional amendments offered a veto-proof solution. The hospitals and nursing homes approached members of the Legislature about the proposals, Matessino said. House Speaker Chuck Kleckley, R-Lake Charles, agreed to author both bills. The next step was getting the Legislature to pass the measures. The next step, which will take place in 2014, is to get voters to pass the amendments, Mattesino said. The third step will be for the Legislature to set up the specifics; the assessments will probably be based on hospital revenue. Hospitals’ base payment rates now are the same as they had in 1993, Matessino said. “We don’t want the state to go below that,” Matessino said. The hospitals would be pretty happy to see Medicaid payments at 80 percent of the actual costs for treatment, he said. Medicaid payments at that level would encourage members of the Hospital Association to do more in the Medicaid arena. Matessino said hospitals also wanted to make sure that the hospital stabilization fund didn’t end up like the state gasoline tax. The tax was intended to pay for highway repairs, but the Legislature ended up backing that amount of money out of the state Department of Transportation and Development’s budget, and the repairs didn’t get done.
Louisiana Medical News
JULY 2013 • 5
Conference Offers PAD, CLI Solutions By TED GRIGGS
Fourteen years ago, when Dr. Craig M. Walker organized the first New Cardiovascular Horizons conference, he had a number of goals, including: • To draw attention to peripheral arterial disease (PAD), a prevalent and deadly malady, and help providers do a better job of diagnosing PAD and making Dr. Craig M. Walker the connection to other health issues; and • To show providers there were other, better options for patients with critical limb ischemia than amputation. The first conference drew around 200 people, most of them podiatrists who didn’t really know what to do for their patients with peripheral artery disease, Walker said. The conference, most recently held June 5-7 in New Orleans, is now the largest peripheral intervention conference in the United States and attracts more than 2,000 physicians, scientists, allied professionals and industry professionals. At this year’s conference, Drs. Nick Cavros, Christopher Daniels, Raghotham Patlola, and Kalyan Veerina of Cardiovascular Institute of the South performed
six, intricate interventional cases at Regional Medical Center of Acadiana. The procedures were among the more than 30 broadcast live at the conference. Walker said the goal of this year’s conference wasn’t to pit one therapy against another but to find the best therapy and make sure that all of the patients get treated appropriately. “What we don’t want to see is amputation first,” Walker said. “We think that’s bad therapy.” This approach, championed by Walker and his colleagues at Cardiovascular Institute of the South, is gaining in popularity nationally and globally, he said. New Cardiovascular Horizons also holds conferences each year in China, Latin America and 10 or so regional meetings throughout the United States, with lots of requests for additional locations. Still, it hasn’t been that long since the first option for a CLI patient was amputation, Walker said. Historically, and at the time of the first conference, anyone who attempted to revascularize the leg of a CLI patient was looked on as “aggressive, i.e. bad,” Walker said. Cutting off the patient’s leg was considered conservative, or good. The problem with the conservative approach, Walker said, is that amputation involves a number of drawbacks, such as phantom limb pain, which never goes away.
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The patients with PAD or CLI are usually older, Walker said. Almost 30 percent of people over age 70, and almost 30 percent of the people over age 50 who have either smoked or have diabetes, have peripheral arterial disease. What people don’t realize is how dangerous amputation is, Walker said. “If you get your leg cut off below the knee at the best centers in America, at centers like the Mayo Clinic and the Cleveland Clinic, you have a five to eight percent 30-day mortality,” Walker said. Below the knee, the 30-day mortality rates range from eight to twelve percent. “Fully one-third of people who get a major amputation from ischemic limb disease go straight to a nursing home, never to leave again,” Walker said. The annual cost for those nursing home patients is more than $100,000, he said. The patients that do return home also face their own challenges and ex-
penses, including medicines, prosthetics and bathroom modifications. In the mid-2000s, Dr. David Allie and Walker published an article in EuroIntervention that estimated society could save $4 billion a year by reducing the number of amputations by 20 percent. Those savings would be much greater today, Walker said, thanks to rising numbers of people stricken by PAD and CLI and healthcare costs. And that’s with only a 20 percent reduction in amputations. With limb salvage rates of better than 95 percent, which Walker said are achievable, “we’re talking about a whole lot more money than $4 billion.” So it’s important in every way, shape or form to save limbs, he said. Walker points to a former patient, 28-year-old Angela Mullins of Ocean Springs, Miss., as proof of that. Last fall, Mullins, an RN, learned that both her legs were again blocked. Mullins had already had seven bypasses on her legs. She was told, by more than one doctor, that her only option was to amputate both legs. Mullins said she visited many doctors before eventually being referred to Cardiovascular Institute of the South. Walker performed three laser treatments on Mullins’ legs. Afterward, Mullins began walking two miles a day and says she no longer experiences pain. Walker said amputation can be a very, very important and lifesaving procedure for certain people. “But in my opinion, it should never be called first step. It should be called last step. It should be called the step you take only when there is no other option,” Walker said.
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Sports Medicine Community Weighs In
Zurich 2012 Concussion Consensus Statement clarifies issues, muddles others, exemplifies mystery of TBI By LYNNE JETER
No RTP (return to play) on the same day, regardless of circumstances. An earlier return to light exercise, recommended. And the differential between pediatric and adult patients, clarified. Those are among the highlights of the 2012 Concussion Consensus Statement derived from the 4th International Consensus Conference on Concussion in Sport, held last November in Zurich. Every four years, the International Ice Hockey Federation, International Olympic Committee, International Rugby Board, International Federation for Equestrian Sports, and FIFA (International Federation of Association Football) host the conference, which results in an updated concussion consensus statement. “The new statement shows that we basically still don’t understand concussions, and there are many opinions on how to diagnose and treat them,” said William Feldner, DO, a sports medicine specialist at South County Family & Sports Medicine and St. Dr. William Feldner Anthony’s Medical Center in St. Louis, Mo., and team physician for Lindenwood University and USA Volleyball. He’s also a board member of the Joint Commission for Sports Medicine and Science, an editorial board member of the Clinical Journal of Sports Medicine, and past president of the American Osteopathic Academy of Sports Medicine. “And, while it’s not in the (consensus) statement, there’s some interesting genetic research going on. We may eventually be able to predetermine if someone is more susceptible to concussion based on their genetic makeup.” Marc Hilgers, MD, PhD, director for sports medicine fellowship, sports medicine research, and a sports medicine physician at Level One Dr. Marc Hilgers Orthopedics with Orlando Health in Central Florida, said he didn’t expect major changes in the 2012 consensus statement. “I’ve been keeping my finger on the pulse of knowledge and I knew what was coming down the pike,” said Hilgers, also the team physician for Orlando City Soccer and the Minor League Umpire Association, medical advisor for the Florida Orthopaedic Institute, and assistant pro-
fessor of family medicine at the University of South Florida. “That’s why I wasn’t surprised, especially with the broad spectrum of specialists from all over the world who met to write the updated statement, that it was kept general and not too progressive.” Bill Hefley, MD, an orthopedic surgeon and partner at OrthoSurgeons based in Little Rock, Ark., said the latest consensus statement showed “great development in the CRT (concussion recognition tool) for lay use.” The 2008 conference resulted in the de- Dr. Bill Hefley velopment of the Sport Concussion Assessment Tool (SCAT2), a standardized method of evaluating athletes ages 10 years and older for concussions. “This tool takes out the ‘guesswork’ and interpretation for laymen,” said Hefley. “The SCAT3 has a background section, which is a great addition to the SCAT2. Also, the SCAT3 is much more streamlined with clinician instructions on its own page, rather than after each section. The Child-SCAT3 is a great new tool for younger athletes who may sustain concussions.” Todd Ross, MS, ATC, an athletic trainer for Pulaski Academy with OrthoSurgeons, highlighted the 2012 consensus statement’s importance “because it continues the worldwide awareness of concussions (and) shows the dedication the medical society has for learning more about concussions, how to recognize concussions, how to properly manage athletes with concussions, and how to properly and safely return an athlete to play after a concussion has subsided.” The only major blip noted repeatedly: the altered position on CTE (chronic traumatic encephalopathy). Hilgers called it “an interesting update … on an issue that had ‘percolated up’ since 2008.” • The 2008 section on chronic traumatic brain injury (TBI) notes: “Epidemiological studies have suggested an association between repeated sports concussions during a career and late life cognitive impairment. Similarly, case reports have noted anecdotal cases where neuropathological evidence of CTE was observed in retired football players. Panel discussion was held, and no consensus was reached on the significance of such observations at this stage. Clinicians need to be mindful of the potential for long-term
Making Louisiana a Better Place to Practice Medicine Since 1878
Become a Part of the Journal of the LSMS by LSMS Communications, Publications, and Social Media Manager Joshua Duplechain For more than 160 years, the Journal of the Louisiana State Medical Society has provided valuable scientific articles and information to physicians. Established in 1844, the LSMS CommuniJournal is one of the cations, Publications and Social oldest periodicals Media Manager of its kind in the Joshua Duplechain country and features clinical trials and cutting edge research being conducted by some of the top physicians and researchers in the state. In addition, the publication presents four “departmental” articles each issue: ECG of the Month, Radiology Case of the Month, Clinical Case of the Month, and Pathology Image of the Month. These articles detail specific case reports and ask the reader to make his or her own diagnosis based on the evidence presented before revealing the outcome – a sort of “whatdunnit?” if you will.
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Sports Medicine Community Weighs In, continued from page 7
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problems in the management of all athletes.” • The 2012 TBI section notes that “clinicians need to be mindful of the potential for long-term problems in the management of all athletes. However, it was agreed that CTE represents a distinct tauopathy with an unknown incidence in athletic populations. It was further agreed that a cause and effect relationship has not as yet been demonstrated between CTE and concussions or exposure to contact sports. At present, the interpretation of causation in the modern CTE case studies should proceed cautiously. It was also recognized that it’s important to address the fears of parents and athletes from media pressure related to the possibility of CTE.” “It seems unclear what their true position is between the two consensus statements and needs to be better explained,” said Ross, particularly given the unfortunate trend of former and current professional athletes taking their own lives for their families “to donate their brain … to prove CTE is in fact an issue.” Among high-profile, self-inflicted deaths in recent years are professional athletes Junior Seau, Derek Boogard, Dave Duerson, who may have been the only one to commit suicide and leave instructions donating his brain for the study of CTE. Former NFL Chicago Bears quarterback Jim McMahon has agreed to donate his brain to science after his death. Another point of controversy: concussion determination. A neuropsychologist in the field of treating concussions
pointed out the 2004 consensus statement was driven largely on a grading scale (1-3) for concussion with loss of consciousness serving as a means of grading the severity of concussion, from which the 2008 consensus statement began to deviate. “My take is that a concussion is more black and white,” he said. “Either you have a concussion or you don’t. When you get into grading scales and severity ratings, you oftentimes relay misinformation to patients and the other providers involved in the case. Calling it a yes-or-no decision takes that away. Oftentimes, athletes get caught up in whether their concussion was mild or severe, which leads to poorly-based expectations about recovery. A concussion is a concussion and everybody recovers differently.” In the clinical treatment and management of concussion, the clinician is the key, said the neuropsychologist. “The consensus statements, the most recent one included, spend a lot of effort discussing sideline assessment tools, baseline testing, cognitive assessment tests, balance testing, RTP decisions, and preferred means of assessment or treatment,” he said. “All these components are tools that, when used correctly by a well-trained clinician, can be extremely valuable. But the clinician remains the most important piece in terms of concussion treatment and management. The consensus statements do very little in terms of providing practical guidelines for the clinical care of concussion with respect to the individual clinician.”
Notable Highlights Todd Ross, MS, ATC, an athletic trainer for Pulaski Academy with OrthoSurgeons in Little Rock, Ark., emphasized other notable 2012 Concussion Consensus Statement highlights: Todd Ross • In the preamble, “ … therapists, certified athletic trainers … coaches and other people” were replaced with “primarily for use by physicians and healthcare professionals,” which better addresses who should be diagnosing concussions and handling RTP decisions concerning concussions.
• “Brain injury” was added to the first sentence to read: “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain induced by biomechanical forces.” “One could argue the point of, by definition, a concussion isn’t an injury but a process,” he said. “Adding the language of brain injury nullifies this objection.” • A timeline for concussion status was identified as “in some cases, symptoms and signs may evolve over a number of minutes to hours,” which could broaden the clinician’s interpretation of signs and symptoms. • The “Classification of Concussion” subtitle was changed to “Recovery of Concussion.” • In the neuropsychological assessment subtitle, the second and third paragraphs were rewritten and show less of an emphasis on the patient seeing a neuropsychologist. However, the emphasis changes to neuropsychological (NP) testing and a multidisciplinary approach to concussion management.
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Louisiana Medical News
Recruiting in an Era of Reform New Landscape Requires Different Leadership Skills By CINDY SANDERS
As healthcare continues to transform and evolve, the skill sets needed to be an effective leader and provider are changing, too. From HIPAA and HITECH to the Affordable Care Act, the regulatory and reimbursement environments have impacted the recruiting process by demanding that physicians, nurses and management teams be able to provide the best outcomes in the most efficient manner possible. “The hospital model is changing so those leaders don’t look the same anymore,” said Brian Kelley, a partner with The Buffkin Group, LLC. “You better have a deep bench,” he continued of the need to have an executive team with different areas of expertise. Just as the ideal apBrian Kelley plicant is changing, the most effective way to recruit that candidate is also undergoing a transformation. “We’re doing a lot of things differently than we did five or six years ago,” noted Susan Masterson, national vice president of provider recruitment for TeamHealth. “The day of placing an ad and waiting
for the right candidate to appear is long gone.” As for the true impact of health reform on job recruitment, the experts all agreed that has yet to fully play out. “We’re building the plane engine as we fly it,” Masterson said wryly. So how are recruiting and management Susan firms attracting and reMasterson taining the right people in a period of great transition, and what skills should candidates hone to answer new challenges posed by the nation’s complex healthcare system? Medical News asked a number of recruiters to share their insights.
Physicians In addition to her national provider recruitment duties with TeamHealth, Masterson is a past board member and committee chair for the National Association of Physician Recruiters and a current committee member for the Association of Staff Physician Recruiters. On the national front, she said the need for primary care physicians is anticipated to rise dramatically. Yet, she continued, only about a quarter of the applicants
coming out of training are headed that direction. “We need more family practice and internal medicine physicians,” she said. “The government is going to have to make more slots for internship and residency, and they’re going to have to incentivize physicians to be primary care doctors,” Masterson added of anticipated demand in the wake of ACA. “Regardless of the specialty,” she continued, “I think there are different competencies for doctors that are a ‘must have’ today than (were necessary) years ago.” A focus on quality, prevention and evidence-based medicine were included on her list. Masterson also noted the need to be comfortable with technology and said two of the biggest skills were to be team-oriented and effective in mentoring and working alongside advanced practice clinicians (APCs). “Another thing I think we’ll see is there will be a lot of physicians that are in small, private practices that will choose to join larger companies or hospitals,” Masterson said. She added that her company is recruiting many physicians who are ready to hang up their shingle because of heavy workload, decreasing reimbursements, increased regulation and uncertainty over how healthcare reform will
impact their practice. Another factor driving this trend, she added, is that the ‘new millennials’ (born between the early 1980s and 2000s) are very focused on a work-life balance and value personal time as much as career … which often translates into a willingness to be hospital employees rather than taking on the stress of owning their own practices. In her own company, Masterson said they have taken a much more proactive strategy to recruit residents for their key focus areas of emergency medicine, anesthesiology, urgent care and the ‘ists’ — hospitalists, laborists, surgicalists. TeamHealth has created a number of support services … from online resources to shadowing opportunities to hosting discipline-specific boot camps … to help the young recruits settle into their new roles. “We’re also signing many more APCs … probably three or four times more than we did just four or five years ago,” she noted of the increased demand for physician assistants, nurse practitioners, nurse anesthetists and other mid-level providers. As demand increases for providers, it has become increasingly competitive to fill open spots. Locum tenens companies have been springing up, said Masterson. Where those temporary providers had been filling (CONTINUED ON PAGE 10)
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Recruiting in an Era of Reform, continued from page 9 in for short periods during vacation or maternity leave, Masterson said it is increasingly common to see them in place for months at a time while the search continues for a permanent hire. TeamHealth has their own internal group known as Special Ops physicians to answer this need. Hiring, however, is only one part of the puzzle. “It’s one thing to recruit the doctors, but then we have to retain them so there is a tremendous focus on retention,” Masterson said.
Advanced Practice Providers MedPlacer, a national recruitment and operational process improvement firm, places healthcare providers and executives in a variety of positions. However, said Jeff E. McCracken, founder and managing director, the company’s core business is on emergency, surgical and cardiovascular service placement. “When we originally founded Jeff our company, we had a McCracken broader approach,” he noted. Over time, he continued, “We’ve really focused in more on a couple of key niche areas, and it’s really driven by the market.” McCracken added, “About 90 percent of the professionals we place have a nursing background of some sort.” The company, he explained, has three main divisions — permanent nursing leadership recruitment, staff nursing recruitment, and interim departmental leadership. Although MedPlacer doesn’t always put an interim director on site, when the company does have a leader on the ground, that person helps clients assess operations, identify weaknesses, outline process improvements, set departmental objectives and align staff appropriately to achieve those goals. McCracken said the strategy has been to not only glean the technical needs of a department but to understand the culture
to recruit the right person. “The retention rate has been much higher because we’ve had an on-the-ground experience within the hospital,” he noted. Like physicians, McCracken said nurses are now recruited nationally. As the housing market has improved, he has found an increased willingness among nurses to consider positions in other parts of the country. An area of rapid growth has been placing staff level nurses in departments to help alleviate dependence on travel nurses. He was quick to add that travel nurses play an important role in helping a facility staff up for seasonal peaks or to meet the needs of increased patient populations for short periods of time. However, he added, hospitals ultimately want staff members who are engrained in their community. Kipper Latham, RN, chief clinical officer for MedPlacer, is the person on the inside. “It helps the nurse understand that hospital before they pick up and move from Pittsburgh to Texas,” he said of being embedded in the hospital while assessing a department’s operations, staffing and processes. Additionally, he spends his time learning about the area … schools, activities, the housing market, and quality of life … to best match a job candidate with both the hospital and community. He added finding the right match is more than just aligning skill sets. “You have to look not only on paper but also understand that professional’s long-range goals and motivation,” he said. Like McCracken, Latham said travel nurses play an important role in staffing solutions but likened them to renters vs. owners. “Travelers are needed, but it’s not the same as if 80-90 percent of your nurses are part of the community,” he explained. During a seven-month stint in the emergency department at a Texas hospital, Latham saw the number of travel nurses decrease from 25 to two, and the Press Ganey hospital scores rise from
the bottom 25th percentile to the top 15 percent. “Patient satisfaction scores went through the roof because now you had ownership in the community,” Latham noted. As with physician recruitment, retention is a key to success. McCracken reiterated turnover not only hurts the bottom line, but it takes a heavy toll on key areas impacting quality and efficiency including morale, institutional knowledge, cultural sensitivity, and patient and employee satisfaction. He added there is no crystal ball to know exactly how ACA will impact hospital staffing, but McCracken pointed out increased volumes are often seen in the Emergency Department first and then have a domino effect in other areas of operation. He said MedPlacer is working collaboratively with colleagues in other firms to try to prepare for increased demand. “We’re continuing our strategic alliance with other recruitment companies nationally. That way we can scale appropriately,” he concluded.
The Executive Suite The Buffkin Group focuses primarily on placements at the C-suite level for service providers and end payers. The landscape … and the skills needed to successfully navigate the new terrain … are definitely changing. “When you’re in the heat of your business, it’s sometimes difficult to take a strategic look at your executive team and ask, ‘Do we have the team in place to meet the regulatory demands that take place in 2014?’” said Craig Buffkin, managing partner and founder of the firm. For non-profit hospitals, he added, that could mean a shift in attention. Previously, these Craig Buffkin facilities were much more focused on outcomes than on cost factors.
Now, both must be equally weighed. “It’s put a lot of pressure on having a different type of leader in different parts of their organizations that didn’t exist five years ago because not only do they have to worry about outcomes but also on driving costs and efficiencies,” Buffkin said. The new regulatory environment and shifts in reimbursement models have brought about some consolidation of acute care facilities and hospitals taking over physician practices. In the short run, said Buffkin, consolidation shrinks the leadership market. However, he continued, “In the long term, it typically increases the need as companies get bigger.” In fact, he continued, “We’ve doubled the number of searches we’ve been completing on an annual basis in the last several years, and the majority of that demand has come from our healthcare clients because of regulatory pressures.” Brian Kelley, a partner based in the firm’s Connecticut office, added the complex delivery and regulatory environment has made it nearly impossible for one person to have all the skills necessary to meet the hospital’s or practice’s needs. Three areas he identified as ‘critical in any management setting’ are knowledge and experience of healthcare services, profit and loss expertise to understand reimbursement challenges and a robust understanding of IT from both a quality and efficiency perspective. “You have to have a team … it’s not one person,” he said. “For one person to have all three of those skill sets is
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SurviveDAT! continued from page 1 gling work, studies and family. They need specific answers and solutions that pertain to their stage in life, but much of the information available to them is geared toward women over 40. Louisiana ranks at the top in the nation for deaths from breast cancer, though our incidence rate is lower than the national stats, suggesting that our women wait too long to be treated, have limited access to information and medical care, and don’t go for mammography. And so SurviveDAT! was conceived. It has a cute name, but a serious purpose – provide breast cancer information for young breast cancer survivors ages 18-44. A partnership between the LSU Health Sciences Center School of Public Health, and Mary Bird Perkins Cancer Center (MBPCC), SuriviveDat! was written as a three-year grant and funded by the Centers for Disease Control and Prevention. Donna Williams, assistant professor at the LSUHSC School of Public Health, who is also director of the Louisiana Cancer Prevention and Control Program, “Young breast cancer survivors have needs which can differ substantially from those of older women with breast cancer. It’s vitally important that we respond to these needs and assist these women, their families and their caregivers in the cancer journey.” Specifically there are three integrated parts to the program: The www.survivedat.org website is packed with both local and national breast cancer resources for
“I have eyebrows!”
the younger breast cancer survivor; a monthly support group meeting at Cancer Services of Baton Rouge where they can network; and quarterly workshops, often with the topics tied to information from the website. The SurviveDAT! participants come from a combination of physician contact and community outreach by representatives making regular visits to Baton Rouge physicians’ offices to let both doctors and patient navigators know about the program, and taking part in community events like the Susan G. Komen Race for the Cure. Younger survivors can come from anywhere or be referred by their doctors from other parts of the state. They don’t have to live in Baton Rouge to attend. Since the program’s kick-off last fall, there have been two quarterly sessions; genetics in January, with Dr. Duane Superneau and fertility in March with Dr. Sissy
Sartor. Chiquita, a 37-year old breast cancer survivor said she first knew about the program when taking treatment for her breast cancer at MBPCC last year, and has been to everything since. “I was so impressed with the strong connection with others, and the program is geared toward the younger patients in an atmosphere of sharing the same feelings and concerns that we all have, especially in the beginning when the group was smaller and more intimate.” She added that the positive and supportive group of nurses and doctors at MBPCC and the SurviveDAT! program “made my journey not nearly as bad as it could have been or I anticipated.”
Bold, Beautiful You! And in May 2013 the event was, ‘Bold, Beautiful You!’ an uplifting, fun but informative, well-attended evening held at the U-WINK Eyelash Studio at the Mall of Louisiana. A reception in a sea of pink color-cupcakes to boas started off the evening, which was geared to the young survivors’ emotional side – it was all about looking good, feeling good and being reenergized. “We wanted to host a fun event that addressed the specific body image concerns of young breast cancer survivors,” said Renea Duffin, vice president of cancer support and outreach for Mary Bird Perkins Cancer Center. “Our goal is for survivors to feel bold, beautiful, and supported by
their community.” The first speaker, Britney Temple of Fit Lab Fitness, discussed basic nutrition of lean meats, fruits and veggies and water consumption, but added that a chemo patient might try spices and seasoning (but not extra salt!) to put taste back in food. And she advised exercise three-four times a week – anything goes! Phyllis Sales, owner of Still Me Boutique, showed many examples of post mastectomy care garments, from the immediately-worn, frankly utilitarian, compression items, and ‘balancers’ and prostheses, to later stage beautiful lingerie, lace-decorated bras and camisoles. She pointed out that there are many products available for all stages of pre- and post-surgery, and that active women need the right clothes to achieve body balance, symmetry and emotional well-being. The make-up sessions were saved until last and models from the audience had fun, but were given good advice for post radiation and chemo hair loss from LaTrice Pinkins, the evening’s hostess. Shana Ballard, one of the participant/models, exclaimed after make-up was expertly applied, “I have eyebrows!” The event for July is “Getting to Know the New You: Renewing Healthy Relationships after Breast Cancer Diagnosis.” Though all the sessions at this time take place in and around Baton Rouge, there are plans for expansion into New Orleans, both for local website information and eventually area meetings.
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2013 Legislative Session Recap The 2013 Regular Session of the Louisiana Legislature ended on Thursday, June 7th. In next month’s report we’ll feature some of the highlights of this past session. Below is a recap of selected healthcare-related measures that made it through the entire legislative process.
HB 10, Pearson Adds certain hallucinogenic substances to the list of Schedule I controlled dangerous substances; 5/23/2013; Becomes Act 7; Effective August 1, 2013 HB 15, Mack Adds certain compounds to the Schedule I classiﬁcation of controlled dangerous substances; 5/23/2013; Becomes Act 8; Effective August 1, 2013 HB 21, Burns, H Provides with respect to reporting of mental health information regarding the purchase of ﬁrearms; 4/18/2013; Substitute bill adopted: HB 717 HB 120, Pugh Authorizes the La. State Board of Nursing and the La. State Board of Practical Nurse Examiners to accept certain accreditations for nurses.; 4/8/2013; Referred to committee on Health & Welfare HB 150, Greene Requires recognition of assignment of health insurance benefits to health care providers; 4/8/2013; Referred to committee on Insurance HB 216, Shadoin Provides relative to the ability of the Patient’s Compensation Fund Oversight Board to invest certain funds; 5/30/2013; Becomes Act 80; Effective August 1, 2013 HB 221, Connick Authorizes certain dual employment and dual ofﬁce-holding for physicians; 6/6/2013; Enrolled in the House HB 228, Fannin Provides relative to balance billing by and reimbursement of noncontracted facility-based physicians for covered health care services rendered in an in-network health care facility; 4/8/2013; Referred to committee on Insurance HB 275, Willmott Authorizes podiatrists to obtain patient histories and perform physical examinations under certain conditions; 4/8/2013; Referred to committee on Health & Welfare HB 322, Thierry Requires birthing facilities to perform pulse oximetric screening for certain heart defects on each
newborn in the care of those facilities; 5/29/2013; Enrolled in the House
ral; 4/8/2013; Referred to committee on Health & Welfare
HB 342, Huval Provides relative to balance billing by and reimbursement of noncontracted health care providers of emergency medical services; 4/8/2013; Referred to committee on Insurance
HB 592, Thibaut Provides for the adequacy, accessibility, and quality of health care services offered by a health insurance issuer in its health beneﬁt plan networks; 5/29/2013; Enrolled in the House
HB 392, Bishop, S. Provides relative to credentialing and claims payment functions of managed care organizations participating in the La. Medicaid coordinated care network program; 6/6/2013; Enrolled in the House
HCR 4, Norton Directs the secretary of DHH to expand eligibility standards for the La. Medicaid program to conform to those established in the Affordable Care Act; 4/8/2013; Referred to committee on Health & Welfare
HB 393, Anders Provides relative to prescription drug beneﬁts of managed care organizations participating in the La. Medicaid coordinated care network program; 6/4/2013; Enrolled in the House
HCR 8, Edward Amends administrative rules to provide that La. Medicaid eligibility standards conform to those established in the Affordable Care Act; 4/8/2013; Referred to committee on Health & Welfare
HB 449, Burrell Provides for a time-limited expansion of Medicaid eligibility standards in La. to conform such standards to those provided in the Affordable Care Act until Dec. 31, 2016; 4/8/2013; Referred to committee on Health & Welfare
HCR 90, Smith Creates a task force to study and evaluate the effectiveness of sexual health education programs used throughout the state and other states; 6/2/2013; Enrolled in the House
HB 451, Barrow Requires hospitals to offer pertussis (whooping cough) vaccinations to parents of newborns; 5/28/2013; Enrolled in the House HB 479, Barras Provides an exception to annual ethics training requirements for certain hospital employees; 6/4/2013; Enrolled in the House HB 508, Cromer Creates an income and corporation franchise tax credit for manufacturers, producers, and importers of medical devices for amounts paid as federal excise taxes on the sale of medical devices; 4/8/2013; Referred to committee on Ways and Means HB 532, Kleckley Provides for a hospital stabilization formula and assessment and creates the Hospital Stabilization Fund and provides for uses of the fund; 5/29/2013; Enrolled in the House HB 533, Kleckley Creates the Medical Assistance Trust Fund as a constitutional fund, creates accounts for each provider paying fees into the fund, and provides for uses of the fund; 6/3/2013; Enrolled in the House HB 549, Leger Establishes the MediFund for statewide advancement of biosciences and medical centers of excellence; 6/6/2013; Enrolled in the House HB 569, Brown Eliminates restrictions on performance of physical therapy services without a prescription or refer-
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HCR 139, Barrow Directs certain state entities to report to the legislature concerning operation and management of state hospitals by private entities; 6/6/2013; Enrolled in the House HCR 140, Hunter Directs implementation of certain requirements for private contractors as conditions for privatizing the operation of any state hospital; 5/21/2013;Referred to committee on Health & Welfare HR 47, Hunter Requires submission for approval by the House Committee on Appropriations of any cooperative endeavor agreement between the Louisiana State University Board of Supervisors and a private entity involving the change in management of a public hospital; 4/18/2013; Referred to committee on Appropriations SB 185, Murray Provides relative to Medicaid and certain managed health care organizations providing health care services to Medicaid beneﬁciaries; 6/6/2013; Enrolled in the Senate SB 189, Heitmeier Provides relative to the practice of optometry; 4/8/2013; Referred to committee on Health & Welfare SB 198, White Consolidates the functions of the Louisiana Emergency Response Network and the Bureau of Emergency Medical Services into the Louisiana Emergency Medical Services and Response Network; 5/13/2013;Substitute bill adopted SB 262 SB 220, Walsworth Provides for the “Louisiana Has Faith in Families” Act; 5/31/2013; Becomes Act 66; Effective May 31, 2013 SB 262, White Provides for the Louisiana Board of Emergency Medical Services; 5/20/2013; Referred to committee on Health & Welfare SCR 25, Gallot Requests the LSU Board of Supervisors and the governor to keep the Huey P. Long Medical Center open and viable; 6/5/2013; Enrolled in the Senate SCR 41, Broome Requests DHH to examine the beneﬁts of routine nutritional screening and therapeutic nutrition treatment for those who are malnourished or at risk for malnutrition, as well as examine the beneﬁts of such actions as part of the standard for evidenced-based hospital care; 5/29/2013; Enrolled in the Senate SCR 42, Broome Acknowledges the role of optimal infant nutrition during ﬁrst year of life and that new
mothers require assistance to provide the best nutritional start for their babies and urges DHH to facilitate maternal and infant nutrition awareness and provide access to nutritional programs. 5/29/2013; Enrolled in the Senate SCR 57, Martiny Requests various state and local departments to take certain actions regarding the commercial construction and operation by Planned Parenthood Gulf Coast of a facility to provide abortions in Louisiana; 6/5/2013; Enrolled in the Senate SCR 87, Heitmeier Directs the Department of Health and Hospitals to submit a Section 1115 demonstration waiver to the Centers for Medicare and Medicaid Services that replaces upper payment limit funding and creates funding pools to replace upper payment limit payments; 6/5/2013; Enrolled in the Senate SCR 98, Johns Expresses support of and provides authority for actions by the Board of Supervisors of the Louisiana State University and Agricultural and Mechanical College for the strategic collaboration with the the division of administration and the Department of Health and Hospitals in planning for a new model of health care delivery throughout the Lake Charles region; 6/5/2013; Enrolled in the Senate SCR 101, White Requests the Department of Health and Hospitals to protect certain hospitals from the negative ﬁnancial consequences of the closure of the Earl K. Long Medical Center by adequately compensating such hospitals for their increased burden of providing health care to the poor and uninsured residents of the greater Baton Rouge region; 6/5/2013; Enrolled in the Senate SCR 108, Heitmeier Directs the Department of Health and Hospitals to submit a request to the Centers for Medicare and Medicaid Services to extend Louisiana’s Section 1115a demonstration waiver for the Greater New Orleans Community Health Connection and authorizes the governor and the secretary of the department to identify a source or sources for matching of non-federal funds required under the extended waiver; 6/5/2013; Enrolled in the Senate SR 18, Broome Designates April 15, 2013, as Earl K. Long Medical Center Day; 4/29/2013; Enrolled in the Senate SR 28, Murray Requires submission for approval by the Senate Committee on Finance of any cooperative endeavor arrangements between the LSU Board of Supervisors and a private entity involving the change in management of a public hospital; 4/29/2013; Enrolled in the Senate SR 51, Mills Designates April 25, 2013, as “School-Based Health Center Awareness Day.”; 5/13/2013; Enrolled in the Senate SR 106, Thompson Urges and requests the Department of Education and the Board of Elementary and Secondary Education to expand and enhance oral health care education in Louisiana public schools; 6/6/2013; Enrolled in the Senate
Legislative Affairs content is provided by Checkmate Strategies, publisher of Health Care Information Services. All content © Checkmate Strategies and Louisiana Medical News, LLC. For more information, readers may contact Cindy Bishop at 225.923.1599 or P.O. Box 80053, BR, LA 70598, or send email to destiny362@aol. com. Our website is www.checkmatestrategies.com
OIG Issues Warning to Hospitals and Other Providers In Special Fraud Alert on Physician-Owned Distributorships for Implantable Medical Devices By Clay J. Countryman, Esq.
On March 26, 2013, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services issued a Special Fraud Alert on Physician-Owned Entities. In the introduction, the OIG provided that this Special Fraud Alert addresses physician-owned entities (i.e., referred to as physician-owned distributorships or “PODs”) that derive revenue from selling implantable medical devices ordered by their physician owners for use in procedures the physician-owners perform on their own patients at hospital and ambulatory surgical centers (ASCs). The OIG also emphasized in the introduction to this Special Fraud Alert that the OIG has previously issued several “general” guidance documents on the topic of physician investment to entities to which they refer, and that they have specifically issued previous guidance addressing physician investments in medical device manufacturers and distributors in a Oct. 6, 2006 letter to the health care industry. In this particular Special Fraud Alert, the OIG noted that this Fraud Alert focuses on “the special attributes and practices of PODs that we believe produce substantial fraud and abuse risk and pose dangers to patient safety.”
Application of the Anti-Kickback Statute to Physician Investments The OIG emphasized its position in “longstanding” OIG guidance that the opportunity for a referring physician to earn a profit, including through an investment in an entity for which a physician investor generates business, could constitute illegal remuneration under the Anti-Kickback Statute. The OIG also listed the following aspects that the OIG has “repeatedly expressed” concerns under the Anti-Kickback Statute in arrangements (i.e., joint ventures) with physicians: Selecting investors because they are in a position to generate substantial business for the entity; Requiring investors who cease practicing in the service area to divest their ownership interests; Distributing extraordinary returns on investment compared to the level of risk involved. The OIG commented that PODs that exhibit any of the above aspects or other questionable features potentially raise four major concerns typically associated with kickbacks, including: (1) corruption of medical judgment, (2) overutilization, (3) increased costs to the Federal health care programs and beneficiaries, and (4) unfair competition. The OIG stated that they were particularly concerned about the presence of financial incentives in the implant-
able medical device context because devices typically are “physician preference items,” meaning that both the choice of brand and the type of device may be made or strongly influenced by the physician, rather than being controlled by a hospital or ASC where a procedure is performed. Hospitals and other providers should note that the OIG commented that a disclosure to a patient of the physician’s financial interest in the POD (which is commonly required by certain state laws) “is not sufficient” to address fraud and abuse concerns. This OIG Special Fraud Alert on Physician-Owned Entities listed the following concerns of which the OIG is “particularly concerned”: The size of the investment offered to each physician varies with the expected or actual volume or value of devices used by the physician. Distributions are not made in proportion to ownership interest, or physician-owners pay different prices for their ownership interests, because of the expected or actual volume or value of devices used by the physicians. Physician-owners condition their referrals to hospitals or ASCs on their purchase of the POD’s devices through coercion or promises, for example, by stating or imply-
ing they will perform surgeries or refer patients elsewhere if a hospital or an ASC does not purchase devices from the POD, by promising or implying they will move surgeries to the hospital or ASC if it purchases devices from the POD, or by requiring a hospital or an ASC to enter into an exclusive purchase arrangement with the POD. Physician-owners are required, pressured or actively encouraged to refer, recommend or arrange for the purchase of the devices sold by the POD or, conversely, are threatened with, or experience, negative repercussions (e.g., decreased distributions, required divestiture) for failing to use the POD’s devices for their patients. The POD retains the right to repurchase a physician-owner’s interest for the physician’s failure or inability (through relocation, retirement or otherwise) to refer, recommend or arrange for the purchase of the POD’s devices. The POD is a shell entity that does not conduct appropriate product evaluations, maintain or manage sufficient inventory in its own facility, or employ or otherwise contract with personnel necessary for operations. The POD does not maintain continual oversight of all distribution functions.
In its conclusion, the OIG noted that the Anti-Kickback Statute is not a prohibition on the generation of profits; however, PODs that generate disproportionately high rates of return for physician-owners may trigger heightened scrutiny. These comments imply the OIG does not consider successful physician investments in other health care providers to be illegal; however, other factors associated in a physician’s investment and the structure of PODs may result in the OIG taking a position that distribution of profits closely aligned with a POD providing implantable medical devices ordered by a physician investor may constitute illegal remuneration for the orders. Hospital’s should pay close attention to this Special Fraud Alert because it highlights the increasing potential for scrutiny and enforcement action by the OIG and other enforcement agencies. A copy of the OIG Special Fraud Alert on Physician-Owned Entities is available on the OIG’s web site at www.oig.hhs.gov/ under “What’s New.” Clay J. Countryman is a partner in the Baton Rouge, LA office of Breazeale, Sachse & Wilson, LLP. Clay.Countryman@ bswllp.com
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In the News First MDA/ALS Clinic in Louisiana Located at LSUHSC Medical School NEW ORLEANS — The Muscular Dystrophy Association announced the designation of the Louisiana State University Health Sciences Center New Orleans School of Medicine as an MDA/ALS clinic. The designation makes LSUHSC the first MDA/ALS clinic in Louisiana and recognizes the high standards of care offered by a team of specialized physicians and therapists for people in the greater New Orleans area who are living with ALS (amyotrophic lateral sclerosis, or Lou Gehrig’s disease). LSUHSC is the 44th MDA/ALS center in the country, joining a national network of MDA/ALS centers that provide a multidisciplinary team of medical professionals skilled in the diagnosis and treatment of ALS. LSUHSC has built a comprehensive medical team of clinicians including a board-certified neurologist, a pulmonologist, and respiratory, physical and speech therapists. “This designation of the MDA/ ALS clinic is a very important step in improving patient care for those who are diagnosed with ALS or a neuromuscular disease,” said clinic director Amparo Gutierrez, M.D. “This will allow us to provide specialty care to patients in Louisiana and other states in the southeastern region. Our clinic will continue to provide patients access to care regardless of their economic background. And we also look
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forward to working with other MDA/ ALS clinics around the country to grow our ALS research program.” MDA/ALS centers are an integral part of MDA’s commitment to developing effective treatments and working toward finding a cure. One of the ways in which they do this is by participating in ongoing ALS clinical research trials. “We welcome the exceptional expertise in ALS care provided by the health care specialists at Louisiana State University to our network of clinics,” said MDA Executive Vice President and Chief Medical and Scientific Officer Valerie A. Cwik, M.D. “We know that the team at LSU will provide help and hope to families who are on the challenging journey that is ALS.” Currently, MDA is funding 63 international ALS research projects at a cost of more than $20 million. For more information, see “New MDA/ALS Center Opens at LSU.”
Touro Rehabilitation Center Earns Three-Year CARF Accreditation
NEW ORLEANS – The Commission on Accreditation of Rehabilitation Facilities (CARF) recently presented Touro Rehabilitation Center with a threeyear accreditation for Comprehensive Integrated Inpatient Rehabilitation, Spinal Cord System of Care, and Brain Injury Rehabilitation. “This accreditation validates Touro
Rehabilitation Center’s standing as one of the premiere destinations for patients seeking rehabilitative services in New Orleans and throughout the Gulf South,” said Gary Glynn, M.D., Touro Rehabilitation Center Medical Director. “By pursuing and achieving accreditation, Touro has demonstrated once again that it meets international standards for quality and is committed to pursing excellence.” This decision represents the highest level of accreditation that can be awarded to an organization and shows Touro Rehabilitation Center’s substantial conformance to the CARF standards. An organization receiving a Three-Year Accreditation has put itself through a rigorous peer review process and has demonstrated to a team of surveyors during an on-site visit that its programs and services are of the highest quality, measurable, and accountable.
Dr. Wilson Receives Tulane Medical Alumni Award
SHREVEPORT- Dr. John T. Wilson, professor of pediatrics, section chief and director of the Children’s Clinical Research Center at LSU Health Shreveport, was recently honored by the Tulane Medical Alumni Association as the 2013 Lifetime Achievement Award Dr. John T. Wilson recipient. “Dr. Wilson has made a remarkable contribution to the field of pediatrics and child public health not only in our country but worldwide,” says Dr. Benjamin Sachs, dean of Tulane University School of Medicine. “He is truly a pioneer of pediatric therapeutics.” Early in his career Wilson’s research findings showed that 78% of drugs lacked sufficient information for use in children. This prompted Wilson to ask a fundamental question “How do we know what medications are safe for our children?” This questioning and the ensuing 40 years of advocacy by the American Academy of Pediatrics helped to support legislative efforts to get products and drugs studied for safety in both adults and children. The congressional passage of the 2012 FDA Safety and Innovation Act signifies Wilson’s lasting impact on the safety of children and our society. This act secures enhanced drug labeling for children making sure that drugs used for children have the same safety standards as those found in adults. Upon receiving the Lifetime Achievement Award at the Class of 1963 50th reunion celebration, Wilson credited his medical education with giving him the basis to achieve such success in his career. Dr. Paul Winder, a former Tulane graduate and Shreveport physician, sponsored Wilson for the award. Wilson complimented his fellow classmates as a strong group of achievers that pushed him to better himself and strive further in his academic studies. Borrowing a quote from Alice in Wonderland, Wilson told his classmates, “I had to run twice as fast just to stay in the same place with you.”
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In the News Our Lady of the Lake Physician Group Welcomes Drs. Garner and Walker
“We are excited to be one of the first QBPC providers and are enthusiastic about working with Blue Cross and Blue Shield to implement this new population health-focused program,” Hankins said. David Carmouche, M.D., chief medical officer for Blue Cross and Blue Shield of Louisiana, said that Quality Blue Primary Care is the next generation of population health management. “This model will significantly improve patient outcomes and support providers. We are making a substantial investment by paying for software and helping the participating
practices through the transformation,” Carmouche said. “This will give our providers the data and support they need to improve both overall healthcare quality and the lives of their individual patients with chronic diseases.” Two years ago, Blue Cross began using a model for primary care called the patient-centered medical home, or PCMH. It focused on improving patients’ health and lowering costs. Both QBPC and PCMH offer organized, team-based, proactive care that works to prevent disease and protect or restore health.
BATON ROUGE – Our Lady of the Lake Physician Group Walker Clinic is now open and staffed by Gregory Garner, MD and Patrick Walker, MD who are accepting new patients. Dr. Garner received his medical degree from Indiana University School of Medicine in Indianapolis, Dr. Gregory Garner IN. He completed his residency in Family Medicine at Louisiana State University Health Sciences Center in Shreveport. Dr. Walker received his medical degree from Dr. Patrick Louisiana State University Walker School of Medicine in Shreveport, LA. He also completed his residency in Family Medicine at Louisiana State University Health Sciences Center in Shreveport. Drs. Garner and Walker treat common disorders of the cardiovascular, respiratory, gastrointestinal and reproductive systems including diabetes, hypertension, hyperlipidemia, asthma, chronic obstructive pulmonary disease and chronic kidney disease. They also perform routine childhood and adolescent health exams. The Walker Clinic is located in the physician tower at OLOL Livingston in Walker.
Hospital and president of the West Calcasieu Virtual Medical Home in Sulphur, La. Hankins said that while the West Calcasieu Virtual Medical Home is centered around the QBPC, it is unique in that seven primary care sites in Calcasieu Parish have joined together and will be part of the program. These sites are The Cypress Clinic, Schlamp Family Medical, Calcasieu Family Physicians, Gamborg and Cavanaugh Family Medicine, The Family Care Center of SWLA, The Family Practice Center of Sulphur and Maplewood Family Medicine.
First Practices Join Quality Blue Primary Care
BATON ROUGE- Three primary care practices—West Monroe Family Clinic, West Calcasieu Virtual Medical Home and Baton Rouge General Physicians—have signed up for Quality Blue Primary Care (QBPC), Blue Cross and Blue Shield of Louisiana’s innovative population health and quality improvement program. QBPC is designed to get better outcomes for patients with chronic diseases, support doctors and transform healthcare delivery. Blue Cross is implementing QBPC in primary care physicians’ offices and clinics, and will roll it out statewide over two to three years. In the early months of QBPC, Blue Cross is signing up network primary care practices that treat the highest number of members with chronic diseases such as diabetes. “We were the first provider group in the state to sign on with QBPC, and we believe this will create a truly collaborative care environment. Our staff will work closely with Blue Cross so that together, we can help our patients become healthier and remain well,” said Steven McMahan, M.D., physician with West Monroe Family Clinic in West Monroe, La. “Partnering with Blue Cross and Blue Shield to offer this program in our community demonstrates the benefits of working together to improve health outcomes, while reducing cost,” said Bill Hankins, chief executive officer at West Calcasieu Cameron
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