St Louis Medical News Sept 2014

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September December 2014 2009 >> $5


Henry Nasrallah, MD ON ROUNDS

Cuts in Compound Prescription Coverage Cause Headaches ‘The implications of this are very broad’


Help Wanted: Older Physicians

The 55-and-over group is more marketable than ever A decade ago, Tony Stajduhar recruited a wellexperienced specialist from the Cleveland Clinic to a rural intermountain community. The physician was looking for a place where he could raise horses and enjoy the last phase of his career. The new job fit the bill ... 4

More Research Links Alzheimer’s and Depression A new study suggests that depression is a risk factor for dementia, and another study found that a common antidepressant can reduce production of plaques found in the brains of Alzheimer’s patients ... page 7

In early June, pharmacy benefits manager giant Express Scripts announced that it was dropping coverage of more than 1,000 compound drug ingredients. Patients must now choose between switching medications or paying up to $1,000 for a single prescription. The St. Louis-based company, which manages pharmacy benefits for 90 million Americans, is the most recent in a string of pharmacy benefits managers to restrict access to compound drugs. The use and costs of compound medications have skyrocketed in the past two years. For Express Scripts’ clients, those costs increased 511 percent from $28 million in the first quarter of 2012 to $171 million in the first quarter of 2014, according to Brian Henry, Express Scripts’ spokesman. He said the average cost per compound prescription per patient increased from $90 in the first quarter of 2012 to $1,100 in the first quarter of this year. The policy change will reduce costs of compound drugs for Express Scripts’ clients by 95 percent, Henry said. “There was a 30 percent increase in demand from 2011 (CONTINUED ON PAGE 8)

When Medicine and Technology Intersect AMA president will discuss how EHRs should center on patients, not technology, at SLMMS-hosted Hippocrates Lecture By LyNNE JETER

True innovation concerning information technology (IT) in the practice of medicine lies in the manner it improves the care and quality of life of patients, emphasized Robert M. Wah, MD, president of the American Medical Association (AMA), who will speak to St. Louis physicians on Thursday, Oct. 16, at the St. Louis Metropolitan Medical Society’s (SLMMS) 12th annual Hippocrates Lecture at Ces & Judy’s Catering in Frontenac. “Physicians must harness technology, not let technology harness us,” Wah shared with AMA members, pointing to the fog of looming health IT, cloud computer and cybersecurity issues facing the medical community. “With that prime directive in mind,” he said, “we can now be open to new ideas, new techniques and new perspectives.” Wah’s topic, “The EHR: It’s About Our Patients, Not Technology,” for the Hippocrates Lecture will focus on not going high-tech for tech’s sake, but also leveraging “an application of science that promotes well-being Dr. Robert M. Wah



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Henry Nasrallah, MD By LUCY SCHULTZE

When Saint Louis University approached Henry Nasrallah, MD, to lead its department of neurology and psychiatry, the mere name of the department held profound attraction for him. “I believe all psychiatric disorders are brain disorders that have been artificially separated from neurology over the past 60 years,” Nasrallah said. “I strongly believe it’s time to bring them back together.” Nasrallah left a satisfying position as professor and vice chair for education and training at the University of Cincinnati College of Medicine in October 2013 to join SLU, where he holds the Sydney W. Souers Endowed Chair and is department chair. SLU is among only three medical schools in the nation in which neurology and psychiatry are integrated in one department. “I came to SLU for the opportunity to create a new model that I believe is the right one, which will enhance clinical care for every patient,” Nasrallah said. “The mind is part of the brain, so I believe any patient who comes forward with any brain complaints – whether headaches, double vision or epilepsy or anxiety, depression or schizophrenia – should all have a complete brain assessment, neurologically and psychiatrically. “With the neuroscience revolution, the amount of knowledge we have about the brain has skyrocketed in the last three or four decades. We can now point out a biological basis for every psychiatric disorder. Psychiatry has moved forward by leaps and bounds, making it much closer to neurology than in the Freudian era. Their separation today is outdated.” Operating from such a clear conviction, Nasrallah has been focused since his arrival at SLU on rebuilding the department in the wake of the leadership transition. At SLU, neurology and psychiatry had been united since the department’s founding in 1892, then separated in 1962. The two fields were re-integrated in 2007 when both departments had an open chair, in a move that was both practical and philosophical. “I believe combining those two brain specialties will be a trend,” Nasrallah said. “I’m interested in making it work and succeed, and demonstrating that this is not only the right scientific model, but also the right model for teaching, research, administration and patient care.” Nasrallah has served in a department chair role before, leading the department of psychiatry at The Ohio State University College of Medicine for 12 years through the late 1990s. His experience in academic medicine also includes a tenured position at the University of Iowa College of Medicine in the mid-1980s and an extended stlouismedicalnews


sabbatical at the University of Mississippi School of Medicine through 2002. In Mississippi, he directed two large federal grants including the genetics of schizophrenia in African Americans. Nasrallah was recruited to the University of Cincinnati at associate dean for faculty development in January 2003. He spent a decade there prior to joining SLU. Over the course of his career, Nasrallah has earned international renown as a neuropsychiatrist, educator and researcher. His main research focus has been the neurobiology and psychopharmacology of schizophrenia and related psychoses. The field of psychiatry has held a

fascination for him ever since his teenage years, when, as an avid reader, he delved into his school library’s collection of psychiatry books and became intrigued by psychiatric disorders. “I also remember meeting a psychotic person during my high-school years,” he said. “The experience scared me – but also inspired me, that we have to fix what we call ‘madness.’ Why do people become ‘crazy’? What happens to their brains? That’s what made me decide to become a psychiatrist.” Nasrallah, a native of Lebanon, earned bachelor of science and medical degrees at the American University of Beirut. While aiming to keep an open mind during medical school, he never wavered from his goal of becoming a psychiatrist. Nasrallah completed residency training at the University of Rochester, deciding at its conclusion that he wanted to pursue an academic career. He applied to the NIH to spend a two-year neuroscience research fellowship at the Laboratory of Clinical Neuropharmacology in Washington, DC, where he began his research in schizophrenia. “This is the most disabling and challenging disease in our field,” he said. “You see these young people become socially and vocationally disabled and lose their lives to this disease. It’s like having Alzheimer’s at age 18 or 20.” For Nasrallah, the appeal of academic medicine has been the opportunity to apply his knowledge and efforts to effect the greatest good. “Through research, we want to treat and help millions of people in the future – not just the few thousands we can see in our lifetime,” he said. “With one discov-

ery, you can change the paradigm of treatment and influence the care of millions of people around the world.” Physicians in full-time patient care play a critical role in the development of the medical field as well, Nasrallah said. “Clinicians may not recognize that they can contribute to discovering new knowledge, but they have tremendous amounts of experience with patients and make clinical observations that can be very unusual,” he said. “When they encounter unusual patients or discover that a medicine is working in a way that’s unexpected, they keep these things to themselves because they’re too busy to write it up. If only they write a brief article and publish it in a journal, then all academic researchers will read it and be stimulated by it, and we might formulate a new hypothesis to conduct a controlled study on it. “Discovering new knowledge really is a partnership between clinical practice and academic research.” In his personal life, Nasrallah applies what research has shown about how exercise stimulates neuogenesis, making the mind sharper and improving memory. He makes sure to allot 30 minutes each day to walking or to exercising in his small home gym. His pastimes include photography, writing poetry and playing word games – particularly, engaging his wife, Amelia, a psychologist, in competitive Scrabble. The couple also travels often to spend time with their two grown children and five grandchildren. Their daughter, Rima, is a pediatrician at the Cincinnati Children’s Hospital Medical Center, while their son, Ramzy, is a healthcare marketing executive in New Jersey.


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Help Wanted: Older Physicians The 55-and-over group is more marketable than ever By LyNNE JETER

A decade ago, Tony Stajduhar recruited a well-experienced specialist from the Cleveland Clinic to a rural intermountain community. The physician was looking for a place where he could raise horses and enjoy the last phase of his career. The new job fit the bill. “On my latest visit to the community, I was happy to see that he’s still there working full-time and is an integral part of the program and community,” said Stajduhar, president of Jackson & Coker, a national permanent physician placement firm, based Tony Stajduhar near Atlanta. Older physicians, overwhelmed by federal mandates complicating the practice of medicine and considering retirement as their only option, may be much more marketable than originally considered in the postAffordable Care Act (ACA) era. For starters, the supply/demand curve is in their favor. According to the American Medical Association (AMA), nearly 1 million physicians practice medicine in the United States. Roughly 36 percent are 55 years or older. Of those physicians, pulmonologists and psychiatrists comprise two of the largest percentage categories. A frightening statistic: up to 76 percent of pulmonologists and critical care specialists are in that age group. “Older physicians are very marketable,” said Stajduhar. “Even though clearly, nobody should be discriminating … in a perfect world, hospital administrators would like to bring in doctors fresh out of residency, who could work

there for 25 to 30 years. That’s utopia. In the real world, we know that when doctors complete their residency programs, more than half of them leave within three years after making their first (placement) decision. That’s a huge percentage! Just because they’re young doesn’t mean they’ll stay.” On the other hand, practitioners in their fifties, for example, who are considering making a change realize it’s probably their last career move and are more motivated to make it permanent, said Stajduhar. “Then it’s just a matter of asking: ‘how long are you willing to practice?’ Perhaps they’re 59, and say they want to work as long as their health holds out. When they’re upfront with the hiring client, you have a very marketable physician.” Surprisingly, hospital administrators rarely ask if qualified candidates are tech-savvy, noted Stajduhar, which quells one worry among older physicians. “It doesn’t seem to be a concern at this point,” he said. “The older recruit may move into a hospital system that makes it fairly easy for them to adapt. For example, they may assign a nurse or nurse practitioner to the physician, who can plug notes into an electronic medical record (EMR) system as the physician tends to the patient.” After the ACA kicked in, most physicians with 25 or 30 years under their belt considered retiring. Unfortunately, it was signed into law less than 18 months after the stock market crash of September 2008, when many physicians watched in dismay as their retirement funds withered. “Many would’ve retired then, if they could have,” said Stajduhar. “The ACA, out of the gate, scared the heck out of

older physicians. If there’s a significant continued uptick in the economy, I wouldn’t be surprised to see the retirement rate of that age group accelerate over the next five or six years. But then we’ll have a huge problem with specialties being in critical shortage areas.” If that happens, older physicians who opt not to retire sooner will be in even more demand, particularly if they’re open to moving to a different location, which melds with another emerging physician employment trend: The best jobs aren’t necessarily in rural areas, defined as a population of 40,000 or less. “We probably have more primary care needs in urban areas than ever before,” said Stajduhar, noting the greatest demand is internal medicine. “Yet we still have many unmet needs in rural areas, especially those areas we know are very rural. Older physicians have more opportunities than perhaps they realize.” The passage of time since the ACA took effect has also softened the attitudes of older physicians, adding to their marketability. “Physicians, as a rule, have been fiercely independent,” said Stajduhar. “They didn’t want people telling them how to practice medicine from a hospital level. When it became imminently clear that we’d have a different industry in five to 10 years, that revelation became the impetus of the dramatic change in the hiring process. Now those physicians are seeing the benefits of being employed by a hospital or health system, perhaps in another location. They’re in an age group where most are empty nesters, and being confined to a

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school district or a place to settle down isn’t holding them back. Only caring for aging parents may play a role in their ability to relocate.” An employment contract for the older physician is a win-win for both parties. “Administrators know the move is probably the doctor’s last hurrah,” he said. “That’s where they’ll retire. Then at a minimum, the client will have six or seven years from a good, experienced physician with a great track record on staff.”

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Shifting Toward Employment More PCPs are becoming hospital employees, according to ACA impact study on physicians and their practices By LYNNE JETER

“Uncertainty prevails” was a common theme in the recently released Jackson Healthcare study on the Affordable Care Act’s (ACA) impact on physicians and practices. “We found that a significantly larger number of physicians desire to be employees (versus independent contractors) in the post-ACA world,” said Sheri Sorrell, manager of market research for Jackson Healthcare, a national healthcare recruitment firm based near Atlanta. “They know a salary is constant, even when reimbursements decline. Plus, they know someone else will navigate the complexities of the ACA.” Jackson Healthcare’s “Physician Practice Trends 2014,” a national study with nearly 2,000 physicians representing all 50 states and medicalsurgical specialties, revealed some rapidly changing statistics that are shaping physicians’ decisions to ink an employment deal with a hospital or healthcare system. The happiness factor. Physicians whose income decreased in the last year are more likely to be age 45 to 64, own their medical practice, work more than eight hours a day, be dissatisfied with their career, and discourage young people from entering the medical field. Because of the ACA roll- Sheri Sorrell out, they say they’ve lost patients, and remaining patients often delay treatments because of higher outof-pocket costs. The “never-known-independence” physicians. Satisfied physicians are more likely to be between the ages of 25 and 44, work eight hours a day, be employed, have chosen employment for lifestyle reasons, and have a greater number of patients with private insurance. “Younger physicians are most likely to have never been in private practice,” noted Sorrell. “They started out employed and remain employed.” The impact of higher deductibles. As a result of higher deductibles resulting from effects of the ACA law, patients are seeking routine care less frequently and postponing certain procedures. The trend attributed to 12 percent of physicians’ responses to the most prevalent effects the rollout of the ACA has had on their practices. The higher deductible has made insurance the equivalent of self-pay. “In reality,” one physician wrote, “patients don’t have insurance until they’ve met their deductibles.” The insurance cancellation aspect. Insurance policy cancellations led to 23 percent of physicians saystlouismedicalnews


ing they’ve lost patients since the ACA implementation; another 15 percent lost patients because their practice could no longer accept their insurance plans. Quality of life and financial reasons are only a part of the reason why older physicians, especially primary care providers (PCPs), are approaching hospitals, with the keys to their practice in hand. “The majority of acquisitions are initiated by physicians,” emphasized Sorrell. “It’s not necessarily the hospitals going after the practices. It’s the practice physicians knocking on the hospital door.” Fortunately, practice acquisitions are mutually beneficial for practice physicians

and hospitals and health systems, the latter of which are welcoming the opportunity to buy PCP practices as they’re forming and growing Accountable Care Organizations (ACOs). The answer to which party has the upper hand depends on the geographic location of the practice. “They’re hedging their bets,” added Sorrell. “They’ve done the math. They know what they need to keep up with the ACA compliance. They see it’s too much to deal with. They realize they’re better off accepting a salary, putting in their eight hours a day, and going home.” Despite the awkward position of prac-

tice physicians approaching hospitals and health systems about a deal, they have a considerable amount of leverage, especially in larger metropolitan areas, Sorrell pointed out. “They’re offering the practice on their terms,” she explained, “and can say, ‘if you don’t take it, I’m going down the street to offer it to your competitor.’” A striking study statistic as a positive benefit to physicians of selling their practice: The number of physicians taking call dropped from 77 percent in 2012 to 55 percent in 2014. “Basically, it’s a result of employment,” Sorrell said. “It’s interesting because physicians, especially older doctors, tend to complain a little bit about the work ethic of younger folks, who want to work eight hours a day and not take call. Those same physicians are making a shift in that percentage by at least limiting on-call time in their contracts.” Sorrell said study statistics align with broader trends seen in other Jackson Healthcare and industry research. “We’ve been tracking the trend toward employment in various ways, with studies on physician practice acquisitions, why physicians decided to sell their practice, or why they want to get out of private practice,” she said. “We’ve also been taking a look at what happens when physicians become employed. These are trends we’ll continue to watch.”

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Creating the Perfect Medical Mortgage By JOSEPH BAYER, SR.

Unfortunately, today very few commercial banks or mortgage banks are willing to create loan programs for individual markets or individual industries. This can be attributed to a lack of motivation, or the skill sets necessary to analyze loan risk for specific industries – such as the medical industry. So, what should be the motivation for lenders to target markets like St. Louis and industries such as medical? Common sense would be a good start. The medical field is the St. Louis region’s largest industry. This field has higher than average incomes, lower than average credit delinquencies. And, finally we have our area’s incredible teaching facilities that create “workers” with excellent long-term job stabilities. As a risk analyst, I cannot see why anyone would not want to develop products that make the home loan process easier for these

individuals to keep and/or lay down their roots in St. Louis. So what are the reasons why lenders do not design such loans? Many mortgage lenders are regional or national in scope, so their loans must be created to meet their institution’s geographic needs. Others simply do not possess the skill sets and/or the desire. An ability to analyze and design prudent and safe loans is the key for creating special mortgages for the St. Louis medical community. This is where the fun begins and common sense rules. Rule #1: Physicians in Practice - Most lenders equate the size of the down payment with risk. Larger down paymentless risk. Really? Typically doctors in practice have assets. A very nice asset is cash. Both they and their financial advisors prefer to keep and leverage that cash. I can count on one hand the number of practicing physicians who have ever defaulted on their home

loan. Rule #2: Private Mortgage Insurance (PMI) – Lenders who underwrite cookie cutter loans use PMI to mollify investors risk from errors in judgment. Loans for practicing physicians are not cookie cutter loans; they are investor portfolio loans and PMI does not add meaningful risk reduction. It is not necessary on these loans. Rule #3: Physicians in Residence – Too many residents pay amazingly high prices for rents. Areas of demand do demand high rents. However, a large number of these residents work incredible hours and have very good household incomes. The amount they are paying in rent could easily cover a mortgage payment in a very desirable area. BUT, resident physicians can carry a large amount of deferred student loan debt. It generally is the deferred student loans that keep residents in the rent trap.

So common sense tells me that if they qualify for homeownership with their existing incomes, and after residency their incomes will dramatically be improved, what is the risk? Well it comes down to those deferred student loans, right? But if they are deferred then why count them? Here is an original thought – don’t count them. With residency behind a physician, they should easily be able to handle their student loan debt. If ever there was an industry that is tailored-made for this form of thinking – it is the medical industry. As for PMI for resident physicians, see Rule # 2. Some of the above common sense rules can also be applied to other non-physician professionals in the medical industry. Joseph Bayer Sr. is a 30 year Mortgage Banker, Underwriter and President of First Integrity Mortgage Services, Inc. He has designed multiple NO PMI loans over the last 15 years for St. Louis area consumers. He can be reached at

When Medicine and Technology Intersect, continued from page 1 and advances tradition.” Empathetic with physicians’ concerns about integrating technology into medicine, Wah noted the tendency of some professionals to respond to change and uncertainty with “unease and anxiety,” quickly adding, “I choose to see change as an opportunity.” “I’m very aware of the issues physicians face in their offices with technology, but I also know how large scale deployment of HIT can work,” he said. “Sometimes, we get too focused on the close-up problems, and don’t keep in sight the top goal, which is using technology to take better care of patients. I’m a big believer in consensus and then moving forward.” A board-certified reproductive endocrinologist and OB/GYN, Wah made the transition from clinical medicine to health IT when he served on active duty as a captain in the U.S. Navy Medical Corps for nearly a

quarter-century. As the nation’s first deputy coordinator in HHS’ Office of the National Coordinator for Health Information Technology, with the goal of ensuring that every U.S. citizen has an electronic medical record (EMR) by 2020, he managed a portfolio of technology tools involved in the care of 10 million patients in 65 hospitals and 45 clinics. “Fortunately, I didn’t have to start from scratch,” said Wah, who served through two wars and helped treat nearly 50,000 injured personnel. During that time, the mortality rate dropped from 25 percent to 5 percent, and marines who saw a medic within an hour of injury had a 96 percent chance of survival. “When I arrived, the military already had a proven record of success in this area. For instance, I haven’t written a prescription on paper in a military clinic for 20 years.” With 17 years’ experience in AMA leadership roles, Wah practices medicine

in McLean, Va., and teaches at the Walter Reed National Military Center in Bethesda, Md., and the National Institutes of Health. He emphasized how physicians must shape and lead the digitization of healthcare. “We all know implementing new technology can be a rocky road,” he said, “and I’m not talking about ice cream. The road is smoother if we keep in mind our goals. For e-prescribing, it’s not just to get the label remotely typed in the pharmacy. The real innovation is that it might prevent a drug-drug reaction, or a drug-allergy reaction, or a duplication of medication.” Wah understands why doctors have been reluctant to “go electronic.” “We did a survey last fall asking practices what are the frustrating things about the practice today, and electronic health records were high on that list,” he told Modern Healthcare. “They wanted it to work better with the workflow in their office

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and help them, not hinder them, in taking care of their patients. We’re going to go to the EHR vendors and tell them about the problems we found.” During the evening, Wah might also touch on myriad issues facing physicians – the pending ICD-10 transition, controversial Independent Payment Advisory Board (IPAB), and other ACA mandates; medical liability reform, Medicare’s data dump, The Sunshine Act, narrowing networks – and how he’s “beyond frustrated” the SGR (sustainable growth rate) formula hasn’t yet been repealed. Yet there’s another issue that piques Wah’s interest for discussion. “We don’t talk enough about delivery reform,” he said. “There’s a clear intersection between delivery and payment, but we need to move the needle a little bit more and talk more often about how to deliver better care for our patients earlier in the (process).”


16 THE DATE American Medical Association (AMA) President Robert M. Wah, MD, will headline the 12th annual Hippocrates Lecture on Thursday, Oct. 16, at Ces & Judy’s Catering in Frontenac. Social hour begins at 6 p.m., followed by a buffet dinner at 7 p.m., and the lecture. The Hippocrates Lecture, hosted by the St. Louis Metropolitan Medical Society (SLMMS), is open to all members of the greater St. Louis medical community. Tickets are $75 for non-members, free for SLMMS members. Proceeds benefit the St. Louis Society for Medical and Scientific Education. Reservations are required and may be made by contacting the SLMMS office at (314) 989-1014.



More Research Links Alzheimer’s and Depression Scientists search for ways to help Alzheimer’s caregivers combat stress By GRETA WEIDERMAN

A new study suggests that depression is a risk factor for dementia, and another study found that a common antidepressant can reduce production of plaques found in the brains of Alzheimer’s patients. Meanwhile, new research is examining how to help caregivers for Alzheimer’s patients reduce their own stress and depression. Researchers found that the association of depression with dementia is independent of dementia-related brain changes. “These findings are exciting because they suggest depression truly is a risk factor for dementia, and if we can target and prevent or treat depression and causes of stress, we may have the potential to help people maintain their thinking and memory abilities into old age,” said study author Robert Wilson, PhD, with Rush University Medical Center in Chicago. The study was published July 30 in the online issue of Neurology, the medical journal of the American Academy of Neurology. A separate study by researchers at Washington University School of Medicine in St. Louis and the University of Pennsylvania found that the antidepressant citalo-

pram can reduce production of the main ingredient in Alzheimer’s brain plaques. The findings are encouraging, but scientists caution that it’s premature for people to take antidepressants solely to slow the development of Alzheimer’s disease, especially since they have risks and side effects. “I think our study is promising for the ability of antidepressants as a way to prevent Alzheimer’s disease, but there is still work to do,” senior author John Cirrito, PhD, told the St. Louis Medical News. “We’ve cured mice of many things using drugs that did not work in people. Our human study here shows antidepressants can lower amyloid (the main ingredient in Alzheimer’s brain plaque) in younger individuals, but ultimately we would need to treat older individuals at risk of Dr. John getting Alzheimer’s disCirrito ease. That study is actually underway now and will hopefully have a positive outcome.” Cirrito is an assistant professor of neurology at Washington University, and the study was published May 14 in Science Translational Medicine.

While depression may be linked to Alzheimer’s disease, and antidepressants may reduce the risk of the disease, caregivers for Alzheimer’s patients themselves experience stress and depression, and researchers are searching for ways to alleviate that. A randomized controlled trial in the United Kingdom found that a psychological support program for family caregivers of people with dementia reduced caregivers’ anxiety, depression and cost of care, and the impact lasted for two years, according to the Alzheimer’s Association. The intervention included eight sessions of education about dementia, caregiver stress, dealing with challenges and where to get emotional support. It’s no secret that caregivers experience extreme stress due to sleep deprivation and juggling multiple responsibilities like work and caring for their own children. “The caregiver feels they’re losing control over their life, and the patient feels the same way,” said Jan McGillick, director of communications at Dolan Memory Care Homes, which operates residences in the St. Louis metro for people with Alzheimer’s and dementia. Financial concerns can also create stress, as can balancing a patient’s auton-

omy with their safety. “Taking the keys away from the person that taught them to drive can be very painful,” McGillick said. Physicians play a pivotal role in encouraging family members to become educated about the disease progression and to reduce their stress by getting help with care, especially since stress increases the risk of various diseases and suppresses people’s immune systems, McGillick said. Physicians should go a step further and ask caregivers how they are doing, if they are feeling isolated and how their health is in general. “It’s vitally important that caregivers take care of themselves,” said Cheryl Wingbermuehle, senior director of client services for the St. Louis chapter of the Alzheimer’s Association. She encourages people to contact the association to learn about resources, including an Cheryl assistance program that Wingbermuehle reimburses families for respite care or products used in care. The program is funded through state grants and donor gifts.


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Cuts in Compound Prescription Coverage Cause Headaches, continued from page 1 to 2014,” he said. “At the same time, costs have gone up 1,000 percent.” The higher costs were due to increased prices of raw ingredients and new billing standards by the National Council on Prescription Drug Programs. The new standards were implemented Jan. 1, 2012. Starting then, compounding pharmacies were permitted to charge for each component in a compound medication and for the labor involved in making it. Previously, pharmacists frequently lost money on compound medications because they were only able to charge for the most expensive ingredient, according to A.J. Day, PharmD, the A.J.Day director of pharmacy consulting at Professional Compounding Centers of America (PCCA), a chemical wholesaler to independent compounding pharmacies. David Miller, RPh, chief executive officer of the International Academy of Compounding Pharmacies (IACP), likened the billing changes to pharmacists previously billing just for the meat in a hamburger, but now David Miller charging separately for the meat, bun, cheese, pickles and onions. Express Scripts and other pharmacy

benefit managers have responded to the cost hikes by eliminating or reducing coverage of compound medications. According to Express Scripts’ Henry, there are other FDA-approved medications that are less expensive and just as effective as compound medications. He also noted that compound medications are not regulated by the FDA. But according to Miller, many drugs that are prescribed today predated the FDA and haven’t been FDA approved either. Some include aspirin, Codeine and morphine, he said. Henry acknowledged that some compound medications, such as liquid forms of pills, are necessary for patients who have difficulty swallowing pills. According to Day, of PCCA, compound medications are also vital for children with autism, patients with allergies to fillers, dyes and inactive ingredients in other medications, patients receiving hormone therapy and as alternatives to highly addictive opiate pain medications, like OxyContin and hydrocodone. Compounding pharmacies also offer patients access to medications that manufacturers have discontinued. “The implications of this are very broad,” Day said. Shana Taylor, PharmD, the compounding pharmacist at St. Louis Hills Pharmacy, said that more than half of the patients she serves that receive compound medications are being affected by Express Scripts’ policy change.

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Other pharmacy benefit managers reducing coverage: In June, pharmacy benefit manager Catamaran Corp. launched a program to help its clients reduce the increasing costs of compound medications. The Chicago-based company said in a statement that its annual expenses for compound medications had increased five-fold due to a jump in use and cost. OptumRx, the pharmacy benefits manager of United Health Group, also recently dropped coverage of some compound ingredients. Officials said it has seen a 35 percent increase in the use of compound drugs among its members over a 12-month period from 2012 to 2013. The number of compounding pharmacies has also grown from 2,500 in 2009 to 7,500 in 2012, according to the company. CVS Caremark, Harvard Pilgrim Health Care and some Blue Cross Blue Shield organizations have also restricted coverage for compound medications.

Most patients who are receiving hormones or are in severe pain are willing to pay the cash price for the compound medications, but they are often shocked when they are faced with paying out of pocket for a prescription that was just covered last month, Taylor said. The coverage changes are causing headaches for physicians and pharmacists, as they are now communicating back and forth to find suitable alternatives for patients who can’t afford to pay the retail cash price for compound drugs. “It gets frustrating, but it’s necessary to do what we can to get the patients what they need,” Taylor said. IACP’s Miller said Express Scripts’ benefit elimination was “draconian.” “People that are not involved in patients’ care have set up processes that prevent patients from receiving medications they need,” he said. PCCA has reached out to meet with Express Scripts officials, but Express Scripts has canceled three meetings with the company, according to Aaron Lopez, PCCA’s spokesman. The coverage change “puts patients in very, very difficult positions,” Day said. He said physicians should encourage patients to talk directly with their employers about opting out of programs that exclude or reduce coverage of compound medications. Can topical pain medications prevent opiate overuse and addiction? Compound pharmacists say they can provide topical painkillers as alternatives to highly addictive prescription painkillers. “The pain creams were the alternative to the addictive opiates like OxyCotin,” said Ford Manion, owner of Genesis Pharmacy in Maryland Heights. “Patients Ford Manion with chronic pain need an alternative to oral pain pills and their addictive properties.” He said the price billed for topical

pain creams hasn’t increased significantly in recent years, but the number of those prescriptions has grown as more compounding pharmacies are marketing them to physicians. There is no debating the national increase in opiate addiction. The number of annual overdose deaths from prescription painkiller was 14,800 in 2008, up 300 percent from 4,000 in 1999, according to the Centers for Disease Control and Prevention. In the 1990s, a handful of studies suggested that opiate narcotic prescription painkillers weren’t as addictive as previously thought, and physicians started prescribing them more frequently. “I can tell you when I went to medical school, the one thing they told me about pain was if you give a patient in pain an opiate painkiller, they will not become addicted, and that was completely wrong. We have a real need to better understand and ensure we use these only when necessary,” said Tom Frieden, director of the Centers for Disease Control and Prevention, during a press briefing last year. The drugs were developed to treat pain in late-stage cancer patients, but physicians began prescribing them for all types of chronic pain, and the studies suggesting they weren’t all that addictive were later debunked. In 2012, healthcare providers wrote 259 million narcotic prescriptions, enough for every American to have a bottle of pills, according to a Centers for Disease Control and Prevention report. Forty percent of U.S. narcotic prescriptions in the United States in 20112012 were written by only 5 percent of opioid prescribers, according to an Express Scripts study. In order to avoid the chance of abuse and addiction, or of unwanted side effects, physicians are prescribing topical compound medications to treat pain. Now those are not covered by the plans that Express Scripts administers. “A lot of these patients receiving these medications, they need these prescriptions for pain management,” Manion said. stlouismedicalnews


In-House vs. Outsourced vs. Hybrid Physician Recruitment: Which is More Effective and Why? By KATHy JORDAN AND REGINA LEVISON

The Affordable Care Act has given approximately 34 million previously-uninsured people access to healthcare; demand for physicians is great and physician supply is scarce. Researchers have estimated that America’s existing primary care provider workforce would need to expand by 52,000 physicians between 2010 and 2025 to keep up with the country’s healthcare requirements. In this current environment, an optimal physician recruitment function is imperative to the continued profitability and longevity of healthcare organizations. But how do you build a well-oiled physician recruitment department so salient to an institution’s survival? Healthcare organizations have options; today, they can invest time and money to develop a robust in-house recruitment team, outsource the entire function and operate with an internal skeleton recruitment staff, or utilize a combination of internal and external resources. In-house physician recruitment Ten years ago, the in-house physician recruitment model was cost-effective for large organizations. A physician recruitment department could run ads in professional journals, receive qualified responses, and bring the top-choice candidates in for interviews. Time to fill the vacancy took approximately 3-6 months. Healthcare organizations were close to fully staffed and patient loads were manageable. This process no longer works. Now, gaining the attention of both active candidates (those actively looking for a job) and passive candidates (those who don’t know they are looking) is mandatory. Plus, the more quickly you can fill a physician vacancy, the sooner that physician can start generating money for your organization. Unfortunately, the typical in-house physician recruiter is only able to spend slightly more than a third of his/her time identifying physician candidates. The need for additional recruiting methods, coupled with the fact that there are fewer physicians out there to recruit, make physician recruitment extremely challenging and many organizations have built-in-house teams to meet this challenge. The Association of Staff Physician Recruiters (ASPR) saw their membership numbers grow from 400 to 1600 in just five years. And, depending on the number of providers to be recruited each year, it can be less costly to fully staff a physician recruitment department than it is to pay the average

$26,000 per retained search fee to leading healthcare recruitment firms. Strictly in-house physician recruitment can be less expensive, but also less effective. Outsourcing physician recruitment In this increasingly competitive environment, many healthcare organizations have chosen to fully outsource their physician recruitment activities. Some may have a physician recruitment department in house, but that department usually only contains 1 or 2 people whose focus is on directing candidate activities once onsite. These organizations frequently benefit from reduced time-to-fill because their healthcare recruitment firm has a ready pool of active and passive candidates to start approaching as soon as they learn of the vacancy. They pre-screen candidates according to the parameters that you set, conduct background checks, coordinate candidate travel and itineraries, and, in some cases, negotiate the candidate’s contract on your behalf. Physician recruitment is comprehensively taken off your plate. A fully outsourced recruitment model may be more costly, but also more effective. Hybrid physician recruitment The number of healthcare organizations realizing the benefits of an in-house/ outsourced hybrid physician candidate sourcing model is growing. According to the 2013 ASPR In-House Physician Recruitment Benchmarking Report, 71 percent of healthcare organizations with a physician recruitment department also paid fees to search firms throughout the year and one in every seven searches utilized a blended in-house/search firm model. Institutions are becoming more informed about the process and procedures involved. For example, within the time devoted to physician recruitment, there are 13 separate tasks ranging from sourcing research to advertising, tele-prospecting, and more. Time and resources are at stake and an increasing number of healthcare

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organizations have realized that engaging a healthcare search firm for candidate sourcing can produce more qualified, prescreened passive and active candidates, reduce the time-to-hire by up to 43 percent, save up to 60 percent or more compared to contingency and retained search models, and enhance retention rates. In this model, once the candidates are presented, the in-house recruitment team takes over with candidate interviewing, itineraries, contract negotiation, and onboarding. The hybrid physician recruitment model is most cost effective – and more time effective for organizations with an in-house recruitment department and also for smaller organizations without a formal provider recruitment department.

Final Thoughts Inevitably, to gain a competitive edge, organizations must evaluate their physician recruitment function. At a time when budget line items are scrutinized, it is imperative to realize that in-house recruitment teams don’t have the resources to identify a wide variety of top-tier candidates or the time to facilitate an efficacious recruitment process. Likewise, a fully outsourced physician recruitment model often involves expenditures for tasks that are better conducted in-house. Competition for top physicians is and will remain one of a healthcare facility’s chief operating concerns, and a hybrid physician candidate sourcing model will provide a way to gain competitive edge. Kathy Jordan is the President of Jordan Search Consultants and Regina Levison is the organization’s Vice President of Client Development. Jordan Search Consultants, an executive, healthcare, higher education, and corporate recruitment firm was founded in 2003 and recently announced the acquisition of Levison Search Associates, a physician and healthcare executive search firm based in Sacramento, CA. For more, visit www., or email

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Recent Healthcare Changes Shift Physician Responsibilities

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An Exploitable Loophole One primary concern for physicians regarding exchange plans is the 90-day grace period before termination of coverage now being given to enrollees that have stopped paying the monthly premium. During the first 30 days of the grace period, the insurer is required to continue to pay any claims filed. Payment can be withheld for the remaining 60 days until the plan is finally revoked by the insurer. This provision has created a loophole that can easily be abused or taken advantage of, leaving physicians on the hook for the cost of treatment. Families that fail to pay will face a tax penalty, but won’t receive a fine, premium rate increase or a repayment order. They also won’t be barred from purchasing another subsidized plan during the next enrollment period. Advocates are arguing on behalf of physicians that insurers should be required to give a practice 15 days’ notice when a patient enters the last two months of the grace period. However, since this is a federal mandate, that would require Congress to make a change to federal law. Until that happens, physicians should reduce their risk of providing uncompensated care by conducting eligibility verification requests for every visit.

We not only reach 8,400 St. Louis area physicians by mail each month, they spend quality time reading our monthly content. Our editorial content is informative, educational, ethical, and created by professional healthcare editors with years of experience. Our content is a combination of clinical and business information needed by today’s physicians. Our news content keeps physician readers aware of significant changes in our region’s healthcare community.



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A staggering 90 percent of doctors believe that the public has not been adequately educated about how marketplace health plans will function under the Affordable Care Act according to a survey by physician-staffing firm This confusion is understandable, as there have been multiple changes and delays in implementation since the ACA was signed into law by President Obama back in 2010. The true impact of the ACA on medical practices remains to be seen as 15 of the 16 key provisions only just went into effect earlier this year. The growth in popularity of high-deductible health insurance plans is expected to be significant as a result of the ACA. Yet, physicians will be the ones bearing the burden when an individual is unable to afford the higher deductible. In order to prevent their revenue from being compromised, physicians will have to make a greater effort to educate patients prior to care about their own coverage and financial responsibilities. Most practices will have to implement a more aggressive collection policy at the time of visit or even begin charging for treatments in advance.

Changing Payment Structure Another source of anxiety in the healthcare industry is how implementation of the ACA will alter existing government programs such as Medicare and Medicaid. Beginning last January, under the Bundled

Payments for Care Improvement (BCPI) initiative, selected organizations participated in a national pilot project where hospitals, physicians and other providers were paid a flat rate for each episode of care. Traditionally, Medicare made separate payments to providers for each of the individual services they furnished to beneficiaries for a single illness or course of treatment. As of right now, there are 48 Diagnosis-Related Groups included in each episode that are eligible for bundled payments. This new method may hinder some physicians when routine complications or patience negligence warrants follow-up visits or procedures. It also bears watching because private insurers and most employers tend to pattern their payment structure after Medicare. Will they adopt bundled payments for treating a specific condition over a period of time? Only time will tell. Transition for Physicians The survey also found that the majority of physicians plan to make changes to their practice in response to the law. Higher call volume, increasing patient questions and greater administrative complexities are a few of the factors precipitating these changes. Practice owners should anticipate additional training hours and costs for current and new employees. Many people with little or no experience regarding insurance prefer to seek advice on health plans from their doctor or pharmacist. Some have even argued that physicians have a responsibility to inform patients about the law and its effect on them, even if that means simply directing them toward state resources. Physicians are often overwhelmed by the growing demands of running a practice, and helping patients navigate the new healthcare landscape could be a timely endeavor. For many practices, having a designated staff person available to explain the details of ACA provisions and assess how they apply to individual patients may be a necessity. They could also handle the additional administrative paperwork when dealing with government regulations and private-payer requirements. At the very least, physicians should consider creating a printed handout with state-based resources where consumers can go for personalized assistance. Not only will they be providing an important service to patients, but they’re ultimately serving the best interests of their medical practice in the long run. Paul Larson is the founder and CEO of Larson Financial and co-author of the book Doctor’s Eyes Only: Exclusive Financial Strategies for Today’s Doctors and Dentists. The reputation of Larson Financial is built on a long-term commitment to responsible financial management that focuses on medical professionals and their unique needs. Advisory Services offered through Larson Financial Group, LLC, a Registered Investment Advisor. Securities offered through Larson Financial Securities, LLC, Member FINRA/SIPC/MSRB.



Southern Exposure

The Medicaid expansion haves … and mostly have nots … in the South By CINDy SANDERS

Which region of the country has the fewest states that opted to expand Medicaid, the highest rate of uninsured nonelderly adults, leads the nation in chronic conditions such as obesity and diabetes, and finds the majority of its states have poverty levels above the national average? No surprises here … it’s the South. Jessica Stephens, a senior policy analyst with the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured, has been instrumental in working on several KFF projects this year assessing coverage and care in Southern states, along with opportuniJessica ties and challenges the Stephens region faces to provide increased healthcare access and equity. Stephens, who received both her under-


Current Medicaid Expansion Decision







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graduate degree and master’s in Health Policy and Administration from Yale, is also part of the Disparities Policy Project for KFF. In looking at expansion decisions by region, Stephens noted KFF uses the U.S. Census Bureau definition of the South, which includes 16 states – stretching westward to Texas and northward to Delaware – plus the District of Columbia. “Six states including D.C. have implemented the Medicaid expansion,” Stephens said, listing Delaware, Maryland, the District of Columbia, Arkansas, Kentucky and West Virginia. “They’ve all taken slightly different approaches,” she noted. “Arkansas, in particular, has adopted a private option where they are using Medicaid funds to assist newly eligible adults pay for private coverage through the marketplace,” Stephens added of a waiver granted by the Centers for Medicare & Medicaid Services to allow the state to provide premium assistance. Nationally, Stephens continued, 26 states plus the District of Columbia have implemented Medicaid expansion, which means nearly half of the U.S. states electing not to expand at this time are located in the South – 11 of the remaining 24. “In the West and Northeast, the majority of states have (expanded). In the Midwest, a larger number are not, but it’s still more than in the South.” The reasons for not implementing expansion are multifactorial. Stephens said that in addition to general political opposition to the Affordable Care Act in many Southern states, there is also a concern over the sustainability of maintaining expanded Medicaid rolls even though the phased down match rate of 90 percent is still much higher than the general Medicaid population. And, she continued, “There are concerns over the Medicaid program overall … how it’s run in general.” On the flip side, though, there is mounting concern over what the decision to not expand means for a large number of people. Stephens said more than a third of the nation’s population, 37 percent, live in the South, and the region is also home to 4 of 10 people of color. “The expansion was important, in part, because it was going to expand Medicaid to adults who were historically excluded from the program,” she said. A very large percent of those who make too much for traditional Medicaid but not enough to qualify for federal subsidies reside in the South. “Overall in the South, there are 3.8 million people who fall into this gap, and nationally, there are 4.8 million … so nearly 80 percent of all those who fall into the gap nationally are in the South,” Stephens stated. She added people are often surprised to find out just how little a family could make in order to qualify for traditional

Medicaid. Citing median levels, she noted, “For a family of three – one adult and two children – that family cannot earn more than approximately $12,000 a year for the parent to be eligible.” Stephens continued, “Non-disabled, childless adults remain ineligible regardless of how much they earn.” Without expansion, she said, Medicaid eligibility for adults remains very limited. Additionally, Stephens noted the decision not to expand Medicaid also further exacerbates healthcare disparities with people of color being disproportionately impacted by the choice. “Six in 10 blacks who would have been eligible for Medicaid in the South, about 1.2 million people, are not because they fall into the coverage gap.” Among states that did expand coverage, Stephens said reports are coming in that those states have been able to improve the efficiency and function of their Medicaid programs by taking advantage of a number of ACA provisions. “We can tell the Affordable Care Act and the Medicaid expansion has important potential to change delivery,” she said. “It also has the potential to reduce disparities in access to coverage and care by race and ethnic-

ity and also by geography if the Southern states would expand.” Even without expansion, though, Stephens said outreach and consumer assistance is critically important to chip away at the 21 million in the region still lacking any type of coverage. About 48 percent of the South’s uninsured currently qualify for existing programs. “Of the 21 million uninsured in the South, we have 7 percent who are Medicaid-eligible adults, 11 percent who are Medicaid- or CHIP-eligible children, 30 percent who are eligible to obtain tax credits to purchase private coverage through the marketplace, 18 percent who are in the coverage gap, 21 percent who are ineligible for financial assistance who have incomes above the tax credit limit or an offer of employer-sponsored coverage, and 13 percent who are ineligible due to their immigration status,” Stephens outlined. Ultimately, improving health outcomes will largely depend on the creation of dependable channels to access care … whether through the expansion of Medicaid, implementation of other solutions to address the needs of the uninsured, or a combination of both.

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Teaming Up to Turn the Tide on Pancreatic Cancer By CINDY SANDERS

Deadly and defiant, pancreatic cancer was one of the major oncologic threats Congress hoped to address with passage of the “Recalcitrant Cancer Research Act,” which was signed into law at the beginning of 2013. Garnering broad bi-partisan support, the statute honed in on cancers with five-year relative survival rates below 50 percent. Starting with pancreatic and lung cancer, the law calls for the National Cancer Institute to develop a scientific framework and strategic plan to move the science forward at a more rapid pace to address these deadly diseases. Leading the call to pass the legislation and increase research, collaboration and patient resources is the Pancreatic Cancer Action Network (PanCAN). Formed in 1999, the California-based national organization will have awarded almost $23 million in grants to 110 research scientists around the country by year’s end. Additionally, the Patient & Liaison Services (PALS) has shared current, reliable information with more than 80,000 patients and family members, including a comprehensive clinical trials database to link patients with the latest treatment options and research studies.

A PanCAN research study published in Cancer Research this past May predicted pancreatic cancer would become the second leading cause of cancer-related deaths by 2020 and also estimated the increase in liver cancer deaths would make lung, pancreas, liver and colorectal the top four cancer killers in the country by 2030. “When we think of ‘big picture’ cancers, we think lung, breast, prostate and colorectal,” said Lynn Matrisian, PhD, MBA, vice president of scientific and medical affairs for PanCAN. More than 800,000 Americans will receive a diagnosis of one of these types of cancer Dr. Lynn this year (see box). Matrisian Yet, noted Matrisian, pancreatic cancer, which is the 12th most commonly diagnosed cancer, is currently the fourth leading cause of cancer deaths in the United States. “Pancreatic cancer surpassed prostate cancer a couple of years ago and is expected to surpass breast cancer in the next year or two and the colorectal cancers around 2020,” she explained. While great strides are being made in lowering overall cancer death rates, Matrisian said it has been much more difficult


Congratulations Dr. Di Bisceglie Adrian Di Bisceglie, M.D., chair of internal medicine at Saint Louis University, was honored at a White House ceremony July 30 for exemplary leadership in furthering the nation’s prevention and treatment of viral hepatitis. The ceremony is held annually as part of World Hepatitis Day.




to gain traction in improving pancreatic cancer survival. “For pancreatic cancer, we haven’t made any change much at all in the death rate since we began keeping records. The five-year survival rate is 6 percent. An estimated 73 percent of patients die within the first year of diagnosis.” She added, “It’s the only one of the major cancers with that five-year survival rate in the single digits.” The reasons for the high mortality rate are multifactorial and include a need to better understand the pathogenesis of the disease and to identify it earlier when treatment options have a greater opportunity for success. “The pancreas is deep within your body. The symptoms are pretty vague and can be attributed to multiple diseases so it’s often diagnosed quite late,” Matrisian said. She added, an aging and growing population is anticipated to increase the number of cases of pancreatic cancer in coming years, which in turn is expected to lead to pancreas cancer becoming the number two cancer killer considering its mortality rates. Yet, she stressed, “It doesn’t have to happen if we can change things now.” Matrisian said she sees the information as a call to action and pointed to the preventive, diagnostic and treatment successes that have occurred in many diseases through focused research efforts. Stand Up To Cancer (SU2C) is answering that call with the formation of their second pancreatic cancer Dream Team. Announced in April, the SU2CLustgarten Foundation Pancreatic Cancer Convergence Dream Team is focused on immunotherapy and is being led by noted physician-scientist Elizabeth M. Jaffee, MD, professor of oncology at Johns Hopkins School of Medicine and codirector of the Gastrointestinal Cancers Program at the Sidney Kimmel Dr. Elizabeth Comprehensive Cancer M. Jaffee Center at Johns Hopkins in Baltimore. University of Pennsylvania translational research expert Robert H. Vonderheide, MD, DPhil, has joined Jaffee as co-leader of the project — “Transforming Pancreatic Cancer into a Treatable Disease.” The multidisciplinary team includes seven other principals from around the country plus three patient advocate members. Funding for the $8 million, three-year grant is a collaborative effort of SU2C, The Lustgarten Foundation and the Fox Family Cancer Research Funding Trust. The Dream Team will use the grant to develop new therapies to engage a patient’s own immune cells in the battle against pancreatic cancer. Jaffee has led the charge on creating an immunologic response, developing a novel pancreas cancer vaccine with colleagues more than a decade ago targeting pancreatic ductal

adenocarninomas (PDAC), the most common form of pancreatic cancer. “Pancreatic cancer suppresses the body’s anti-tumor immune response,” Jaffee explained. “These tumors do not allow immune cells that can recognize and kill them to even enter the pancreas. We think we can use vaccination to activate anti-tumor immune cells and then use other agents to get those cells into the pancreas where they can attack the tumor.” Most recently, she noted, “We tested our newer vaccine, which is a combination of two vaccines – the first primes the immune system and the second targets cancer cells – and we now give a boost to the immune system.” She continued, “We’ve tested this in advanced patients who have failed all other chemotherapies, and we showed it significantly improved survival.” Jaffe added the median survival doubled from three months to more than sixand-a-half months. “Patients who did well are doing well long-term,” she added, noting some of these advanced patients have now survived more than a year out from the immunotherapy. “There really aren’t side effects so the patients have a better quality of life,” she added of another plus. The outcomes have resulted in accelerated approval status from the Food & Drug Administration. While Jaffee and her colleagues at Johns Hopkins have made important progress, she noted bringing the Dream Team together will enhance everyone’s work. “Each center has come up with a project based on the science they were developing,” she said of the two Phase I studies and three multicenter Phase 2 trials being launched. “We’re going to combine now and share our technologies to analyze the different clinical trials. We’ll compare mechanisms to see if we should combine agents,” Jaffee continued. Calling the Dream Team an “all out massive attack on pancreatic cancer,” Jaffee said it is a wonderful opportunity to bring experts from eight different centers together to advance pancreatic research. She also said it’s possible immunotherapy could be widely available to patients in the next two years pending outcomes of current trials. While improved treatment clearly would be a critically important advance, Jaffee said there is another exciting development underway. She and her team have recently published their first paper showing prolonged progression of the disease in animal models. “We don’t know when the first genetic changes are occurring and at what age,” Jaffee noted. However, she continued, “Cancer starts to develop 20-30 years before you see it.” By looking for early changes, such as mutated KRAS, the hope is to target a pre-malignancy and keep it from ever developing into pancreatic cancer. “Our goal is to eventually prevent this disease from the start,” Jaffee concluded. stlouismedicalnews


From Russia, With Love

Salt rooms are popping up across U.S., using haloaerosol therapy for the treatment and prevention of respiratory diseases By LYNNE JETER

Prior to the collapse of the USSR, Alina V. Chervinskaya, MD, PhD, and her team built the first salt room at the Institute of Pulmonology in Leningrad as a way to treat respiratory diseases. The salt room, dubbed the halochamber, created an environment for dry salt aerosol treatment, known as halotherapy. Chervinskaya, a pulmonologist and head of the Clinical Research Respiratory Center in St. Petersburg, Russia, noted that earlier attempts to create an artificial microclimate with “all sorts of saltbased minerals,” such as halite, sylvinite, and salt bricks, had failed. In research papers, Chervinskaya showed that dry sodium chloride aerosol with a negative electrical charge could penetrate deep into the respiratory tract, dissolve mucus, improve the function of cilia and fight bacteria and bronchial inflammation. “The only effective way to build a functioning salt cave was the creation of dry salt aerosol with the help of special equipment: halogenerators,” said Chervinskaya, whose team collabo- Dr. Alina V. rated with Aeromed, Chervinskava a St. Petersburg-based engineering firm, to create a scientifically substantiated method – controlled halotherapy – in 1995 as a new method of treating diseases of the respiratory system. Controlled halotherapy, Chervinskaya explained, allows for differentiated metering and control of the level of salt aerosol when performing treatments. “This is very important, because it allows for objective treatment, which enhances the effectiveness and safety of the procedure, and optimizes the length of each session,” she said. Chervinskaya also helped develop the Halomed device, a salt generator that can be set for different levels of salt concentration. It’s recommended for patients with colds, sinusitis, bronchitis, allergies and asthma, and also for eczema and psoriasis. “Before our invention, it was impossible to manage and maintain different levels of the concentration of dry salt aerosol in the salt chamber,” she said. “Our halogenerators receive feedback from a concentration sensor and a microprocessor, which allows us to establish the necessary concentration of aerosol for our patients and maintain its level throughout the procedure.” When salt rooms began popping up outside Russia and the Baltic countries in the early 2000s, Chervinskaya was faced with a significant hurdle that required educating the medical community and patients independently seeking salt therapy about the proper use of halotherapy. stlouismedicalnews


“The term, halotherapy, came into fashion, but it was being used in the entirely wrong way! These unscrupulous offers, practically changing the meaning and introducing confusion and distrust, discredited halotherapy and (gave) rise to sharp criticism in the European medical community,” she pointed out. Chervinskaya realized that of the hundreds of salt rooms built in Europe and the United States, only a few had modern equipment for full, effective, and safe use of the method of controlled halotherapy. “This situation,” she cautioned, “hindered the advancement of halotherapy, and aroused distrust in the medical community.” Since the 1990s, Chervinskaya has penned hundreds of scientific publications, chapters in monographs and textbooks, and dozens of papers at professional forums

on the subject. She chronicled the development and implementation of a comprehensive system of preventive and restorative treatment of diseases affecting the respiratory system in her doctoral dissertation, “Haloaerosol Therapy in the Treatment and Prevention of Respiratory Diseases.” She’s also become a well-known speaker to physician groups on topical problems of rehabilitation in pulmonology, physiotherapy, aerosol medicine, speleotherapy, halotherapy, air ion therapy, nebulizer therapy, and also controlled re-

spiratory environments. “I get referrals from some naturopathic and homeopathic MDs. Some mainstream MDs approve of patients using salt therapy, but don’t seem to mention it to other patients,” said Chervinskaya. “I do have several MDs as clients and/or MDs who send family members for a respiratory condition.” Perhaps one reason for the lack of enthusiasm: “In general, salt therapy is too new and insurance companies don’t know about it yet,” Chervinskaya said. “Some very flexible spending plans in the U.S. cover salt therapy.” Salt therapy can easily pay for itself, she emphasized. “However, due to improving respiratory conditions so that less medical intervention is needed, salt therapy works as a course of therapy, and most salt rooms offer especially good rates for multiple sessions,” she said. At the St. Louis Salt Room, for example, a course of therapy (10-20 sessions) costs $150 to $250 for adults; $225 to $400 for children. “The average annual cost, when two courses of therapy are done, is $300 to $500 (for adults); $450 to $800 for children,” she said. “Thousands can be saved on medical expenses, not to mention the much higher quality of life that comes with fewer sick days, more energy and less risk for otherwise high-risk individuals.”

Salt Rooms in Missouri offering Modern Halotherapy Perryville, St. Louis,




GrandRounds Esse Health Office of Drs. Byrne & Launch Welcomes Physician

Esse Health’s office of Drs. Byrne and Launch welcomes board certified Internal Medicine physician Aneela Qayum, M.D. to its practice. Dr. Qayum is seeing patients at the Bridgeton office, in St. Louis, and at the St. Charles office. Dr. Aneela Dr. Qayum graduated Qayum from Fatima Jinnah Medical College and completed her residency training in Internal Medicine at Forest Park Hospital in St. Louis, MO. Dr. Qayum has a special interest in geriatrics. Dr. Qayum joins board certified Internal Medicine physicians Robert M. Byrne, M.D. and Leslie A. Launch, M.D., along with Nurse Practitioners Donna Hall, FNP-BC and Regina Iman, ANP.

Vigilant Anesthesia Care & Pain Management Welcomes New Physician Vigilant Anesthesia Care & Pain Management, LTD is pleased to announce the addition of Chad A. Ermis, D.O. to their practice. Dr. Ermis earned his Bachelor of Science in Biology/Physiology from Northern Michigan Dr. Chad A. University and his osteoErmis pathic degree from Kirksville College of Osteopathic Medicine, Kirksville, MO. Dr. Ermis completed his OMS3/OMS4 at Genesys Regional Medical Center, Grand Blanc, MI. He completed his PM&R internship at William Beaumont Hospital, Royal Oak, MI. His Physicial Medicine and Rehabilitation residency was completed at William Beaumont Hospital, Royal Oak, MI. He then completed his Spine and Pain Management fellowship at Cleveland Clinic Hospital, Cleveland, Dr. Ermis’s addition to the practice will ensure greater accessibility and increased services to our patients. Dr. Ermis has broad clinical interests which include chronic/complex pain syndromes utilizing interventional modalities and multidisciplinary pain management. His clinical interest is interventional pain management procedures. Dr. Ermis will be seeing and treating patients at Memorial’s Pain Center.

Wahl to Become Head of Radiology Richard L. Wahl, MD, has been named the Elizabeth E. Mallinckrodt Professor and head of radiology at Washington University School of Medicine in St. Louis. He also will serve as director of the Mallinckrodt Institute of Radiology. Dr. Richard L. Wahl The appointment, which will begin in October,




was announced by Larry J. Shapiro, MD, executive vice chancellor and dean of the School of Medicine. Wahl is a 1978 graduate and former resident and fellow of the School of Medicine who has gone on to do groundbreaking work in developing specially targeted radiopharmaceuticals for diagnosing and treating cancer, Shapiro said. Wahl succeeds R. Gilbert Jost, MD, who was head of Mallinckrodt for 15 years. Jost’s many accomplishments included the creation of the Center for Clinical Imaging Research, one of the first hospital-based facilities dedicated to providing state-of-the-art imaging technology to researchers in a patientcare environment. Jost will continue to be active in research. Wahl comes to the university from Johns Hopkins University, where he is the Henry N. Wagner Jr., MD, Professor and director of the Division of Nuclear Medicine. Wahl was among the first to combine radiation therapy for non-Hodgkin’s lymphoma with techniques that use the immune system to precisely target treatments. The combined approach, now FDA-approved, is known as radioimmunotherapy. He has been a leader in using positron emission tomography (PET) to diagnose a broad array of human cancers and other diseases. He also is at the forefront of more recent efforts to combine quantitative data from PET scans with computerized tomography (CT) to form “fusion” images that can help physicians more precisely diagnose and characterize cancers. He and his research group have received research support from the NIH and other agencies for nearly three decades. At Johns Hopkins, he also is vice chair for technology and new business development in the Russell H. Morgan Department of Radiology and Radiological Sciences, and a professor of oncology. A fellow in the American College of Radiology, Wahl holds 18 radiology patents and has published more than 400 peer-reviewed scientific manuscripts. He is the primary author of several textbooks, including “Principles and Practice of PET and PET/CT.” He also is a member of multiple professional societies and plays a leadership role in Radiological Society of North America Quantitative Imaging Biomarker Alliance Projects designed to standardize imaging approaches.

SLU’s Di Bisceglie Honored for Leadership in Hepatitis Prevention and Treatment In July SLU hepatologist Adrian Di Bisceglie, M.D., was honored at the White House for exemplary leadership in furthering the nation’s prevention and treatment of viral hepatitis. The Office of National Drug Control Policy and the Office of National AIDS Policy recognized Di Bisceglie’s contributions to fighting

this liver disease at a ceremony to commemorate World Hepatitis Day. Di Bisceglie, who is chair and professor of internal medicine at SLU, currently serves as the president of the American Association for the Study of Liver Diseases (AASLD). Before coming to SLU, he served as the chief of the liver diseases section at the National Institutes of Health, where he supervised that group’s research in viral hepatitis. Together with Bruce R. Bacon, M.D., he co-directs the Saint Louis University Liver Center. Di Bisceglie’s research has focused particularly on hepatitis B and hepatitis C. Both of these viral infections may become chronic and lead to inflammation of the liver, causing fibrosis and cirrhosis, as well as other complications that may lead to liver cancer and death. Recently though, dramatic advances have been made in therapy of hepatitis C. Worldwide, experts estimate that nearly 180 million people are infected with the hepatitis C virus. About 4 million people in the U.S. have been infected with hepatitis C; an estimated 10,000 to 12,000 people die from complications each year in this country. From discovery of the hepatitis C virus in 1989 to the advent of new drugs that improve patient cure rates to 95 percent, Di Bisceglie, has seen remarkable progress in treating viral hepatitis over the course of his career. Leading clinical trials and authoring research, Di Bisceglie’s contributions to these new treatment options have been significant. Of particular note is Di Bisceglie’s leadership of the landmark NIH-funded HALT-C clinical trial. In 1999, he was named chairman of the steering committee of this nationwide study that began, for the first time, to make real strides in understanding the nature of the hepatitis C virus.

Mercy Names Hu Chairman of Oncology Services As Mercy Oncology Services continues to grow with the recent addition of six oncologists to Mercy Clinic, Mercy has named H. Shawn Hu, MD, chairman of oncology services across its east region. In this newly created role, Dr. Hu will focus on further developing Mer- Dr. H. Shawn Hu cy’s oncology services across the St. Louis metro area, including Franklin and Jefferson counties. He will work to provide a new level of coordinated care to patients with a unified team of physicians across specialties. Dr. Hu, a medical oncologist, has cared for patients at Mercy hospitals in St. Louis and Washington since 2002, joining Mercy Clinic in March 2014. He earned his medical degree at Beijing University School of Medicine. He completed his internal medicine residency at Saint Louis University and medical oncology fellowship at The University of Chicago.

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GrandRounds Brunt Named Chief of Minimally Invasive Surgery

L. Michael Brunt, MD, a nationally recognized laparoscopic surgeon, has been named chief of the Section of Minimally Invasive Surgery in the Department of Surgery at Washington University School of Medicine in St. Louis. Over a 25-year career Dr. L. Michael Brunt at the School of Medicine, Brunt has focused on laparoscopic abdominal, solid organ and biliary surgery, particularly procedures to remove the gallbladder and repair complex hernias. He earned his medical degree from Johns Hopkins University School of Medicine in 1980 and completed a residency in general surgery at Washington University School of Medicine in 1987. A professor of surgery, Brunt serves as program director of Washington University’s Minimally Invasive Surgery Clinical Fellowship. He also initiated a skills training course for fourth-year medical students entering a surgical specialty. That course has gained national attention as a model for preparing students for their surgical internships.

are back up. Scientists continue to try to stay a step ahead of the virus, both to combat drug resistance and to develop better treatments. To develop better drugs, scientists want to use a process called x-ray crystallography to develop a complete picture of how integrase inhibitors – the class of HIV drugs that target integrase-- interact with the virus. To do this, Grandgenett and his team, including investigators Krishan Pandey, Ph.D., and Sibes Bera, Ph.D., needed to develop an integrase-DNA

complex and then kinetically stabilize the complex in the presence of the drug. Researchers used a surrogate virus to take a shortcut. Because integrase structures are similar in all retroviruses, Grandgenett tried his approach in Rous sarcoma virus (RSV), whose integrase is more readily manipulated than HIV integrase. All current clinical integrase inhibitors work in the same way: They block integrase which prevents HIV from replicating. Specifically, they do this by stopping viral DNA strand transfer with STIs – strand transfer inhibitors.

Those inhibitors work by binding three components together: viral DNA; viral integrase; and the drug itself. Before this study, no one had been able to produce a synaptic complex (SC) in solution, the place where these three elements meet. The researchers developed conditions where the HIV strand transfer inhibitors (STIs) trapped the SC of the surrogate RSV integrase. Grandgenett reports that this experiment is first time anyone has ever captured an integraseDNA-inhibitor SC in solution.

Trapped: Cell-Invading Piece of Virus Captured in Lab

In recent research published in the Journal of Biological Chemistry, Saint Louis University investigators report catching integrase, the part of retroviruses like HIV that is responsible for insertion of the viral DNA into human cell DNA, in the presence of a drug designed to thwart it. This achievement sets the stage to use x-ray crystallography to develop complete images of HIV that include integrase, which in turn will help scientists develop new treatments for the illness. Duane Grandgenett, Ph.D., professor at SLU’s Institute of Molecular Virology and senior author of the study, discovered integrase in 1978, little knowing the piece of virus would provide the basis for an entire class of drugs that now treats HIV. When a person is infected with HIV, there is an initial burst of virus production. This is when integrase inserts the virus DNA into many human cells, including CD4 T-immune cells, brain cells and other lymph cells. HIV is particularly devastating to the immune system’s T-cells, which protect the body from infection. Most people do not die from virus replication but from secondary causes, Grandgenett said. Their immune system collapses and opportunistic infections and cancer are what really kill the person. Now, scientists have developed drugs that are very successful at managing HIV. Combinational drug therapy is particularly effective. The virus mutates so that it can quickly become resistant to a drug. But when three different drugs aim at three different targets, as in combination drug therapy, the probability of drug resistance is much smaller. There is one catch, however. Patients must take the drugs every day. If they do not, the virus starts cycling again and within a few weeks the viral levels



THE STRENGTH TO HEAL and get back to what I love about family medicine. Do you remember why you became a family physician? When you practice in the Army or Army Reserve, you can focus on caring for our Soldiers and their Families. You’ll practice in an environment without concerns about your patients’ ability to pay or overhead expenses. Moreover, you’ll see your efforts making a difference. Visit or call 877574-7037.

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