Rumblings Newsletter Fall 2016

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Fall 2016



President’s Message

“The Times They Are a-Changin’”

Annual Meeting Highlights

By Ralph D. McKibbin, MD, FACP, FACG, AGAF It has been just a couple of months since the annual PSG scientific meeting held at the new Kalahari Resort in the Poconos. The meeting was a tremendous accomplishment. The family oriented resort provided a great escape for members and their families. As this stillgrowing resort develops, I anticipate that it will be a great success and will likely be the site of a future meeting. The success of meetings like this is dependent on the hard work and dedication of those behind the scenes and recognition and thanks are in order. I first want to acknowledge the fabulous support work done by our executive staff. Jessica Winger, as Meeting Manager, has again done a great job at organizing the meeting and all of the little details that go with it. The meeting went very smoothly. Our Association Executive, Robbi Cook and Assistant Association Executive, Megan Jones, have supported the administrative efforts of the PSG throughout the year and at the Board meetings held during the annual event. They all deserve a gigantic “thank you” for their thorough and consistent support of the organization and its efforts.

Secondly, I want to acknowledge the fine scientific program designed by Dr. Karen Krok. The lectures provide timely and informational talks to bring us up to date with the scientific changes in our field. It is difficult to wrangle speakers and talks into meaningful groups but she did a great job of keeping the proceedings on time. Thank you for a superb job.

Membership Application & Benefits Legislative Update Welcome New Members

PRESIDENT Ralph D. McKibbin, MD Blair Gastroenterology Associates 810 Valley View Blvd. Altoona, PA 16602-6342 (814) 946-5469 (Phone) (814) 946-4970 (Fax) PRESIDENT-ELECT Richard E. Moses, DO, JD Phila. Gastroenterology Consultants, Ltd. 700 Cottman Ave., Suite 201 Philadelphia, PA 19111 (215) 742-9900 (Phone) (215) 742-7051 (Fax)

PSG President Ralph D. McKibbin, MD presents PSG Program Chair Karen Krok, MD, with an award for her notable work in planning an extraordinary meeting this year. Thirdly, I want to recognize the fellows in training who took the time to come to the meeting. We are blessed to have so many training programs in our state and the quality of the work presented was very high. Congratulations to the winners continued on page 10

SECRETARY Ravi Ghanta, MD Digestive Disease Associates 1011 Reed Ave., Suite 300 Wyomissing, PA 19610 (610) 374-4401 (Phone) TREASURER David L. Diehl, MD Geisinger Medical Center Mc21-11, 100 N. Academy Ave. Danville, PA 17822 (570) 271-6856 (Phone) (570) 271-6852 (Fax) ADMINISTRATIVE OFFICE EXECUTIVE DIRECTOR Robbi-Ann M. Cook 777 East Park Drive, P.O. Box 8820 Harrisburg, PA 17105-8820 (717) 558-7750 ext. 1584

2 PSG Flocks to the Pocono Mountains! Highlights from the 2016 Annual Scientific Meeting By Karen Krok, MD 2016 PSG Program Chair What a great annual meeting we had at the Kalahari Resorts! I would like to thank all of the people who came to the meeting and made it such a success. It is a wonderful opportunity to see some colleagues, learn about updates in the field of gastroenterology, watch the fellows play Jeopardy, and relax! This year we had 146 registrants at the meeting. It was a superb turnout. Congratulations to this year’s Jeopardy winners (L-R): Shefali Shah (2nd year resident from Hahnemann University Hospital); Bolin Niu (2nd year fellow from Thomas Jefferson University Hospital); Laura Connor (3rd year fellow from Lankenau Medical Center); Eric Nellis (1st year fellow from Lehigh Valley Health Network) In addition, we had three research posters that were awarded prizes this year. The winners were: 1st place: Dr. Amir Rezk from Geisinger Health System for his poster: “Patient Perception of Bowel Preparation for Colonoscopy is Inflated Compared to Endoscopist Assessment of Rectal Effluent” PSG members, family, staff, and exhibitors mingled and watched the stunning sunset from the resort’s veranda during the Friday night welcome reception.

2nd place: Dr. Jinyu Zhang from Thomas Jefferson University Hospital for her poster: “The Prevalence of Binge Eating Disorder in Patients with Non-Alcoholic Fatty Liver Disease”

As always there is also a lot available to the fellows and this year was no different. We had a GI Jeopardy game on Saturday (and I think that even the practitioners in the room enjoyed this!).

3rd place: William Park (medical student) from Drexel University for his poster: “Celiac Block for Chronic Pancreatitis EUS v Percutaneous approaches – A Systematic Review”

3 Of course, this year we also honored Dr. Harris Clearfield for his dedication to the field of gastroenterology and his mentorship to so many Pennsylvania gastroenterologists. PSG President-Elect Richard Moses, DO, JD and Harris Clearfield, MD after the Saturday dinner and entertainment. Dr. Clearfield is sporting his gold headed cane awarded to him by the Society in recognition of his contributions to the gastroenterology community and his service to the Pennsylvania Society of Gastroenterology.

Read the Winning Poster Abstract Patient Perception of Bowel Preparation for Colonoscopy is Inflated Compared to Endoscopist Assessment of Rectal Effluent Amir Rezk, MD; Kimberly Fairley, DO; Kimberly Chaput, DO; Matthew Shellenberger, DO; Stacy Prall, DO; Genci Babameto, MD; Nicholas Inverso, MD Geisinger Medical Center, Danville, PA

Please mark your calendar for next year’s annual meeting, which will be held at Nemacolin Woodlands Resort in Farmington, PA on September 8-10, 2017!

See You at

Nemacolin! Mark your calendars for September 8-10, 2017! The next PSG Annual Scientific Meeting will be held at Nemacolin Woodlands Resort in Farmington, PA. Watch your inbox in the coming months for registration and program information!

PSG Program Chair Karen Krok, MD presents 1st Place FIT Poster Competition winner Amir Rezk, MD with his $750 award.

Background Limited data are available on the accuracy of patient assessment of bowel preparation prior to colonoscopy. Prior studies often used written patient surveys and have not been shown to correlate well with the endoscopist’s assessment. Moreover, few studies provided patients with a visual placard at the completion of bowel preparation to foster patient understanding of adequate colon cleansing.

Aim Our study compares patient perception of bowel preparation through written and pictorial descriptions of final evacuation to physician evaluations of residual contents.

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5 Annual Meeting continued from page 3

Methods We performed a prospective analysis of 1099 consecutive outpatients undergoing colonoscopy between February 2013 and September 2013. Patients completed a questionnaire that included the character of stool output and image selection that most closely represented final effluent. Physicians also scored bowel preparation quality and selected images of the stool from the same choices. Exclusion criteria were patients under 18 years old, pregnant, blind, CKD stage 4 or 5, or prior colon surgery. Other data collected included age, gender, type of bowel preparation used, adverse events from bowel preparation, and quantity of bowel preparation completed.

Results We analyzed 1099 consecutive patients at our tertiary care center and 35 patients were excluded by the criteria above. Among the 1064 patients included, 541 (51%) were male. Comorbidities including diabetes, hypothyroidism, COPD, and CKD less than stage 4 were present in 39, 34, 10, and 10% of patients respectively. Inadequate bowel preparation requiring repeat colonoscopy occurred in 85 patients (8%). Most patients (89%) completed > 75% of the bowel preparation, while none consumed < 25% of the bowel preparation. Nausea prevented completing the full volume of the bowel preparation in 32% of patients. 17% of patients stopped the bowel preparation prematurely believing their stools were clear. A significant difference occurred between patient perception of an inadequate preparation (solid or dark liquid stool) as identified by written patient survey compared to self-selection of an image of an inadequate preparation (6.5% vs. 11.4%; p < 0.0003). Endoscopists identified an inadequate preparation 22.7% of the time based on the picture placard, a two-fold increase from patient’s visual assessment (p < 0.0001). For adequate preparations (transparent colored stools), good correlation occurred between written and pictorial patient self-assessments. For those with the most thorough (“clear”) preparation, patients still significantly overrated the cleanliness of preparation via pictorial placard as compared to the physician’s image selection (18.35% vs. 8.2%; p <0.0001).

Conclusion Our data reveals that patients often overestimate thoroughness of bowel cleansing by written and pictorial descriptors as compared to the physician assessment during colonoscopy. A standardized visual placard of interim and final stool output may permit patients to improve preparation and optimize exam quality.

THANK YOU to Our 2016 Exhibitors and Sponsors! Join PSG in acknowledging the following organizations for their support of the 2016 Annual Scientific Meeting:

Exhibitors AbbVie Alexion Allergan Altus Infusion Boston Scientific CDx Diagnostics Diplomat DRG Laboratory Ferring Pharmaceuticals Gilead Sciences GI Supply Janssen Biotech

Merck & Co. Olympus America, Inc. Physicians Endoscopy Prometheus Laboratories QOL Medical Retrophin Shire Sigman-Tau Takeda Pharmaceuticals UCB US Endoscopy

Corporate Sponsors AbbVie Allergan Diplomat Gilead Sciences Janssen Biotech Pfizer Takeda Pharmaceuticals

6 The Benefits of Your PSG Membership Annual Meeting • Free to members. The non-member meeting physician registration fee is $175 and $100 for physicians’ assistants and nurses. (Pending members who have a completed application on file are entitled to free registration.) • The 2017 Annual Meeting will be held September 8-10 at Nemacolin Woodlands Resort in Farmington, PA. • The PSG Annual Scientific Meeting provides an excellent opportunity to earn CME credits.

Interaction with Other State and National Medical Societies • PSG is a member of the DDNC and is represented at their meetings. • PSG maintains a regular dialogue with the AGA, ACG, and ASGE on national issues that impact Pennsylvania gastroenterologists. • PSG has a seat on the PA Medical Society (PAMED) Specialty Leadership Cabinet and a vote at their House of Delegates. Together, PSG and PAMED advocate for gastrointestinal issues on a state level. • The two PA regional governors for ACG are now members of the PSG Board and we will closely collaborate with them on matters of common interest.

Representation by GI Fellows In Training

• Four FITs sit on the PSG Board. • PSG hosts a FIT poster competition at the annual meeting. Those who submit a poster and attend the meeting receive generous stipends.

Reimbursement and Health Care Issues

• PSG routinely corresponds with carriers to convey gastroenterology concerns and clarify questions. • PSG sends a gastroenterology representative to the PA Medicare Carrier Advisory Committee.

PSG Website The PSG Website ( has many features that benefit our physician members and their patients. Website features include: • membership information – online join/renew opportunities; • meeting information; • legislative and payor relations updates; • fellows in training details; and • electronic copies of the PSG newsletter, Rumblings.

Rumblings Newsletter • • • •

Contains reimbursement news and updates Alerts members of pending issues and problems relative to gastroenterology Informs members of state and federal legislative issues effecting Pennsylvania gastroenterologists Provides helpful information for GI fellows and new practitioners

If you received this issue of Rumblings as a non-member, PSG invites you to consider membership benefits such as free registration for the PSG Annual Scientific Meeting, representation in physician advocacy activities, and opportunities for dialogue with other GI professionals across Pennsylvania. To learn more about the Society, visit

Join us today! A membership application is enclosed.

measurement of exhaled nitric oxide in patients with asthma. PA Medicaid and other payers do not recognize nitric oxide expired gas determination and consider it experimental.

response. The next meeting of the PAMED Specialty Leadership Cabinet is Tuesday, February 4, 2014.

The PSG would like to thank the following corporate sponsor for their support:

Janssen Pharmaceutical Companies

Setting Innovation in Motion We’re driven to improve people’s lives. Takeda strives toward better health for people worldwide through leading innovation in medicine. At Takeda, we make a commitment to make a difference. Takeda Pharmaceuticals U.S.A., Inc.


8 Legislative Update By Richard E. Moses, DO, JD Chair, PSG Legislative Committee The PSG, in cooperation with the PAMED and other State Societies, continues to track Health Care Bill Legislation introduced into the Pennsylvania Congress. The PSG has made access to select bills available to members through a portal on the PSG website: This list of bills is periodically updated. 2016 remains a very active year for the Pennsylvania Congress with the introduction of a number of Health Care related bills. We will touch on the major bills of interest to date. Pennsylvania Congress has dealt with medical marijuana, the Nurse Practitioner Reform Bill, Hepatitis C screening, Telemedicine, and has introduced a number of bills in an attempt to deal with the current opioid crisis including OxyContin and heroin. Pennsylvania’s Medical Marijuana Act (Act 16): Pennsylvania is the 24th state in the U.S. to offer medical marijuana. Governor Wolfe signed the bill into law on April 17, 2016. Act 16 allows physicians to prescribe marijuana to patients who have qualifying conditions. It may be prescribed in pill, liquid form that can be vaporized or inhaled, oil, or ointment form. Smoking is currently not permitted. The Department of Health has until November 17 to start publishing temporary regulations, although it has issued the first round of temporary rules. During implementation, the Department is investigating the possibility of providing temporary legal protections for patients. Before physicians can recommend medical marijuana to patients, they must participate in a four-hour course developed by the Department of Health. This will likely become available in the fall or winter. After the physician has taken the course and registered with the department, he/she may write recommendations for patients who suffer from qualifying conditions. After receiving the doctor recommendation, a patient will then register with the Department to receive a certification from the state, which will allow the patient access to state-permitted dispensaries.

The health department will regulate 25 processors/ growers, along with 50 dispensaries, which may have up to three locations each. The details of implementation are progressing such that we should see dispensaries open in the near future. Independent Nurse Practitioner Reform Bill (SB 717): Recall SB 717 amends the Professional Nursing Law, further providing for definitions, and providing practice autonomy for licensed certified nurse practitioners. Under the current state law, nurse practitioners may practice alone only if they have a collaborative agreement with 2 physicians. SB 717 grants them full authority to practice without collaboration. The bill remains in Committee since Pennsylvania Congress has returned from summer recess after previously been marked up. As of the time of this writing, it is unclear whether the Independent Nurse Practitioner Reform Bill will come up for a vote later this year. Hepatitis C Screening Act (Act 87): On July 20, 2016, Governor Wolf signed this Act into law. The Act took effect September 18th. It requires each individual born between 1946 and 1965, who receives primary care services in an outpatient setting of a hospital, health care facility, physician’s office, or health services as an inpatient in a hospital, to be offered a Hepatitis C screening or diagnostic test. The patient is not mandated to accept the test. If the individual consents to being tested, and he/she is positive for HCV, the health care provider must either offer the patient follow-up care or refer the individual to a health care provider who can follow and treat the person accordingly. Follow-up care must include a HCV diagnostic test if not initially done. Exceptions exist under Act 87 such that the health care practitioner is not required to provide screening services if he/she reasonably believes one of the following: • The patient is being treated for a life-threatening emergency; or • The patient was previously offered or has been the subject of a HCV screening test; or • The patient lacks the capacity to consent to a HCV screening test.

9 Telemedicine Act(s) HB 2267 & SB 1342: The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Patient Protection and Affordable Care Act (PPACA), served to establish Telemedicine as another modality to deliver health care. This has created a number of legal issues, as physician licensure and practice scope are determined by State law. HB 2267 and SB 1342, referred to as the Telemedicine Act(s), are mirror bills providing for Telemedicine and for insurance coverage of the service in Pennsylvania. The bills define Telemedicine services and would require private insurance and Medicaid reimbursement. HB 2267 was referred to the Committee on Insurance on July 21, 2016 and remains there at the time of this writing. These bills address several barriers and bring some clarity to the expanded use of Telemedicine in the Commonwealth. Opioid Legislation & PA Prescription Drug Monitoring Program (PDMP): The number of bills that are currently being introduced to deal with the growing epidemic of prescription opioid abuse are almost too numerous to count and beyond the scope of our discussion. A number of them areVBZ102434_R01_ELUX_PSG_ReminderAd_EPS_X1a.pdf directed at physician requiring education for pain 2:06 1 9/30/16 management and prescribing practices of opioids including

continuing medical education credits as requirements for licensure and renewal. The PSG calls your attention to recent launching on August 25, 2016 of the Pennsylvania PDMP (PA PMP AWARxE). Pennsylvania physicians who are licensed, registered, or otherwise lawfully authorized to prescribed controlled substances in the course of professional practice or research in Pennsylvania are required by law to register in PA PMP AWARxE. The link is: By law, prescribers must query the system for each patient the first time the patient is prescribed a controlled substance by the prescriber for purposes of establishing a baseline and a thorough medical record. A prescriber shall also query the system if he/she believes or has reason to believe, using sound judgement, that a patient may be abusing or diverting drugs. To make consistent use of the PA PDMP more practicable, prescribers and pharmacists may grant access to any delegates under their employment or supervision to query the system on their behalf. Delegates register for their own accounts and enter the email address of their supervising PM

Visit for more information Allergan® and its design are trademarks of Allergan, Inc. VIBERZI® and its design are registered trademarks of Allergan Holdings Unlimited Company. © 2016 Allergan. All rights reserved. VBZ102434 09/16

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10 President’s Message continued from page 1

“Come mothers and fathers Throughout the land

of the GI Jeopardy tournament and to the winners of the poster competition. The future of gastroenterology in Pennsylvania seems bright.

And don’t criticize

I also wish to give one more congratulations and thank you to Dr. Harris Clearfield, recipient of our first Gold Cane Award, for his lifetime of dedication to the field of gastroenterology. He has been a great inspiration to many.

Yours sons and your daughters

Lastly, Dr. Vinay Chandrasekhara has been selected to organize the 2017 scientific program to be held at the Nemacolin Woodlands Resort. I know this program will be very exciting and we hope to see everyone again next year. The coming year will also bring with it some major changes. The presidential election will set the tone for much of what is to come but major shifts are underway which will proceed regardless. The paradigm for the delivery of health care will be based on quality rather than just quantity. Max Planck, the eminent theoretical physicist, is often quoted regarding the process of a paradigm shift. “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.” MACRA and MIPS are early steps in the development of the developing quality paradigm. Our baby steps included simple documentation of PQRS markers such as checking an HCV genotype prior to treatment or a TB test prior to IBD biologic therapy. While clearly associated with better outcomes, these can hardly be classified as “quality health care.” The life-cycle model of organizational growth and development shows us how, just as living organisms, businesses and organizations will grow and become more complex. This has been true of medical knowledge, specialty training, health care delivery, government, and clearly CMS as the supervising entity. In the future, our documentation will become more involved. The subsequent creation of data bases and “big data” will drive quality to the next level. Many will complain about the burden and intrusion on our daily lives and practices but there will be no turning back. It is perhaps ironic that the Nobel Prize Committee has given the Nobel Prize in Literature to Bob Dylan, the voice of change for a generation. His call to action still rings true:

What you don’t understand

Are beyond your command Your old road is Rapidly agin’ Please get out of the new one If you can’t lend your hand For the times they are a-changin’” The quality paradigm is here to stay. We should engage the process and change or we must fade away. Luckily, CMS, in its final ruling, considers 2017 a “Transition Year and Iterative Learning and Development Period” for the Quality Payment Program and, thereby, has reduced the reporting requirements during 2017 from what was initially proposed. CMS has provided four options for reporting in 2017 to allow clinicians to pick their own pace. We should use this opportunity to grow and learn about the new paradigm. Our state and national medical societies are providing constant updates and education on the subject which will ease the transition.

Legislative Update continued from page 9

prescriber(s) or pharmacist(s) to request access to the database. Further information may be obtained at: PaPrescriptionDrugMonitoringProgram/Pages/PDMP-Portal. aspx#.V_qRNCvD-Uk.

11 Welcome New Members (April 25, 2016 – October 31, 2016) Active

John Altomare, MD Elie Aoun, MD Nina Bandyopadhyay, DO Pardeep Bansal, MD Marc Bernstein, MD Corey Brotz, MD Jesse Civan, MD Michael Davis, DO Naudia Jonassaint, MD Richard Kalman, MD John Levenick, MD Noel Martins, MD Octavia Pickett-Blakely, MD Farid Razavi, MD

Associate Therese Bittermann, MD Laura Connor, DO Shelly Kakar, DO Nancy Kesavarapu, DO Nancy Khov, MD Jeffrey Kim, MD Gene Ma, MD Zubar Malik, MD Hanisha Manickavasagan, MD Barani Mayilvaganan, MD Seyedehsan Navabi, MD Eric Nellis, MD Bolin Niu, MD William Park



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CALL 800.604.6068 FAX 800.599.5560 VISIT Copyright © 2016 by Diplomat Pharmacy Inc. Diplomat is a registered trademark of Diplomat Pharmacy Inc. All rights reserved. MAR-004377-0516

Kamran Qureshi, MD Elizabeth Richardson, DO Nikhil Seth, MD Apeksha Shah, MD Shefali Shah, MD Anupam Somashekar, BS Jinyu Zhang, MD

Non-Physician Clinician (NPC) Rebecca Costa, PA-C Jen Flannery, PA-C Lauren Wiggins, PA-C

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