Issuu

Summer 2016

www.pasg.org

PSG

INSIDE

President’s Message

Join Us at the 2016 Annual Meeting

History Repeats Itself

Combating Opioid Abuse in PA

By Ralph D. McKibbin, MD, FACP, FACG, AGAF

“Those who cannot remember the past are condemned to repeat it.” – George Santayana

Membership Application & Benefits Risk Management Legislative Update

“A higher degree of civilization, bringing with it increased mental development among all classes, increased cares, duties and shocks, seems to have caused the habitual use of narcotics, once a comparatively rare vice among Christian nations, to have become alarmingly common.” “Finding pain, ‘nervousness’ and hysteria constantly claiming his attention, and that nothing relieves them so well as opium, or its alkaloid morphia, which is six times the parent strength, the physician resorts to their use more and more freely, expecting as soon as the more distressing symptoms pass away to pursue another and more permanent plan of treatment. The patient, however, having once experienced relief, insists upon the further use of the drug, sometimes feigns illness, in order to procure it, finally obtains some herself, and in guilty secrecy drifts rapidly into the habit. Some physicians are weak enough to place the means of gratifying this morbid appetite directly in the hands of the patient.

This is more especially the case since the hypodermic use of the drug has become common. So magical is the effect of this mode of administration, so rapid and forcible the action of the drug, that many persons will not rest content until they possess and are using the instrument… …Those not acquainted with the truth in this matter will be surprised to learn that there are to-day thousands of educated and respectable people in all countries and among all classes, confirmed habitués; slaves to a habit that is more exacting than the hardest taskmaster, that they loathe beyond all else, and yet that binds them in chains that they are wholly unable to break. Everything must give way to this vice. Business is neglected or but imperfectly performed; family ties are sundered; hope, ambition, happiness, self-respect are meaningless words; the one thing that fills the mind is the gratification of this passion, which they loathe, but from which they cannot break.” “The therapeutics of any epoch is strictly in conformity with the most prominent disease or symptom of the people upon continued on page 9

DDNC Report PRESIDENT Ralph D. McKibbin, MD Blair Gastroenterology Associates 810 Valley View Blvd. Altoona, PA 16602-6342 (814) 946-5469 (Phone) (814) 946-4970 (Fax) ralphmckibbin@hotmail.com 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) remoses@mosesmedlaw.com SECRETARY Ravi Ghanta, MD Digestive Disease Associates 1011 Reed Ave., Suite 300 Wyomissing, PA 19610 (610) 374-4401 (Phone) rghanta@hotmail.com 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) dldiehl@geisinger.edu 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 gastro@pamedsoc.org

3 Join PSG at the Kalahari Resorts & Conventions for the 2016 Annual Scientific Meeting By Karen Krok, MD 2016 PSG Program Chair This year’s PSG Annual Scientific Meeting is fast approaching! This year it will be held in the Poconos at the new Kalahari Resorts & Conventions from September 23-25, 2016. I am excited to be program chair for the meeting this year! Every year, this meeting attracts over 100 gastroenterology providers and nurses from all over Pennsylvania. It is a great time to connect with colleagues and meet up with friends and former trainees! There have been some beautiful locations chosen recently for the Annual Scientific Meeting – Nemacolin Woodlands Resort, The Hotel Hershey, and Skytop Lodge to name just a few of them. This year’s venue will continue in that tradition and we hope that you will consider bringing your family, as the Kalahari Resorts has an indoor water park for all to enjoy! The resort also provides state of the art conference rooms for the educational component of the meeting. The program will start on the night of Friday, Sept. 23, with cocktails and hors d’oeuvres. The sessions will run on Saturday from 7:45 am-12:30 pm and on Sunday from 7:45 am-12:00 pm. Breakfast is provided both mornings prior to the start of the sessions. Saturday evening there will be a reception and dinner. This year we will be honoring one of our own – Dr. Harris Clearfield – as the recipient of the Gold-Headed Cane Award. Dr. Clearfield is an icon in the world of gastroenterology to those in the Philadelphia region. He practices at Drexel University Gastroenterology in Philadelphia and is coeditor and/or coauthor of three text books. Dr. Clearfield is a past member of the American College of Gastroenterology Board of Trustees, past president of the Pennsylvania Society of Gastroenterology, past president of the Philadelphia County Medical Society, past President of the Bockus International Society of Gastroenterology, and past chair of the Council of Interspecialty Societies for the American College of Physicians. He sits on the Board of Trustees for the

Philadelphia Chapter of the Crohn’s and Colitis Foundation of America. He has won a mastership from the American College of Gastroenterology, the Lindback Award for excellence in teaching at Hahnemann University, and has been named a “Best Doctor” in Philadelphia numerous times. He also was the past president of the Philadelphia Gastroenterology Training Group – which is very appropriate as he has trained many of the GI physicians in Pennsylvania and this evening we will acknowledge his dedication to field of GI. If you have worked with or been trained by Dr. Clearfield, we would love to see you attend this meeting and reception in order to honor him! In addition to honoring Dr. Clearfield, we are excited to have the comedian, Joe Conklin, as our special guest entertainer for the evening on Saturday. Joe Conklin’s comedy show is geared towards a Pennsylvania audience, featuring lots of topical sports humor and impressions of celebrities, sports figures, and politicians, both past and present. We have a fantastic line up of dynamic speakers representing all of the academic centers in Pennsylvania. We heard your requests for topics last year and this year’s program will focus on some of those themes.

2016 Program Topics: • Fecal Transplant for C. Difficile • New Colonoscopy Techniques to Improve Adenoma Detection Rate • Management of IBD in the Childbearing Years • Disparities in Liver Transplant • Hepatitis C • Metabolic Liver Diseases • Endoscopic Management of Obesity • Nutritional Information for the GI Practitioner continued on page 5

4 Combating Opioid Abuse in Pennsylvania – PAMED Launches “Opioids for Pain: Be Smart. Be Safe. Be Sure.” Initiative Provided by: The Pennsylvania Medical Society

The following article is offered as the opinion of the author and does not necessarily reflect the view of PSG as a whole. The problem: Opioid abuse, misuse, and overdoses are increasing, both in Pennsylvania and nationally. Opioid overdoses accounted for nearly 2,500 deaths in Pennsylvania in 2014 – that’s nearly 7 people a day – and indications are that those numbers are climbing. The solution: A multi-pronged approach that includes physicians, patients, and health care organizations like the Pennsylvania Medical Society (PAMED) working collaboratively to address this growing epidemic. PAMED recently launched its Opioids for Pain: Be Smart. Be Safe. Be Sure. initiative, which focuses on patient empowerment and physician education. This initiative consists of a five-step physician call to action and seven questions patients should ask when prescribed an opioid.

The Physician Call to Action – All Pennsylvania physicians should take these five steps: 1. Know the prescribing guidelines. They are available on PAMED’s website at http://www.pamedsoc.org/ OpioidResources. The first session in PAMED’s online CME series focuses on the guidelines. In this session, analyze your prescribing practices against statewide guidelines and identify when and why to prescribe opioid medications. Get the CME at www.pamedsoc.org/ OpioidsCME. 2. Use Pennsylvania’s prescription drug monitoring program (PDMP) once it’s up and running (it’s expected to be operational in August 2016). The fourth session in PAMED’s online CME series will address common physician questions regarding governance, user access, and provider and dispenser reporting

requirements. Watch PAMED’s Daily Dose email for when this session is available. 3. Refer patients who have a substance use disorder to treatment. Referral to treatment is covered in the third session in PAMED’s online CME series. This session addresses substance use disorders; explores screening and assessment tools; reviews intervention strategies; and assesses best practices in referrals to specialists, rehabilitation services, and community resources. Get the CME at www.pamedsoc.org/OpioidsCME. 4. Discuss alternatives to opioids with patients. 5. Ask patients to keep their pills safe, and properly dispose of a prescribed medication when they no longer need it. A list of drug take-back locations is available at https://apps.ddap.pa.gov/GetHelpNow/PillDrop. aspx.

Patient Empowerment – Patients should ask these seven questions when prescribed a pill for pain: 1. 2. 3. 4. 5. 6.

Is this prescription an opioid? At what level of pain should I take this prescription? Do I have to take every pill in the prescription? Where can I safely dispose of remaining pills? What can I do to avoid addiction? What are possible warning signs of dependence or addiction? 7. What can I do if I believe that I might have developed a dependence on this drug? Resources for physicians, patients, and lawmakers are available at www.pamedsoc.org/OpioidInfo. “We need to make sure that we – as physicians – are doing everything we can to stop this wave of abuse, and empowering our patients to do the same,” said PAMED Board Chair David Talenti, MD. “If physicians don’t suit up for the battle, who will?” he asks. “Education is a silver bullet.” In addition to the above-mentioned educational sessions, PAMED’s online CME series also has a session on naloxone. This session addresses the use of naloxone as

5 an opioid antidote, reviews regulatory requirements for prescribing naloxone to third-party first responders, and assesses naloxone prescribing options. PAMED is collaborating with the Pennsylvania Department of Health and 11 other health care associations on this educational series. “I think that we have to understand this is a public health crisis and we all have a role to play in terms of solving this,” said PAMED member and Pennsylvania Physician General Rachel Levine, MD.

“This crisis hits everyone – our mothers, fathers, brothers, sisters, sons, daughters, rural, urban, suburban,” she said. “We have to get past the idea that this is someone else’s problem. We have to get people into treatment and recovery. “Addiction is a medical illness. It is not a moral failing. We have to erase the stigma.” PAMED’s educational series seeks to address the many layers and complexities of this crisis. Learn more and get CME credit by visiting www.pamedsoc.org/OpioidsCME. Access additional resources such as prescribing guidelines in PAMED’s Opioid Abuse Resource Center at www. pamedsoc.org/OpioidResources.

Annual Meeting continued from page 3

• • • •

POEM and Treatment of Achalasia The IBD Medical Home Telemedicine and Telehealth And More!

For trainees there are some exciting events as well: • Saturday includes a revival of the GI Fellow Jeopardy from 12:30 pm-1:30 pm, with lunch provided. Last year the fellows were divided into three teams and even the providers in the audience were getting into the game. • A research poster competition will take place and will offer monetary awards (1st prize is $750.00, 2nd prize is $500.00, and 3rd prize is $250.00).

REGISTER NOW! You will find the link to register along with information on how to make hotel arrangements at www.pasg.org on the Annual Meeting page of the website. We look forward to seeing you at this year’s Annual Scientific Meeting at Kalahari Resorts & Conventions in the Poconos in September!

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 2016 Annual Meeting will be held September 23-25 at the Kalahari Resorts & Conventions in Pocono Manor, PA. • The annual 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 (www.pasg.org) 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 www.pasg.org.

Join us today! A membership application is enclosed.

7 Risk Management

Text Messaging Risks: Protected Health Information & Communicating with Patients By Richard E. Moses, DO, JD Communication has evolved to become electronic based and fast paced. In the U.S. alone, 75% of the population own a hand held device that can receive text messages. A recent survey conducted by the Pew Research Center’s Internet and American Life Project queried how cell phone users preferred to be contacted. Over 30% responded they preferred text messaging to talking on the phone. Although many patients prefer to receive reports and reminders from their health care providers through voicemail, many prefer to receive health care information via text messaging. This also allows for the possibility of real time communication regarding where the message is sent by the health care provider. It is becoming common practice for medical practices and health systems to text patient reminders for appointments with a reply option to confirm the text was received and the patient is keeping the appointment. However, texting with patients at this time is not always advisable. There are privacy and security risks associated with text messaging, among other risk management issues. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects patient health care information. It is the most apparent issue for physicians when thinking of texting despite the variety of other issues that arise when health care entities utilize text messaging. HIPAA requires health care providers to implement reasonable safeguards to protect the privacy and security of patient health information. Identifying data that should not be disclosed includes names, geographic subdivisions smaller than a state, significant dates (date of birth, date of death), Social Security numbers, telephone numbers, email addresses, et cetera. For our discussion, health care providers who decide to use text messaging must conduct a risk analysis to determine where the electronic protected health information (ePHI) it is texting is created,

maintained, and received on mobile phones and other mobile communication devices. However, providers must be cognizant that ePHI, text messaging in this scenario, may also reside on cloud-computer servers, workstations, and/or be embedded into the medical record. HIPAA requires that reasonably anticipated threats to ePHI be identified. The health care provider then needs to evaluate the potential impact and likelihood of such threats. For example, ePHI threats in the context of text messaging include: • Theft or loss of the mobile communication device • Access to ePHI by unauthorized or unintended recipient (text sent to wrong person) • Improper disposal of the mobile communication device • Hacking (unauthorized interception of transmission of ePHI) Recent data from the Department of Health and Human Services on HIPAA breaches show that loss or theft of mobile devices and misdirection of transmission of ePHI are the most common reasons for HIPAA breaches. However, there is an increasing prevalence of hacking as the cause of breaches. There is technology available that allows a more secure platform for text messaging communications. Unfortunately, the cost of this technology puts it beyond the reach of the average health care provider with limited resources. Since experts believe text messaging is going to have a more important role in future health care communication with patients, the current thinking is that more secure text messaging technologies will become a standard and be more affordable. Secure technology making texting with patients safer may become available as part of mobile device internal technology. In the interim, any health care provider using text messaging to communicate with patients needs to take the proper precautions to maintain ePHI protection, and develop a written policy that needs to be followed by all employees utilizing text messaging to communicate with patients.

8 Legislative Update By Richard E. Moses, DO, JD Chair, PSG Legislative Committee

The PSG, in cooperation with PAMED and other State Societies, continues to track the 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: www.pasg.org. This list of bills is periodically updated. 2016 has become an 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, and has introduced a number of bills in an attempt to deal with the current opioid crisis, including but not limited to OxyContin and heroin. Pennsylvania has become the 24th state in the U.S. to offer medical marijuana. SB 3 was passed by the Pennsylvania House of Representatives (149-46) after being passed by the Senate with a 42-7 vote in April. Governor Wolfe signed the bill into law on April 17th. SB 3 will allow physicians to prescribe marijuana to patients who have qualifying conditions. It may be prescribed in pill, liquid, oil, or ointment form that can be vaporized or inhaled. Smoking is currently not permitted. The bill outlines the approved medical conditions where these forms of marijuana might be prescribed. It will be required for patients to apply for a medical marijuana identification card and to obtain a prescription from a registered physician. Pennsylvania will allow 50 medical dispensaries. Each dispensary will be permitted up to three locations. Patients may not grow their own marijuana. The Medical Marijuana Program is anticipated to be active between 18 to 24 months from the date of the signing of the bill. SB 717, also known as the Independent Nurse Practitioner Reform Bill, gained momentum and rapidly moved through committees over the past months. Recall that 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 two physicians. SB 717 grants them full authority to practice without collaboration. The bill was marked up and therefore could not move out of the Senate Appropriations Committee as of June 29th. Pennsylvania Congress will be on summer recess. As of the time of this writing, it is unclear where SB 717 will stand when Congress reconvenes in September.

Some recently introduced drug abuse related bills that may be of interest include: HB 2201 Amends Title 35 (Health & Safety) providing for emergency overdose involuntary commitment. HB 2202 Amends the Controlled Substance, Drug, Device and Cosmetic Act, further providing for drug overdose response immunity. HB 2214 Amends the Health Care Facilities Act, in licensing of health care facilities, providing for Emergency Drug and Alcohol Detoxification Program. HB 2128 Amends the Controlled Substance, Drug, Device and Cosmetic Act to provide for drug overdose medication in recovery housing. The bill calls for the authorization of trained individuals in recovery houses to obtain, stock, and administer the anti-opioid drug naloxone, known by the brand name Narcan®. Authorization is not a requirement to administer. If Narcan is administered, recovery house staff members are required to ensure that the person is then transported to the nearest hospital emergency department. SB 1202 Amends the Achieving Better Care by Monitoring All Prescriptions Program (ABC-MAP) to require all licensees who are licensed as dispensers or prescribers under the Department of State’s jurisdiction to receive two hours of continuing education in pain management and at least two hours of education in the dispensing or prescribing practices of opioids for license renewal. New licensees must complete these requirements within 12 months of obtaining their initial license or certification. The continuing education must be approved by each licensing board in consultation with the Department. Dispensers or prescribers who are exempt from the DEA’s requirements for a registration number do not have to comply with the continuing education provisions.

9 President’s Message continued from page 1

whom the physicians practice. This is true of whole countries and sections of countries as well as of times.” “Of late years physicians are becoming more and more addicted to the subcutaneous use of morphine, and as a consequence, the number of persons who habitually use the drug in this way is daily on the increase. Eight-tenths of those from whom I hear and of those who come to me for treatment are using the drug subcutaneously.” “I simply say that in my experience this manner of using the drug is largely on the increase among habitués, and will go on increasing from year to year, in the same manner that morphine is rapidly replacing opium in the practice of physicians.” Source: Kane, H. H. (1881). Drugs That Enslave: The Opium, Morphine, Chloral and Hashisch Habits. Philadelphia: P. Blakiston, Son & Co.

MEET JACQUE.

DIAGNOSED WITH HEPATITIS C IN 2004.

“My experience with Diplomat was incredible. I’ve never experienced such a loving team and care environment. They would follow up, and check with me. [That] made all the difference in the world, because then I could relax. “When the doctors said, ‘You’re cured, there is no virus,’ I just couldn’t believe it. It was probably the most significant thing that has happened to me in my life.” –Jacque, former Diplomat patient

DIAGNOSED. TREATED. CURED.

In reviewing the excerpts above, it definitely seems that little has changed. Those who seek out the text, which is available in the public domain, will find the descriptions of users and their symptoms to be identical to what we see in our offices today. It is also important to “read between the lines.” Often, it is the physician who introduces the patient to narcotics and starts them down the path to addiction. Pain relief is necessary but carries significant risk. U.S. Department of Health statistics reveal that between 1999 and 2008 abdominal pain visits to the emergency department (ED) increased by 31.8% from 5.3 million to 7.0 million, or 11.3% of all ED noninjury visits. Gastroenterologists see many or most of these patients. It is imperative that we prescribe narcotics in a responsible fashion. Please utilize the educational materials that are readily available. Educate yourself and your staff to understand the importance of appropriate prescribing. The state is making available a web portal to enable prescribers to easily look up your patients’ controlled substance prescription history before prescribing. It is also important to educate your patients, especially those with children, to place pain prescriptions out of reach. It is important that we be part of the solution.

10 Digestive Disease National Coalition By Ralph D. McKibbin, MD, FACP, FACG, AGAF DDNC Representative The DDNC is an advocacy group comprised of more than 52 members representing national patient and provider organizations and has been active in Washington, DC in support of patients with gastrointestinal diseases. Key areas of recent activity include the CMS Part B Drug Demonstration (CMS-1670-P), patient access to medical foods regulations, and support for the 2017 VA Appropriations funding. A unified Biosimilars policy is also being drafted. The CMS Part B Demonstration proposes to reduce infusion payments in parts of the country to assess the impact on prescribing. Access to care issues and the impact on patient quality of life and care are not measured in the project. This places patients at risk. The DDNC has sent a letter ratified by the member organizations to key sponsors in hopes of opening the project to stakeholder input. A copy of the letter was sent to members of the PSG. Medical foods are for the management of irritable bowel syndrome, phenylketonuria, gastroparesis, inflammatory bowel diseases, various cancers, cachexia, celiac disease, burn victims, and many other conditions. Recently, First Databank (FDB), a major drug compendium, decided to classify medical foods as an over-the-counter product rather than as a prescription product. FDB feels as if this is justified because medical foods are in a regulatory

no man’s land – they are regulated by the FDA, but are not “approved” the way a prescription drug is approved, complicating this development. Medical foods cannot be over-the-counter because their use must generally be ordered and overseen by a physician. As a result of the FDB decision, Express Scripts and others in the benefits and coverage industry have announced that medical foods will no longer be covered. Patients renewing or filling a prescription will likely be responsible for the full cost of their product. The DDNC is serving as a clearinghouse for medical foods coverage access challenges. Please share this information with medical foods patients to help determine the scope of this problem. The VA Appropriations Bill provides increased funding but specifically includes funding for the treatment of hepatitis C. Funding is recommended at $1,500,000,000 which is $840,000,000 above the President’s request. The Patient Protection and Affordable Care Act (Affordable Care Act), signed into law by President Obama on March 23, 2010, amends the Public Health Service Act (PHS Act) to create an abbreviated licensure pathway for biological products that are demonstrated to be “biosimilar” to or “interchangeable” with an FDA-licensed biological product. This pathway is provided in the part of the law known as the Biologics Price Competition and Innovation Act (BPCI Act). Under the BPCI Act, a biological product may be demonstrated to be “biosimilar” if data shows that, among other things, the product is “highly similar” to an already-approved biological product. The draft policy, to be vetted by the member organizations, seeks to balance the interests of patients, many with severe disease, against the obvious financial drive to place them on less expensive medications.

14 Specialty Leadership Cabinet Report, September 2013 continued from page 13

PaACEP and PaPS spoke about a centralized exchange that would keep track of what beds are available at psychiatric centers and detoxification units so that emergency room and hospital beds aren’t being held by behavioral health patients. Already, Maryland, Florida, and Minnesota are working with their regulatory agencies and allied groups to create voluntary shared-bed tracking systems. The desired outcome is to gain SLC and PAMED support to assist PaACEP and PaPS in securing stakeholder commitment, such as the Department of Health and Hospital & Healthsystem Association of Pennsylvania, to develop a real-time voluntary reporting system of available psychiatric and substance use detoxification beds by region.

PAAA also reported that the Academy of Asthma Allergy and Immunology (AAAAI) is developing a standardized allergy elective for those residencies not affiliated with Allergy Immunology Fellowship Programs. These electives will include web-based educational programs combined with clinical experience in a private practice. They will be hosted on the AAAAI CME website.

Use of the Term “Physician” by Non-MDs or DOs The Pennsylvania Academy of Ophthalmology (PAO) wanted all specialty societies to be aware of the efforts of PAO and PAMED to have the Department of State enforce an existing law stating that use of the term “physician” by anyone other than an MD or DO. PAO recently sent a cease and desist letter to an optometrist who used the term “Optometric Physician.” When the optometrist did not respond to the letter, PAO submitted a formal complaint to the state. The Department of State responded that the situation did not merit formal prosecution. PAMED and PAO both sent letters of protest to the Department of State but have yet to receive a response.

The Pennsylvania Allergy and Asthma Association (PAAA) Innovation in Motion spokeSetting about its collaboration with PAMED Practice Economics and Payer Relations to obtain reimbursement for the measurement nitric oxide in patients asthma. We’re drivenoftoexhaled improve people’s lives. Takeda striveswith toward better health for people worldwide through leading innovation in medicine. PA Medicaid other payers do not recognize nitric oxide At Takeda, and we make a commitment to make a difference. The next meeting of the PAMED Specialty Leadership expired gas determination and consider it experimental. Cabinet is Tuesday, February 4, 2014. Takeda Pharmaceuticals U.S.A., Inc. www.takeda.us

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

Janssen Pharmaceutical Companies

PSG 777 East Park Drive PO Box 8820 Harrisburg, PA 17105-8820

PRSRT STD U.S. POSTAGE PAID HARRISBURG PA PERMIT NO. 922