ACMS Bulletin March 2022

Bulletin Allegheny County Medical Society

March 2022

Love Thy Neighbor Osher

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Allegheny County Medical Society

Bulletin March 2022 / Vol. 112 No. 3

Opinion

Departments

Articles

Editorial ....................................5 Society News .........................17 Materia Medica .......................18 • Love Thy Neighbor • Pittsburgh Ophthalmology Society • Breaking Down the Cost Barrier: Deval (Reshma) Paranjpe, MD, MBA, FACS

Editorial ....................................8 • Osher Richard H. Daffner, MD, FACR

welcomes David Crandall, M.D

Helping Patients Afford Their Medications Melanie Riggio, Pharm.D., PGY-1 Ambulatory Care Pharmacy Resident, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA

Editorial ..................................11 • Move it or lose it: Promoting

Legal Summary .....................22

Perspective ............................13 • What is the future of cybersecurity in

Meeting Schedule .................28

wellness and exercise in senior adults Terence W. Starz, MD

health care? Ransomware, patient safety, and the protection of physician-patient communications.

Bruce Wilder, MD

Perspective ............................15 • SERVING THE UNDERSERVED Michael G. Lamb, MD

• Employment Contract Issues For New (and maybe old) Physicians Michael A. Cassidy, Esquire Tucker Arensberg, P.C. • 2022 ACMS Meeting and Activity Schedule by Committee

On the cover

Tranquility, Cooks Forest Alexanndra Kreps, MD Dr. Kreps specializes in Psychiatry

Bulletin Medical Editor Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com) Associate Editors 2022 Executive Committee and Board of Directors President Peter G. Ellis President-elect Matthew B. Straka Vice President Raymond E. Pontzer Secretary Mark A. Goodman Treasurer Board Chair Patricia L. Bononi DIRECTORS 2022 William F. Coppula Micah A. Jacobs Keith T. Kanel G. Alan Yeasted Alexander Yu 2023 Steven Evans Bruce A. MacLeod Amelia A. Pare Maritsa Scoulous-Hanson Adele L. Towers 2024 Douglas F. Clough Kirsten D. Lin Jan B. Madison Raymond J. Pan

PEER REVIEW BOARD 2022 Niravkumar Barot Kimberly A. Hennon 2023 Lauren C. Rossman Angela M. Stupi 2024 Marilyn Daroski David J. Levenson

PAMED DISTRICT TRUSTEE G. Alan Yeasted COMMITTEES Awards Mark A. Goodman Bylaws Raymond E. Pontzer Finance Keith T. Kanel Membership Matthew B. Straka

Douglas F. Clough (dclough@acms.org) Richard H. Daffner (rdaffner@acms.org) Kristen M. Ehrenberger (kehrenberger@acms.org) Anthony L. Kovatch (mkovatch@comcast.net) Joseph C. Paviglianiti (jcpmd@pedstrab.com) Anna Evans Phillips (evansac3@upmc.edu) Andrea G. Witlin (agwmfm@gmail.com)

Nominating Chair Raymond E. Pontzer

ADMINISTRATIVE STAFF

ACMS ALLIANCE

Executive Director Sara Hussey (shussey@acms.org)

Co-Presidents Patty Barnett Barbara Wible

Governance Administrator Mrs. Dorothy Hostovich (dhostovich@acms.org) Vice President—Operations and Physician Services Nadine M. Popovich (npopovich@acms.org) Director of Publications Cindy Warren (cwarren@pamedsoc.org)

Recording Secretary Justina Purpura Corresponding Secretary Doris Delserone Treasurer Sandra Da Costa Assistant Treasurers Liz Blume Kate Fitting

www.acms.org

Improving Healthcare through Education, Service, and Physician Well-Being.

EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212; (412) 321-5030; fax (412) 321-5323. USPS #072920. PUBLISHER: Allegheny County Medical Society at above address.

The Bulletin of the Allegheny County Medical Society is presented as a report in accordance with ACMS Bylaws, Articles 6, 8, and 11.

The Bulletin of the Allegheny County Medical Society welcomes contributions from readers, physicians, medical students, members of allied professions, spouses, etc. Items may be letters, informal clinical reports, editorials, or articles. Contributions are received with the understanding that they are not under simultaneous consideration by another publication.

Issued the third Saturday of each month. Deadline for submission of copy is the SECOND Monday preceding publication date. Periodical postage paid at Pittsburgh, PA. Bulletin of the Allegheny County Medical Society reserves the right to edit all reader contributions for brevity, clarity and length as well as to reject any subject material submitted.

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COPYRIGHT 2022: ALLEGHENY COUNTY MEDICAL SOCIETY POSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212.

ISSN: 0098-3772

Editorial

Love Thy Neighbor Deval (Reshma) Paranjpe, MD, MBA, FACS

M

ost of us have been glued to the news recently, stunned and horrified by the Russian invasion of Ukraine. The news is full of images of death and destruction, of fleeing refugees huddled under bridges and desperate to take the last trains out of the country. If you decolorize the images, they eerily resemble images of WWII that are seared into the minds of many adults.

As Mark Twain famously pointed out, history may not repeat itself, but it often rhymes.

The people impacted by this conflict are just like people you know. In fact, they may be people you know. The young CFO of a Silicon Valley tech startup and her teenage children are among the victims of Russian mortar fire, memorialized in a photograph splashed across the internet.

Physicians are finding themselves under fire as hospitals are bombed.

Office workers and baristas, ballet dancers and beauty queens—an unlikely cross section of society has united in taking up arms to defend their homeland. Women and children and the elderly are struggling to escape, often without adequate food, medicine, clothing or shelter.

ACMS Bulletin / March 2022

Innocent children are being emotionally and physically traumatized by war in a way that dwarfs our peacetime first world problems of “the kids are behind a whole year because they had to learn online because of the pandemic” and “my kid missed his prom and graduation and the dorm experience freshman year of college.”

How can kids learn when bombs are falling around them? How will the psyches and bodies of these Ukrainian children be scarred, and how will they ever recover? How do you explain their pain and fear to your own children?

The four horsemen of the Apocalypse are War, Pestilence, Famine and Death. The first three clear the way for the last. So far, we have war and pestilence. War creates famine where it would not otherwise exist, and that will undoubtedly be next in the news cycle as refugees struggle to find assistance and those left behind in Ukraine suffer untold deprivations.

Our beloved Pittsburgh icon Mr. Rogers told us as children that we should always “look for the helpers.”

As adults, it is our job to be the helpers that children can look to for comfort.

As physicians, it is our job to be the helpers that adults can look to for comfort.

What can one person far away do to help?

You can educate yourself and study the history of the region and its conflicts with your family.

You can be grateful that you are not in the same situation, for all that separates us from refugees of any stripe is luck—and an accident of birth counts as luck.

You can open your heart to the Ukrainian people, while also opening your heart to the humanity of the Russian people---so many are aghast at what their leadership is doing and are protesting in the streets at great peril to themselves and their loved ones.

You can hold your children close while you watch the news together and explain it to them. This may help you regain a sense of perspective regarding your own problems and will help your children develop a sense of perspective in life. “At least I have peace of mind that my neighborhood will not be shelled and I will not be shot. I have food, a roof over my head, clean clothes, medicine, freedom, and hope. There are people elsewhere just like me who do not, through no fault of their own.” And then it is a small but logical leap to realize that there are Continued on Page 6

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Editorial From Page 5

children and adults in our own country who are hungry, homeless, or live with the real threat of violence. Food insecurity, experiencing homelessness, school shootings, gun violence: these exist even without war, but war compounds their misery.

While watching the news 24/7 may be too traumatic, sheltering ourselves and our children completely from it prevents us from learning valuable lessons. If we don’t know or learn from history we are doomed to repeat it, and history is happening all around us.

The images on the internet teach us a lot. This is what terror looks like. This is what real patriotism looks like. This is what bravery looks like. This is what selflessness looks like. This is what real charity looks like. This is what real gratitude looks like. This is what fear looks like. This is what real desperation looks like. This is what hopelessness looks like. Look! This is what helpers look like.

Strangers helping strangers is the phenomenon that makes any of this survivable or bearable. Here is a wake-up call for the people of the world to rediscover and affirm our humanity towards each other. It is a clarion call to step away from the video games and disconnected society and engage with each other. We must change. We must be better. We must care about each other. We must love our neighbors as ourselves.

What can one person do, in a tangible way?

Donate. Welcome Ukrainian refugees, for many will undoubtedly be headed to the US in the days ahead.

1. Brother’s Brother Foundation (with Eden Hall Foundation, Highmark/AHN, the Pittsburgh Technology Council, Giant Eagle and others), is helping to provide supplies for those still in in Ukraine as well as to over 1.5 million refugees who have migrated to Poland and Romania. Visit www. brothersbrother.org and click Ukraine Relief on the donations page. Checks payable to Brother’s Brother Foundation can be sent to P.O. Box 645934, Pittsburgh, PA 15264-5257; note “Ukraine Relief” on the memo line.

2. The United Way of Southwestern Pennsylvania and The Pittsburgh Foundation are sponsoring a joint program #PghUnitedforUkraine. To donate visit www.uwswpa.org

3. Nataliya European Food Market, 4370 Murray Ave., Greenfield; and Sts. Peter & Paul Ukrainian Orthodox Church, 220 Mansfield Blvd., Carnegie; are collecting hand warmers; feminine hygiene products, diapers, baby bottles and formula; non-perishable snacks; socks and gloves for men; and other items. Call 412-421-2380 or 412-279-2111.

4. UNICEF https://www.unicef.org/ ukraine/en because over half a million Ukrainian children have become refugees.

5. Red Cross: https://www.icrc.org/ en/donate/ukraine 6. Caritas Poland (largest Polish Catholic Charity): https://caritas. pl/ukraine 7. Polish Good Initiatives Foundation: https://www.fdi.org. pl/zbiorkadlaukrainy 8. Doctors Without Borders Emergency Relief Fund www.doctorswithoutborders.org

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

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www.acms.org

e long Bengali tradition Square Drive, South Side ellectual discourse with Craving fried green tomatoes, and coffee. Here’s your buttermilk biscuits, shrimp and grits e art of Adda, with a and banana pudding – and oh yes, Editorial teas and coffees. fried chicken and waffles? Tupelo y Square delights: Honey Café will open this fall in Station Square, 6425 Penn Square to remedy that, in style. rty Con Alma Downtown, 613 Penn Burrito’s Alta Via pizza Ave., Downtown an venture to Bakery The new jewel of the Downtown e casual California style Cultural District features insanely good f its cousin, AVP. Enjoy Miami/Latin/Caribbean cuisine along able-forward dishes with live jazz. s and sandwiches for Gaucho Parrilla Argentina, 146 r seven days a week.

Sixth St., Downtown y Square, 6425 Penn The resident jewel of the Downtown rty Cultural District dazzles with an wntown Richard incredible array of steaks and wood of a restaurant called fired meats with a variety of sauces et a reservation in the and accompaniments. Takeout and ? Come enjoy its vast dine-in available. outpost, complete with Wild Child, 372 Butler St., Etna et of space and both The brainchild of Chef Jamilka oor dining.

Borges, Wild Child emphasizes coastal kery Square, 6425 and island cuisine and is sure to delight. t Liberty Mount Oliver Bodega, 225 ery Square is the Brownsville Road, Mt. Oliver

with creative food and cocktails.

Coming in the fall.

And finally …

Chengdu Gourmet, McKnight Road, Ross Township Chengdu Gourmet (the beloved James Beard-nominated Squirrel Hill hole-in-the-wall Sichuan restaurant that regularly inspires pilgrimages from all over Western PA) is planning an outpost on McKnight Road at the site of the former Oriental Market, in the plaza next to Red Lobster. This will offer a much larger dining space – 6,000 square feet – and an expanded dining menu. Something to look forward to in early 2022.

Enjoy, and be safe.

Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at reshma_paranjpe@hotmail.com.

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

Improving Healthcare through Education, Service, and Physician Well-Being.

/ August 2021

ACMS Bulletin / March 2022

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Editorial

Osher Richard H. Daffner, MD, FACR

P

hysicians, like all healthcare professionals are required to take continuing education courses to stay relevant with the stateof-the-art practices in their respective specialties as well as to maintain licensure. But what happens after they retire and are no longer practicing?

Does the love of learning stop? To an extent, that depends on the individual.

I have always had a love of learning.

I often told my students and residents that the day I stop learning is the day I’m put in the ground for eternity.

Pittsburgh is blessed with many colleges and universities that offer a

variety of learning opportunities to its large senior population. Two of the major institutions, Carnegie Mellon University (CMU) and the University of Pittsburgh (Pitt) are affiliated with the Osher Lifelong Learning Institutes (Osher, OLLI). Each of these programs provide an array of noncredit courses and activities specifically developed for adults aged 50 and older who are interested in learning simply for the joy of learning. I briefly mentioned these programs in a previous Editorial1.

The programs are named for Bernard Osher, a native of Maine, who became a successful banker and

entrepreneur. Mr. Osher, who earned his bachelor’s degree from Bowdoin College, managed the family hardware and plumbing supply business before moving to work for Oppenheimer & Co. in New York. From there, he moved to San Francisco, where he was a founder of Golden West Financial and a founding director of one of its subsidiaries, World Savings, which became the second largest savings institution in the United States. In 1970, he bought Butterfield & Butterfield, a San Francisco auction house, and sold it to eBay in 1990. World Savings merged with the Wachovia Corporation

Barbro and Bernard Osher 8

www.acms.org

Editorial in 2006 (which was acquired by Wells Fargo in 2008). As a result of these acquisitions, mergers, and his own business sense, Mr. Osher became a very wealthy man.

In 1977, he established the Bernard Osher Foundation, the purpose of which was to support higher education and the arts. It is estimated that 80% of the foundation’s funds go to education programs and 17% are designated for the arts. In 2007, Bloomberg Businessweek magazine listed Mr. Osher as the 11th most generous philanthropist in the US, citing the $805 million he had given to arts, educational, and social services up to that time. His wife Barbro is Executive Director of the Foundation.

Bernard Osher was aware of the Fromm Institute for Lifelong Learning at the University of San Francisco and approached the Senior Program in his home state at the University of Southern Maine (USM) in 2001 to offer them a grant to expand their noncredit programs for older adults.

USM renamed their program that became the first Osher Lifelong Learning Institute. From there, other colleges and universities applied for development grants. Today there are 123 OLLI programs throughout the country that are supported by million-dollar grants from the Osher Foundation. In 2004 Osher established the National Resource Center at USM to support the OLLI programs.

In 2014 the center was moved to Northwestern University’s downtown campus in Chicago.

Osher in Pittsburgh In 1974, the College of General Studies at Pitt first offered older adults the opportunity to audit undergraduate courses through a program called “College Over Sixty”. This name subsequently changed to the “Third Age Learning Community”. Beginning in 2004, a series of grants from the Bernard Osher Foundation allowed a successful OLLI program to be established at the University of Pittsburgh.

CMU established the Academy for Lifelong Learning (ALL) in 1992 with an initial membership of 300. By 2007 ALL had grown to over 1,200 members and received a grant from the Bernard Osher Foundation. This prompted joining forces with OLLI and a name change ensued. At the present time Osher at CMU has just over 2,000 members. The growth of the program combined with limited campus facilities has prompted the need for a new physical home. Plans are in place to occupy newly renovated classroom space in Cyert Hall on the CMU campus once Covid-19 restrictions are lifted and on-campus classes can resume.

Only a small portion of the seniors in the Greater Pittsburgh area have access to the courses offered by Osher at CMU and OLLI at Pitt. To address this situation, in August of 2019 the Executive Director and the President of Osher at CMU began a series of meetings with Chatham University’s President. These meetings led to an agreement for the CMU Osher program to begin partnering with Chatham University to offer courses at their Eden Hall Campus in Gibsonia, PA. The

rationale for this move was the result of a membership analysis that revealed that as many as a quarter of the CMU members lived either in the North Hills or places where the Eden Hall Campus is more easily accessible than the CMU campus in Oakland.

The programs at both universities offer a variety of classes in three broad categories: Academic, Exploration, and Enjoyment. Academic classes make up the majority of the offerings. These are like undergraduate college courses with an instructor or study leader lecturing most of the time. Exploration courses are more “hands on” or may be an academic topic taught through interactive group discussion.

Enjoyment courses are spent with the learners discussing a topic, practicing a skill, or engaged in group sharing or discussion. During the COVID-19 pandemic, all classes at Pitt and CMU were held on Zoom®. The CMU Osher program is planning on offering some classes on-campus and some on Zoom®.

The catalogs at OLLI at Pitt categorize their offerings in the following areas: Art History and Architecture; Film, Music, and Theater; Fitness, Health & Self-Interests; History, Classics, and Philosophy; Language Studies; Literature and Creative Writing; Math and Economics; Political, Social Sciences and Society; Religious Studies; Science, Technology, and Medicine; and Visual and Performing Arts. All programs are held on various parts of the Pitt Oakland campus.

Osher at CMU offers courses in Arts and Humanities (Art, Cinema / Film, Literature, and Music); Business Continued on Page 10

ACMS Bulletin / March 2022

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Editorial From Page 9

Editorial

and Commerce (Economics, Law); Learning by Doing (Art, Crafts / Hobbies, Dance / Exercise, Rear End Gastropub & Finance, Garage, Insurance, Games, Language, Self399 Butler St., Etna Improvement, Wellness, and Writing); For a culinary cross-country road Science (Architecture, Environment, trip, stop in this converted auto service Life Science, and Medical); and Social station for a taste of roadside delights Science (Contemporary Topics / from coast to coast from Chef Anthony Sociology, History, Pittsburgh, Politics Tripi. Twenty draft beers and fun /cocktails Government, Religion / Philosophy, to boot. andAdda Travel.

The majority of the Bazaar, 725 Penn Ave., programs are on the CMU campus.

Downtown However, a number areCoffee at remote The newest of Adda & Tea sites, such as the Mellon Institute, the House’s multiple downtown cafes. Adda Pittsburgh various theaters and is the term Aviary, for the long Bengali tradition dance studios, and Friends Meeting of stimulating intellectual discourse with House Oakland. in-person friends in over tea andOnce coffee.

Here’s your classes resume, Osher will chance to try the art of Adda,have with aa satellite at the Hall selectionprogram of fine teas andEden coffees. campus of Chatham University.

Three Bakery Square delights: With excellent programs AVP, two Bakery Square, 6425 Penn available, how does one decide which Ave., East Liberty program to Big join?Burrito’s The instructors for Fans of Alta Via pizza both programs are, for the most part, in Fox Chapel can venture to Bakery retired in their areas style Squareprofessionals to try the casual California of expertise.

Most held previous Italian cuisine of its cousin, AVP. Enjoy academic appointments. Thedishes Pitt seasonal vegetable-forward program is under the auspices of the as well as pizzas and sandwiches for College of dinner Generalseven Studies. lunch and daysAta the week. present OLLISquare, at Pitt has täkō,time, Bakery 6425open Penn membership because of adequate Ave., East Liberty space forthe classes.

Faculty members Love downtown Richard receive a small Annual DeShantz jewelhonorarium. of a restaurant called membership (three consecutive täkō, but can’t get a reservation terms) in the is $225. Single membership is crowded space?term Come enjoy its vast $125.

Catalogs listing current courses Bakery Square outpost, complete with are on-line.

5000available square feet of space and both The Osher at CMU program is a indoor and outdoor dining. welcome of Carnegie Galleyguest – Bakery Square,Mellon.

6425 Penn Ave., East Liberty Galley – Bakery Square is the

When on campus classes were in person, they had two classrooms as wellbranch as office space in Wein Hall. latest of the Galley restaurant As a result of space limitations, incubator concept, featuring the same membership limited to Federal 2,000, and formula as itsissister sites Galley there is a waiting list to join.

Osher at on the North Side and the Strip District CMU is inFour the emerging process ofchefs completing location. are their fundraising efforts to build out selected to open their own restaurant their Cyert Hall.

They to withinnew the space space,inwith 12-18 months now have two lounges, contiguous win over an audience and establish their office and and brand.space, You can tryadjustable a little of everything expandable classroom space, from all four restaurants during as thewell as meeting The space in same meal –rooms. heaven fornew foodies.

Cyert Hall is expected to be open in Tupelo Honey, 100 West Station time for the second halfSide of the Winter Square Drive, South 2022 term.

Also, many of the members Craving fried green tomatoes, ® format prefer usingbiscuits, the Zoom buttermilk shrimp and which grits will continue even after in person and banana pudding – and oh yes, classes resume. membership fried chicken andAnnual waffles?

Tupelo is currently $100.

In addition, is Honey Café will open this fall there in Station aSquare $60 registration to remedyfee that,forineach style.of the three terms.

Once registered forPenn a Con Alma Downtown, 613 term, member may attend as many Ave., aDowntown courses as they Faculty receive The new jewellike. of the Downtown honoraria and their parking expenses Cultural District features insanely good are reimbursed.

Catalogs listing current Miami/Latin/Caribbean cuisine along courses with live are jazz.available online.

IGaucho have been a member of Osher Parrilla Argentina, 146at CMU 2015. I am a Study Leader Sixthsince St., Downtown for five courses.

Three,of“History of The resident jewel the Downtown Medical “Med-Mal Cultural Imaging”, District dazzles with 101”, an and “First Aid: You are the First Responder” incredible array of steaks and wood fit in with mywith medical background. fired meats a variety of sauces However, as Monty Python oftenand said, and accompaniments. Takeout “And now, for something completely dine-in available. different,” I have372 added twoSt., history Wild Child, Butler Etna courses, “Ancient of Historians,” and The brainchild Chef Jamilka “History’s Villains.”

These courses Borges, Wild Child emphasizes coastal resulted from my lifelong interest in and island cuisine and is sure to delight.

Mount Oliver Bodega, 225 Brownsville Road, Mt. Oliver

history. I have also been faculty at OLLI at Pitt, as have many of the Study Leaders from CMU. I find thatproject teaching Chef Kevin Sousa’s new will in these programs is a rewarding combine a wine shop, bar and pizzeria experience. teaching medical in the formerUnlike Kullman’s Bakery space. students, residents, and fellows, Sustainable, biodynamic and organic the learners in Osher a mature wines from around theare world will be audience, who are highly motivated featured along with a down to earth, to learnmenu. (otherwise, they wouldn’t rustic Nonalcoholic wines and be there). cocktails also will be showcased.

Learning shouldn’t endLiberty when one G’s On Liberty, 5104 Ave., retires.

I encourage you to visit the Bloomfield websites of each of these excellent G’s turns former Alexander’s Italian programs to see what they offer.

Bistro into a seasonal scratch kitchen Regarding thefood CMU program, I with creative and cocktails. recommend applying before anticipated Coming in the fall. retirement because And finally … of the waiting list.

(I waited nearly two yearsMcKnight before being Chengdu Gourmet, admitted.)

YouTownship won’t be disappointed.

Road, Ross Chengdu Gourmet (the beloved James Beard-nominated Squirrel Hill Reference: hole-in-the-wall Sichuan restaurant 1. Daffner RH. You can’t go home that regularly inspires pilgrimages from again. ACMS Bulletin, October all over Western PA) is planning an 2021, 282 – 284. outpost on McKnight Road at the site of the former Oriental Market, in the plaza next to Red Lobster. This will offer Dr.Daffner is a retired radiologist, a much larger dining space – 6,000 who practiced at Allegheny General square feet – and an expanded dining Hospital for over 30 years. He menu. Something to look forward to in is Emeritus Clinical Professor of early 2022.

Radiology at Temple University Enjoy, and be safe.

School of Medicine and is the author of 9 textbooks.

Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at The opinion expressed in this column is that of reshma_paranjpe@hotmail.com. the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, the Allegheny County Medical Society.

Theoropinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

Improving Healthcare through Education, Service, and Physician Well-Being.

Editorial

Terence W. Starz, MD

Move it or lose it: Promoting wellness and exercise in senior adults

Being healthy and practicing healthy living activities including proper diet, exercise, sleep, and stress control are goals that most individuals desire.

However, desiring and achieving these are frequently mismatched. The science of aging and body restoration has advanced tremendously over the past two decades including the significant inherent capacity of the body to adapt, heal, and weather the many internal and external stresses placed on it. While this capacity has limitations with aging, an individual can do much to influence it. Over a lifetime, changes occur in all organs with associated reductions in reserve capacity. For example, the peak bone mass, visual acuity, and hearing range occurs at approximately age 30. If needed, some correction can be made with medicines, glasses, and a hearing aid.

Aging changes also occur in muscles primarily related to inherent factors and reduction in physical activity.

These include decreased number and size of muscle fibers with fibrous and fatty tissue replacement (sarcopenia), decreased contractility, and less tone.

Joints are then impacted because decreased muscle support increases mechanical stress with activity. Muscle and joint alterations are daunting and difficult to improve; however, wellness strategies including a regular directed ACMS Bulletin / March 2022

exercise program can positively impact the musculoskeletal system.

The benefits of exercise can result in enhanced physical, mental, and social well-being especially when done consistently and with other individuals.

Conceptualization of well-being solutions to musculoskeletal aging changes are relatively straightforward, however, their implementation has been extremely challenging. Barriers have been cost, program development with valid outcomes, training of program leaders, access logistics including transportation, marketing, and political commitment that supports long-term program sustainability. In Allegheny County 19.3% or 241,250 individuals of the 1,250,758 total population are over 65 as of 2021.

This group has a significant incidence of diabetes, arthritis, heart disease, and hypertension. A laudable goal would be to have Pittsburgh and Allegheny County become the healthiest and most physically active areas in Pennsylvania. Seattle’s example of promoting physical activity and recreation would be a good comparable city to follow.

In 2016, the Jewish Healthcare Foundation created the multi-pronged Senior Connections initiative “aimed at strengthening connections to services and supports that our region’s

seniors require to live safely and satisfyingly in the community.” Three core components were developed in partnership with the Allegheny County Medical Society and others which included: recreation and exercise opportunities for seniors, applications to lower isolation and loneliness among seniors, and transformation efforts to create geriatric friendly medical practices. Challenges to the initiative have been developing engagement with patients and primary care physicians and other healthcare professionals, program training, and establishing collaboration with community shareholders. Although existing community exercise programs such as Silver Sneakers, Vintage, Jewish Community Centers (JCCs), and health clubs are generally quite effective, they have some utilization issues including limited senior citizen awareness of programs, seniors’ hesitancy to “try new things,” attracting underserved populations, marketing with electronic and other media, focus primarily on indoor programming, and cost. COVID has had a major impact on all programs over the past two years.

With the help of ACMS and Venture Outdoors, Senior Connections in 2017 developed the “Fit with a Physician” Continued on Page 12

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program. Venture Outdoors is a nonprofit organization founded in 1991 whose mission is to “remove barriers and create access to outdoor activities for all ages and demographics.”

The goal of “Fit with a Physician” was to explore how a physician and healthcare professional team could provide an outdoor exercise experience for seniors coupled with an educational component in Pittsburgh and Allegheny County parks. The program initially had Walks in area parks on most months however has been limited by COVID epidemic. Walks are promoted as “an easy paced walk that gets our bodies moving and stimulates our minds.”

The number of walkers range between 10 and 25, and there is one physician, two physical therapists along with 1-2 leaders from Venture Outdoors who provide the Walk organization and are trained in safety and First Aid. Trails are chosen by Venture Outdoors for their suitability to seniors including relatively flat surfaces with manageable irregularities, and access to rest rooms and emergency services.

During the walks there are 5-6 twoto-three-minute pauses on the trail for interactive discussions between the the healthcare professionals and walkers about the day’s topic. Topics include understanding the mechanics of proper walking, exercise and healthy living principles, and the role of exercise in weight control, diabetes, arthritis, osteoporosis, and heart disease. There is a content manual for these topics to ensure reproducibility for the discussers. Walks are being planned that incorporate flora and fauna identification, Tai Chi, meditation, 12

is offered to residents of these facilities and poetry readings. A typical Walk and other Western Pennsylvania lasts one- and one-half hours or less seniors. depending on the walkers’ capabilities In summary, the “Fit with a and are currently free to individuals Physician” program has been well 55 and older funded by the Jewish received and has achieved its goals Healthcare Foundation. of helping seniors better understand Ten outdoor Walks were live of the importance of regular exercise streamed via the Virtual Senior in promoting their physical and mental Academy (currently run by the JCC) health. Many individuals have gone to individuals unable to do the Walk, which have been currently discontinued on multiple walks. One individual who needed a cane for stability stated at the because of technical and production beginning of a Walk that “I’ll never be issues. In addition, programming in able to do this, but I’ll give it a try”. selected Pittsburgh Senior Healthy At the end of the Walk, she said, Living facilities is on hold because “I feel so much better. Why didn’t I of COVID. With the help of AARP, the program get out and do this before?”

With the evolution and expansion has expanded to have “Fit with your of the “Fit with a Physician” Walks, Legislator” Walks with the healthcare great opportunities are available team and legislators including PA House Representative Ed Gainey (now for physicians including those who Mayor of Pittsburgh), PA Senator Sara have retired and other healthcare Innamorato, PA State Senator Lindsey professionals to participate in programming which can provide them Williams, and City Council members with significant satisfaction in being Erica Strassburger, Corey O’Conner, and Deb Gross. Plans are underway to able to impact the lives and health of seniors and our community. If you have “Fit with Friends,” “Fit with your would like to consider volunteering in Dog,” “Fit with and Actor,” “Fit with an Athlete,” “Fit with a Librarian,” “Fit with this Venture Outdoors program, please contact me at starztw12@gmail.com. a Grand-friend,” and “Fit with a Grad” Walks.

Over the past year the “Fit with a Physician” Walk program has added indoor and outdoor programming in : two senior living facilities: Friendship Village with the help of exercise specialist Ernie Tolantio, retired ” I will not let age change me. dancer with the Pittsburgh Ballet and I will change the way I age.” in Cumberland Woods. Other Venture outdoors programming including fishing “ Age is not a number. If there on the Allegheny River, kayaking, walks was ever an anti-aging pill, of varying degrees of difficulty, biking, snow shoeing, and cross-country skiing I would call it exercise.”

Health and exercise quotes

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Perspective Perspective

What is the future of cybersecurity in health care?

Ransomware, patient safety, and the protection of physician-patient communications.

Bruce Wilder, MD The health care sector was slow to adopt the electronic health record (EHR) as part of its health information technology (HIT) strategy, for several reasons. Unfortunately, caution apparently was not one of them. It was not until shortly after the EHR became widely adopted in the first decade of this century that the, perhaps inevitable, array of new problems began to emerge. New problems and new challenges, some anticipated, and some not, commonly arise after new technologies are introduced. That has been true for centuries.

Patient-safety issues related to the EHR are being identified and dealt with, but the struggle is just beginning.1,2 The phenomenon of ransomware is, of course, not unique to HIT and the health care sector. It appears to be increasing, but there a number of ways in which it can be combatted.

Ransomware is a computer code that is surreptitiously inserted into computer networks, and has the capacity to make systems ineffectual, and restorable only by payment of ransom, usually on the order of several millions of dollars, depending upon the victims’ ability to pay. The availability of digital currency schemes, such as Bitcoin, a still rapidly-evolving technology,

enables the transfer of funds in a way that protects the identity of the perpetrator (which may be domestic or foreign—both non-governmental and governmentally supported or tolerated). Governments and industry are, however, beginning to find ways to thwart such transfers and identify the criminals that use it.

The use of block chain3 technology to store medical record information can protect the availability of such information but at significant potential risk to the privacy of such information, including the protection of physicianpatient confidentiality. Moreover, it, too is an evolving technology and is by no means a ready panacea.4 The use of open-source code in the EHR can improve the potential to detect the presence of malicious code in computer networks, in that “many eyes” can be on the lookout for such code, as opposed to only those of the vendor if the code is secret. But “many eyes” are only effective if they are actually looking. Vendors have a greater incentive to develop protections against hacking, including insertion of ransomware or data-breaching software, if they are not allowed to require “hold harmless” clauses in their contracts with health care entities. Data breaches can occur on many levels

and it is not always easy to determine liability. Nonetheless, institutions and/or vendors can be fined huge amounts for data-breaches, depending upon the circumstances.

The use of cloud5-based EHR, a phenomenon that is increasing in popularity, can be of value, especially to smaller entities like group practices that do not have the sophisticated expertise and other resources to maintain protection against malware.

The downside is that the cloud is still faced with the challenges of hacking and ransomware. If things go wrong, there may also be troublesome questions of liability. Service contracts with cloud service providers should be carefully scrutinized.

The need for powerful encryption of medical information, whether at the point of care, or remotely stored, should go without saying.

However, encryption systems are not impenetrable, and need constant updating to maximize their effectiveness.

The need for regular back-ups cannot be overemphasized, and health care entities should be constantly improving their backup systems, including maintaining multiple locations, whether in the cloud, on site, Continued on Page 14

ACMS Bulletin / March 2022

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Perspective Perspective From Page 13

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The upside is that we may learn – painful as the process may be – a great deal about how to make our health care systems more secure in the process.

An important step toward strengthening cybersecurity is the recent passage of S.3600, Strengthening American Cybersecurity Act of 2022 (also known as the Federal Information Security Act of 2022), currently under consideration in the House. That legislation, if enacted, would require critical infrastructure (including healthcare and public health) entities to report “substantial cyber incidents” to the Cybersecurity and Infrastructure Security Agency (CISA) within 72 hours, and to report ransomware payments within 24 hours.9 I believe that, ultimately, we will learn how to manage the new problems that have arisen with the introduction of HIT, but it will take hard work and a rearranging of priorities to reach the point where we are able to reap its benefits without sacrificing the basic underpinnings of a safe and effective infrastructure for the delivery of health care.

4. Afraz N, Is blockchain a friend or foe in ransomware attacks?, https://www. siliconrepublic.com/enterprise/blockchaincybersecurity-nima-afraz

References:

9. Jercich K, Senate mandates cyberattack reporting to CISA, 3/9/22, Healthcare IT News, https://www.healthcareitnews. com/news/senate-mandates-cyberattackreporting-cisa

1. Blease C, et al. Sharing Clinical Notes: Potential medical-legal benefits and risks, JAMA 2022;327(8):717-718.

5. Although the term “cloud” suggests some remote, ephemeral location of data and software, its infrastructure is really physically identifiable so-called data and server farms very much located on this earth.

6. A logic bomb is code that triggers the execution of other code when certain conditions are met. It may have a legitimate or illegitimate purpose. Here, I refer to its illegitimate purpose of triggering malware capable of corrupting or deleting data or legitimate programs, stealing sensitive date, or siphoning off funds, and that may be dormant until certain conditions are met. A time bomb is basically a sub-category of logic bomb that does so at a given date and time. See https://en.wikipedia.org/wiki/ Logic_bomb for further details

“

or siloed in private remote locations.

Obviously, there are significant cost considerations, but they need to be weighed against the potential costs of fines for data breaches or ransom demands. Regular, isolated backups without concurrently searching for malware may provide a false sense of security if the possibility of “time bombs” or other “logic bombs”6 is not considered. In other words, malware may exert its effects long after it has been inserted, and long after monthsold pre-hacking backups have been deleted to save storage space.

Finally, the Achilles heel of nearly all protection systems are the users themselves, who must necessarily have access to health care information at the point of care, and in claims processing (the latter being, at least in theory, arguably not necessary).

That means ongoing training of users in prevention against hacking, and the development of methods for prevention of sabotage by, say, a disgruntled authorized user.

As I am putting the final touches on this article, we are beginning to see the cyber fall-out of the Russian invasion of Ukraine. Not surprisingly concerted efforts to hack the Russian economic infrastructure have already begun, and it remains to be seen how effective (and devastating) cyberwarfare by either side will be in the coming months. Certainly, though, we will have entered into a new era of international conflict and there is much uncertainty as to how much this will affect us in the years to come, including in the area of health care.7,8

7. Henderson J, Watch Out for Cyberattacks Following Russia’s Invasion of Ukraine, 2/25/22, https://www.medpagetoday.com/ special-reports/exclusives/97385

8. Gerstell G, America Isn’t Ready for the Cyberattacks That Are Coming, 3/5/22, New York Times, https://www.nytimes. com/2022/03/04/opinion/ive-dealt-withforeign-cyberattacks-america-isnt-ready-forwhats-coming.html

2. Sittig D, et al. Guidelines for US Hospital and Clinicians on Assessment of Electronic Heath Record Safety Using SAFER Guides, JAMA 2022;327(8):719-720.

3. Block chain is a relatively new technology that has the potential to protect the integrity of encrypted data. See https://en.wikipedia. org/wiki/Blockchain

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

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Perspective Perspective

SERVING THE UNDERSERVED (Catholic Charities Free Healthcare Center celebrates its 15 year Anniversary) Michael G. Lamb MD Medical Director Catholic Charities Free Healthcare Center Back in the 1990s, millions of Americans had no health insurance.

As a result, access to health care was a real problem for many Americans, especially the working poor. In 1994, in cooperation with Dr. Bruce Dixon, director of the Allegheny County Health Department, Quest Diagnostics, Allegheny General Hospital, the Catholic Physicians Guild of Pittsburgh, myself and several volunteer physicians and nurses created some outreach programs in the inner city to provide preventive health care to Pittsburgh’s underserved communities.

The volunteer doctors and nurses made use of local neighborhood churches and a mobile health care van to provide basic physical examinations, as well as screening programs for hypertension, diabetes, prostate cancer, and hyperlipidemia. When the Allegheny Health Network (formerly known as AHERF) collapsed, most of these programs also faltered, except for the hypertension and prostate cancer screening initiatives that were adopted and improved by the UPMC Department of Family Medicine under the direction of Dr. Jeannette South-Paul.

ACMS Bulletin / March 2022

It was in 2002 that Dr. Ed Kelly, an orthopedist at Pittsburgh’s Mercy Hospital and Sister Pat Cairns of Catholic Charities of Pittsburgh, decided to take things several steps further. They worked with Catholic as well as non-Catholic volunteers and the Diocese of Pittsburgh to start an initiative that eventually became the Catholic Charities Free Healthcare Center. Dr. Kelly recruited multiple medical and dental volunteers to staff the center and he personally served as a volunteer medical director for over a decade. Once the fundraising, staffing, equipping, and remodeling processes were completed, the clinic officially opened its doors in 2007 (in what was formerly the Federal Reserve Building at the corner of Ninth Street and Liberty Avenue). Sister Carole Marie Blazina, one of the Sisters of Charity of Seton Hill and a nurse practitioner, functioned as the center’s first clinical director. The center immediately filled a dire need in our city. It was very busy and provided both primary and specialty medical care as well as extensive dental services. The Free Health Care Center has all the basics except a billing department. No one is charged any payment for services rendered at the Free Health Care Center. The original partners of the Free Health Care Center included

the Diocese of Pittsburgh, Highmark, UPMC, Marenick Dental Associates, Giant Eagle Inc., Duquesne University and the Mylan School of Pharmacy.

According to Dr. Kelly, during the early years of its operation, the clinic saw between 3,000 to 4,000 patients per year. Dr. Kelly stepped down as the medical director about 5 years ago. He received several prominent awards in recognition of his efforts including the Catholic Charities’ Caritas Award and the John Heinz Award.

The center continues to thrive and excel in its mission to provide basic and specialty dental services, preventive medical care, primary medical care and specialty medical care to those in need.

More people in our region have health insurance benefits now in comparison to 2007 and yet a UPMC study in 2018 reported a little over 40,000 medically uninsured within the Pittsburgh city limits. Plus, having health insurance doesn’t necessarily equal good access to care or quality care (especially for the working poor, immigrants and minorities). Currently nearly 70% of the clinic’s patients are immigrants.

Eligibility criteria are periodically reviewed and revised to ensure that those most in need have access to the center’s medical and dental services.

Eligibility may soon be based only Continued on Page 16

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Perspective Perspective From Page 15

on economic criteria (regardless of insurance status) with a possible cutoff at incomes of 2.5 times the poverty level.

The Catholic Charities Free Healthcare Center’s medical clinic is overseen by Clinical and Nurse Manager Carolyn Garver RN, CNP who was Pennsylvania’s Nurse Practitioner of the Year in 2018. Currently the clinic has six family medicine specialists, two general internal medicine specialists, as well as subspecialists in the fields of cardiology, infectious disease, pulmonology, physical therapy, endocrinology, general orthopedics, spinal orthopedics, general surgery, audiology, optometry, ophthalmology, psychology/counseling and rheumatology that donate their time working on site. Multiple volunteers in nursing, pharmacy and clerical disciplines support this staff. There is also a nurse certified in diabetic teaching and a podiatrist will soon be joining the staff. Additionally, the clinic is associated with offsite consultants in general surgery, upper extremity orthopedics, gynecology, lower

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extremity orthopedics, family medicine, urology, otolaryngology, retinal disease, ophthalmologic surgery, hand surgery and dermatology who agree to see patients at no charge.

The Catholic Charities Clinic partners with UPMC (especially UPMC Mercy and UPMC Saint Margarets), AHN, The AGH Department of Imaging, the Hillman Cancer Center, Global Links, Giant Eagle Pharmacy, the Diocese of Pittsburgh, Duquesne University School of Nursing, the University of Pittsburgh Graduate School of Public Health, the Greentree Highfield Imaging Center, and Weinstein Imaging as well as multiple corporate and individual donors. The dental clinic offers both basic and advanced adult dental care. It partners with the University of Pittsburgh Dental School and is directed by Frank Parise DMD. The clinic is open Monday through Friday from 8:30 AM to 4:30 PM. Physician, nurse, physical therapy, clerical, dental, and pharmacy volunteers are always welcome. Major needs currently are for gynecology and psychiatry specialists. Presently, the center is not involved in pediatric

care, obstetrics, pain management or substance abuse treatment. The Catholic Charities Free Healthcare Center also has a strong teaching mission. The physicians at the center teach basic and advanced physical diagnosis to first, second, and thirdyear University of Pittsburgh medical students. They also teach Pitt nursing students, Pitt Dental School SCOPE students, Duquesne University Nurse Practitioner students and graduate students from the University of Pittsburgh Graduate School of Public Health. Research initiatives involve the way to best deliver early detection cancer screening to indigent and minority populations.

The Catholic Charities Free Health Care Center is a source of excellent care for needy people in our region, especially immigrants and minorities.

Unfortunately, it is not as well known or as frequently utilized as it should be, but it’s getting there. It won’t remain Pittsburgh’s best kept healthcare secret for very long.

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

www.acms.org

Society News Pittsburgh Ophthalmology Society welcomes David Crandall, M.D. The Pittsburgh Opthalmology Society concluded their 2021-2022 monthly meeting series on February 3, 2022 and welcomed guest faculty David Crandall, M.D., staff ophthalmologist, Henry Ford Eye Care Services, Department of Ophthalmology, Henry Ford Hospital, Detroit, MI. Thank you to Ian Conner, M.D., Ph.D. for inviting Dr. Crandall and to Aerie Pharmaceuticals for support of the program.

Dr. Crandall presented, Update on Pseudoexfoliation and Outreach Ophthalmology. Both presentations provided the basis for an engaging question and answer session. Manuel Paez-Escamilla, MD., Resident at the University of Pittsburgh Eye Center, presented an interesting case for commentary by Dr. Crandall.

The Pittsburgh Ophthalmology Society’s 2022-2023 monthly meetings series will begin in September. Members will receive complete meeting details in August and are asked to visit the website at www.pghoph.org periodically for updates.

Attendees at the February 3rd meeting include (l to r) Albert Biglan, M.D.; President Marshall Stafford, M.D.; Ian Conner, M.D., Ph.D.; Presenter David Crandall, M.D.; Patrick Commiskey, M.D.; Manuel Paez-Escamilla M.D. (Resident Case Presenter)

ACMS Bulletin / March 2022

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Materia Medica

Breaking Down the Cost Barrier: Helping Patients Afford Their Medications Melanie Riggio, Pharm.D., PGY-1 Ambulatory Care Pharmacy Resident, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA A national survey performed by West Health/Gallup in 2021 reported that 15.5 million adults younger than 65 years old and 2.3 million adults 65 years or older were unable to pay for at least one prescription medication in their household.1 Medications can be life-saving, yet unaffordable. Disease states can worsen, which can cause ER visits and hospital admissions/readmissions, overall increasing healthcare costs.

How can we as healthcare providers help?

The first step to helping a patient with medication affordability is to determine the type of prescription coverage. Commercial insurance, Medicare, and Medicaid all cover prescriptions differently. Next, determine which medication affordability option is best for the individual patient.

Commercial Insurance: This type of insurance can be provided by an employer or be self-bought, and the patient pays a monthly premium. Most plans have an annual deductible that must be met before the insurance will cover any of the medication costs. Once the deductible is met, the patient will still be responsible for a copay or coinsurance. A copay is the dollar amount patients owe for their prescriptions, while coinsurance is the percentage patients owe.

The copay or coinsurance is determined by the drug tier that the prescription falls into.

Insurances usually have a formulary, where they place drugs into five tiers. Typically tier

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1 medications are preferred generics, and patients have lower copays. Tier 5 medications are usually specialty medications, and patients pay a coinsurance instead of a copay.2,3 Some options to help with medication affordability for commercially insured patients include coupon cards and 340B clinics.

Coupon cards are provided by manufacturers and can be found on their websites. The coupons do expire, and can be terminated by the manufacturer at any time. To use a coupon card, the medication must go through commercial insurance first. Previously, the full copay amount of the drug would still go towards a patient’s deductible. Starting in 2021, copay accumulator adjustment programs were approved. These programs allow insurance to deduct the cost from the coupon, so less money goes towards the patient’s deductible.

For example, if a patient’s copay was $100 and the coupon card lowered the copay to $5, previously the full $100 would go towards the deductible. Now, if the insurance participates in the program, only $5 will go towards the deductible. This means it takes longer for patients to reach their deductible, which may increase out-of-pocket costs. Another caveat to coupon cards is the “max spending.” This is the maximum amount the card will remove from the patient’s copay. For example, when a coupon states, “For as little as $25, with a max spending of $100,” a patient with a $200 copay would pay $100 with the coupon. This is because the maximum amount the coupon will cover is $100. A patient with a copay of $100 would pay $25. This is because the

minimum copay with the card is $25. Some manufacturers also offer free trial cards that do not need to go through insurance first, but can typically only be used once.4,5,6,7 Another option is 340B clinics. 340B is a drug price control program for eligible providers, also known as covered entities.

To be eligible, the facility must serve a disproportionate number of low-income and indigent populations. These covered entities can purchase drugs from manufacturers at a discount (typically up to 50% off). The entity can still bill the insurance for the full cost of the drug, generating revenue known as 340B funds. These funds can be used for any patient/service, but the purpose of the program is to use the revenue to support low-income and uninsured patients. Manufacturers must participate in this program to be included on the Medicaid preferred drug list.8,9

Medicare: Patients who are 65 years or older, on disability for at least two years, or have ESRD or ALS are eligible to receive Medicare. There are many different plans to choose from, which can be overwhelming for patients. The PA Medicare Education and Decision Insight (PA MEDI) is a resource that provides patients with a counselor to help with choosing a Medicare plan. Medicare part D is the prescription drug coverage. Patients pay a monthly premium and drugs are classified into tiers based on the formulary similar to commercial insurance.

Medicare patients go through four phases of their part D plan that resets each year:

www.acms.org

Materia Medica The coverage gap, also known as the “donut hole,” is where many patients experience affordability difficulties. At this phase, patients are responsible for 25% of their drug costs. This can be extremely expensive for brand name medications such as insulin or DOACs.10,11 Some options to help with medication affordability for Medicare patients include Patient Assistance Programs (PAPs), PACE/ PACNET, Extra Help/Low-Income Subsidy (LIS) Program, and 340B clinics. PAPs are free or low cost medications provided by manufacturers to eligible patients. Each program/medication has its own eligibility requirements. Applications and requirements can be found on manufacturer websites.

To apply, patients will likely need to provide income and/or tax information and get the prescriber’s signature. If approved, the medication is typically delivered to the patient’s

home or to the doctor’s office for pick-up. The caveat for PAPs is that some require a “spend down.” This means the patient must pay a certain amount out-of-pocket for prescription drugs for the year before he/she is eligible.12 PACE/PACENET is a program funded by the Pennsylvania lottery. Eligible patients (see below) can get prescriptions at low cost.

This program does have its own formulary and can require prior authorizations just like a regular insurance plan. The application can be completed online, by mail, or over the phone.

If a patient completes the application over the phone, he/she will automatically be checked for eligibility for certain other programs as well.

Of note, if a patient does not have a part D plan, he/she can still be eligible for PACENET, but will have to pay a monthly premium. This does not apply to PACE.13 The PACE/PACNET program is specific to Pennsylvania, but other states may have similar programs.

The Extra Help/LIS Program assists with prescriptions costs, covers monthly premiums, and allows patients to switch plans outside of the enrollment period. To be eligible, patients must meet certain income requirements and have a part D plan. Medicaid, Supplemental Security Income (SSI), and Medicare Savings Program (MSP) patients are automatically enrolled.14 340B clinics can also be an option for Medicare patients (discussed above).

Medicaid: This federal program provides medical assistance to individuals and families with low incomes. Medicaid has a statewide preferred drug list that is similar to a formulary, except drugs not on the list may still be covered with a prior authorization. Exact eligibility requirements varies by state. Patients with Medicaid will pay very low copays for medications, and in some states if a patient cannot pay, the copay is required to be waived.15

Uninsured: The best way to help these patients is to recommend insurance. They may be eligible for a government program such as Medicaid.

Some other options to help with medication affordability for uninsured patients include Patient Assistance Programs (PAPs), 340B clinics, nonprofit pharmacies, GoodRx, and cost support. Nonprofit pharmacies provide prescriptions at much lower cost to patients who are underserved or uninsured.

Rx Outreach is an example of a nonprofit, mail order pharmacy.16 GoodRx is a free resource that gathers prices from surrounding pharmacies near the patient to provide a cost comparison. Coupons can be printed and brought into the pharmacy, and cannot be used with insurance.17 Cost support options for uninsured patients may be provided on manufacturer websites.

Continued on Page 20

ACMS Bulletin / March 2022

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Materia Medica From Page 19

Summary: Cost of medications is a barrier to adherence for many patients. Low adherence leads to uncontrolled disease states, and hospital admissions/readmissions. As healthcare providers, we can help patients break down the cost barrier, by determining a patient’s prescription coverage and then choosing a medication affordability option that is best for that individual patient.

Summary of the medication affordability options based on insurance type.

References:

1. Americans struggling with high cost of prescription drugs. HealthDay. Sept 2021. https://consumer.healthday.com/americansstruggle-with-rx-costs-2655027927.html.

2. Understanding commercial health insurance. Medical Billing & Coding Certification.

2021. https://www.medicalbillingandcoding. org/health-insurance-guide/commercial-health-insurance/.

3. Davalon BY. What you need to know about prescription drug costs and coverage. eHealth. Nov 2021. https://www.ehealthinsurance.com/resources/affordable-care-act/ need-know-prescription-drug-costs-coverage.

4. H ilas O. A pharmacist’s primer on prescription discount cards. US Pharm.

2021;46(10):21-23. https://www.uspharmacist.com/article/a-pharmacists-primer-on-prescription-discount-cards.

5. Coupons, rebates, & more. NeedyMeds. https://www.needymeds.org/coupons.taf?_ function=name_list&gname=apixaban.

6. Ryan E, Fitts E. The hidden costs of discount cards: understanding copay accumulator adjustment. diatribe Learn Making Sense of Diabetes. Mar 2019. https://diatribe.org/hidden-costs-discount-cards-understanding-copay-accumulator-adjustment.

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7. Chase L. What are manufacturer copay cards? GoodRx Health. Sept 2019. https://www.goodrx.com/healthcare-access/patient-advocacy/what-are-manufacturer-copay-cards.

8. What is the 340B drug pricing program?

Azalea Health. 2021. https://www.azaleahealth.com/blog/340b/.

9. 340B drug pricing program overview.

340B Health. https://www.340bhealth.org/ members/340b-program/overview/.

10. Costs for Medicare drug coverage.

Medicare.gov. https://www.medicare. gov/drug-coverage-part-d/costs-formedicare-drug-coverage.

11. Phases of part D coverage. Medicareinteractive.org. https://www.medicareinteractive.org/get-answers/medicare-prescription-drug-coverage-part-d/ medicare-part-d-costs/phases-of-part-dcoverage.

12. Chase L. What are patient assistance programs? GoodRx Health. 2019. https://www.goodrx.com/healthcare-access/patient-advocacy/what-are-patient-assistance-programs.

13. PACE - prescription assistance. Pennsylvania Department of Aging. 2021. https:// www.aging.pa.gov/aging-services/prescriptions/Pages/default.aspx.

14. The extra help/low-income subsidy (LIS) program. MedicareInteractive.org. 2021. https://www.medicareinteractive.org/ get-answers/cost-saving-programs-forpeople-with-medicare/the-extra-helplow-income-subsidy-lis-program.

15. Statewide preferred drug list information.

Department of Human Services. 2021. https://www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Preferred-Drug-List.aspx.

16. Our Story. RxOutreach The Nonprofit Pharmacy. 2021. https://rxoutreach.org/.

17. How goodrx works. GoodRx. 2021. https:// www.goodrx.com/how-goodrx-works.

Dr. Riggio is a PGY-1 Ambulatory Care Pharmacy Resident at Allegheny General Hospital. For any questions concerning this article, please contact Melanie Riggio, Pharm.D., at the Allegheny Health Network, Allegheny General Hospital, Center for Pharmaceutical Care, Pittsburgh, PA. (412) 359-3192 or email melanie.riggio@ahn.org

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GRASS ROOTS SUPPORT

Sarcomas are rare tumors in the world of oncology. Approximately 12,000 new cases are diagnosed in the U.S. yearly. This compares to 926,000 new breast cancer cases each year.

For this reason alone, support for sarcoma research is difficult to obtain. Larger cancer patient advocacy organizations are able to appeal to a national base and raise significant amounts of research money. Pittsburgh is blessed with a grass roots movement, Pittsburgh Cure Sarcoma (PCS), which has been successful in supporting local sarcoma researchers.

PCS began in the winter of 2011 as an idea among UPMC sarcoma survivors Bill Suit and Carl Firetto. Also involved at that time were, doctors Kurt Weiss and Hussein Tawbi and sarcoma researcher Dr. Anette Duensing. Under the leadership of Sarcoma Foundation of America, PCS established the first 5K Sarcoma Run at North Park in the summer of 2011. Initially a small group of a few hundred gathered and spent the morning running, walking, fund raising and supporting patients, survivors, and families of those lost to sarcoma. Through the years this has grown to over 2,000 attending the summer 5k race.

The Pittsburgh model has been successfully adopted in many cities. In the early years, the funds raised were shared between PCS and Sarcoma Foundation of America.

ACMS Bulletin / March 2022

In 2019, PCS leadership felt successful and experienced enough to become an independent 501c3 charity. Part of this decision was the growth of sarcoma research in Pittsburgh and the formation of the Pittsburgh Sarcoma Research Collaborative (PSaRC).

PCS’s mission is to raise funds for sarcoma research, and to provide patient advocacy.

PCS’s board and all of its committees are run by volunteers, keeping the overhead costs to a minimum. The first 5K for the independent PCS had to be converted from a live event to a virtual event in June 2020 due to the Covid 19 pandemic. Despite this obstacle, a very successful fund raiser was carried out from the Lemieux Garden of the UPMC Hillman Cancer Center. The first beneficiaries were Dr. Weiss’ Tumor registry and tissue bank and Dr. Duensing’s lab which needed a new minus 80-degree ultracold freezer.

2021 saw a hybrid 5K race in June with about 800 people live in North Park and several hundred on You Tube Live. It was

a very successful fund raiser and great fun to be back live with friends. In addition, the organization ran two virtual “Beer Tasting” events. Volunteers packed and delivered 160 4 packs of beer, snacks and glasses. PSaRC scientists were given the opportunity to discuss PCS supported research and a Beer Meister lead an hour-long seminar regarding the beers selected. A fun evening was had by all in the comfort of their own homes, and the group raised over $10,000 with each event. More PCS beer events are planned!

These successes allowed the group to advertise the first ever PCS request scientific grant applications. Fourteen PSaRC researchers submitted grant requests.

These were reviewed by a medical advisory committee of sarcoma researchers and ultimately 6 were funded. These included researchers at UPMC Hillman, Magee, Children’s, West Virginia University, and Pitt’s School of Dental Medicine. Also funded were the sarcoma research funds at Allegheny Health Network and the UPMC Hillman Cancer Center. Once again, the tumor registry and tissue bank, vital to all of the local researchers, was supported. In all $250,000 was granted

by PCS to support local researchers continue their work.

Pittsburgh is a very generous and supportive community. PCS recognizes that they are blessed with top notch sarcoma physicians, scientists, and research facilities.

PCS appreciates the need to support these doctors and has stepped up time and time again. As a charity supporting research for an orphan disease, we have been keenly aware of the irreplaceable value of grass roots support.

We thank all of our sponsors and supporters and look forward to helping in the continuing fight to cure sarcoma.

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Legal Summary

Employment Contract Issues For New (and maybe old) Physicians Michael A. Cassidy, Esquire Tucker Arensberg, P.C. With the upcoming end of the academic year, residents and fellows are beginning to review and sign employment agreements with healthcare systems, and private practices, to commence this fall. In some highly-recruited specialties, the recruiting is already starting for the next academic year.

Although all contract provisions should be reviewed and understood by new physicians, even without the negotiating leverage to change anything, there are several key issues which are perhaps more important than the others: • Compensation • Term and Termination • Restrictive Covenants • Malpractice Insurance

I. Compensation Compensation provisions typically consist of base salary, productivity arrangements, and perhaps signing and relocation bonuses. Over the years, there have been many false starts focused upon replacing objective productivity models (typically WRVUs or collection) with quality incentives.

Some systems have been moving 22

away from productivity arrangements based upon work relative value units (WRVU) or actual collections. This has been part of the quality or payfor-performance initiative, but it has also been defensive in nature, from a compliance perspective, to protect against perceived overutilization.

We need not debate the efficiency of either approach, but new physicians should evaluate the compensation offers from the following viewpoints: 1. Is the base compensation sufficient, regardless of whether the incentives are attainable? One cannot simply assume that productivity-based compensation is attainable simply because national data provides certain averages. The fact that any particular physician’s specialty should be able to obtain those targets is both dependent upon whether the physician practices sufficiently diligently to hit those targets, and whether the volume to support those targets is available at the system of practice of which the physician is joining.

• If the incentives, whether they be WRVUs, collections, or even quality programs, are to be a significant part of the compensation, are they attainable?

• Will you be the new physician in a “solo practice location” for a system that has no track record?

• Will you be joining an existing practice where other physicians are hitting those numbers, and does this practice expect the volume to expand proportionately or will you just be one more physician dividing the same volume?

• Is there an established history of physician productivity for the physicians?

2. You also should not assume that quality targets are easily attainable either. Although quality incentives might once have been taken for granted, viewed as simply part of the base, their payment history is also important.

II. Term and Termination Termination provisions seem to occupy opposite ends of the contract spectrum; the contracts either allow termination at will or without cause on relatively short notice, i.e., 60 to 90 days, or the contracts specify a certain term and do not permit, either specifically or inferentially, earlier resignation. www.acms.org

Legal Summary This question is a lifestyle question for the physician, i.e., are you more interested in some guarantee period or are you more interested in flexibility?

Of course, if you are interested in the flexibility, you must also consider the restrictive covenant provisions, if any, in your planning. You will not have much flexibility if resignation requires you to relocate, unless you actually intend to relocate outside of the restricted area regardless, in which case the restrictive covenant is not all that relevant.

Those employers offering contracts with fixed terms, i.e., that do not specifically allow for earlier resignation, are typically focused upon planning their staffing needs for a certain period of time. Some contracts go so far as to actually specify a premature termination penalty that will result in some type of liquidated damages or financial penalty.

Whether you may resign when the contract is silent on the issue is a state-by-state question, because some states are employment-at-will states which provide freedom of resignation unless the contract specifies otherwise.

If the contract specifies otherwise, then a premature termination is actually a breach of the agreement. Although an employer may not be able to legally compel a physician to practice at a particular location, that employer might threaten damages, and those damages would typically consist of either the loss of revenue due to the physician’s departure for the replacement costs of filling that space, and the replacement cost, if filled by locums, could be significant.

ACMS Bulletin / March 2022

III. Restrictive Covenants Restrictive covenants are also a state-by-state issue; some states specifically restrict or prohibit restrictive covenants in general or restrictive covenants for physicians in particular. Obviously, you should consult with counsel with regard to the enforceability of the restrictive covenant in your contract in your jurisdiction. However, the concept that restrictive covenants are generally unenforceable is a myth; restrictive covenants are routinely enforced in many states.

The only general restriction is that the restrictive covenant must be designed and intended to reasonably protect the employer without unreasonably restraining the physician.

It would generally be reasonable for a restrictive covenant to prohibit a physician from practicing in the immediate area of that physician’s employment for a reasonable period of time. The reasonableness of the time and the area are also issues of fact.

A 50-mile radius in an unpopulated western state might be reasonable, whereas a 50-mile radius in New York City for almost all specialties would obviously not be reasonable.

A negotiating consideration, with respect to restrictive covenants, is the enforceability depending upon the nature and timing of the employment termination. In those situations where both the employer and the physician have the opportunity to terminate without cause on 60 or 90 days’ notice at any time, then it is the physician who is taking more-significant risk in turning down other offers, relocating

to a specific area, only to face the prospect of both premature termination and a restrictive covenant. In those situations, you would hope to negotiate either a longer-guaranteed employment period or the release of the restrictive covenant for premature termination.

The argument from the potential employer that it’s equal because both parties can do it is obviously misleading. If the practice exercises that opportunity, nothing has changed in the practice itself except the physician is no longer there. On the other hand, from the physician’s perspective, that physician has lost his or her position, must secure a new position, may need to relocate, may need to change a spouse’s or significant other’s employment, take children out of school, etc. it’s not equal.

IV. Malpractice Insurance Malpractice insurance comes in two versions: occurrence and claims made.

Occurrence malpractice insurance covers the physician for whatever the event is if the event occurs while employed, regardless of when the claim is made. Therefore, no “reporting endorsement” or “tail” is necessary.

Conversely, claims-made insurance covers the physician only if the event occurs and the claim is made while the physician is employed. Therefore, post-employment, this reporting endorsement or tail is necessary, and the contract issue is who is responsible Continued on Page 24

23

Editorial Legal Summary Rear End Gastropub & Garage,

From Page 23St., Etna 399 Butler

For a culinary cross-country road trip, stop in this converted for the payment of the tail. auto Sinceservice station for a taste of roadside delights claims-made insurance is typically from coast to coast from Chef Anthony less expensive than occurrence Tripi.

Twenty beersthought and funis, insurance, thedraft general cocktails to boot. since the employer is saving money Bazaar,in725 Ave., the on Adda the insurance thePenn first place, Downtown employer should pay the tail. However, newest of Adda & TeaYou theThe contract might stateCoffee otherwise.

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Tupelo Honey, 100 West Regardless of whether youStation have Square Drive, South Side the negotiating leverage to change any Craving fried green of these provisions, it istomatoes, nevertheless buttermilk shrimp and critical thatbiscuits, you understand the grits impact, and begin banana pudding oh yes, i.e., with the end– and in mind. fried chicken and waffles? Tupelo Honey Café will open this fall in Station TADMS:5665905-1 030205-167727 Square to remedy that, in style.

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Mount Oliver Bodega, 225 Brownsville Road, Mt. Oliver

Chef Kevin Sousa’s new project will combine a wine shop, bar and pizzeria in the former Kullman’s Bakery space.

Sustainable, biodynamic and organic wines from around the world will be featured along with a down to earth, rustic menu. Nonalcoholic wines and cocktails also will be showcased.

G’s On Liberty, 5104 Liberty Ave., Bloomfield G’s turns former Alexander’s Italian Bistro into a seasonal scratch kitchen with creative food and cocktails.

Coming in the fall.

And finally …

Chengdu Gourmet, McKnight Road, Ross Township Chengdu Gourmet (the beloved James Beard-nominated Squirrel Hill hole-in-the-wall Sichuan restaurant that regularly inspires pilgrimages from all over Western PA) is planning an outpost on McKnight Road at the site of the former Oriental Market, in the plaza next to Red Lobster. This will offer a much larger dining space – 6,000 square feet – and an expanded dining 1613 Overton Hill menu. Something to- Squirrel look forward to in $735,000 early 2022.

Enjoy, and be safe.

Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at reshma_paranjpe@hotmail.com.

5825 Fifth Ave #315 - Shadyside $249,900 The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

Improving Healthcare through Education, Service, and Physician Well-Being.

ACMS Bulletin / August 2021 24

223 www.acms.org

Duquesne University PreMedical & Health Professions Students Seek Shadowing Opportunities In Allegheny County and across the country for the past two years, students interested in medicine have had difficulty identifying physician mentors and securing shadowing opportunities in preparation to apply to medical school. According to the AAMC (Association of American Medical Colleges), shadowing experiences not only provide future physicians with an introduction to the profession of medicine and day-to-day responsibilities of all members of the health care team, but they also offer opportunities for the physicians being shadowed to model the type of professionalism and ethical and culturally-sensitive care that is highly valued in medical students and providers alike.

While there are structured shadowing opportunities available in some practices and health systems in Allegheny and surrounding counties, those opportunities are severely limited in both time and scope. COVID restrictions have changed access of non-essential personnel (pre-med students) to medical facilities and providers, and this lack of access has the potential for long-term ramifications for the future of medicine and the preparation of qualified physicians. In a June 2020 report, the AAMC projected that the United States will face a shortage of between 54,100 and 139,000 physicians by 2033, including shortfalls in both primary and specialty care. This anticipated shortage, combined with increased physician demand brought on by population growth, an aging community and the anticipated retirement of a large portion of the physician workforce over the next decade, magnifies the need to provide more, not less, shadowing and mentoring opportunities.

In Allegheny County alone, there are hundreds of pre-medical students in our local universities who would benefit greatly from your experience, guidance, and examples in their quests to pursue careers in medicine. Providing shadowing opportunities is one way to help address this need; however, a more individualized approach also could work. If your practice cannot allow students to shadow right now, perhaps you and your colleagues might consider becoming mentors for these students or just sharing your patient care experiences with them over a cup of coffee or in presentations to their student organizations. If you or your colleagues would be open to providing any of these types of opportunities for the pre-med students in Allegheny County, please reach out to us. We will share these opportunities with our local colleagues. Contact: Paula S. Turocy, Director of Pre-Medical & Health Professions Programs, Duquesne University (turocyp@duq.edu or pmhpp@duq.edu).

You also are welcome to call—412-396-6335.

Thank you for your membership in the Allegheny County Medical Society The ACMS Membership Committee appreciates your support. Your membership strengthens the society and helps protect our patients.

ACMS Bulletin / March 2022

Please make your medical society stronger by encouraging your colleagues to become members of the ACMS. For information, call the membership department at (412) 321-5030, ext. 109, or email membership@acms.org.

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ACMS/FYI

Allegheny County Medical Society Announces New Executive Director Top Association Executive to Lead County Medical Association

“ I am very much looking forward to this new adventure.”

—Sara C. Hussey, MBA, CAE

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The Board of Directors of the Allegheny County Medical Society (ACMS) are pleased to announce the appointment of Sara C. Hussey, MBA, CAE as its new Executive Director.

With over a decade of experience in association management, Ms. Hussey has a successful track record of creating revenue driving initiatives, managing member recruitment and retention, and leading an organization through continuous growth and change.

According to Dr. Peter Ellis, ACMS’ Board President and Search Committee Chair, “Ms. Hussey was a standout during the entire Executive Director search process and we are thrilled to begin our work together.”

Ms. Hussey most recently served as the Vice President - Member Experience at the Pennsylvania Institute of Certified Public Accountants (PICPA); an organization of 22,000 financial services professionals and student affiliates.

She brings with her experience in member relations, volunteer management, continuing education, board and governance management, event planning, strategic partnerships, and advocacy and foundation support.

“It’s clear that the ACMS is an organization whose mission is rooted in tradition and rich history, with a focus on the good of the medical profession

and the overall vision of a healthy community. As executive director, I will be a steward of what is core to the ACMS – using the mission as the north star while leading the organization forward. It is an honor to be selected to lead an organization that supports the medical professionals in Allegheny County. I am very much looking forward to this new adventure.” says Ms. Hussey.

Ms. Hussey holds a Bachelor of Arts degree in Communications (2007) and Master of Business Administration degree (2010) from Duquesne University. Ms. Hussey is also an avid member of the broader association community. She received the Certified Association Executive (CAE) designation in 2019 and was selected to participate in the ASAE’s Emerging Leaders Program later that year. In October 2021, Ms. Hussey was recognized as one of the Association Forum’s Forty under 40 award winners, a national award recognizing top association professionals from around the country. Sara and her husband Patrick reside in the North Hills area of Pittsburgh with their two children Bellamy and Bowen.

Ms. Hussey officially joins the ACMS on March 14. She can be reached at shussey@acms.org and on LinkedIn at linkedin.com/in/sarahussey.

www.acms.org

ACMS/FYI

Retired and Interested in Becoming a Physician Volunteer?

Are you retired or retiring and interested in applying as a physician volunteer? With a dogged persistence, Dr. Patricia Canfield uncovered and simplified the process for others, providing ACMS with a shortcut to the application. https://www.dos.pa.gov/ProfessionalLicensing/BoardsCommissions/Nursing/Documents/Applications%20and%20Forms/Volunteer%20License%20Application.pdf According to PAMED, “Volunteer licenses are available to retiring health care practitioners or non-retired practitioners who are not required, because the practitioner is not otherwise practicing medicine or providing health care services in Pennsylvania, to maintain professional liability insurance under the Medical Care Availability and Reduction of Error (MCARE) Act. To qualify for a volunteer license, a physician must currently hold an active unrestricted license.”

To learn more about CME requirements, liability protection and other information, visit https://www.pamedsoc.org/education-cme/CME-Tracker/TakeCME According to Dr. Canfield, “Once the application is completed, it must be mailed (versus submitted electronically).”

Thank you, Dr. Canfield and all physician volunteers!

ACMS Bulletin / March 2022

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2022 ACMS Meeting & Activity Schedule By Committee Finance Committee April 26 Keith T. Kanel, MD, Chair August 30 November 15

Board of Directors May 10

Patricia L. Bononi, MD, Chair September 13 December 6

Delegation

Deborah Gentile, MD, Chair Bruce A. MacLeod, MD, Vice Chair

House of Delegates October 21-23

Meetings begin at 6:30PM. If you are interested in attending any of the meetings, please contact Mrs. Hostovich at 412.321.5030.