ACMS Bulletin April 2023

Bulletin Allegheny County Medical Society

April 2023

An Unexpected Perspective Why We Need ICD Codes for Rare Conditions

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Allegheny County Medical Society

Bulletin April 2023 / Vol. 113 No. 4

Opinion

Departments

Editorial....................................5 • An Unexpected Perspective Deval (Reshma) Paranjpe, MD, MBA, FACS

Articles

Society News .........................18 A Quick Guide: The End • Pennsylvania Geriatrics of the COVID-19 Public Health Emergency.........7 Society – Western Division hosts 3rd Virtual Conference

Jenny Bender, MPH, BSN, RN, CIC (PHE)

Associate Editorial ..................8 Society News .........................18 • Why We Need ICD Codes for Rare • Pittsburgh Ophthalmology Society Tweenage Scientists...............10 Challenge Conventional Conditions Hosts 58th Annual Meeting Wisdom Kristen Ann Ehrenberger, MD PhD Foundation Featured Grant Anthony Kovatch, MD Editorial ..................................12 Recipient ................................22 • Meatball Medicine • Jeremiah’s Place Materia Medica ......................28 Richard H. Daffner, MD, FACR

ACMS News ...........................24 Perspective ............................16 • Information on the Medication • Canute v. The Sea Access and Training Expansion Bruce L. Wilder, MD JD MPH

(MATE) Act Training Requirement – Information and FAQ’s

• Neonatal Abstinence Syndrome Abree Cowan, PharmD Candidate 2023; Jamie L. McConaha, PharmD, NCTTP, BCACP, CDCES

Legal Summary.......................32 • Private Equity: Investigation and Enforcement Michael A. Cassidy

On the cover

Beautiful Evening in Pittsburgh Alexanndra Kreps MD Alexanndra Kreps MD specializes in Psychiatry.

Our Best Tools Against.......34 COVID-19: Vaccines and Antivirals Megan McGrady, MPH

ACMS Meeting Schedule ......36

Bulletin Medical Editor Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com) Associate Editors 2023 Executive Committee and Board of Directors

PAMED DISTRICT TRUSTEE G. Alan Yeasted

Douglas F. Clough (dclough@acms.org)

COMMITTEES

Richard H. Daffner (rdaffner@acms.org)

President-elect Raymond E. Pontzer, MD

Bylaws Raymond E. Pontzer

Kristen M. Ehrenberger (kehrenberger@acms.org)

Secretary Keith T. Kanel, MD

Finance William Coppula, MD

President Matthew B. Straka, MD

Treasurer William Coppula, MD Board Chair Peter G. Ellis, MD

Nominating Raymond E. Pontzer, MD

DIRECTORS Term Expires 2023 Michael M. Aziz, MD Micah A. Jacobs, MD Bruce A. MacLeod, MD Amelia A. Paré, MD Adele L. Towers, MD Term Expires 2024 Douglas F. Clough, MD Kirsten D. Lin, MD Jan B. Madison, MD Raymond J. Pan, MD G. Alan Yeasted, MD Term Expires 2025 Anuradha Anand, MD Amber Elway, DO Mark Goodman, MD Elizabeth Ungerman, MD Alexander Yu, MD

Anthony L. Kovatch (kovatcha42@gmail.com) Joseph C. Paviglianiti (jcpmd@pedstrab.com) Andrea G. Witlin (agwmfm@gmail.com)

ADMINISTRATIVE STAFF Executive Director Sara Hussey (shussey@acms.org) Vice President - Member and Association Services Nadine M. Popovich (npopovich@acms.org) Manager - Member and Association Services Eileen Taylor (etaylor@acms.org)

Administrative & Marketing Assistant Melanie Mayer (mmayer@acms.org) Director of Publications Cindy Warren (cwarren@pamedsoc.org) Part-Time Controller Elizabeth Yurkovich (eyurkovich@acms.org)

ACMS ALLIANCE Co-Presidents

Corresponding Secretary

Patty Barnett

Doris Delserone

Barbara Wible Treasurer Recording Secretary

Sandra Da Costa

Justina Purpura Assistant Treasurer Liz Blume

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

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ISSN: 0098-3772

Editorial

An Unexpected Perspective Deval (Reshma) Paranjpe, MD, MBA, FACS

A

rtificial Intelligence (AI) can provide valuable insights and support to physicians in their everyday practice of medicine.

Here are a few ways in which physicians can use AI: 1. Medical imaging analysis: AI algorithms can help physicians analyze medical images, such as X-rays, CT scans, and MRI images, to identify abnormalities and diagnose diseases. This can help speed up the diagnostic process and improve accuracy 2. E lectronic health records (EHRs): AI can help physicians manage large amounts of patient data, including EHRs. Machine learning algorithms can analyze this data to identify patterns and predict outcomes, such as the likelihood of readmission.

3. Virtual assistants: AI-powered virtual assistants can help physicians manage their schedules, answer patient queries, and assist with administrative tasks, allowing physicians to focus on patient care.

ACMS Bulletin / April 2023

4. C linical decision support: AI algorithms can help physicians make informed decisions by providing relevant information and recommendations based on patient data, medical literature, and best practices.

5. D rug discovery: AI can help physicians and researchers discover new drugs and treatments by analyzing large datasets and identifying potential drug targets.

Overall, AI can help physicians improve patient outcomes, reduce workload, and enhance the efficiency of health care delivery. However, it is important to note that AI should not replace the human element in medicine, but rather augment it. Physicians should use AI as a tool to support their decision-making process and provide the best possible care to their patients.

Physician well-being is a critical aspect of health care delivery. AI can help improve physician well-being in several ways, including: 1. R educing administrative burden: AI-powered tools can automate administrative tasks, such as appointment scheduling and recordkeeping, allowing physicians to spend more time on patient care and reducing their workload.

2. Improving efficiency: AI can help streamline clinical workflows, enabling physicians to work more efficiently and see more patients in less time. This can reduce stress and burnout.

3. Enhancing diagnostic accuracy: AI algorithms can analyze large datasets and identify patterns that may not be apparent to human clinicians. This can help improve diagnostic accuracy and reduce the risk of misdiagnosis, which can be a significant source of stress for physicians.

4. Facilitating personalized care: AI can help physicians provide more personalized care by analyzing patient data and providing tailored treatment recommendations. This can help physicians feel more connected to their patients and increase job satisfaction.

5. Providing decision support: AI can provide physicians with decision support tools that can help them make more informed decisions based on evidence-based guidelines and best practices. This can reduce uncertainty and stress associated with clinical decision-making.

Continued on Page 6

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Editorial From Page 5

Overall, AI can help reduce administrative burden, improve efficiency, enhance diagnostic accuracy, facilitate personalized care, and provide decision support, which can all contribute to physician well-being.

However, it is important to note that AI should not replace human interaction and connection in medicine, but rather augment it. Physicians should use AI as a tool to support their work and provide the best possible care to their patients while maintaining their own well-being.

Of course, this is only one perspective, and clearly does not take into account the risks of artificial intelligence to the practice of medicine, patient care, and the physician-patient relationship. Why the bias? The entirety of this article before this paragraph was written by ChatGPT. Don’t believe me? Head over to https://openai.com/blog/chatgpt and see for yourself.

Welcome to the age of Artificial Intelligence.

Tucker Arensberg lawyers have experience in all major healthcare law issues including: Compliance & Cybersecurity Reimbursement Mergers & Acquisitions Peer Review and Credentialing for Physicians Employment Contracts and Restrictive Covenants Tax & Employment Benefits

FOR ADDITIONAL INFORMATION CONTACT ANY OF THE FOLLOWING ATTORNEYS AT (412) 566-1212

Mike Cassidy - Compliance; Contracts, Peer Review, Stark/AKS Jeremy Farrell - Labor & Employment Ryan James - Commercial Litigation Rebecca Moran - Mergers & Acquisitions and Physician Contracts Jerry Russo - Criminal Defense and Investigations Paul Welk - Mergers & Acquisitions

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VISIT OUR MED LAW BLOG FOR THE LATEST NEWS AND INFORMATION FOR YOU AND YOUR MEDICAL PRACTICE:

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A Quick Guide: The End of the COVID-19 Public Health Emergency (PHE)

By Jenny Bender, MPH, BSN, RN, CIC We are now three years into the COVID-19 pandemic and the CDC reports that cases, deaths, and hospitalizations have been steadily declining, noting that much of the US population has some form of immunity (either due to natural infection or vaccination).1 Based on these trends, the Department of Health and Human Services (HHS) is planning for the federal Public Health Emergency (PHE) for COVID-19 to expire at the end of the day on May 11, 2023.2 In a statement by the Executive Office of the President, released January 30, 2023, the White House wrote: “an abrupt end to the emergency declarations would create wide-ranging chaos and uncertainty throughout the health care system — for states, for hospitals and doctors’ offices, and, most importantly, for tens of millions of Americans.” That said, the end of the public health emergency (PHE) fortunately coincides with some additional policies that will make the transition out of the PHE less abrupt for healthcare, but it will still have a large impact on physicians, insurers, and patients in Pennsylvania.

The Centers for Medicare and Medicaid Services (CMS) has issued a fact sheet outlining the flexibilities that physicians and other clinicians were granted under the PHE to fight COVID-19. This fact sheet also outlines how the end of the PHE will affect all these flexibilities.

Some of the biggest changes in care provision of the PHE included services eligible for telehealth and how those visits were billed. This is one area where an additional policy is being introduced to bridge the gap. After the PHE ends, the Consolidated Appropriations Act of 2023 provides for an extension for telehealth flexibility through the end of 2024. In addition, some behavioral health telehealth

ACMS Bulletin / April 2023

visits are being approved permanently and without geographic restriction. Telehealth visits greatly expand the availability of behavioral health care and have been very successful.3 COVID-19 tests will no longer be available for free by mail-order to US addresses, and by law, Medicare does not generally cover over-the-counter services and tests. Current access to free over-the-counter COVID-19 tests will end with the end of the PHE. However, some Medicare Advantage plans may continue to provide coverage as a supplemental benefit. All states must provide Medicaid and CHIP coverage without cost sharing for tests through the last day of the first calendar quarter that begins one year after the last day of the PHE. This coverage requirement will end on September 30, 2024. For private health plans, many insurance providers will still reimburse the cost of over-the-counter tests purchased by enrollees, but the benefits will vary by plan.4 Specifically regarding COVID-19 immunizations—although these immunizations may eventually be paid under a different model, the timing will not coincide with the end of the PHE. The federal government plans to continue purchasing and distributing COVID-19 immunizations, and any federally purchased vaccine will be available at no cost to patients with both private and public health plans. Medicare and Medicaid will continue to cover the entire cost even after the government supply runs out.

Private insurance providers will also continue to cover the cost, but there may be exceptions if the vaccine was provided out of network. For underinsured and uninsured Americans, free vaccines will be provided through a CDC program at their local health department.5

Here are a list of resources to help you learn more about the end of the COVID-19 Public Health Emergency: U.S. Department of Health & Human Services Centers for Medicare and Medicaid Services Allegheny County Health Department – Office of Child Development & Early Learning American Medical Association Jenny Bender, MPH, BSN, RN, CIC is a Clinical Science Liaison at PDI and she also serves as the Secretary of the County Immunization Coalition.

Reference

1. COVID Data Tracker Weekly Review. Centers for Disease Control and Prevention. Published April 10, 2020. Accessed March 31, 2023. https://www. cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html 2. Fact Sheet: COVID-19 Public Health Emergency Transition Roadmap. HHS.gov. Published February 9, 2023. https://www.hhs.gov/about/ news/2023/02/09/fact-sheet-covid-19-publichealth-emergency-transition-roadmap.html#:~:text=Based%20on%20current%20COVID%2D19 3. Department of Health and Human Services.

Telehealth Policy Changes After the COVID-19 Public Health Emergency. https://telehealth.hhs. gov/providers/policy-changes-during-the-covid-19public-health-emergency/policy-changes-after-thecovid-19-public-health-emergency 4. Centers for Medicare & Medicaid Services. CMS Waivers, Flexibilities, and the Transition Forward From the COVID-19 Public Health Emergency. https://www.cms.gov/newsroom/fact-sheets/ cms-waivers-flexibilities-and-transition-forward-covid-19-public-health-emergency#:~:text=Testing%3A%20After%20the%20expected%20 end,depending%20on%20the%20health%20plan.

5. Pennsylvania Department of Health. COVID-19 Vaccine FAQs. https://www.insurance.pa.gov/coronavirus/Pages/covid-vaccine-faqs.aspx

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Editorial

Why We Need ICD Codes for Rare Conditions Kristen Ann Ehrenberger, MD PhD

H

er: Did you know there is no ICD-10 code for GRI disorders?

Me: Really???

A friend from high school texted me on a Saturday from this year’s GRI Conference in Boston, MA. (Her husband and daughter share a GRIA2 mutation.) We’ve kept in touch regularly since her high-risk pregnancy, through her daughter’s surprise congenital heart defect and surgery at just 7 weeks old, and then the realization that this adorable little girl was not just developmentally delayed but losing milestones. Abby was eventually diagnosed with an uncommon variant of a genetic condition affecting ionotropic glutamate receptors that can cause cortical vision impairment, epilepsy, intellectual disability, Autism, and movement and feeding issues due to hypotonia and motor planning difficulty.

I take care of adults with childhood onset medical complexity, but I had never heard of “GRI Disorders” before my friend’s family was diagnosed.

This cluster of mostly missense mutations affects 9 genes for the AMPA receptor (GRIA Disorder), the delta receptor (GRID Disorder), the kainite receptor (GRIK Disorder), and the NMDA receptor (GRIN Disorder). Usually, mutations 8

arise sporadically and de novo, as likely happened with her husband; most cases are due to a single pathological allele with autosomal dominant inheritance. Incidence is currently thought to be as high as 32:100,000 live births for all the known and testable variations (personal correspondence; Lempke 2020). This is many times the incidence of other rare neurodevelopmental conditions such as Rett Syndrome (10:100,000; F84.2) or Dravet Syndrome (6:100,000; G40.834), yet there are no ICD-10 codes for GRI Disorders.

German philosopher Immanuel Kant (1724-1804) is said to have quipped once, “Physicians think they do a lot for a patient when they give his disease a name.” It is true that merely naming a problem does little to relieve a person’s physical suffering. However, it can do a lot to relieve the psychological distress of not knowing what is wrong. The one lesson I still remember from a college professor who is an internist as well as a historian of medicine, Kenneth Ludmerer, is that it is insufficient for the medical team to rule out conditions (malignancy, serious infection, etc.); patients want to know, “What do I have, doc?” The worry may be even greater for parents or caregivers of a child being diagnosed with a lifelimiting condition, as early mortality for

neurodevelopmental disorders such as GRI is estimated to be 3x that of the general population, primarily from respiratory infections but also from sudden unexplained death in epilepsy, or SUDEP. When a collection of subjective symptoms and objective signs can be sorted into a recognizable disease entity, it validates the patient’s complaints. It suggests a pathological why, a therapeutic what, and a prognostic when. In this late-capitalist stage of American health care, in which electronic medical records are designed primarily for billing and secondarily for documentation, a disease name comes with a financial how much. The above numbers for GRI Disorders were derived from calculations of new mutations expected in the population, because we don’t have actual statistics. ICD codes would enable more accurate clinical notes as well as better epidemiological statistics and more clinical trials (there are at least 4 underway right now). Having a name for their child’s condition entitles parents or caregivers to more resources (such as Medicaid waiver funding). Finally, it enables them to locate other families dealing with similar issues, for practical and emotional support.

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Editorial My friend told me the CureGRIN Foundation has petitioned the Center for Disease Control and Prevention’s National Center for Health Statistics to rectify the lack of specific diagnostic codes, but the conference speaker reported that they were told these conditions are untreatable and therefore don’t need any. That is shortsighted and pessimistic, as there are plenty of (currently) “untreatable”—or better, “uncurable”—conditions with ICD-10 codes (e.g. Alzheimer’s Disease, G30.9). Not to mention the fact that the International Classification of Diseases was born in the 1890s as a standardized list of causes of death and only expanded to include causes of morbidity in 1949. The last time I checked, death is an “untreatable” condition, while the many different therapists who are teaching Abby to stand, drink from a bottle, and use an augmentative and alternative communication device would argue that they are in fact “treating” her.

ACMS Bulletin / April 2023

Now is the perfect time for organizations representing rare but diagnosable conditions to petition for inclusion in the International Statistical Classification of Diseases and Related Health Problems, as the 11th edition was approved by the World Health Organization’s Health Assembly in 2019 and officially went into effect on January 1, 2022. Implementation in the United States has lagged since ICD-8, when the American Hospital Association and US Public Health Service created an adapted version in 1968 (ICDA-8), 3 years after the WHO version, but especially since ICD-9 and 10. Given the expense of updating multiple computer systems for clinical and billing purposes around the country, the US used ICD-9-CM (Clinical Modification) from 1979 through 1998 for mortality, but until 2015 for morbidity. Its successor (ICD10) had been developed in the 1980s, approved by the WHO in 1990, and used throughout the world since 1994.

Clearly it is time for an update. ICD11 is supposed to be adopted here in 2025, or more likely 2027. Hopefully it will include codes that recognize GRIA2 and its sibling conditions.

Sources: Lemke JR. Predicting incidences of neurodevelopmental disorders. Brain 143:4 (April 2020): 1046-48.

You can read about Abby’s story at curegrin.org/abby. Her mom reports that in the year since her story was published, Abby has learned to sit independently, crawl, and hold her bottle. Explicit permission was received to share these details publicly.

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Tweenage Scientists Challenge Conventional Wisdom Anthony Kovatch, MD “Old man,” she said, “have you lived so long and forgotten so much that you don’t remember anything you ever knew or felt or even heard about love?”----from “Go Down, Moses” by American author William Faulkner Although I was taking it out of context, I was convinced that the 7th and 8th grade students were secretly addressing that quote to me as I struggled to judge their projects at the annual Science Fair on March 28-29, 2023, sponsored by the Carnegie Science Center. I imagined that the young precocious scientists were reading my mind, which was silently spouting out random rhetorical questions like these: “Why are these middle school students so avid in their pursuit of scientific inquiry?”

“What motivates these youngsters to dedicate so much arduous effort and time to a project that will be understood and appreciated by so few adults and even fewer of their peers?

“Should not these tweenagers be amusing themselves in the prime of their childhood by frolicking on their cell phones and videogame devices like the rest of us?”

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The answer was simple: To a man, they were doing it for LOVE: Love of science and the workings of the universe. Love of collaborating with their young colleagues to inspire their mentors and teachers. Love of fostering pride within their own hearts by accomplishing goals well beyond their years. Love of debunking “old wives tales” and invalidated conventional wisdom. Doing good solely for the sake of good---and for honor. Gratia honoris!

“I’m wild again, beguiled again A simpering, whimpering child again Bewitched, bothered, and bewildered am I” In spite of “downgrading” myself to a judge of the middle school research projects rather than the high school projects like last year, I unfortunately was equally overwhelmed, but fortunately was again equally astonished and proud of our youthful scientists! I sensed that this year’s focus was challenging time-honored unjustified fallacies, like the proverbial

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Appropriately, the heart got a lot of attention---specifically, the negative effects of human emotional states (ironically the primary emotion causing tachycardia was sadness, rather than joy or excitement) and of caffeine (demonstrated in a clever animal model). A 3-5 millimeter long arthropod named Daphnia Magna possessing a translucent thorax allowed visible beating of its myogenic heart under a microscope and assessment of its sensitivity to various concentrations of caffeine!

5 second rule. For those readers from a cleaner planet than Spaceship Earth, here is the dogma: The five-second rule states that food dropped on the ground will be safe to eat and not covered in germs as long as it is picked up within 5 seconds of being dropped.

This often-stated belief was proven to be fallacious to the delight of the investigators using bologna—and to this judge who has a neurosis about discarding “good food.”

ACMS Bulletin / April 2023

a “soft spot in my heart” for 3 boys, who claimed that they were united in their project merely by the fact that they were “buddies”! They put on a dazzling presentation with welldefined assignment of the essential components of their project: materials and methods, data presentation, and conclusions. I left the Science Center convinced that I had learned more than I previously knew about collaboration, camaraderie, and even LOVE! The tweens had disproven the old cynical hypothesis attributed to French critic and journalist Alphonse Karr as long For those of us wishing to speed up our ago as1849: “Plus ca change, plus heart rates with exertion and produce c’est la meme chose.” That is, “The an “athletic heart,” a study focusing on more things change, the more they the positive effects of different modes stay the same!” of dance demonstrated that tap is superior to ballet and jazz. There was widespread appreciation of the racial and ethnic diversity of the researchers, as well as of the creativity of the titles of the posters. Similar to their high school counterparts, the middle school scientists were their own most ardent critics.

I left the fair compelled that every student deserved an award, a scholarship, or, at the very least, a certificate. I did discover that I had

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Editorial

“Meatball Medicine” Richard H. Daffner, MD, FACR

R

esidents of the Pittsburgh region are blessed with access to sophisticated health care that is often not only state-of-the-art, but also, in many instances, at the cutting edge of medicine and surgery provided by the two major systems, AHN and UPMC. Furthermore, both systems provide excellent training for medical students, residents, and fellows. Even some of the smaller facilities offer sophisticated care. Unfortunately, in twenty-first century America, that type of care is not available to all.

Dr. James Strosberg, a lifelong friend from childhood, was a classmate of mine in medical school in Buffalo, NY. Until his retirement a few years ago he practiced rheumatology in Schenectady, NY, part of the Capitol District (along with Albany and Troy, our hometown). Jim recently published a book containing anecdotes of his two years (1968 – 70) as a medical officer in the U.S. Public Health Service (USPHS) on a Sioux Reservation in South Dakota1. As I read Jim’s book, some of the events he described brought back memories of my own service in the Air Force. The difference, of course, in our experiences was that while I practiced in a modern medical center (Wright-Patterson) in Dayton, Ohio, with all medical and surgical specialties available, he was in a small 12

(23 bed) hospital with an adjacent clinic. Jim was one of four physicians, all just out of internship, along with one dentist and a pharmacist. There were no specialists on site and the nearest ones were hours away in either Rapid City or Pierre. And so, with the limited facilities and resources on-site, Jim and his colleagues had to “MacGyver” it and practice “Meatball Medicine”, making do with the limited resources on hand.

In his book, Jim describes administering care that included the “bread and butter” conditions seen by every family practitioner as well as reducing fractures, delivering babies and, on occasion, performing amputations. The most common conditions he dealt with were injuries sustained as the result of alcohol consumption. He and his colleagues would often accompany patients during their medical evacuation to either Rapid City or Pierre1. Out of necessity he and his colleagues had to use the resources available to them, often playing a real-life MacGyver.

“Meatball Medicine” is a derivation of the term “Meatball Surgery”, coined

by Dr. H. Richard Hornberger (1924 – 1997), better known by his nom de plume of Richard Hooker, the author of MASH 2. Hornberger’s dark comedy was based on his experiences as a

combat surgeon during the Korean War. He defined “Meatball Surgery” as a distinct specialty. He wrote, “We are not concerned with the ultimate reconstruction of the patient. We are concerned only with getting the kid out of here alive enough for someone else to reconstruct him. “Up to a point, we are concerned with fingers, hands, arms, and legs, but sometimes we deliberately sacrifice a leg in order to save a life, if the other wounds are more important. In fact, now and then we may lose a leg because, if we spent an extra hour trying to save it, another guy … could die from being operated on too late. Our general attitude around here is that we want to play par surgery. Par is a live patient.2” Those of us who have been in the military, particularly those who served in a combat zone can relate to this.

I had similar experiences moonlighting during my residency at Duke (1970 – 73), working with several fellow residents in a community clinic in rural Yanceyville, NC, the county seat of Caswell County, along the North Carolina – Virginia border. The clinic was owned by Dr. Tom Lea Gwynn, the only remaining physician in the county after his father, with whom he was in practice, died. In 1970, Caswell County was the poorest county in North Carolina, where the average annual www.acms.org

Editorial per capita income was $1,200, mainly from tobacco farming. The clinic had been built with the support of the Sears Roebuck Foundation. In 1957, the Foundation established the Community Medical Assistance Program (CMAP) to assist rural communities in attracting physicians. Between 1957 and 1970, 163 such clinics were built, financed primarily through community ownership3. The Yanceyville clinic had a waiting room, three office/consulting rooms, three examining rooms, a small laboratory, an x-ray room, and a small operating room. When I was there the x-ray room and its ancient equipment were inoperative.

The nearest hospital was in Danville, VA, fifteen miles up the road.

Complicated cases were referred to either Duke Medical Center in Durham or North Carolina Memorial Hospital in Chapel Hill. Both were approximately 50 miles away. “Ambulance” service was provided by the local sheriff using his pickup truck with a mattress in the cargo bed. This was, indeed, a medically indigent community.

My colleagues and I had all served two years in the military, where we were all General Medical Officers, in military parlance, prior to beginning our residency. We provided three hours of coverage two evenings a week as well as on Saturday afternoons. Our arrangement with Dr. Gwynn was that we kept 80% of any fees generated.

He paid the receptionist from his 20%.

Each of the resident physicians was paid the net proceeds depending on the number of shifts worked.

This was preferable to moonlighting in emergency rooms since the Yanceyville clinic was only an hour away from Durham and we were able ACMS Bulletin / April 2023

to sleep in our own beds at home, ensuring we were ready for work at Duke the next day.

Most of the patients we saw had the typical diagnoses seen by any busy family practitioner or at a modern urgent care clinic – colds, ear infections in children, cuts and scrapes. Dr. Gwynn managed his regular patients with diabetes and hypertension. I asked him what we should do if a woman was in labor and was close to delivering a baby. (None of us had any obstetric experience beyond that which we learned in medical school.) He said, in that case, call him and he will come in and handle the delivery.

So, why were we practicing “meatball medicine”? A few examples stand out in my memory. One of the most frequent diagnoses we made was gonorrhea (GC), which I thought was endemic in the community.

As each patient was treated, my colleagues and I dutifully notified the county health department, as the law required. One evening, the county health commissioner paid me a visit and asked me to stop reporting cases of GC. He said he didn’t have the resources to do contact tracing. “Just treat ‘em, Doc,” he told me. “That’s the important thing.” I made a correlation between the incidence of GC and the frequent revival meetings staged by itinerant preachers, who promised salvation in return for the few dollars his flock provided him. North Carolina is the buckle on the “Bible Belt”. An old-fashioned revival is something everyone should experience once in their lifetime regardless of their religious affiliation. When the preacher would extoll his flock in his deep Southern accent to “Cleeeeng to your

loved ones”, they would literally heed his word when they left. Hence, the high incidence of GC. One night I saw a local farmer who had cut his forearm on a corn picker.

The laceration was about a half inch deep, but surprisingly was not bleeding at the time he came to the clinic. The man’s arm was covered with cakedon dirt, and it was also obvious that personal hygiene was not important to him. I took him into a treatment room and handed him a scrub brush to clean the wound so I could suture it. Fifteen minutes later I returned and was surprised to find that he had no laceration. He had over a half inch of mud on his arm, and that was what had been cut through!

The most serious injury I had to deal with was a man who walked into the clinic with a knife stuck in his back after he had been stabbed during a drunken brawl. After assuring that his vital signs were stable, and his lungs were clear, I taped the knife in place, started “an IV and waited for the sheriff, whom “the receptionist had called to take the man to Danville Hospital. He sat in the ““back of the pickup truck with my receptionist holding the IV. “He miraculously survived.

I mentioned the poverty in the county. Most of the patients we saw were on welfare. Nobody had health insurance. Even so, the cost of a “nofrills” visit at that time was $10. Blood tests, urinalysis, and wound suturing were charged extra (but way below today’s prices). Some patients bartered fresh vegetables, fruit, or eggs in lieu of cash payments (Dr. Gwynn received 20% of whatever was used for payment).

Continued on Page 14

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Editorial From Page 13

There still are communities where poverty is common, and lack of sophisticated medical resources necessitates practicing “meatball medicine”. My fellow residents who worked at Yanceyville agree with my friend Jim Strosberg that our shared experiences allowed us to see another side of society. We feel we became better physicians for that experience.

Physician Billing Reviews and Audits For information contact John Fenner Email: fenner@fennercorp.com

Fenner Consulting References 1. Strosberg JM. Two Years on the Cheyenne River Sioux Tribe Reservation. Troy, NY, The Troy Book Makers, 2022 2. Hooker R. MASH: A Novel About Three Army Doctors. New York, William Morrow & Co., 1968.

3. Kane RL, Warnick R, Proctor PH, Olsen DM, Gourley D. Mail-order medicine. An analysis of the Sears Roebuck Foundation’s community Medical Assistance Program. JAMA 1975; 232:1023-1027.

Dr. Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine.

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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Congratulations to the Doctors' Day honorees from the Allegheny County Medical Society and the Pennsylvania Medical Society.

On March 30th the ACMS celebrated Doctor's Day by visiting doctors across the city to hand-deliver their recognition certificates. This year, PAMED received over 300 nominations from the public, patients, and colleagues, recognizing physicians across Pennsylvania who have gone above and beyond in their care.

Yesterday, today, and every day, we celebrate Pennsylvania’s physicians.

The full list of Honorees can be found at: www.pamedsoc.org/DoctorsDay

Top: ACMS Board Member, Dr. G. Alan Yeasted and ACMS Team Member Nadine Popovich, award Robert Shogry, MD with his Doctors’ Day Certificate. Bottom: ACMS Executive Director, Sara Hussey, awards Kirsten Lin, MD with her Doctors’ Day Certificate.

ACMS Bulletin / April 2023

Top to Bottom (L-R): Sarahgene Defoe, MD, Mark Biedrzcki, MD, William Coppula, MD and Raymond Pan, MD were all awarded Doctors’ Day Certificates.

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Perspective

Canute v. The Sea Bruce L. Wilder, MD JD MPH If there is one thing I learned in law school, it is that we cannot always make a law to solve every problem in our society. This thought came to mind after reading articles and letters in the last few issues of the Bulletin on the subject of elective abortion.

It is not my place here, or my intent, to engage in the debate about the rightness or wrongness of elective abortion. We have all heard both sides, and I don’t think I can add anything to it that will change anybody’s mind. But we should not conflate that debate with the debate about how we regulate or prohibit elective abortion and the ripple-effects that follow.

We should question the view that those who oppose criminal or burdensome civil penalties are “abortion supporters.”

The uncertainty among physicians and their patients created by some of the state legislation (or would be created by proposed legislation) that has followed the Dobbs decision cannot simply be brushed aside.

In some instances, attempting to change behavior by enacting punitive measures, whether effective or not, may produce a greater harm than it seeks to eliminate. Not true, of course, for most activities we consider criminal.

Before the 1973 case of Roe v.

Wade, safe abortions were available to 16

those with the resources, and always will be, whether legal or illegal. As a medical student in the pre-Roe years at the Providence (R.I.) Lying-In-Hospital, as it was known at the time, I witnessed the ugly and sometimes tragic side of illegal abortions performed on women desperate enough, for various reasons, who had no such access to safe abortions. It was not always because those women were fine with having an abortion, it was because, rightly or wrongly, they saw the alternative as much worse.

To further complicate matters, the issue of criminalization of abortion has become a political football,1 and I suspect there are more than a few stories about politicians who publicly opposed or oppose abortion but had a different view and/or course of action when faced with a dilemma posed by the prospect of a child that, for any number of reasons, they would rather not see born.

Unfortunately, not just in the case of abortion, but in many situations where we, as a society, look to the law to solve a perceived problem, we also rely on it to the point where we pass up the opportunity to solve it in other ways.

We should be mindful of the brief history of prohibition, which began with the ratification of the XVIIIth Amendment in 1919, but because of the unanticipated consequent wave of gun violence and organized crime and its ineffectiveness

in achieving the goal of national sobriety, it was repealed with relatively lightning (for a Constitutional Amendment) speed in 1933. We should also consider the failure of the so-called War on Drugs, and the preposterous belief that “Just say No” would actually work, that has contributed to the growth and destructive influence of drug cartels in many nations that supply illegal drugs to Americans. And we should also reflect on the long history of the criminalization of homosexuality (which, only within the last few years has finally almost disappeared, at least in the U.S. Criminalization didn’t work for more complex reasons, but at least decriminalization helped us to somewhat eliminate the devastating effects of public attitudes toward a class of individuals by its declassification as a disease, recognition of same-sex marriage, and generally more widespread (but not complete) acceptance in our society. More recently the wave of state legislation dealing with gender issues, whether well-meaning or not, may have the effect of dehumanizing those among us who are either confused about their gender or who identify as other than what others wish them to be, or who are gender-indeterminate based on their genome or genitalia.2 While the Mississippi statue in the Dobbs case does not criminalize abortion (although it does provide for civil sanctions against a physician www.acms.org

Perspective under certain circumstances), the effect of the Supreme Court’s decision has been to unleash a raft of legislative proposals in several states, some of which do impose criminal penalties – including for homicide3 – for both patient and physician. Some proposed legislation would also impose criminal penalties for those who assist patients in traveling from states where abortion is illegal to those where it is legal.

It is also of further interest that Ireland, in 2018, was able to enact legislation that legalized abortion in certain cases. It is likely that this would not have happened—even in the presence of a majority favoring it—but for the revelations regarding the disappearing and abused children of Tuam, a scandal that came to light in 2017. More recently, the outgoing prime minister of Scotland apologized for the forced adoptions of children (“domestic supply of infants [for adoption]” anyone?) born to unwed mothers who had little alternative than to bear children under the nation’s abortion laws, and some of whom even wanted to keep their children but weren’t allowed to.4 It is well to remember that although the illegality of abortion (along with the maternal morbidity of carrying a pregnancy to term, and deaths and morbidity that ensued from clandestine and improperly performed abortions) was the norm prior to Roe, it had been seen largely as a civil rights issue.5 But the public debate reached a fever-pitch in Nixon’s campaign for re-election in 1971, fueled by Pat Buchanan, who “set out to attract Democrats to the Republican Party over the issue of abortion, which he called a ‘rising issue and a gut issue with Catholics,’ who ACMS Bulletin / April 2023

tended to vote Democratic.”6 Using the debate about abortion as a political strategy has endured.

The destruction of an otherwise healthy fetus is indeed profoundly disturbing, and I suspect that is so even for the vast majority of people who undergo abortions.

For those folks who truly want to prevent abortion (as opposed to those who use the issue for political or other ends), I submit that the best approach to that goal is to study the nations7 and societies that have much lower abortion rates (even where permitted under the law) and consider factors that contribute, such as sexeducation, availability of contraception,8 safety-nets and support systems for impoverished (especially single) women and work to implement those preventive measures in our society.

King Canute, in the 11th or 12th century, as the legend goes (and details of legends have a way of growing like branches), as a way of proving to his courtiers who believed his power was infinite, that it in fact it was not infinite, staged an event in which he commanded the sea to roll back its tide. Needless to say, he made his point.9 Attempts to use legislation or judge-made law as a substitute for meeting new challenges that arise with increasing knowledge and understanding about ourselves as human beings tend to shift the focus away from finding the optimal way forward. As we continue to learn about ourselves as a species there are bound to be conflicts with established institutions and long-held beliefs about who we are or should be. We should meet those challenges with more

circumspection and creativity, and with the hindsight of experience—not just by enacting criminal statues in the hope that we can absolve ourselves from dealing with new realities of a changing society and advances in science and technology.

1. For details on the politicization of abortion see Heather Cox Richardson, Letters from an American, 1/21/23, available athttps:// heathercoxrichardsonvsubstack.com/p/ january-21-2023 2. Marci L. Bowers, State Legislators Have No Role in Trans Health Care, New York Times, 4/3/23, available at https://www.nytimes com/2023/04/01/opinion/transhealthcare-law.html 3. Available at https://trackbill.com/bill/southcarolina-house-general-bill-3549-southcarolina-prenatal-equal-protection-actof-2023/2290084/ 4. Jenny Gross, Scotland’s Leader Apologizes for Legacy of Forced Adoptions, New York Times, 3/26/23, available at https://www.nytimes com/2023/03/24/world/europe/ scotland-forced-adoption.html 5. Heather Cox Richardson, HOW THE SOUTH WON THE CIVIL WAR, Oxford University Press, 2020, p. 174 6. See note 1 above 7. Such as The Netherlands, described in Dobbs (597 U.S. ___ 2022, Opinion of the Court, p. 6, and footnote 15) as permitting “abortion-on-demand.”

8. Unfortunately, too often opponents of legal elective abortion are also opponents of contraception.

9. See https://en.wikipedia.org/wiki/King_Canute_ and_the_tide 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.

17

Society News

Pennsylvania Geriatrics Society—Western Division hosts 3rd Virtual Conference

(top to bottom) Lyn Weinberg, MD, Course Director and Patricia Bononi, MD, Presenter Over 330 health care professionals gathered virtually to attend the 31st Annual Virtual Clinical Update in Geriatric Medicine held March 23–24, 2023. This is the 3rd year the conference was presented in a virtual format.

This year’s virtual conference attracted attendees from 21 states and representation from Canada, England, and Germany.

Attendees recognized and appreciated the convenience of attending the conference from their home or office, while participating in dynamic educational sessions. An added benefit for all registrants: the ability to view recorded lectures and download the handout materials, up to 30 days after the conference.

With the fastest growing segment of the population comprised of individuals more than 85 years of age, this conference is a premier educational resource for health care professionals involved in the direct care of older people. Presented by the Pennsylvania Geriatrics Society – Western Division, UPMC/ University of Pittsburgh Division of Geriatric Medicine and University of Pittsburgh School

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of Medicine Center for Continuing Education in Health Sciences, the program offered an evidence-based approach to help clinicians take exceptional care of these often-frail individuals.

Highlights of the meeting included live Q&A sessions with presenters. By using the chat feature, attendees had the opportunity to engage with speakers in these informative sessions. New this year: the course provided 10.0 hours of physical therapy credit!

Distinguished guest faculty Edward R. Marcantonio, MD, SM, Section Chief for Research in the Division of General Medicine at Beth Israel Deaconess Medical Center, and Professor of Medicine at Harvard Medical School gave an Update on Delirium. Paula Leslie, FRCSLT, Reg HCPC, CCC-SLP joined this year from the UK and presented Modern Approaches to Supporting People with Eating, Drinking, & Swallowing Impairments.

Back by popular demand, the Geriatric Cardiology Expert Panel featuring Deirdre O’Neill, MD presented Beware of the Elevated Office Blood Pressure Assessment; Eiran Gorodeski, MD, MPH presented Ideal Heart Failure Care: Pearls for Geriatrics, and Daniel Forman, MD presented Optimizing Functional Status in Older Adults with Cardiovascular Disease.

(Top l to r): Eiran Gorodeski, MD, Presenter; Shuja Hassan, MD, Course Director; Daniel Forman, MD and Deirdre O’Neill, MD, Presenters interact during the popular Cardiology Q&A session Immediately following, the cardiology panel participated in a live, rapid-fire Q&A session.

Moderated by Shuja Hassan, MD and Course Director, the lively session included a framework for each presenter to comment and host a dialogue with their colleagues on a variety of cardiology questions.

Thank you to our Premier Sponsor: UPMC Health Plan, and to our exhibitors who sponsored the program: AHN Healthcare@ Home, Community LIFE, Highmark Blue Cross Blue Shield and Allegheny Health Network, and Xeris Pharmaceuticals.

The Virtual Exhibit Hall featured 4 exhibitors and offered attendees the opportunity to engage with representatives to learn more about their products and resources.

Congratulations to the winners of the raffle (sponsored by the Society): Carina Antypas, Rebecca Davis, Michelle Govan, Jessica Hutchison, and Mary Whitman. Winners received a $50 Visa Gift Card.

If you have any questions regarding the conference or obtaining CME, please reach out to Eileen Taylor, Administrator at 412-321-5030 x105 or etaylor@acms.org.

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Society News

Pittsburgh Ophthalmology Society Hosts 58th Annual Meeting American Glaucoma Society and is a member of the American Academy of Ophthalmology (AAO) where he was a member of the first class of the Leadership Development Program. He has authored over 100 peer-reviewed papers, lectured nationally and internationally, and has participated in several research projects related to glaucoma.

Attendees were enlightened and educated with presentations from the following prominent and distinguished guest faculty:

l to r: Leon W. Herndon, Jr., MD, Thorpe Lecturer accepting the Thorpe Scroll from Marshall Stafford, MD. The Pittsburgh Ophthalmology Society (POS), hosted their 58th Annual Meeting and the 43rd Meeting for Ophthalmic Personnel on March 10, 2023 at the Omni William Penn Hotel in Pittsburgh, PA. Both meetings were well attended with over 95 physicians welcoming distinguished ophthalmologist Leon W. Herndon, Jr., MD, as the 42nd annual Harvey E. Thorpe Lecturer.

The named lecture honors Harvey E. Thorpe, MD, an ophthalmologist whose techniques and inventions of medical instruments contributed to the study of the eye series.

Dr. Herndon is a Professor of Ophthalmology, Duke University Medical Center, Durham, North Carolina and also serves as Chief of the Glaucoma Division at the Duke University Eye Center where he has trained 84 clinical fellows.

He was recently appointed President of the

ACMS Bulletin / April 2023

l to r: Guest Faculty Presenters Thomas Oetting, MS, MD; José-Alain Sahel; POS President, Pamela P. Rath, MD; Immediate Past President, Marshall W. Stafford, MD; Guest Faculty Philip Custer, MD

Philip Custer, MD, FACS, Professor, Ophthalmology and Visual Sciences, John E. Hardesty, MD Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO. Tom Oetting, MS, MD, Professor in Clinical Ophthalmology; Deputy Director, VA Medical Center Surgical Service; Associate Residency Program Director, Department of Ophthalmology and Visual Sciences University of Iowa Carver College of Medicine, Iowa City, IA; and Michelle Pineda, MBA, Risk Management Specialist, Ophthalmic Mutual Insurance Company (OMIC).

In addition, the society was pleased to welcome local faculty José-Alain Sahel, MD, Distinguished Professor and Chairman; The Eye and Ear Endowed Chair Department of Ophthalmology; Director, UPMC Eye Center University of Pittsburgh School of Medicine Pittsburgh, PA. The Agenda included an informative legislative update by POS Board Member, Kenneth Cheng, MD. The POS gratefully acknowledges all industry representatives who sponsored or exhibited at the event. A complete list of exhibitors can be found on the Society website at www.pghoph.org.

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Society News

POS Annual Banquet This year’s annual banquet was held Thursday, March 9, the evening prior to the Annual meeting. The event doubled in size from previous years, with 60 members and their guests enjoying the evening.

The Sofia Room at the Hotel Monaco provided a chic, yet casual setting for members and guests to enjoy fellowship and camaraderie. Several guest faculty members joined the evening’s festivities and took advantage of the opportunity to socialize with colleagues and meet members of the Society.

The night ended with remarks from Marshall W. Stafford, MD outgoing President and comments from Pamela P. Rath, MD, who

begins her term as president. Dr. Rath looks forward to working with the Board of Directors to further the mission of the organization and

to welcoming exceptional guest presenters for the upcoming educational series.

43rd Annual Ophthalmic Personnel Meeting—Highlights Running concurrently with the Pittsburgh Ophthalmology Society’s (POS) 58th Annual Meeting was the 43rd Annual Meeting for Ophthalmic Personnel. This year, 155 attendees comprised of ophthalmic technicians, assistants, coders, photographers, and front staff attended this full-day program. The well-respected program is designed specifically for ophthalmic personnel to enhance the quality, expertise and safety of ophthalmic patient care.

The program featured a hybrid of plenary and breakout sessions, all of which were approved for 1.0 IJCAHPO credit. Participants selected their own Agenda in the afternoon, choosing from several front- and back-office courses. A new offering this year included a refractive workshop with a didactic and workshop component.

Course directors Pamela Rath, M. D., Avni Vyas, M.D., Cari Lyle, M.D., and Zachary Nadler, M.D. worked tirelessly to plan this high-level educational offering. The Society depends and relies on local expertise and talent to present each session. This year was no exception, with local physicians and health care professionals providing quality presentations. The course directors would like to thank all POS members who gave of their time to participate as a speaker for the program.

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43rd Annual Ophthalmic Personnel attendees receive instruction during the refraction workshop

Course Directors for the 43rd Ophthalmic Personnel Meeting include: (l to r) Pamela Rath, MD and Avni Vyas, MD

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BREAKFAST BRAINSTORMING CONSOLIDATED APPROPRIATIONS ACT (CAA) AND THE RELATED DIRECT CONTRACTING OPPORTUNITIES FOR PRACTICES

THURSDAY MAY 11, 2023 $10.00 8:00 - 10:00 AM ALLEGHENY COUNTY MEDICAL SOCIETY 850 RIDGE AVENUE PITTSBURGH, PA 15212

REGISTER NOW

ACMS Bulletin / January 2023

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ACMS Foundation | 850 Ridge Avenue | Pittsburgh, PA 15212

Featured Grant Recipient Jeremiah’s Place Jeremiah's Place protects children and strengthens families by providing a safe haven of respite, health, renewal, and support for children when their families are experiencing a critical need for childcare. Providing emergency childcare eliminates the possibility of child neglect and child abuse daily. This care also allows parents/guardians to focus their full attention on the crisis they are experiencing, such as medical emergencies, mental health emergencies, domestic violence situations, and more, knowing that their children are in safe hands.

Jeremiah's Place is located in the Larimer neighborhood of Pittsburgh, PA, serving the entire city and surrounding areas. As the only crisis nursery in the region, the services at Jeremiah’s Place are taken advantage of by individuals near and far. In 2021 specifically, JP served individuals from 64 zip codes, some of whom were as far away as New Jersey, Maryland, and Florida. The five neighborhoods that Jeremiah’s Place serves most often includes East Liberty, Wilkinsburg, Penn Hills, Homewood, and Braddock.

Jeremiah's Place provides 24/7, judgment-free emergency childcare for children ages 0-6 at no cost to families.

This service strives to eliminate scenarios where families place children in unsafe situations. Support from the Allegheny County Medical Society Foundation helps Jeremiah’s Place to continue to offer families support specifically from an evening social worker, a member of our Strong Families Team. This Family Encouragement Specialist offers additional support during our evening and weekend hours when calls continue to come in from parents seeking emergency care. A crisis can occur at any time. Therefore, having a social worker available to speak to beyond weekday and daytime hours is crucial to 24/7 care.

To learn more about Jeremiah’s Place visit: jeremiahsplace.org

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Donate to the ACMS Foundation to help support annual grant giving. www.acms.org

To learn more about the ACMS Foundation visit: acms.org/acmsfoundation

ACMS Foundation | 850 Ridge Avenue | Pittsburgh, PA 15212

MISSION

Founded in 1960, the Allegheny County Medical Society Foundation has extended the reach of physicians into the community through grant giving to local organizations.

The mission of the Foundation is: Advancing Wellness by confronting Social Determinants and Health Disparities. This mission works to fulfill an overall vision of a healthy and safe Allegheny County.

Throughout the ups and downs of the past few years, the Foundation’s work has become even more important in supporting local non-profits.

As physicians, you know that it takes a village to keep the community healthy and safe. Please consider a donation to the Allegheny County Medical Society Foundation.

Your donation will help the Foundation fund local non-proŃts in future grant cycles, and will help further the mission of the ACMS Foundation.

Donations can be mailed to: ACMS Foundation 850 Ridge Avenue Pittsburgh, PA 15212

Scan this QR Code to Donate via Qgiv:

The desire to give back to the community is an inherent trait of those who become physicians.

Please consider how you can personally help support the Foundation and, in turn, continue to support a healthy region.

Contact the ACMS team to learn more about how your organization can help support the ACMS Foundation.

ACMS Bulletin / March 2023

The Allegheny County Medical Society Foundation is a 501(c)3 nonprot organization with tax ID number 25-6064355. Contributions to the Allegheny County Medical Society Foundation may be fully deductible to the extent allowed by law.

To learn more about the ACMS Foundation visit: acms.org/acmsfoundation

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ACMS News Information on the Medication Access and Training Expansion (MATE) Act Training Requirement—Information and FAQ’s On June 27, 2023, a new one-time requirement will go into effect for all DEA prescribers to complete 8 hours of education on the treatment of management of patients with opioid or other substance use disorder. The team at the Allegheny County Medical Society has worked with the DEA to put together some information and FAQ’s regarding the new training requirement.

FAQ’s What is the MATE Act and what does it mean for accredited continuing education?

The DEA now requires that the nearly 2 million DEA licensees nationally demonstrate that they have completed 8 hours of relevant accredited education before they obtain a new license or renew their current licenses.

What is the goal for the new requirement?

“Given the urgency of the nation’s overdose crisis, the importance of practitioners receiving training in substance use disorders (SUD) cannot be overstated. Incorporating training on SUD into routine healthcare will enable practitioners to screen more widely for substance use disorders, treat pain appropriately, prevent substance misuse, and engage people in life-saving interventions.” -SAMHSA (Substance Abuse and Mental Health Services Administration)

Who is responsible for satisfying this new training requirement?

All DEA-registered practitioners, with the exception of practitioners that are solely veterinarians.

How will practitioners be asked to report satisfying this new training requirement?

Beginning on June 27, 2023, practitioners will be required to check a box on their online DEA registration form - regardless of whether a registrant is completing their initial registration application or renewing their registration - affirming that they have completed the new training requirement.

What clinicians are deemed to have already satisfied this training requirement?

Physicians who are board-certified in addiction medicine or addiction psychiatry. Practitioners who have graduated from their professional school within 5 years of June 27, 2023 or 5 years of their license renewal following June 27, 2023, and completed a curriculum that included at least eight hours of coursework regarding SUD during that time.

Practitioners who previously took training to meet the requirements of the DATA-2000 waiver to prescribe buprenorphine can count this training towards the 8-hour training requirements.

What is the deadline for satisfying this new training requirement?

The deadline for satisfying this new training requirement is the date of a practitioner’s next scheduled DEA registration submission— regardless of whether it is an initial registration or a renewal registration - on or after June 27, 2023.

This one-time training requirement affirmation will not be a part of future registration renewals.

Providers whose renewal expires June 30th and renew between now and June 26 will have to attest upon their next renewal, three years later.

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www.acms.org

ACMS News How can practitioners satisfy this new training requirement?

There are multiple ways that practitioners can satisfy this new training requirement.

First, the following groups of practitioners are deemed to have satisfied this training: 1. Group 1: All practitioners that are board certified in addiction medicine or addiction psychiatry from the American Board of Medical Specialties, the American Board of Addiction Medicine, or the American Osteopathic Association.

2. G roup 2: All practitioners that graduated in good standing from a medical (allopathic or osteopathic), dental, physician assistant, or advanced practice nursing school in the United States within five years of June 27, 2023, and successfully completed a comprehensive curriculum that included at least eight hours of training on: • treating and managing patients with opioid or other substance use disorders, including the appropriate clinical use of all drugs approved by the Food and Drug Administration for the treatment of a substance use disorder; or • safe pharmacological management of dental pain and screening, brief intervention, and referral for appropriate treatment of patients with or at risk of developing opioid and other substance use disorders.

Second, practitioners can satisfy this training by engaging in a total of eight hours of training on treatment and management of patients with opioid or other substance use disorders from the groups listed below. A few key points related to this training: 1. The training does not have to occur in one session. It can be cumulative across multiple sessions that equal eight hours of training.

2. Past trainings on the treatment and management of patients with opioid or other substance use disorders can count towards a practitioner meeting this requirement. In other words, if you received relevant training from one of the groups listed below - prior to the enactment of this new training obligation on December 29, 2022 - that training counts towards the eight-hour requirement.

3. Past DATA-Waived trainings count towards a DEA registrant’s 8-hour training requirement.

4. Trainings can occur in a variety of formats, including classroom settings, seminars at professional society meetings, or virtual offerings.

What accredited groups may provide trainings that meet this new requirement?

• The American Society of Addiction Medicine (ASAM) • The American Academy of Addiction Psychiatry (AAAP) • American Medical Association (AMA) • The American Osteopathic Association (AOA), or any organizations accredited by the AOA to provide continuing medical education • The American Dental Association (ADA) • The American Association of Oral and Maxillofacial Surgeons (AAOMS) • The American Psychiatric Association (APA) • The American Association of Nurse Practitioners (AANP)| • The American Academy of Physician Associates (AAPA) • The American Nurses Credentialing Center (ANCC) • Any other organization accredited by the Accreditation Council for Continuing Medical Education (AACCME) or the Commission for Continuing Education Provider Recognition (CCEPR), whether directly or through an organization accredited by a State medical society that is recognized by the ACCME or CCEPR • Any other organization approved or accredited by the Assistant Secretary for Mental Health and Substance Use, the ACCME, or the CCEPR

Who can I contact with questions?

ACMS/PAMED will continue to keep you informed as this guidance evolves. If you have questions please contact acms@acms.org or knowledgecenter@pamedsoc.org

Questions for the DEA? Contact ODLP@dea.gov.

Additional information can be found by visiting https://www.deadiversion.usdoj.gov/

ACMS Bulletin / April 2023

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ACMS News

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Materia Medica

Neonatal Abstinence Syndrome Abree Cowan, PharmD Candidate 2023; Jamie L. McConaha, PharmD, NCTTP, BCACP, CDCES What is Neonatal Abstinence Syndrome Neonatal abstinence syndrome (NAS) is characterized by symptoms of withdrawal in the neonate after chronic intrauterine exposure to a substance(s) near or at the time of delivery.1 The neonate is physically dependent on the substance(s) but not addicted. Withdrawal symptoms begin shortly after delivery due to the abrupt cessation of the substance at birth.

Neonatal opioid withdrawal syndrome (NOWS) is the specific subset of withdrawal associated with maternal opioid use disorder.

Short- and Long-Term Effects of Neonatal Opioid Exposure Opioid exposure in the neonate can have serious side effects. Exposed neonates are at higher risk of low birth weight, small head circumference and premature birth. Although more research on the long-term effects of neonatal abstinence (NAS) or neonatal opioid withdrawal syndrome (NOWS) is needed, it is suspected to negatively impact hearing, vision, and cause problems with learning and overall behavior.6 Due to the suspected long-term effects of opioid exposure and withdrawal in the neonate, close monitoring and follow-up should be done. After discharge, the neonate should be referred to a center or program that offers comprehensive care and services. Close monitoring of developmental, behavioral, and mental health status of the neonate after discharge is crucial.5

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Substances of Abuse There are multiple different substances of abuse that can cause neonates to experience withdrawal symptoms. Marijuana is commonly used but is not associated with withdrawal symptoms in the neonate.

Similarly, cocaine does not cause a physical dependence, but when used in conjunction with other substances, like opioids, it can potentiate symptoms of withdrawal. When benzodiazepines and opioids are used during pregnancy, withdrawal symptoms may occur in the neonate.

Neonatal abstinence syndrome is not always a result of illicit drug use during pregnancy, it can also occur due to treatment of chronic disease states of the mother. When someone on chronic opioid therapy becomes pregnant, there are safe and evidence based alternative therapies for disease state management. The two literature supported alternatives for the pregnant population are methadone and buprenorphine.

Methadone, a full µ-opioid receptor agonist, is available through federally licensed opioid treatment programs. Buprenorphine, is a partial µ-opioid receptor antagonist and partial µ-opioid receptor agonist. Due to the Drug Addiction Treatment Act of 2000, buprenorphine is available through a prescriber that has obtained the appropriate waiver. Similar to methadone, it is also available through federally licensed opioid treatment programs.

Prevalence of Maternal Substance Abuse in the United States Maternal substance abuse in the United States leads to increased rates of maternal morbidity.3 Substance abuse also increases risk of negative health outcomes of the infant, such as still birth. It is estimated that about five percent of the pregnant population uses one or more addictive substances9. With the increased risks of negative maternal and neonatal side effects due to substance abuse, it is important to be aware of what substances can be abused, maternal and neonatal screening options as well as symptoms of withdrawal in the neonate.

Prevalence of Neonatal Abstinence Syndrome and Opioid Use Disorder in Allegheny County The opioid epidemic affects the entire state of Pennsylvania but is more prominent in certain counties than others. In 2020, the annual rate of maternal opioid use disorder (OUD) diagnosis at delivery was 17.37 out of every 1,000 births in Allegheny County.2 During that same year in Allegheny County, 48.91 out of 1,000 births resulted in neonatal abstinence syndrome.2 Rates in rural counties tend to be higher than in urban areas.

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Materia Medica Symptoms of Withdrawal in Neonates

Non-Pharmacotherapy Management

Symptoms of NAS can be categorized into three groups. Those groups are gastrointestinal (GI) symptoms, central nervous system (CNS) symptoms and metabolic/ respiratory symptoms. Common GI symptoms include poor feeding, regurgitation, projectile vomiting, diarrhea, and excessive sucking.1 CNS symptoms include high pitched crying, poor sleeping, tremors, myoclonic jerks, and generalized convulsions.1 Finally, common metabolic and respiratory symptoms include sweating, fever, frequent yawning, nasal stiffness and flaring, sneezing, and increased respiratory rate.1 When attempting to determine if a neonate is experiencing NOWS, it is important to rule out other diagnosis that have similar presentation. This would include diagnosis such as sepsis or hypoglycemia.

To evaluate the severity of withdrawal in neonates, a scoring system is often used.

There are multiple different scoring systems that have been developed to help determine the proper treatment regimen of a neonate experiencing withdrawal. The most common scoring systems include Finnegan Scoring System, The Lipsitz Neonatal Drug-Withdrawal Scoring System, The Neonatal Withdrawal Inventory, and The Neonatal Narcotic Withdrawal Index.4,5 Of these, the Finnegan Scoring System is commonly used among institutions. It is the most complex of the scoring systems, but also the most comprehensive.

The neonate is scored on 31 different items every 3-4 hours before feedings. The scoring directly correlates with severity of symptoms and institutions commonly have protocols in place on how to treat the neonate based off the scores.

Nondrug therapy is the standard of care in the management of withdrawal symptoms associated with NOWS. To help alleviate the associated GI, CNS and respiratory/metabolic symptoms of withdrawal, neonates are often swaddled, kept in a dark room, and stimulated minimally. Other techniques used are breastfeeding, if the mother is a candidate, and skin to skin contact to soothe the infant.1

Pharmacotherapy Management of Withdrawal Not all cases of NOWS require the addition of pharmacotherapy. Treatment is often based on a scoring system and the severity of withdrawal symptoms the neonate is experiencing.4 If scoring indicates pharmacotherapy, or if withdrawal symptoms are severe enough, it is key to know what substances the neonate has been exposed to.

This information is what the treatment plan is based off.

Most hospitals or institutions have a set protocol on how to treat neonatal opioid withdrawal. Literature supports an opioid as first line therapy for the treatment of neonatal opioid withdrawal.7 Morphine is most commonly used in scheduled titration. The dose of morphine is often weight based and titrated until the infant’s withdrawal symptoms or score is stabilized. If the neonate is not showing a strong enough clinical response with morphine monotherapy, there is evidence to support the addition of clonidine or phenobarbital to the treatment regimen.8 These additional pharmacotherapy agents are also titrated to appropriate doses to help ease the symptoms of withdrawal. Eventually, all medications used in the treatment of withdrawal are titrated down and discontinued before the neonate can be discharged from the NICU.

Allegheny County Resources To prevent NOWS, resources are needed for the pregnant population, their families, or anyone looking for help in Allegheny County.

In Allegheny County there are “Centers of Excellence,” which are recognized for their ability to provide treatment for opioid use disorders. These centers include the Gateway Rehabilitation Center, Tadiso Incorporated, Magee Womens Hospital of UPMC, UPMC General Internal Medicine Center for Opioid Recovery, and West Penn Allegheny Health System.

Gateway Rehabilitation Center offers inpatient and outpatient drug rehabilitation care, substance abuse support programs for patients and for families, medically monitored withdrawal management, and medications for substance use disorders.13 Tadiso Incorporated offers methadone and suboxone therapy management, group and individual counseling services, family therapy as well as pregnancy, postpartum and childcare services.14 Magee Womens Hospital has the Pregnancy and Women’s Recovery Center that offers comprehensive care to women with an opioid use disorder. Through the recovery center they can receive routine medical care, behavioral health counseling, psychiatric care, social support services and medication for opioid use disorder such as buprenorphine products and naltrexone.10 UPMC Mercy contains the UPMC General Internal Medicine Recovery Engagement Program (IM-REP). This center offers programs such as medication management for opioid use disorder, behavioral health counseling, community-based support, guidance from recovery specialists, social service support and routine medical care.11 West Penn Hospital of Allegheny Health System offers the Perinatal Hope Program.

Within the program patients can receive all-in-one appointments during pregnancy Continued on Page 30

ACMS Bulletin / April 2023

29

Materia Medica From Page 29

and postpartum, drug and alcohol counseling (individual and group), group support programs that educate on breastfeeding and infant safety, Hepatitis C testing and treatment, medication for opioid use disorder, ability to refer to a methadone clinic, high-risk pregnancy care, and post-pregnancy services.12

Summary Maternal substance abuse can result in neonatal abstinence syndrome. The chronic intrauterine exposure to opioids resulting in withdrawal symptoms in the neonate is known as neonatal opioid withdrawal syndrome.

The associated symptoms experienced by neonates can be categorized into GI, CNS, and respiratory/metabolic symptoms. Nonpharmacotherapy is the standard of care when it comes to treatment of NAS and NOWS. If withdrawal symptoms are severe enough, pharmacotherapy can be initiated to mitigate them. Common substances of abuse are marijuana, cocaine, benzodiazepines, opioids, methamphetamine, and amphetamines. The short- and long-term effects on neonates who experience intrauterine exposure to substances of abuse should be monitored closely. After discharge from the hospital, the infant should be referred to a program or center that can provide comprehensive care and follow-ups.

Within Allegheny County, there are many resources for those with opioid use disorders

or those who struggle with substance abuse.

There are specific programs designed for the pregnant population and mothers who are seeking help. This patient population requires special care and monitoring and within Allegheny County there are many resources designed to provide this care.

6. Yeoh SL, Eastwood J, Wright IM, Morton R, Melhuish E, Ward M, et al. Cognitive and motor outcomes of children with prenatal opioid exposure: a systematic review and meta-analysis. JAMA Netw Open. (2019) 2:e197025. 10.1001/jamanetworkopen.2019.7025

Citations

1. Holmes AP. NICU Primer for Pharmacists. Bethesda, MD: American Society of Health-System Pharmacists; 2016.

7. Osborn DA, Jeffery HE, Cole MJ. Opiate treatment for opiate withdrawal in newborn infants. Cochrane Database Syst Rev. 2010;(10):CD002059

2. Pennsylvania opioids impact on families and children. Commonwealth of Pennsylvania Open Data Portal. https://data.pa.gov/stories/s/Pennsylvania-Opioids-Impact-on-Families-and-Childr/5jbf-sr7p/. Accessed March 27, 2023.

8. Agthe AG, Kim GR, Mathias KB, et al.

Clonidine as an adjunct therapy to opioids for neonatal abstinence syndrome: a randomized, controlled trial. Pediatrics. 2009;123(5).

Available at: www.pediatrics.org/cgi/content/ full/ 123/5/e849

3. Jarlenski M, Krans EE, Chen Q, et al.

Substance use disorders and risk of severe maternal morbidity in the United States.

Drug Alcohol Depend. 2020;216:108236. doi:10.1016/j.drugalcdep.2020.108236

9. Wendell AD. Overview and epidemiology of substance abuse in pregnancy. Clin Obstet Gynecol. 2013;56(1):91-96. doi:10.1097/ GRF.0b013e31827feeb9

4. Jansson LM, Velez M, Harrow C. The opioid-exposed newborn: assessment and pharmacologic management. J Opioid Manag. 2009;5(1):47-55.

5. Patrick SW, Barfield WD, Poindexter BB, AAP COMMITTEE ON FETUS AND NEWBORN, COMMITTEE ON SUBSTANCE USE AND PREVENTION. Neonatal Opioid Withdrawal Syndrome. Pediatrics.

2020;146(5):e2020029074

10. Pregnancy and women’s recovery center: UPMC Magee-Womens Hospital. UPMC. https://www.upmc.com/locations/hospitals/ magee/services/obstetrics-and-gynecology/ obstetrics/magee-recovery-services/pregnancy-recovery-center. Accessed March 20, 2023.

11. Recovery engagement program: UPMC General Internal Medicine. UPMC. https:// www.upmc.com/services/internal-medicine/ opioid-recovery. Accessed March 20, 2023.

12. Recovery engagement program: UPMC General Internal Medicine. UPMC. https:// www.upmc.com/services/internal-medicine/ opioid-recovery. Accessed March 20, 2023.

13. How we help. Gateway Rehab. https://www.gatewayrehab.org/.

Accessed March 20, 2023.

14. Medication-assisted treatment: Pittsburgh, PA - tadiso, Inc.. Quality Approved. https:// www.tadiso.org/medication-assisted-treatment/. Accessed March 20, 2023.

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www.acms.org

Editorial

Check out the 2023 Dr. Daffner, associate editor of the calling, is meant in a benign fashion, it adjacent lumbar vertebra, explaining Bulletin Media is considered harmless. her pain.

My resident, from Georgia, Kit. ACMS Bulletin, is a retired radiologist However, in today’s politically upon seeing the findings said, in his who practiced at Allegheny General Did you know members divisive atmosphere, it is best to use deep southern drawl, “Fellahs, there’s for more than 30 years.

ReachingHospital the Most Physicians humor only when you truly know a lesson here. Crocks daah (die), He is emeritus clinical professor of in Allegheny County your audience. As a good example, I too.” can Unfortunately for theads patient, and CT post more!

Radiology at Temple University School scanning and ultrasound exams had not been developed. The important lesson is that for most patients with a diagnosis of psychosomatic illness, the symptoms are real, and in fact a small number of these patients indeed have real abnormalities accounting for their symptoms.

Sigmund Freud’s view of humor was that it was a conscious expression of thoughts that society usually suppressed or was forbidden.2 As long as the humor, in this case name-

THE UNIQUE OPPORTUNITY TO REACH THE NEARLY UNREACHABLE: PHYSICIANS, HEALTHCARE ADMINISTRATORS, A N D P R AC T I C E M A N AG E R S .

remember the not so “good old days,” when it was expected that a speaker at a conference or a refresher course would tell jokes. Many of the “old timers” were very colorful characters.

Today, fortunately, speakers are business-like and jokes are tacitly forbidden, since they are bound to offend someone. Finally, we should always remember that no matter how unpleasant some of our patients are to us, they are still our fellow human beings.

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of Medicine and is the author of nine textbooks. He can be reached at bulletin@acms.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.

ACMS.org 850 Ridge Ave., Pittsburgh, PA 15212 Phone: 412-321-5030 Fax: 412-321-5323

References 1. Shem S. The House of God. Richard Marek Publishers 1978.

2. Freud S, (Strachey J, Trans.). Jokes and their relation to the unconscious New York: W. W. Norton, 1960 (Original work published 1905).

January 1, 2023

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Three Penn Center West Pittsburgh, PA 15276 fennercorp.com ACMS Bulletin / August 2021 ACMS Bulletin / April 2023

229 31

Legal Summary

Private Equity: Investigation and Enforcement

By Michael A. Cassidy

Since the private equity issue was last addressed in the Bulletin in the Summer of 2022, the volume of health care private equity deals has subsided somewhat, according to statistics presented at the March 2023 Pennsylvania Bar Institute Health Law Conference, and that has generally been attributed to unfavorable market conditions affecting investments of all types.

However, although the volume has leveled off or in some cases subsided, enforcement and investigation activity apears to be ramping up. In March 2023, the House Ways and Means Committee hosted an investigative hearing on “private equity’s expanded role in the US healthcare system”.

As you might expect from a federal investigation, conducted by politicians with media present, the tone of the meeting was more hostile rather than supportive. Two quotes will set that stage:

“It’s past time for a bright light to be shined on how private equity ownership in our healthcare system affects patient safety, costs and jobs.

Private equity’s influence stretches like an octopus arms through the American healthcare system and born heavily by the most vulnerable: communities of color, rural underserved areas, the elderly, people with disabilities…private equity’s expansion into healthcare is troubling because private equity’s focus on profits is often at odds with what is best for patient care. Private equity’s business involves buying companies, saddling them with debt, and then squeezing them like oranges for every dollar.”

— House Committee on Ways and Means Sub-Committee on Oversight Chair Rep. Bill Pascrell “I’m so concerned about the increasingly outsized influence of private equity on our healthcare system. Private equity firms are investment firms set up to increase profits for their shareholders, not to provide better quality medicine. We saw that issue up close last year as the committee considered the role of PE firms in the increase of patients receiving surprise medical bills.”

— House of Representatives Judy Chu (D-CA)

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This concern for suspected ulterior financial motives behind these clinical investments is not unfounded, because the healthcare business system is drastically different from most other business environments, in that professional fees paid from government third party payers cannot be raised unilaterally at all, payments from large third party commercial insurance systems are very difficult to raise, if at all. This leaves revenue enhancement possibilities limited to situations in which the private equity roll ups have created leverage, which is one of the goals, or situations in which there is significant self-pay patient activity, i.e. aesthetics, dermatology, rehabilitation, and specialties that have significant ancillary revenue opportunities such as ambulatory surgery centers. Revenue can only be increased in most instances by increased volume, not increased charges. This “fee obstacle” was what precipitated many of the bankruptcies in the 1990s physician practice management ventures, as mentioned in my prior article.

Please note that the potential for ulterior financial motives does not automatically presume that the intent is somehow suspect, in the same way that potential medical malpractice concerns does not legitimately question the clinical motives of all other providers. These are simply potential risks involved in the transactions, and they should be evaluated appropriately.

www.acms.org

Legal Summary Similar issues were raised with respect to the private equity acquisition of Hahnemann Hospital. In the article titled “The Death of Hahnemann Hospital” published in the New Yorker magazine in May 2021, the author, Chris Pomoroski, speculates that the PE acquisition of Hahnemann Hospital was always, at least partially, a real estate play. Senator Bernie Sanders was quoted in the article as saying: “If an investment banker like Joel Freedman is able to shut down Hahnemann and make a huge profit by turning this hospital into luxury condos, it will send a signal to every vulture fund on Wall Street that they can do the same thing, in community after community after community”.

Just from a historical perspective, it should be noted that Hahnemann has had an illustrious clinical history but a recently troubled financial history.

Hahnemann was acquired by AHERF, the forerunner of Allegheny Health Network, in 1993. Tenet Healthcare bought Hahnemann out of the AHERF

bankruptcy in 1998. Tenet went through its own bankruptcy difficulties and, in 2018, sold its remaining Philadelphia assets, i.e. Hahnemann Hospital and St. Christopher’s Hospital, to American Academic Health System, which then closed Hahnemann Hospital in June of 2019.

Additional Investigative and Enforcement Activity In 2017, a whistleblower suit was filed against Surgery Partners, Inc. in United States ex rel. Cho and Baker v. Surgery Partners, Inc. alleging liability on behalf of the private equity managers because of their management control and direction.

However, federal appeals court recently upheld the dismissal of the whistleblower suit against the private equity firm, HIG Capital.

In February of 2021, the National Bureau of Economic Research published a paper by Atul Gupta, Sabrina T. Howell, Constantine

Yannelis and Abhinav Gupta positing that their research shows that “PE ownership increases short term mortality of Medicare patients by 10%, in nursing homes”.

In November of 2022, the Office of the Attorney General of the State of New York and the NY Medicaid Fraud Control Unit filed an action against Comprehensive at Orleans LLC, d/b/a The Villages of Orleans Health and Rehabilitation Center, alleging inadequate care at the facility and naming not only the nursing home facility, i.e. “The Villages”, but the real property holding company, the management company, an entity identified as the pass-through entity “Villages of Orleans LLC” and various other investors.

Conclusion Multiple sources, including CMS, have reported that healthcare spending in the USA exceeded $4 trillion in 2022, and constituted almost 19% of USA GDP. Therefore, it is obvious that the healthcare sector will provide massive investment opportunities. Those of us who “advise” healthcare clients obviously must recognize all points of view.

ACMS Bulletin / April 2023

33

Our Best Tools Against COVID-19: Vaccines and Antivirals Megan McGrady, MPH CSTE Applied Epidemiology Fellow, Allegheny County Health Department Bivalent Vaccine Data: The COVID-19 bivalent vaccine booster protects against the virus and reduces the risk of severe outcomes, including hospitalization and death. In a study conducted by the National Institutes of Health from September to December 2022, the bivalent booster was found to be 62% effective against COVID-19, and 37% more effective in preventing severe outcomes when compared to the original booster.1

58.9% had not received a bivalent booster recommendation from their provider. In the NIS-Child COVID Module, 52.0% of parents were receptive to their adolescents receiving the booster, but 32.4% of them had not received any COVID-19 vaccine recommendation from their provider.3 Health care providers should continue to recommend the bivalent booster by informing adults and parents about COVID-19 related illness and the benefits and safety of the bivalent booster.

The bivalent vaccine has been recommended for people ≥ 12 years old since September 1, 2022, for those aged 5-11 years since October 12, 2022, and for those 6 months-4 years since December 9, 2022.

In Allegheny County, uptake of the bivalent vaccine has been low, even among seniors who are at risk for severe disease. Among those aged 70+ years, only about 42% have received the bivalent booster.

The National Immunization Survey (NIS) Adult COVID Module in 2021 found that adults who received a provider recommendation for a COVID-19 vaccine were more likely to be vaccinated, to be concerned about COVID-19 and to believe COVID-19 vaccines are important and safe.2 In 2022, the survey found that of eligible adults, 27.1% received a bivalent booster, 39.4% had not received a booster but were receptive to getting one, and the rest were unsure or reluctant.3 Among those receptive,

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COVID-19 Outpatient Treatment: 2-8 days after recovery or a negative Nirmatrelvir-ritonavir (Paxlovid), an outpatient antiviral medication given orally, is recommended for persons ≥ 12 years old, with mild-moderate COVID-19, who are at an increased risk for severe illness. Nirmatrelvir-ritonavir has been shown to be 80% effective in preventing COVID-19 hospitalization or death when given within five days of symptom onset.4 Possible side effects include dysgeusia, diarrhea, increased blood pressure and myalgia.5 COVID-19 rebound has occurred in a small percentage of those initially infected who take the antiviral medication, occurring

test.6 Rebound symptoms are similar to the initial symptoms, but milder, and there are no recommendations for additional treatment. Rebound also occurs in persons with COVID-19 who do not take Paxlovid.7 Remdesivir (Veklury) and molnupiravir (Lagevrio) are additional COVID-19 antiviral medications. Remdesivir is an intravenous infusion administered at health care facilities for adults and children with a positive COVID-19 test who are at risk for severe disease.

Remdesivir should be started as soon as possible, and definitely www.acms.org

within seven days of symptom onset.

Possible side effects include nausea and hypersensitivity. Remdesivir has been shown to reduce the risk of hospitalization and death by 87% among patients at high risk for severe disease.8 Molnupiravir is an oral antiviral medication authorized for adults ≥ 18 years of age. Molnupiravir should be given within five days of symptom onset. Possible side effects are nausea, vomiting and diarrhea. It is reported that molnupiravir reduces the risk of hospitalization or death due to COVID-19 by about 30% among unvaccinated adults at high risk for disease.9 Molnupiravir should not be given to anyone who is pregnant.

See the CDC’s COVID-19 treatment guidelines for health care providers to determine best treatment options for patients: COVID-19 Treatments and Medications | CDC. The infectious Disease Society of America has a quick reference guide for nirmatrelvir-ritonavir treatment: https://www.idsociety.org/ covid-19-real-time-learning-network/ therapeutics-and-interventions/ nirmatrelvir-ritonavir-paxlovid-point-ofcare-reference/

ACMS Bulletin / April 2023

References: 1. N IH. Bivalent boosters provide better protection against severe COVID-19.

US Department of Health and Human Services, NIH; 2023. Bivalent boosters provide better protection against severe COVID-19 | National Institutes of Health (NIH).

2. N guygen KH, Yankey D, Lu P, et al. Report of Health Care Provider Recommendation for COVID-19 Vaccination Among Adults, by Recipient COVID-19 Vaccination Status and Attitudes – Unites States, April-September 2021. MMWR Morb Mortal Wkly Rep 2021;70:1723-1730.

DOI: http://dx.doi.org/10.15585/ mmwr.mm7050a1.

3. L u P, Zhou T, Santibanez TA, et al. COVID-9 Bivalent Booster Vaccination Coverage and Intent to Receive Booster Vaccination Among Adolescents and Adults – United States, November-December 2022.

MMWR Morb Mortal Wkly Rep 2023;72:190-198. DOI: http://dx.doi. org/10.15585/mmwr.mm7207a5.

4. L ewnard JA, McLaughlin JM, Malden D, et al. Effectiveness of nirmatrelvirritonavir in preventing hospital admissions and deaths in people with COVID-19: a cohort study in a large US health-care system. Lancet Infect Dis. 2023 Mar 15:S14733099(23)00118-4. doi: 10.1016/ S1473-3099(23)00118-4. Epub ahead of print. PMID: 36933565.

5. FDA. Frequently asked questions on the emergency use authorization for Paxlovid for treatment of COVID-19.

US Department of Health and Human Services, FDA; 2023. Paxlovid FAQs 02072023 (fda.gov).

6. CDC. Interim clinical considerations for COVID-19 treatment in outpatients. US Department of Health and Human Services, CDC; 2023.

Interim Clinical Considerations for COVID-19 Treatment in Outpatients | CDC. 7. Deo R, Choudhary MC, Moser C, et al. Symptom and Viral Rebound in Untreated SARS-CoV-2 Infection. Ann Intern Med. 2023 Mar;176(3):348354. doi: 10.7326/M22-2381. Epub 2023 Feb 21. PMID: 36802755.

8. Gottlieb RL, Vaca CE, Paredes R, et al. Early Remdesivir to Prevent Progression to Severe Covid-19 in Outpatients. N Engl J Med. 2022 Jan 27;386(4):305-315. doi: 10.1056/ NEJMoa2116846. Epub 2021 Dec 22. PMID: 34937145; PMCID: PMC8757570.

9. Jayk Bernal A, Gomes da Silva MM, Musungaie DB, et al. Molnupiravir for Oral Treatment of Covid-19 in Nonhospitalized Patients. N Engl J Med. 2022 Feb 10;386(6):509-520. doi: 10.1056/NEJMoa2116044. Epub 2021 Dec 16. PMID: 34914868; PMCID: PMC8693688.

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ALLEGHENY COUNTY MEDICAL SOCIETY — 2023 MEETING SCHEDULE ALL MEETINGS BEGIN AT 6:00 PM Upcoming Events No upcoming events E xecutive Committee* Tuesday Evenings—2nd Tuesday at the start of each new quarter.

July 11, 2023 October 10, 2023

Committees

Finance Committee Tuesday Evenings

Board of Directors* Tuesday Evenings

August 29, 2023 November 14, 2023

May 9, 2023 September 12, 2023 December 5, 2023

Dates to be announced

Delegation April, June, August, October Nominating May, August ACMS Honors April 27, 2023

Heinz History Center

ACMS Foundation June 20—Prep for Grant Proposals October 24—Grant Proposal Review

PAMED BOARD

PAMED HOUSE OF DELEGATES / HERSHEY

May 4 October 27-28, 2023 August 3 October 26-27, 2024 AMA HOUSE OF DELEGATES

June 10-14 Chicago, IL AMA Interim Meeting November 11-14 National Harbor, MD AMA Annual Meeting June 2024 Chicago, IL ACMS HOLIDAYS – OFFICE CLOSED January 2—New Year’s Day (Monday) September 4—Labor Day (Monday) January 16—Martin Luther King (Monday) November 10—Veteran’s Day (Friday) February 20—President’s Day (Monday) November 23—Thanksgiving Day (Thursday) May 29—Memorial Day (Monday) November 24—Thanksgiving Friday (Friday) June 19—Juneteenth Day (Monday) December 25—Christmas (Monday) July 4—Independence Day (Tuesday)