The Stethoscope, Newsletter of the Erie County Medical Society, March 2021

the Stethoscope the Stethoscope

September 2019 Issue

Quarterly Newsletter of the Erie County Medical Society

Quarterly Newsletter of the Erie County Medical Society • March 2021 Issue

A Message From Your President

Dr. Andrew Manson and the Erie Physician

by Jeffrey McGovern, MD, FCCP, FAASM, President, ECMS “ Don’t you remember how you used to speak of life, that it was an attack of the unknown, an assault uphill-as though you had to take some castle that you knew was there, but couldn’t see, on the top.”

Jeffrey McGovern, MD, FCCP, FAASM, President, ECMS Rebecca Doctrow Association Executive rdoctrow@pamedsoc.org Phone: 833-770-1542 1438 West 38th Street Erie, PA 16508 Administrative Office/ Mailing Address: 400 Winding Creek Blvd.

Mechanicsburg, PA 17050 eriecountymedicalsociety.org

—The Citadel, A.J. Cronin Physicians read voraciously. University, medical school, residency, fellowship and our post graduate years are marked by hours and hours filled with reading. It is almost as if the tabula rasa, or empty tablet of our minds, proposed by ancient philosophers has never-ending pages.

What physicians read besides clinical medicine treatises probably depends on their free time, their desire to escape from the stress of their work day and their search for some meaning amidst the difficulties of patient care.

In that light I wanted to resurrect an older book which I reread.

Perhaps we all have a book or two we read early in our careers.

While the list is not exhaustive, some of the titles may include: Dear and Glorious Physician, Taylor Caldwell The Road less Traveled, M. Scott Peck, MD House of God, Samuel Shem, MD

The opinions expressed in this publication are for general information only and are not intended to provide specific medical, legal or other advice for any individuals. The placement of editorial content, opinions, and paid advertising does not imply endorsement by the Erie County Medical Society.

Emperor of All Maladies, Siddhartha Mukherjee, MD When Breath Becomes Air, Paul Kalanithi, MD The book I reread has more yellowed pages than those above as I read it while contemplating going to medical school. My background in Latin and Greek gave me a unique ability to consult the classics and, in turn, look more deeply through the weeds of world literature. One of the gems I found was The Citadel (1937). Written by a physician who turned from medicine to literature, the book chronicles the professional and personal life of Dr. Andrew Manson in the years prior to the creation of the National Health Service in England.

A brief summary of the book (S. O’Mahoney, 2012) is helpful to appreciate the themes Idealism and Focused Energy, Brokenness and Redemption. Newly graduated Dr. Manson takes up a post as a Continued on page 2

Dr. Andrew Manson and the Erie Physician Continued from page 1

he resigns and buys a broken-down practice in London. Manson soon becomes busy as patients are attracted to his medical skills, but succumbs gradually to the temptations of money and sex.

He befriends two unscrupulous society doctors (Hamson and Ivory) who effectively steer him away from any remembrance of his ethical standards. He becomes rich from exploiting rich, neurotic clients and fee-splitting and carries on an affair with a wealthy sponsor despite the ever-faithful Christine at his side. Christine and Dr. Denny both try to rein him in to no avail.

Manson comes abruptly to his senses after the botched operation of one of his beloved patients by the incompetent Dr. Ivory. Andrew vows after this incident to return to the honest practice of medicine. He sells his lucrative practice and reconciles with his wife. Shortly after tragedy once again strikes as Christine is mortally wounded in a bus accident as she leaves the apartment. Manson’s true friends, Drs. Denny and Hope, bind his wounds as they plan to build a practice together in the most ethical means possible. The other doctors he left (Hamson and Ivory), however, seek their revenge against Manson for his tirade against their unethical behavior and report him on trumped up charges to the medical board. Andrew delivers an impassioned speech on the failures of the healthcare system. The board which includes his patron, Sir Robert Abbey, exonerate him. The book ends with a new beginning for the three men as they begin a combined practice serving a Welsh mining community.

general practitioner in a Welsh mining town.

He discovers much to his distress that his new partner, Dr. Page, has been completely incapacitated by a stroke. Dr. Page’s sister tries to conceal the fact of the debility and exploits Dr. Manson. During this crucible of post graduate work he befriends a cynical physician (Dr. Denny) who though burned out remains steadfast to caring for his patients.

Dr. Manson toils daily to care for the roughhewn Welsh miners and eventually impresses them with his medical skills. He marries a local schoolteacher, Christine, voice of the quote noted in the beginning, who endeavors to keep him grounded in his ideals and values.

As the exploits of Dr. Page’s sister become too unbearable he transfers to a post at another Welsh town. There, the principal doctor expects to receive a part of Dr. Manson’s salary. Frustrated by the new arrangements, Andrew focuses his attention on obtaining the coveted MRCP (Membership of the Royal Colleges of Physicians of the United Kingdom).

Working long hours and studying for the arduous exam he passes and impresses his examiner, the distinguished and sympathetic Sir Robert Abbey. Tragedy strikes the Manson family as Christine becomes pregnant and loses the baby in a freak accident and is told she may never bear children. Dr. Manson carries on and become interested in lung disease caused by coal dust. Although he carries out exacting research the ignorant townspeople and his enemies accuse him of experimenting with animals without a license.

Although exonerated, he resigns his post there and is appointed Chief Medical Officer for the Mining Fatigue Board. He soon discovers that the board is controlled by mine owners and populated by figure heads with the exception of his advocate, Sir Robert Abbey. The board tries to distract him from his ongoing research into the ill effects of coal dust on the lungs, and he seeks an alliance with an idealistic microbiologist named Dr. Hope, who along with his wife continues to encourage his waning idealistic streak. After an unfruitful year of fighting against the tide on the Fatigue Board

Manson unleashed himself upon the community with idealism and focused energy and probably mimics the same qualities of the writer himself.

The Citadel contains reminiscences of Cronin’s own experiences in his early career. The days are arduous and seemingly never-ending and the personal tragedy heaps upon his medical burdens. His brokenness does not rear its ugly head, however, until Manson turns away from his ethics and is subsumed by the lure of money and sex. It is not the work itself which burns out the protagonist but rather the distractions Continued on page 3

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Dr. Andrew Manson and the Erie Physician Continued from page 2

We too as Erie physicians may be like that Welsh doctor. We too may be in any of those stages in our professional lives. Do we experience burn out? Why? Do we have a Denny and Hope in our lives? If not why not? We experience frustration with the EMR, prior authorization and rightly so but do they overshadow the satisfaction of caring for that person behind the hospital or office door?

In the end we are a fortunate few who are privileged to lift at least a part of the burden of our suffering neighbors. That is the essence of our “assault uphill.”

which steer him away from his medical course.

Manson’s redemption arrives through a singular moment (senseless death of his patient at the hands of an incompetent and unscrupulous associate) but even more importantly his true associates (we could call them our colleagues, our medical associates who understand the difficulties and seek to buttress our weaknesses) come to his aid and reinstate in him his focus to do for the patient what is in their best interest.

In his impassioned speech before the medical board which threatens to strip away his medical credentials, Manson reveals how much he has redeemed himself by calling for improved education and training of the doctor, reverencing evidence-based medicine and recalling the moral certainties of life as a physician.

Member News New

Reinstated

Sarah Elizabeth Achenbach, MD Kirsten Elizabeth Blakeslee Patrick Eller Jason Guzowski Andrea T. Jeffress, MD David Jonathan Kadouri, MD Andrew Kroemer, MPH Sara Meyer, DO Daniel Dudley Noble, MD Larry Wade Thompson Jr., MD

Jan F. Brzozowski, MD Sarah Elizabeth Gertrude Carter , MD Christopher C. Clark, DO, MHA Ellen E. Dailey, MD Peter Joseph Din, DO Leonard Aubrey Ferreira, MD Paul J. Gmuer, MD Peter M. Intrieri, MD Kiet Ma, DO Michele L. Polon, DO Lindsey K. Roach, DO Michael A. Scutella, MD Annette Veronica Wagner, MD Sarah L. Warner, MD Elizabeth N. Wise, DO

Lisa Wood

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Editorial: Denied Treatment Scott J.M. Lim, DO If you are like me, one of the most frustrating and exhausting parts of my day is dealing with denials from insurance companies for treatments I have carefully thought out, counseled my patients about, and patients have mutually agreed upon. Literally, I have sent an eRx from my iPad in the exam room, walked out and within 5 minutes my staff has added to my pile of papers a fax from the pharmacy stating the order I just sent is not covered or requires prior authorization. It is a huge burden to our medical practice, and moreover, the consumption of time and resources adds salt to the wound during the COVID-19 pandemic and our resulting staff shortages. Yet, we forge on, trying to figure out “work arounds” to avoid more headaches while trying to do what is best for our patients. Frankly, if I don’t advocate for patient access to specialized dermatology medications, then they likely won’t ever get it. Patients suffer--they can even die--waiting for the opportunity to get the proper treatment since they must first try a different medication and fail before being approved for the medication deemed most appropriate by the physician. This tactic to save money by the insurance companies is referred to as step therapy or “fail first” policies.

The above scenarios likely resonate with you. In my world of dermatology, it has been a priority of the American Academy of Dermatology (AAD) to address the problem with federal legislation and work with our states to help our local organizations like the Pennsylvania Academy of Dermatology & Dermatologic Surgery (PAD) to address the problem. The Pennsylvania Medical Society (PAMED) has also made it a priority to advance state legislation. Unlike many other states around us, Pennsylvania still lacks Prior Authorization and Step Therapy (PA/ST) legislation easing the burden for doctors and their patients. Much effort and energy was put forth in the last legislative session by organized medicine, patient advocates and organizations in a coalition to advance HB 1194 and SB 920, which address PA/ST legislation. Sadly, with no help from the COVID-19 pandemic, the bills died at the end of 2020. Still, in the new legislative period of 2021-22, Rep. Steven Mentzer and Sen. Kristin Phillips-Hill will introduce HB 225 and SB 225 in the House and Senate, respectively, as this issue remains a priority.

Since serving as President of the PAD in 2019, where my goal was to have the PAD help advance PA/ST legislation, I have had the privilege of working with many dedicated physicians, leaders, patient advocates and legislators both on a federal and state level. I’ve come to know first-hand how much energy and effort has gone forth to get traction on this noble legislation that is a win-win for all health care providers and patients of all specialties. In order to make change, we must stimulate our patients and the public to contribute in a grassroots effort. This can be achieved by understanding why it is important legislation, taking action, understanding how to take action, and engaging our patients to help them understand how and why they can voice support of this legislation to their representatives. After all, they should have some skin in this game (no pun intended!).

So, here is the essence...

Why it matters to me? nT he prior authorization process is a drain on the resources of the physician and their staff nM ost of the time and resources spent on prior authorization efforts pertain to higher cost medications but can even pertain to inexpensive and generic medications. nS ome specialists may be the only ones trained or experienced to prescribe medications that require significant monitoring and management. We should not have a skewed burden to care for patients needing these medications.

Continued on page 5

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Editorial: Denied Treatment Continued from page 2

nS tep therapy (“Fail First”) requirements directly impact patients in terms of lost time, income, more expense and/or potential risk to health due to the delay in appropriate treatment or the potential for negative side effects. Patient safety is a key factor. nL oss of patient autonomy- patients do their own research and are often already critical of being required to take medication that may have adverse side effects. n Impact of the COVID-19 pandemic •M ore step therapy means additional office visits, potential exposures, and transmission of the coronavirus.

•S taffing shortages due to furlough, quarantine or illness as well as challenges hiring staff in during the pandemic has compounded the administrative and economic burden on small practices.

• More

time off work due to trials of inappropriate medical therapies takes patients away from their jobs and further impacts them financially.

What are the solutions I can communicate to my legislators? n Improve transparency and navigation of administrative process. n Require the health plan to grant or deny an exception request within 72 hrs for a non-emergency and 24 hrs for emergency situations. nC learly disclose the list of drugs when step therapy is implemented, including required documentation and information. nE nsure step therapy protocols are based on widely accepted clinical guidelines, so medical expertise dictates requirements. nA ppeals: When a physician appeals a decision by an insurance company, the reviewing physician should be of the same specialty. n Provide reasonable exceptions to step therapy requirements: • The

patient has already tried and failed on the the preferred medication; • The

patient is already stabilized on physician-recommended medication; • The

patient has already tried and failed insurance-preferred medication or one with the same mechanism of action; or • The

preferred medication is not in the patient’s best interest, based on medical necessity.

How can I help? nC ontact your legislator! Ask them to support HB 225. Note: SB 225 only addresses prior authorization, so communicate to your Senator, “we hope to have language include step therapy.” n Personal email or by phone (or both) works better than a form email. Let them know why it is important to you and your patients. Here are some tips: • Begin with “As your constituent, ...”

•S hare a personal story - Be concise, hitting on key points of what this legislation does. n Engage your patients and ask them to help!

• Patient stories carry weight when it is personal, and they are the legislator’s constituent.

Encourage them to take the effort. Encourage them to share their stories on PAMED website.

Does it matter and will it make a difference?

Yes! Twenty states already have laws with fail first policy. Pennsylvania is overdue.

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Pennsylvania Medical Society Quarterly Legislative Update March 2, 2021 2021-2022 Legislative Session: Legislative Activity The new legislative session is gathering some momentum as both the Senate and House begin considering legislative proposals. At present, most lawmakers are focusing on COVID-19 vaccinations, budget related matters, and possible election reforms.

As with any new legislative session, the Pennsylvania Medical Society’s (PAMED) focus is on securing the reintroduction of legislation that failed to get across the finish line in the last session and working to educate new lawmakers on our legislative priorities.

Chief among those priorities is the reintroduction of prior authorization reform proposals mentioned below. PAMED has historically been the driving force on this issue, but has welcomed the addition of a number of patient advocacy organizations into our coalition.

Organizations seeking prior authorization and step therapy reforms now number near 40.

Patient engagement on this issue is critical.

We also continue to advocate for liability protections related to physicians treating COVID-19 patients. PAMED is part of a broad coalition of statewide organizations seeking protection from lawsuits stemming from the pandemic.

A resolution on how best to address restrictive covenants in physician employment contracts is also being pursued. Rep. Toren Ecker (R-Adams) plans to again reintroduce legislation aimed at protecting patient access to physicians otherwise barred from treating them as a result of contractual agreements.

Although PAMED focuses its legislative efforts on issues that have been identified as priorities, we continue to advocate for the passage of other legislative “fixes” important to our members.

Among those issues are IMG licensing parity, disclosing frivolous medical board complaints, and the enactment of a statewide POLST program.

PAMED continues to oppose legislation that seeks to expand the clinical practice of non-physician health care providers, such as the reintroduction of SB 25, legislation that would give independent practice authority to CRNPs. These legislative issues require constant monitoring and ultimately physician engagement.

It is critically important for physicians to “engage” when called to do so.

Continued on page 7

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Pennsylvania Medical Society Quarterly Legislative Update Continued from page 6

Legislators who have received phone calls from physicians on issues affecting medical practice and patient care consistently report the positive impact they have on their decision making.

Reaching out to your representatives should not wait until there’s a legislative crisis. Reach out to your local lawmakers now and get to know them. Developing a relationship when you don’t have a specific “ask” is the key to a lasting relationship. Physicians interested in getting more involved in legislative and political grassroots should call PAMED’s Governmental Affairs staff at 800-228-7823.

Prior Authorization Reform (PAMED supports) House Bill 225 (Mentzer)/Senate Bill 225 (Phillips-Hill) – Prior authorization reform bills.

There is a large coalition with multiple provider entities and patient advocacy groups seeking to make wholesale changes to the prior authorization process in the Commonwealth. PAMED has played an integral role in developing this legislation and working to advance it. Though there are reserved bill numbers, there has been no legislative language introduced at this time.

International Medical Graduates (IMG) Licensure Parity House Bill 245 (Kaufer) – Rep. Kaufer has reintroduced his effort to support IMGs through this legislation, which seeks to modernize the process by which graduates of international medical schools become licensed. Similar legislation passed the House last session, but stalled in the Senate.

CRNPs Senate Bill 25 (Bartolotta) – PAMED has long opposed these efforts, but last session agreed to listen/negotiate a pilot program where CRNPs would be granted independent practice with specific guidelines and restrictions. As this effort did not come to fruition, stakeholders are working to determine what legislative action, if any, would look like given the outcome of the previous session.

Out-of-Network Balance Billing HCO 128 (Rapp) – Co-sponsor memorandum to advance legislation that would protect consumers from surprise balance bills from medical providers. PAMED has played a lead role in this effort to advance fair legislation dealing with balance billing. Given the recent passage of the Federal legislation on this topic, No Surprises Act, comprehensive protection to consumers was provided. At this time, we are asking the General Assembly to defer consideration of state level legislation pending the full implementation of the new Federal law. There still may be need for state level legislation in the future, but we won’t know until the Federal law is fully in place.

Continued on page 8

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Pennsylvania Medical Society Quarterly Legislative Update Continued from page 7

Restrictive Covenants (PAMED supports) House Bill 681 (Ecker) – Recently, Representative Ecker reintroduced legislation that aims to prevent the use of non-compete agreements in health care practitioners’ employment contracts. PAMED is in the process of developing legislative language, in consultation with Rep. Ecker, to amend HB 681 with language that would better protect physicians employed by hospitals and health systems while at the same time not disenfranchising physicians who own independent practices. It is important that any proposal addressing this issue takes into account the concerns of all PAMED members.

Liability Protection (PAMED supports) Senate Bill 273 (Baker) – COVID-19 liability protection effort; providing for limited, temporary, and targeted COVID-19-related liability protections for health care workers engaged in the care and management of patients with or suspected of having COVID-19. SB 273 seeks to address the disparity between independently practicing physicians with those associated with hospitals.

Interstate Medical Compact Act (PAMED supports) House Bill 192 (Topper) – Legislation to allow Pennsylvania to fully join the Interstate Medical Licensure Compact, providing for criminal background checks for expedited licensure applicants.

Opioid Prescribing Limits Senate Bill 169 (Yaw) – This bill would limit the prescription for a controlled substance containing an opioid to seven days unless there is a medical emergency that puts the patients’ health or safety at risk. PAMED has been in discussions with Senator Yaw’s staff regarding the bill’s text.

Lyme Disease CME (PAMED opposes) Senate Bill 281 – (Brooks) – This legislation would require health care practitioners to learn more about Lyme disease and other tick-borne illness as part of their continuing education (CME).

Stay up to date on these and other issues at www.pamedsoc.org and in The Dose.

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ECMS President-Elect Kelli DeSanctis, DO was awarded with the PAMED Everyday Hero Award.

Congratulations, Dr. DeSanctis!

The Quote

CORNER

“ We practice medicine that our historical ancestors could only dream of, and we have access to amazing treatments and cures for our patients on a daily basis.” ― Suneel Dhand, MD

2020–2021 ECMS Board of Directors Jeffrey P. McGovern, MD, FCCP, FAASM President

Thomas Falasca, DO, FACA, FACPM At Large Member

Narendra Bhagwandien, MD Immediate Past President

Timothy D. Pelkowski, MD At Large Member

Kelli DeSanctis, DO President Elect

Paul Malaspina, MD At Large Member

Terence O. Lillis, MD Secretary/Treasurer

Kirk Steehler, DO At Large Member

Peter S. Lund, MD, FACS AMA Representative

Amanda Marie Wincik, DO At Large Member

Kathleen Anne Costanzo, DO At Large Member

Michael Furey Student Representative