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PSG

Rumblings SPRING 2020

PENNSYLVANIA SOCIETY OF GASTROENTEROLOGY / NEWSLETTER

President’s Message / Ravi K. Ghanta, MD, PSG President

www.pasg.org

Dear Colleagues,

@RAVIGHANTA5

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! OOK L NEW AT DOK? WH THIN U O Y

Spring is finally here! For most of us in the state, it has been a fairly mild winter. While it is refreshing to see the vibrant changes of spring, we are currently facing one of the greatest challenges of a lifetime. As of this writing, we are facing a global pandemic from SARS-CoVCoronavirus 2 which manifests with a disease state known as COVID-19. This is currently affecting the patients, friends, family and our own peers that reside here in our own great state of Pennsylvania. There has been a significant impact on the global community from both a healthcare and economic perspective. This public health nemesis is no longer a world away. It is now in our home state and the unanswered question is not whether it’s going to affect us, but how and to what extent. As a medical community we must be prepared for the potential detrimental effects on our local populations and develop strategies to help provide care while maintaining safety for all. Predictably, the ensuing uncertainty of its

PSG/SOCIAL: @PAGastroSoc

INSIDE: 2 President’s Message

continued effects has led to fear. Whether you are part of a private medical practice or an employed physician of a hospital system, the impact is very deep. Due to mandated shutdown of various areas of the economy, this has resulted in negative consequences for our patients as well as the financial health of the entire system. The shut downs seen are not limited to nonmedical facilities. As many of you are aware, many medical practices have now limited access to patients to their offices as well as their endoscopy centers to try to limit the spread of this aggressive virus. The effects of this cannot be understated. Closures such as what we are seeing can result in overburdening emergency departments and acute care facilities. The economic impact can also not be understated. Many of these private practices have provided stable jobs for many employees. However, with limiting access of patients to the practices, the practice revenue will plummet and there will be inadequate reserves to sustain incomes for salaried employees. The potential for bankruptcies of certain medical practices is a very possible continued on page 2

8 S oMe Ambassadors

12 Practice Mgmt Update

4 FIT Update

10 Legal Corner

16 COVID-19 Resources

6 Clinical Case

11 Legislative Update

18 Q&A Milestones


President’s Message

continued from page 1

situation. Large hospital systems are also not immune to the devastation of this virus. From a health care standpoint, the system could be crippled if the numbers of infected patients outpace the available medical resources. Already many of us are seeing shortages of fairly standard things such as cleaning supplies, masks, gloves, goggles, etc. Even the large medical institutions face a tremendous economic crisis with the current pandemic. Due to limited access for patients in our offices, it is imperative that we have the ability to utilize telemedicine as an option to take care of our patients. However, Pennsylvania is one of a handful of states that still do not provide full coverage for telemedicine. The PSG is working hard to try to push for insurance coverage for this very important tool in treating our patients.

Although the PSG is almost 40 years old, we have always strived to maintain relevance and advance the needs of our members as we adapt to the changes in medicine. We are fortunate here in Pennsylvania to have a very robust specialty society for gastroenterology. I do not take for granted the hard work of my predecessors who had built our great organization to what it is today. Our team continues to strive to grow the organization and remain impactful. The field of medicine is constantly changing. Our field of gastroenterology, in particular, is no exception and is undergoing rapid changes. In the current environment, there has been increased consolidation of medical practices, hospitals and health systems within our own state. As mentioned in our previous communications, private equity investment has been a relatively new player in healthcare.

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Over a short period of time, there has been a large expansion of private equity across our country. Indeed, Pennsylvania is one of a select number of states that has seen more recent private equity investment in gastroenterology. It is highly likely that this influence will continue to grow in our state and across the USA. The PSG will keep you updated with these changes and other news as it relates to GI in our state. As healthcare providers in the field of gastroenterology, we need a strong voice to represent our interests as well as our patient’s interests. The PSG is that voice and we will continue to advocate for legislation that aims to optimize our ability to take care of our patients in an efficient and compassionate fashion. However, we cannot do it alone. We need your support and your input more than ever. What we are experiencing currently as it relates to the pandemic is frightening, and we must work


together to get through these trying times. If you are already a member of the PSG, I thank you for your support. If not, please consider joining. The streamlined application process only takes a few short minutes with nominal membership dues. I encourage you to become a member of the PSG which has been the voice of gastroenterology specialists in our great state of Pennsylvania for almost 40 years. In this issue, you will read about advances in gastroparesis in addition to the latest updates on COVID-19. Also, we will provide the best tips and tricks on navigating the prior authorization process for our medicines. We will provide the latest updates on the Mcare statue, a summary of recent legislative proceedings and a highly relevant review on how to tidy up your financial strategies to accomplish your future retirement goals. I would like to give a special thank you to Dr. Neil Nandi as he was one of the driving forces to help modernize and socialize our newsletter. Also, Dr. Nandi in collaboration with Dr. Austin Chiang and other members of the team, is helping advance the PSG social media presence. In this light, we also welcome back our Fellows In Training (FIT) leaders and our inaugural class of Social Media (SoMe) Ambassadors who help advocate GI focused education through digital platforms to reach our members and the lay public with trustworthy information. We hope you enjoy this latest issue of Rumblings! Sincerely,

In Memoriam Michael M. Geduldig, M.D. Past PSG President 1992-1993

The PSG family mourns the loss of Dr. Michael Geduldig of Mechanicsburg who passed away peacefully at his home on December 13, 2019 at the age of 89. Dr. Geduldig was the President of the PSG from 1992-1993. Originally from Brooklyn, New York, Dr. Geduldig started his college education at Cornell University at age 16, graduating with a degree in biochemistry. He earned his medical degree from New York University College of Medicine. Dr. Geduldig served as a captain in the United States Army Medical Corps, stationed in Germany, in the late 1950s. He completed his internship, residency, and a fellowship at Johns Hopkins in Baltimore, Maryland. He then moved to Harrisburg in 1964 to establish a medical practice. He was the first board-certified gastroenterologist in central Pennsylvania. Dr. Geduldig was recognized for his clinical expertise and compassionate care of patients and their families. Throughout his career, he held appointments as Professor of Medicine and Director of Gastroenterology at Hahnemann Medical College, Professor of Medicine Emeritus at Hershey Medical School, and as noted previously, President of our Pennsylvania Society of Gastroenterology. For years he served in leadership positions at local hospitals, and was a member of multiple professional organizations and associations. Michael was a relentlessly curious person, a Civil War buff who audited college history classes well into his late 70s. He was a voracious reader, an avid gardener, worldwide traveler and master bread

Ravi Ghanta, MD President Pennsylvania Society of Gastroenterology

baker. Our sincere condolences to his family and friends.

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FIT Update: COVID-19: Gut Feeling, It’s Time to Prepare Catherine Bartnik MD, MPH, University of Pittsburgh Medical Center, Gastroenterology Hepatology Fellowship FIT Board Member

@CatBartnik

The outbreak of Severe Acute

Respiratory Corona Virus 2 (SARSCoV-2), also known as COVID-19 is coming to a community near you. Is your healthcare system and endoscopy suite prepared to handle this rapidly spreading pathogen? As of March 13, 2020, the World Health Organization (WHO) reported 132, 758 confirmed cases worldwide among one hundred twenty-four countries1. Within the United States, the Centers of Disease Control (CDC) reported a total of 1,629 cases in forty-seven states, with the highest concentration of cases in California and Washington state. Presently, the mortality of this virus is estimated to be roughly 2-3% in the general population although the elderly that are greater than age 80 years old may have an estimated 10-15% mortality risk. Additional at risk populations are those who are chronically ill and also younger immunocompetent individuals have succumb to respiratory failure and have died as a result of this infection. Our immunosuppressed IBD patients have also been a concern. Fortunately, as of March 8,

2020, there were no reported cases of COVID-19 from China’s IBD Elite Union patient registry of >20,000 IBD patients2. That said, there is much that remains unknown about this infectious agent and nonspecific symptoms and suboptimal detection remain a grave concern. As healthcare professionals, we must stay ahead of this outbreak and prepare ourselves and our health care delivery systems as this virus continues to spread rapidly within the United States. Within this article, I plan to highlight a summary of this novel pathogen with respect to clinical symptoms and spread, as well as to provide a protocol tailored to gastroenterologists to decrease the risk of transmission to themselves as well as their staff and patients. As a reminder, in order for us to provide quality healthcare, we too must protect ourselves from exposure. Recently, Guan et al. published a study in the New England Journal of Medicine describing the clinical symptoms of COVID-19, identified among hospitalized patients in Wuhan, China3. The most common symptoms included fever (defined as a temperature greater than 37.5C, 88.7% of 1099 cases), cough (67.8%), and shortness of breath (18.7%). Roughly 20% of individuals develop serious illness with pneumonia and acute respiratory distress syndrome requiring mechanical ventilation. While the Wuhan group reported gastrointestinal symptoms to be less common (nausea and/or vomiting at 5% and diarrhea at 3.8% of 1099 cases), the initial presentations of some patients with COVID-19 are primarily gastrointestinal. Hence, a

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fecal-oral route of transmission is also thought possible in addition to respiratory droplet transmission. COVID-19 has also been implicated to play a role in liver toxicity with 2-11% of patients developing liver comorbidities4. Abnormal AST values identified on presentation correlated with the need of ICU care, whereas those who presented with normal aminotransferase levels were less likely to be cared for in the ICU4. The possible mechanism involves viral entry into cholangiocytes mediated by ACE2 receptors found throughout the gastrointestinal tract. An unpublished post mortem analysis of a patient who died from COVID-19 did not have viral inclusion bodies on liver histology in the setting of high viral titers. It is unclear if AST elevations could alternatively be explained by ischemia, hypoxia due to respiratory failure, or drug induced injury. No reported liver transplantation for acute liver failure has occurred in a COVID-19 positive patient thus far. With respect to spread, we understand that having close contact (within 6 ft) with an infected patient or when handling their secretions increases the likelihood of transmission1. Therefore, infection control and prevention remain the cornerstones in curbing further disease spread. As this coronavirus has been found in stool samples of infected patients, endoscopy poses a significant risk of transmission6. Likewise, the sterilization and reprocessing of endoscopic equipment presents its own challenges as more frequent sterilization, in the midst of a pandemic, may place greater demand on cleansing solutions and filters depleting


available supplies. Therefore, delay of elective procedures may help conserve supplies and limit infectious transmission. When urgent or emergent cases must be conducted, then a transmission prevention protocol is of paramount priority. We may do very well to learn from fellow gastroenterologist, Professor Zhen Ding, et al in Wuhan, China who have been on the frontline and epicenter of the pandemic7 (Figure 1). First and foremost, the Chinese group developed a “Pre-Procedure Time Out” with the purpose to screen patients for active disease as well as to determine the appropriateness of performing an endoscopic procedure. Appropriate procedures were limited to emergent or urgent endoscopy defined as acute GI bleeding, obstructive jaundice with infection, foreign body or esophageal impaction, biliary acute pancreatitis, and feeding tube placement. Prior to rooming, each patient was screened for fever, contact history, and respiratory symptoms. Patients that screen positive for high risk of infection

then underwent CBC evaluation to assess for leukopenia, as well as a CT chest to evaluate for pulmonary infection. If a patient was suspected to be infected by COVID-19, they were moved to a negative pressure room for the endoscopy. If a negative pressure room was not available, the procedure room with the optimal ventilation capability was designated for these patients to spare contamination of other rooms. Prior to the start of the procedure, a second “Procedure Time Out” was performed to address appropriate personal protection: each staff member donned a gown, mask, goggle or face shield, and gloves. At the completion of the procedure, care was taken to disinfect all surface areas within the procedure room. All members taking part in the highrisk procedure were instructed to wash their hands after appropriate removal of their personal protective equipment. The waste was then clearly labeled as biohazardous and disposed of according to biohazard protocol. Finally, the health of all personnel involved in the procedure were closely monitored.

As the clinical landscape for this pandemic evolves, we must remember not to panic but to stay calm and reassure both our patients and ourselves. We must remain vigilant, monitor our health, screen all patients regardless of the encounter, and stay informed.

For more information please see the following resources:

https://www.cdc.gov/ coronavirus/2019-ncov/hcp/caringfor-patients.html https://www.cdc.gov/ coronavirus/2019-ncov/downloads/ hcp-preparedness-checklist.pdf https://www.cdc.gov/hai/pdfs/ppe/ PPE-Sequence.pdf References: 1. W  orld Health Organization. Coronavirus disease (COVID-2019) situation reports (https://www.who.int/emergencies/diseases/ novel-coronavirus-2019/situation-reports). 2. M  ao, R, Liang, J, Shen, J, Ghosh, S, Zhu, L, Yang, H et al. Implications of COVID-19 for patients with pre-existing digestive diseases. Lancet 2020; published online March 11, 2020. 3. G  uan W-J, Ni Z-Y, Hu Y, et al. Clinical characteristics of 2019 novel coronavirus infection in China. N Engl J Med 2020; published online Feb 28. DOI:10.1056/ NEJMoa2002032 4. Z  hang C, Shi L, Wang, F. Liver injury in COVID-19: management and challenges. Lancet 2020. Published online March 4, 2020. 5. H  uang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395: 497–506. 6. Y  eo C, Kaushal S, Yeo D. Enteric involvement of coronaviruses: is faecal–oral transmission of SARS-CoV-2 possible? Lancet Gastroenterol Hepatol 2020; published online Feb 19. DOI:10.1016/S2468-1253(20)30048-0.

Figure 1. Proposed protocol for endoscopy in high risk individuals suspected of having COVID-19.

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7. D  ing, Z. How tomanageendoscopy room during outbreak of the COVID-19 virus: Prof. Zhen Ding. Thai Association of Gastrointestinal Endoscopy. Feb 27, 2020 webinar. (https://www.youtube.com/ watch?v=tVOWgTswkWY).


Pyloric Therapy in Gastroparesis Botox and Beyond Nitin K. Ahuja, MD, MS She was admitted to the hospital shortly thereafter for symptom exacerbation, and an EGD with botulinum toxin injection (200 units in a four-quadrant distribution) was performed on an inpatient basis (Figure 1).

@nitinkahuja

A

50-year-old woman was referred to the neurogastroenterology and motility clinic with a chief complaint of nausea and vomiting, present and progressive for the past year. She had a history of well-controlled diabetes and multiple myeloma status post stem cell transplant. From a baseline weight of 300 pounds, she had lost 150 pounds over the prior year. A gastric emptying test performed a few months prior revealed approximately 80% meal retention at 4 hours. She had tried multiple medications without symptomatic benefit, including prokinetics (metoclopramide, prucalopride), antinauseants (ondansetron, promethazine, lorazepam, scopolamine, dronabinol), and neuromodulators (olanzapine, buspirone). Additionally, a history of QTc prolongation (550 msec) had made her provider team reluctant to consider other agents. At the end of our visit, a decision was made to pursue an EGD with pyloric botulinum toxin injection and, if unhelpful, consideration of an enteral feeding tube.

Figure 1. Pre-pyloric stomach above); pylorus s/p 200 unit botulinum toxin injection (below)

She was discharged tolerating an oral diet without difficulty. In clinic followup one month later, she reported significant and persistent symptom improvement and had gained back close to 20 pounds. In light of slowly

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recurrent symptoms, a repeat pyloric Botox injection was performed six months later, again with marked benefit. The therapeutic use of botulinum toxin in gastroparesis remains controversial. Its first published use at the pylorus was in 1998 (three years after the first report of botulinum toxin being successfully used at the lower esophageal sphincter in achalasia). Open-label case series of pyloric botulinum toxin injection have shown a substantial rates of symptom benefit, often just shy of 50%, though the effects are reliably temporary (usually on the order of months). Two small randomized controlled trials, however, showed no significant benefit of pyloric botulinum toxin injection for either gastroparesis symptoms or gastric emptying when compared to a saline placebo. On the basis of the RCT data, current society guidelines recommend against offering botulinum toxin as conventional gastroparesis therapy. The skeptic’s reading of these data, however, is that they may have been underpowered (n=32 in the larger of the two RCTs) to detect significant differences between study arms, particularly given that pyloric dysfunction likely affects only a minority of the gastroparesis population at large. Recognizing that gastric emptying delay elides a wide range of organ-specific pathology, including gastric dysrhythmia, impaired fundic accommodation, and sensory neuropathy, many gastroparesis patients are simply not predisposed to respond to botulinum toxin injection at a mechanistic level (Figure 2).


not predisposed to respond to botulinum toxin injection at a mechanistic level (Figure 2).

Motility Program at the University of Pennsylvania, we utilize a range of techniques in both clinical and research contexts – including FLIP, botulinum toxin, G-POEM, electrical stimulation, and various approved and investigational medications – in order to better understand and manage this complex cohort of patients.

References 1. B  romer MQ, Friedenberg F, Miller LS, et al. Endoscopic pyloric injection of botulinum toxin A for the treatment of refractory gastroparesis. Gastrointest Endosc 2005;61:833-9. Figure 2. Pyloric dysfunction is one of several potential mechanisms for the clinical manifestations of gastroparesis.

Additional technologies directed toward pyloric dysfunction in gastroparesis have been developed with variable success. Published case series of pyloric stents demonstrated reasonable rates of clinical response but were associated with significant practical challenges related to stent migration. More recently, exciting results have emerged from the paradigm of gastric per-oral endoscopic myotomy (G-POEM), though data thus far remain limited to aggregated case series. Diagnostically, novel tools like the functional lumen imaging probe (FLIP) have been studied as a means of identifying pyloric dysfunction in gastroparesis, thus enriching the population poised to benefit from pyloric therapy. Anecdotally,

symptomatic response to botulinum toxin is often used as a retrospective marker of pyloric dysfunction, though the ability of such responses to predict benefit from more definitive procedures like G-POEM remains unproven. Particularly in the context of a diagnosis like gastroparesis, providers are reasonably inclined to maintain a grasp on any therapeutic option that may offer potential benefit, including those undermined by ostensibly rigorous trials. Research is active and ongoing at our institution and elsewhere into the optimal approach to recognizing and treating pyloric dysfunction in gastroparesis. Within the Neurogastroenterology and

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2. A  rts J, Holvoet L, Caenepeel P, et al. Clinical trial: a randomized-controlled crossover study of intrapyloric injection of botulinum toxin in gastroparesis. Aliment Pharmacol Ther. 2007;26(9):1251-8. 3. F  riedenberg FK, Palit A, Parkman HP, et al. Botulinum toxin A for the treatment of delayed gastric emptying. Am J Gastroenterol 2008;103:416-23. 4. C  amilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013;108(1):18-37. 5. K  hashab MA, Besharati S, Ngamruengphong S, et al. Refractory gastroparesis can be successfully managed with endoscopic transpyloric stent placement and fixation (with video). Gastrointest Endosc 2015;82:1106-9. 6. D  acha S, Mekaroonkamol P, Li L, et al. Outcomes and quality-of-life assessment after gastric per-oral endoscopic pyloromyotomy (with video). Gastrointestinal Endoscopy 2017; 86(2): 282-89. 7. G  ourcerol G, Tissier F, Melchior C, et al. Impaired fasting pyloric compliance in gastroparesis and the therapeutic response to pyloric dilatation. Aliment Pharmacol Ther 2015;41:360-7.


Meet Your PSG Social Media AMBASSADORS Samantha Dougherty, Pennsylvania Medical Society

PSG is proud

to welcome the first inaugural class of Social Media (SoMe) Ambassadors. We recognize that the the rise of social media platforms has become a primary medium by which physicians connect and learn from each other. We are proud to have selected one distinguished fellow from each fellowship program to constitute our PSG SoMe Ambassadors. They will be tweeting during various GI focused disease state awareness campaigns all year around. Follow their words of wisdom by following @pagastrosoc on Facebook, Twitter and Instagram. Remember: —Samantha Dougherty

Sharing is Caring!

#PAGastro #PSG2020

Neena Mohan @Neena_MD

Ruchit Shah @RuchitShahDO

Sharing is Caring!

Gastroenterology Fellow at Cooper University Hospital

Internal Medicine Resident and incoming Gastroenterology Fellow at Geisinger Commonwealth School of Medicine

Keerthi Kesavarapu

Vivian Ortiz

Brianna Shinn

—Samantha Dougherty

#PAGastro #PSG2020

digestivedoc @KeerthiShahDO Gastroenterology and Hepatology Fellow at Temple University

@VivianOrtizMD Gastroenterology and Hepatology Fellow at the Hospital University of Pennsylvania

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@BriannaShinn Gastroenterology and Hepatology Fellow at Thomas Jefferson University Hospital


Ben Stern @GIStern3

Catherine Bartnik @CatBartnik

Gastroenterology and Hepatology Fellow at Penn State

Second Year Gastroenterology/ Hepatology Fellow at the University of Pittsburgh Medical Center; Future Transplant Hepatology Fellow PSG FIT Representative

Shannon Tosounian

Aaron Martin

@shanny_DO Second Year Fellow at Einstein Medical Center SoMe Ambassador PSG FIT Representative

@amartin187 Gastroenterology and Hepatology Fellow at Thomas Jefferson University PSG FIT Representative

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Allison Baragona @ajbaragona Third Year Gastroenterology and Hepatology Fellow, Penn State Health Milton S. Hershey Medical Center PSG FIT Representative


Legal Corner

Mcare Statute of Repose Update

Richard E. Moses, D.O, J.D. plaintiff can bring a lawsuit. The law stipulates that no action asserting a medical professional liability claim may be commenced more than seven years after the date of the alleged malfeasance. There are two exceptions: injuries to minors and injuries caused by a foreign body unintentionally left within an individual’s body. The two exceptions may be brought after the seven year limitation under the statute of repose.

@therealgidoc

M care Statute of Repose Update

The Medical Care Availability and Reduction of Error Fund (Mcare) was created by Act 13 of 2002 (Mcare Act). It was signed into law on March 20, 2002. Mcare is a special fund within the Pennsylvania State Treasury established to ensure reasonable compensation for persons injured due to medical negligence. The fund pays claims against participating health care providers and eligible entities for damages awarded in medical professional liability (MPL) actions in excess of the basic insurance coverage. Mcare was enacted to stem escalating MPL insurance premiums during the medical malpractice crisis in Pennsylvania that was causing physicians to leave the state or decide not to practice here. The purpose of the Mcare Act was to ensure that medical care would continue to be available in the Commonwealth. Section 513 of the Mcare act deals with the statute of repose. The statute of repose places an outer limit on the timeframe within which a

On October 31, 2019, the Pennsylvania Supreme Court issued a decision striking down the Mcare statute of repose as unconstitutional in Yanakos v. UPMC. UPMC subsequently filed an application asking the Pennsylvania Supreme Court for reconsideration of its decision to strike down the statute of repose. On January 31, 2020, the Court denied UPMC’s request for reconsideration. This finality has raised concern from a number of medical and other organizations that had filed briefs in support of the UPMC petition. The Court’s decision weakens the Mcare Act that was specifically enacted to combat the professional liability and malpractice crisis. MPL claims that were potentially barred by the statute of repose can now be filed. This is confusing as the Pennsylvania statute of limitations for MPL claims remains two years from the date of reasonable discovery. The statute of limitations requires patients to file their MPL claims within two years of a medical procedure or other event that potentially caused their injury, or within two years of reasonably discovering their injury if they could not have discovered the injury at the time of the procedure. Prior to the

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court ruling, the statute of repose barred any plaintiff claims, except those involving the two exceptions noted, from being filed more than seven years after the medical procedure in question. By way of example, if a plaintiff discovered an injury four years after an endoscopic procedure that potentially caused an injury, the plaintiff would then have two years from that date of discovery to file the claim under the statute of limitations. However, if the plaintiff discovered the injury 8 years after the endoscopic procedure, a MPL claim could not be filed because the seven year statute of repose would have expired. This is no longer the case. There are two immediate concerns created by the Supreme Court’s decision. The first involves medical records, while the second pertains to MPL insurance premiums. Currently, regulations under the State Board of Medicine and the State Board of Osteopathic Medicine require healthcare providers to maintain medical records for seven years past the date of the last service for adults and longer for minors. Record retention requirements may now need to be longer. In addition, MPL insurance carriers no longer have the seven year date, previously anchored by the statute of repose, to calculate insurance premiums based on actuarial predictability. This could result in a rise in MPL insurance premiums. It will be important to follow the impact of the Court’s decision in Yanakos v. UPMC finding the statute of repose unconstitutional on Pennsylvania healthcare, physicians, and other healthcare providers over the ensuing years.


Legislative Update David Thompson, Pennsylvania Medical Society

David Thompson @PAMEDsociety

While we enter the second phase

of the current legislative session, one thing for certain is change. The Pennsylvania General Assembly begin the 2019-2020 legislative session with 44 new faces in the House of Representatives and 7 new Senators. Since the session has been underway, we saw scandal cost another Senator his seat and welcomed an 8th new Senator in a short time period. Over in the House, we saw the addition of a 45th new member this session with Rep. Fred Keller made the jump to Congress and was replaced by State Representative David Rowe. Both chambers are close to operating at full capacity for the first time in a while once the House conducts upcoming special elections to fill seats that where vacated in Fall 2019 elections by former Reps. Justin Walsh, Ted Nesbit and Gene DiGirolomo.

There will be some new faces in the Capitol hallways when the 20212022 regular legislative session commences but not at the same level we experienced at the beginning of this session. As of this writing, eighteen members of both chambers have announced they would not be seeking reelection at the end of their current terms. Most notably and a rarity in politics, each chamber will say farewell to their top leadership, Senator Joe Scarnati, President Pro Tempore, and Representative Mike Turzai, Speaker of the House. Additionally, it is important to note and remember that state politics can be dramatically impacted by what is happening at the national level in Presidential election year. Election day performance by President Trump or his yet to be determined challenger in the Commonwealth can have a significant impact on those down ballot, meaning that the party of whichever presidential candidate wins Pennsylvania may seek to benefit greatly. Looking at legislative activity of the state House and Senate, it will be interesting to see what issues they decide to prioritize as there is not a significant amount of session days remaining to advance legislation. Both chambers return to Harrisburg in mid-March and will be around sporadically leading into the Spring primaries. The entire state House is up for reelection and half of the state Senate is up for reelection. This is important to note as that is where a lot of focus will be in the coming months. Once the calendar hits June, the General Assembly will shift its focus to passing a state budget in a

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timely manner. They will then recess for the summer and come back for a very short fall session where it will be hard to think much else will be on anyone’s minds other than the upcoming general election. This is key to remember as bills that are not flagged to be fast tracked or those that are not already at a latter stage in the legislative process might simply lack the time needed to get to the Governor’s desk and be signed into law. PAMED will continue to sink our time and resources into our member determined priority issues and policies. It is our hope that, together with our provider stakeholder partners, we will be able to advance important legislation such as prior authorization reform, telemedicine, credentialing, and telemedicine. We continue to work toward protecting patients by working on key surprise billing legislation and prescription drug price transparency and affordability issues.


Practice Management Update The Rise of Prior Authorization Ralph D. McKibbin, MD, FACP, FACG, AGAF Budget-neutral RVU payments make limiting accelerating overhead expenses a critical task for every practitioner. It is important to be paid for the services we provide but it is equally important to limit losses due to poor workflow processes.

@RalphMcKibbin

Managing a physician practice

requires a wide range of skills. The responsibilities are broad and require detailed management of multiple processes, including the revenue cycle, compliance regulations, human resources, health information, and general business processes. It is important to understand that the skills needed apply to all of us, not just those in private practice Managing a small or large practice, a department or division requires a strong grasp of fundamentals. Business decision making needs to be based on sound principals and is subject to constant review like our clinical decision making. Even those who are “only” employed need to understand basics so that they can advocate for themselves and their patients.

One important change that accelerated in 2019 is the requirement for prior authorizations for diagnostic testing and medications. The Council for Affordable Quality Healthcare, Inc. (CAQH) reported in the 2019 CAQH Index, their 7th update, on the changes in the administrative burden in the healthcare industry.

Physicians and their staff spend on average 14.6 hours per week securing 29.1 authorizations per physician each week. This amounts to as much as $85,000 each year to support a full-time physician. The cost for providers to manually generate a prior authorization increased from $6.61 in 2018 to $10.92 in 2019. The policies adopted by insurance carriers are also not uniform. There is a wide variation in authorization requirements creates confusion which greatly increases the burden. A study of 23 health plans conducted by McKesson counted 1,300 procedure-specific authorization policies, with only 8 percent of those policies shared in common.2

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This is despite a consensus statement put out by the American Medical Association, the American Hospital Association, America’s Health Insurance Plans, the Medical Group Management Association, the Blue Cross Blue Shield Association and the American Pharmacy Association calling for meaningful improvement in prior authorization programs and processes.3 Overall industry use of electronic transactions which reduces practice costs increased only slightly from 12% in 2018 to 13% in 2019 according to the CAQH report. Controlling the rising burden and cost of prior authorizations should be a priority in your practice. The PSG and our national societies are working with state and federal decision makers and legislatures to adopt standardized practices. This advocacy has resulted in the CAQH CORE® (Committee on Operating Rules for Information Exchange) approving a Two-Day Rule to accelerate prior authorization process. 4 The group represents over 80 percent of industry stakeholders, but prior reform commitments have not been met. Legislative standardization may be needed.


AMA Tips on Limiting PA Burden The American Medical Association has put together a list of tips which can be adopted now to help limit this rising burden.5

TIP NO. 1: Check PA requirements

before providing services or sending prescriptions to the pharmacy Benefits: Prevent claim denials and lost payment due to unmet PA requirements

TIP NO. 3: Select the PA method

that will be most efficient, given the particular situation and health plan’s PA options Benefits: Reduce the time your practice spends on PA • Minimize workflow disruptions by selecting the best available PA option

TIP NO. 4: Regularly follow-up to ensure timely PA approval

TIP NO. 2: Establish a protocol to consistently document data required for PA in the medical record

Benefit: Prevent delays due to information “lost” or not received by payers

Benefits: Avoid delays in patient therapy • Prevent potential followups with patients for additional information • Minimize physician time needed in PA process

TIP NO. 5: When a PA is inappropriately denied, submit an organized, concise and wellarticulated appeal with supporting clinical information

Benefit: Increase chances of appeal success and reduce treatment delays for your patients Under the Affordable Care Act, all health plans are required to have an appeal process for denied PA’s. External appeals by independent third-party reviewers for upheld denials can be requested. It is important to prevent delays in patient care to avoid adverse outcomes, patient frustration and dissatisfaction and unnecessary expense to your practice. A periodic review of your office processes for prior authorizations will provide the opportunity to share best practices. References: 1. 2  019 CAQH INDEX® Conducting Electronic Business Transactions: Why Greater Harmonization Across the Industry is Needed. © 2020 CAQH 2. R  ogers, Jennifer. 2017. “Tackling Prior Auth: New Solutions to Address Provider-Payer Friction.” Chilmark Research. Accessed April 23, 2018. https://www.chilmarkresearch. com/chilmark_report/tackling-priorauthnew-solutions-to-address-provider-payerfriction/ 3. h  ttps://www.ama-assn.org/sites/ama-assn. org/files/corp/media-browser/public/ arc-public/prior-authorization-consensusstatement.pdf 4. https://www.caqh.org/about/press-release/ caqh-core-approves-two-day-ruleaccelerate-prior-authorization-process 5. T  ips to help physicians reduce the prior authorization burden in their practice. © 2015 American Medical Association.

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$/Financial Basics Phil Elbaum and Louis La Luna

more you save now, the greater the chance of you saving enough for your retirement and relying less on market returns. Your parents have probably told you that a penny saved is a penny earned. However, with higher tax brackets, a penny saved is like a penny and a half earned. A Chinese proverb says:

Whether you are just starting off as a practicing physician or have been practicing for years, there are a few important financial steps we should all be following. Learn the financial basics. No one is asking you to be your own financial advisor, but no one will care more about your money or financial wellbeing more than you. It is important to learn the basics to protect yourself and not be taken advantage of. This can be accomplished by going to a bookstore or library (hahaha) or online. Remember that many times, advice is coming from someone trying to sell you something, so be careful. Unfortunately, you cannot control market returns, real estate prices, tax rates, etc. You can, however, control your savings rate. A great goal to strive for is to save about 15-20% of your post-tax income (including the money you put in retirement accounts). If you can make it 30-40% that’s even better! The earlier and

“The best time to plant a tree was 20 years ago. The second-best time is now.” We can’t discuss saving without bringing up spending. The two go hand in hand. It will be near impossible to save enough for retirement or hit that 20% mark if your spending is out of control. No one is telling you not to buy the $4 coffee, but do you need the $100,000 car? The $1,000,000 house? Just because the bank says you can afford it, does not mean you truly can. Now if you have a large enough salary to afford those things and still save 20-30% of your salary then great. However, for most of us, this won’t be the case. Keep in mind, the less you spend annually means the less you will need to save for retirement. If you can live off of $100,000/year vs $500,000/year, your goal savings for retirement will be vastly different. Physicians, in general, earn a lot more than the general public but often get caught up in trying to keep up with the Kennedy’s (or Kardashian’s) and not the Jones’. Don’t confuse high earner with high net worth. It’s not how much you make; it’s how much you keep.

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Along with saving and spending, we need to discuss your assets and liabilities. It is very important to keep a record of your assets (cash, investments, savings, house, car, business, etc.) and liabilities (mortgage, car loans, student loans, credit cards etc.) Why is this important? It gives you a true idea about where you stand with your financial health. You should try your best to make your assets worth two times your liabilities as a start, with the hope of eventually being much more than that down the road. Now, for those starting off as a physician with student debt, mortgage, etc., this may take a few years. Okay, so once you have your spending under control and you are saving money and following your assets/liabilities ratio, what do you do with your savings? First, make sure you have an emergency fund saved up for 6-12 months of living expenses for those unforeseen circumstances. Next, you need to get rid of bad debt. Bad debts are things like credit card debt, student loan debt, and high interest car debt. Good debt? Things like business loans (like the loan on an ambulatory procedure center), for which the interest may be tax deductible or low interest rate mortgages, as you might be better off investing the money than paying off that 2-3% mortgage rate. If your mortgage rate isn’t that low, you should perhaps look into refinancing now! So, once the bad debt is paid down, max out those retirement accounts with the money you are saving. Your practice/health system should have a retirement account like 401k or 403B and this should be maxed out due to the tax advantages it offers for high income professionals. You are most likely


TAKE HOME POINTS $ Pay down bad debt

• G  ood vs bad debt (mortgage, business loan good) (CC, school, other- no good)

$S  ave 10-20% of you post tax salary (more would be better)

offered a high deductible health insurance plan with a health savings account (HSA). This is a stealth way to save money for retirement as it’s the only type of account where the money goes in tax free, grows tax free, and if removed for medical costs, is tax free coming out. I would strongly consider maxing out your HSA and investing that money for the long term (not spending it on medical bills now but letting it compound and grow over time). If eligible to contribute to a Roth IRA, I would recommend maxing this out as well. Maxed out all the retirement accounts? Anything left over can be invested in a brokerage account (taxable account). In addition, if you have children, you should consider opening a TAP529 PLAN where money goes in post-tax but grows tax free if used for education.

$L  ive within means (being able to save 10-20% of salary) $M  ax out your tax advantaged accounts first

• 4  01k/403B/IRA, HSA, 529 accounts

$ Prioritize retirement saving---start as early as possible

• Make sure you are saving enough before saving for kids’ school/college. • Can always have kids take out student loans but you only get 1 shot at retirement savings

This article is not written to insult or judge anyone but rather to stimulate financial awareness. For your individual situation, please discuss with a financial advisor or accountant as we have not taken your individual situation into account. We are not financial advisors and this article is not meant to give personal financial advice.

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$S  tart Early-If you invested $200/month from age 20 to 29 (9 yrs, $21,600) then stopped putting money in, with average returns, you would have $2.5 million dollars at age 67. If you start at age 30 and put in $200/month until age 67 (37 yrs, $91,200), at age 67 you would have $1.4 million dollars. $K  eep track of assets/ Liabilities

 • Want to have this equation positive and not fall deep into debt. Can you afford it?

$ I nvesting should not be complicated •  No “get rich quick” schemes •  Slow and steady wins the race • Low cost investments and advice (Be aware of how much people are charging you to manage your money).


Helpful COVID-19 links for GI; here is one below on joint task force. Joint GI Society Recc’s covid

https://www.gastro.org/ press-release/joint-gi-society-message-covid-19-clinical-insights-for-our-community-of-gastroenterologists-and-gastroenterology-care-providers

CMS—telehealth

https://www.cms.gov/newsroom/ fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

PSG Practice Management Task Force COVID-19 Recommendations https://conta.cc/2WBUgl7

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Jenkintown, PA Gastrointestinal Associates, Inc. is seeking a BC/BE gastroenterologist to join our practice. We are especially interested in expanding our advanced therapeutic program and would welcome applicants completing an advanced therapeutic fellowship. You would provide a full ange of care to patients, both in hospital and through outpatient procedures. This is a full-time position with shared clinical and administrative responsibilities. Gastrointestinal Associates, Inc. was founded in 1972 and has grown to a team of 19 professional health care providers. We serve a wide range of patients over various locations in the Philadelphia, Montgomery and Bucks County areas. We offer a competitive salary package to include benefits along with a partnership track. To apply, please fax or email a CV and cover letter to: Alfreda Rawlings, Executive Director Gastrointestinal Associates, Inc. 215-885-7528, Fax Email: ARawlings@gastropa.com

Two new fellowship programs will begin this upcoming 2020-2021 academic year! Tower Health Tower Health at Reading Hospital is excited to begin a new GI fellowship program that will train 2 fellows per year. Learn more at: http://bit.ly/TowerGIFellowship

• The University of Pennsylvania

The University of Pennsylvania will introduce a new advanced 4th year fellowship in Neurogastroenterology & Motility in addition to their existing advanced fellowship in Esophagology & Swallowing Disorders. Learn more at: http://bit.ly/PennMotilityFellowship

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Q&A: Milestones Brian P. McAllister, MD, MPH

PSG: We recognize that the process of seeking employment after fellowship can be a quite overwhelming for trainees. Since fellowship programs are tasked with the responsibility of developing excellent clinicians, endoscopists, educators, and researchers, the process of guiding trainees in their post-fellowship employment search can be overlooked. In an effort to shed some light on the process, for current fellows but also for potential employers seeking to hire new graduates, we asked recent graduate Dr. Brian McAllister to share from his experience. PSG: How did you go about finding practices to interview with? Dr. McAllister: I was contacted by practices either directly or through a friend/colleague in some instances. In others, I reached out to the practices in the regions where I was interested in working, whether they seemed to be hiring or not. I also used job postings and recruiters (not very successfully), and did explore a handful of 4th year fellowship positions that had openings. @mcallister_md

PSG: When did you start looking for a job? Dr. McAllister: I had my first interview in May of my second year of fellowship. I am certainly aware of fellows signing contracts and/ or making verbal commitments to a practice as early as their first year of fellowship or even before starting fellowship. On the other hand, I know of fellows deferring the job search entirely until after graduation for one reason or another. Obviously, this is a very individualized process. However, I do believe that the earlier one starts planning for this decision, the less stressful and more informed the process will be for them.

PSG: What are some important considerations in finding your first job after fellowship? Dr. McAllister: Of course, the first step on the algorithm for everyone seems to be what type of job they desire, whether its academic, employed hospital/health systembased, or a private practice in a multispecialty or single specialty group. For some people, particularly those with a true penchant for research or a desire to have a very specialized practice, the decision to pursue an academic position may be very obvious and they may have known this for some time. I do think that the decision of “academic vs private� for most of us is fairly tortured, as many of us come from academic backgrounds. The purpose

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of this discussion is certainly not to delve in to the pros and cons of each time of employment environment. What I will say is that I believe that the academic vs private practice conundrum is not at all as black and white as it initially seems. Personally, I realized that the part of academic medicine that gave me the most satisfaction was the ability to teach medical students, residents, and fellows and was able to find that in a private group. I recall another academically-leaning private group that actually had their own pathology case conference. On the other hand, there are academic groups with a private ambulatory surgery center (ASC) component as well. With respect to interviewing with private practices, of course you are going to want to meet each and every person you’ll be working with so it is important for the practice to facilitate this opportunity either in one or likely multiple visits. Take the opportunity to ask about physician turnover and if possible, speak to physicians that have left the practice and find out why. Other factors that were critically important to me included the size and age distribution of the partners and the amount of call and number of sites at which call is taken at the same time. Is the call schedule relatively equal? What does the day-to-day schedule look like? Are any of the current partners moving toward retirement and if so, would


that leave you in a difficult situation in a relatively short period of time in a small group? It is absolutely ok to ask about the financial side of things early on, but I would not make it a focus of the initial conversation. Practices will be very forthcoming with that information but the initial focus should be on whether or not there is a good fit for both parties. And I would discourage applicants from trying to compare earnings across different locations of the state – generally speaking, the earning potential will go down the “more desirable” a place is to practice. Try to familiarize yourself with the process and timeline of ownership with respect to the ASC, office, and any additional revenuegenerating entities like anesthesia and pathology. What percent is owned by the partners versus another party? Does the practice own its own property and what are the plusses and minuses of this? And I would take the opportunity to learn a bit about private equity and the big health systems across the state and their impact on the GI landscape in that is not something you are in tune with, find someone who is. Is the practice independent and does it have plans to stay that way for

the foreseeable future? What are the relationships with the practice and surrounding practices/health systems? These are important. How are they being nurtured?

environments advertising the most lucrative signing bonus and earning potential are also the most desperate for at least one but often more than one reason.

PSG: Did you have a lawyer review your contract(s)?

PSG: Is there any other advice that you would give current fellows thinking about the interview process?

Dr. McAllister: Absolutely, highly recommended. There was a medical lawyer in Hershey who would give the trainees a flat rate for review of any/all contracts that they wanted to review during the application process. In the end, the lawyer will be able to help you identify the potential pitfalls of the contract. Unless you have a legal background, it is highly unlikely you’ll be able to pick these out on your own as the language is unclear. Certain items like restricted covenant or tail coverage that may not seem important could make it very difficult for you to pick up and relocate from a geographical or financial perspective if you needed to. While a lawyer may encourage you to ask for more money or a signing incentive, I would not make this a focus of your negotiations. While it does not hurt to ask, I think practices try to keep things relatively equitable for new hires. The practice

Dr. McAllister: Have fun and try not to be overwhelmed. Watch for red flags (you’ll know then when you see them) and don’t ignore them! Be flexible, there is no one perfect job but the more you get out and see the more you’ll discover what’s most important to you. It is a great opportunity to get to know gastroenterologists across the state, whether you chose to work with them or not you get to meet a lot of very smart people who you will undoubtedly see again. Brian P. McAllister, MD, MPH completed his fellowship training at Penn State Health Milton S. Hershey Medical Center in 2019. He is a member of PSG and serves on the board as a representative in the specialty leadership cabinet. He practices at Digestive Diseases Associates in Wyomissing, PA.

CME (GI) /EVENTS/2020 DDW

CANCELLED

PSG

ACG

Hershey September 11-13

Nashville October 23-28

AIBD

Orlando December 10-12

Please Note: Virtual CME & Programs are currently being planned. Please stay tuned to PSG communications for the latest updates. (due to Corona, we are converting other conferences to web)

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PSG

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

BOARD&STAFF PRESIDENT

Ravi K. Ghanta, MD Digestive Disease Associates (610) 374-4401 rghanta@usdhealth.com

@RAVIGHANTA5

1st VICE-PRESIDENT

David L. Diehl, MD Geisinger Medical Center Gastroenterology/Nutrition (570) 271-6439 dldiehl@geisinger.edu

SECRETARY

Karen Krok, MD Penn State Hershey Gastroenterology (717) 531-4950 kkrok@pennstatehealth.psu.edu

@klkrok

TREASURER

Manish Thapar, MD Thomas Jefferson University Hospital (215) 955-8900 Manish.Thapar@jefferson.edu

@thoughtstoday

Rumblings EDITOR

Neilanjan Nandi, MD, FACP University of Pennsylvania 215-662-8900 Neilanjan.Nandi@pennmedicine.upenn.edu

@fitwitmd

ADMINISTRATIVE OFFICE ASSOCIATION EXECUTIVE Jason Harbonic (717) 558-7750 ext. 1584 info@pasg.org

STAFF

Melissa Harper Deputy Association Executive Jessica Winger Meeting Manager Resaica Cannon Member Service Specialist Tom Notarangelo Marketing and Communications Specialist Samantha Dougherty Marketing and Communications Specialist

Profile for SSMS

PSG Rumblings Spring 2020  

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