Birmingham Medical News November 2013

BY JANE EHRHARDT

Epic diagnosis coding changes have begun. This year, Blue Cross Blue Shield of Alabama tripled their diagnosis code request from four to twelve. Next fall, the entire U.S. healthcare fi eld will shift from the 35-year-old coding system of ICD-9 to ICD-10.

The introduction of ICD-10 starts next October. It will expand diagnosis coding choices from about 13,000 to 68,000, not including hospital codes. “They’re more specifi c in nature,” says Mike Candelaria with MediSYS. “If you get injured in the abdomen, you’ll be able to tell in the coding whether it’s in the upper or lower quadrant, if it’s acute, if it’s temporary… and that’s across the board.”

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Navigating the Affordable Care Act

By Ann B. DeBelliS

When the Affordable Care Act (ACA) Health In-surance Marketplace exchanges opened on October 1, insurance companies in Alabama were ready to accept enrollments in plans mandated by federal health care reform. Blue Cross and Blue Shield of Alabama, Humana, and United Healthcare are offering plans to the more than 640,000 uninsured Alabamians.

The enrollment process got off to a slow start on day one when consumers had trouble access-ing the exchanges and completing applications for health plan coverage due to high volumes of traffi c and other glitches on the healthcare.gov web site. A major glitch appeared during the registration process as the site tried to confi rm identities of those enrolling. While federal offi cials continue to fi ne tune the web site, users are still reporting problems.

In an October 17th Wall Street Journal report, insurance company executives said they were receiving faulty data from

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John M. Morgan, MD: After Hours as an ArtistJohn M. Morgan, MD, claims picking up a paintbrush was a late blossoming thought. “I could do artistic things,” says the Brookwood Medical Center obstetrician-gynecologist. But painting on canvas never occurred to him until his daughter Jayne began her artistic career ... page 3

REIMBURSEMENTCoding Detail Will Defi ne Patients and Score Physicians“It used to be that the doctor did the work, documented the chart, produced the CPT code, and they got paid,” says Jim Stroud, CPA, with Warren Averett Kimbrough & Marino. “That’s an oversimplifi cation. But the point is, that’s changing now.” ... page 9

(CONTINUED ON PAGE 16)


Mike Candelaria

2 • NOVEMBER 2013 Birmingham Medical News

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By nAnCy DorMAn-hiCkSon

John M. Morgan, MD, claims pick-ing up a paintbrush was a late blossom-ing thought. “I could do artistic things,” says the Brookwood Medical Center obstetrician-gynecologist. But painting on canvas never occurred to him until his daughter Jayne began her artistic career. After training in Savannah, Georgia and in France, the oldest of Morgan’s three children is now a full-time Birmingham artist with Artists on the Bluff.

“She kind of helps me, the fl edgling artist,” Morgan says. He is in his daugh-ter’s studio for a lesson every Thursday evening. He points out his artistic skills “are more second-fi ddle to my daughter’s” although he did enjoy training with Linda Vance, a Birmingham-area artist.

Morgan earned his medical degree from the University of Alabama School of Medicine in 1986, followed by a residency at Carraway Methodist Medical Center. He became a certifi ed diplomat of the American Society of Bariatric Physicians in 1997, and is the owner and founder of the Bariatric Health & Wellness program. He is board certifi ed by the American Board of Obstetrics and Gynecology and is a pioneer in robotic gynecological pro-

cedures at Brookwood, where he began practicing in 1990.

A Birmingham native, he lived in Hoover but went to school in Ensley. “I was good at sports and Ensley just had a better sports team,” he says. He entered medicine because he wanted a challenge and “everybody in my family is a dentist or a doctor.”

Ob-Gyn was a nice fi t for Morgan. “I was comfortable with women,” he says. “Women take care of themselves whereas men don’t. I love watching the babies I delivered grow up. Now I’ve even delivered some of their kids.” In his 25-year career, he guessti-mates he’s helped bring between 7,000 to 8,000 infants into the world.

But long before beginning his medical career, Morgan showed signs of his artistic creativity. As a teenager, he made balsa wood replicas of Monticello, Thomas Jefferson’s home, and of the White House, which won state awards. He also helped build a life-size dwelling. His father built the exterior of the Morgan’s home, but “I built my own bed-room at age 16,” Morgan says.

In addition to Jayne, he and Missy, his wife of 30 years, are also parents to Pauli, a summa cum laude graduate in management information systems from

the University of Alabama, and Jack, a Berry College freshman.

“When the kids were younger, part of the basement had a wooden fl oor so I

painted a little trail with a pond and an alligator on it. The kids would ride their tricycles down there,” he says. “I built myself a little cubbyhole art studio in the corner.”

He fi nds the past-time re-laxing. “This is kind of a late-life escape,” he says. “This is what I like to do to get away—pick up a paintbrush.” His subject might be of an architectural drawing, an exotic fl oral still life, or a Venice canal scene, mostly done in acrylics but occasionally in oil. In his offi ce, art from his daugh-ter mingles with his own works of a Toucan bird, a palm tree, and crabs.

He considers his artistic pursuit strictly a hobby. “Calling myself an artist would be analo-gous to referring to someone who plays putt-putt golf to a pro-fessional golfer,” he says. “But I would recommend anyone with a hectic lifestyle to escape to a canvas full of clouds, open fi elds, or far-away destinations.”

Although he attends art shows throughout the southeast, he is there to help his daughter promote her art, not to promote

his own work. At these events, life often imitates art for the doctor-by-day, artist-by-night. “A lot of my patients will come by,” he says. “I enjoy that.”

John M. Morgan, MD: After Hours as an Artist

Morgan’s art, including this Venice canal scene, is displayed at his offi ce.

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Health care news articles and blogs are replete with references to ACO’s, Ex-changes, Navigators, and the like. These and similar topics are popular because they are new concepts and, for lack of a bet-ter term, “splashy.” By comparison, concepts like the False Claims Act (“FCA”) seem worn and tired.

Do not lose sight of the basic building blocks on which all transactions and finan-cial relationships are stacked: compliance with the FCA. Furthermore, all the while that there has been a flurry of activity on ACO building and the development of managed care networks, the federal gov-ernment continues to expand its enforce-ment activities. As recently as October 10, 2013, Westlaw Insider posted information identifying Department of Justice statistics that reflect a dramatic increase in qui tam suits filed by physicians, nurses and hos-pital staff, and that report that the federal government appears to be on track to set even larger records with estimated collec-tions of $5 Billion from January to July, 2013 alone (up from $4.9 Billion for the entire 2012 fiscal year ended September 30, 2012).

These figures are wholly consistent with the estimates by the OIG Semi-Annual Report to Congress in the Spring of 2013 that reported, for the period be-tween October 1, 2012 and March 31, 2013, 436 criminal and 232 civil actions against individuals or entities that en-gaged in health care related offenses and $2.64 Billion in investigative receivables and another $640 Million in non-HHS investigative receivables but arising out of civil and administrative settlements and civil judgments related to Medicare, Med-icaid and other Federal, State and private health care programs.

Part of the increase in law enforce-ment activity arises out of statutory modi-fications of the FCA to close prosecutorial loopholes that had developed as a result of primarily federal case law in the United States. Three laws, The Fraud Enforce-ment and Recovery Act of 2009, The Pa-tient Protection and Affordable Care Act signed into law on March 23, 2010 and The Dodd-Frank Wall Street Reform and Consumer Protection Act, have impacted the FCA and its interpretation. Among the other changes to the FCA include the following:

In a dramatic expansion of the defi-nition of claim under the FCA, no longer must a claim be presented directly to the federal government but may include any claim “if the money or property is to be spent or used on the [federal govern-ment’s] behalf.” As there is an overhead component to every DRG payment, all

downstream suppliers to hospitals are now exposed to attack even if they have no contractual relationship with the fed-eral government or, indeed, no direct pa-tient care function or health care license. In response, covenants regarding compli-

ance with FCA state-ments have literally begun to appear in utility contracts with hospitals. Query the effect on a construc-tion contractor that bills for storage unit repairs at a hospital facility when a mem-ber of the construc-

tion crew is debarred by Medicare? Does that bill now become null and void and is there an FCA allegation waiting to be asserted?

Concepts about intent have also been softened in a number of ways including an express statement that claims that violate the Anti-kickback Statute are, by defini-tion, violative of the FCA. These changes create a high standard indeed given the still binding precedent that, if even one purpose of a proposed transaction is to make or receipt payment in return for a referral, the Anti-kickback Statute is vio-lated.

The concept of materiality has also changed. Whether a provider intended to make a false statement in support of a false claim—the more traditional con-cepts of fraudulent activity—have been supplanted with whether the statements or records are “material” which has been defined as “having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or prop-erty.”

Relatedly, the definition of claim under the FCA has been expanded to include any person who “knowingly con-ceals or knowingly and improperly avoids or decreases an obligation to pay or trans-mit money or property to the Govern-ment.”

Identified overpayments must now be paid over to the federal government without delay and without offset or an additional FCA violation will be trig-gered.

As tired and worn as FCA issues may appear to be, ongoing refresher training is essential to avoid ever-expanding investi-gative and prosecutorial activity. Indeed, understanding the core operational guide-lines for a hospital and effecting compli-ant billing and operations may be far more valuable to the long term success of a hospital than that shiny new binder full of ACO documents. In essence, do sweat the small stuff.

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Philip Sprinkle is a Partner with the law firm of Balch & Bingham LLP where he serves as Co-Chair of the Firms’ Health Care Practice Group.


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“You can clearly see that ICD-9 has been outgrown just by the dif-ference in the number of codes,” says Tammie R. Olson, CPC, CPCO, with Management Resource Group. “ICD-10 is going to provide a much more clear picture of what hap-pened at each patient encounter.”

The Blue Cross coding change, though not so dramatic, could have a far greater

impact on the bottle line of healthcare in Alabama. It stems from the federal Risk Adjustment Program. “We have been able to accept 12 diagnosis codes on a claim for several years but have not proactively requested additional diagnosis code infor-mation until now. This is largely due to the changes mandated under the Affordable Care Act, which established a plan for lev-eling risk among insurance carriers within a state,” says Koko Mackin with Blue Cross.

Insurance carriers must participate in the risk adjustment process beginning Janu-

ary 2014. The program transfers money made from premiums among insurers based on the complexity of their member popu-lations. Basically, payments from carriers with healthy member populations will go to carriers with less healthy member popula-tions. The additional diagnosis codes will help define those populations.

“In addition, if we are to maintain competitive premiums going forward, it is critical that we are able to accurately reflect the complexity of our member population to the federal government,” Mackin says.

“We are encouraging physicians to include the diagnosis codes for all conditions as-sessed, treated or considered in their medi-cal decision making for their patients.”

“That’s a big change for clients who are only used to coding based on the pro-cedure. They’ll have to change their mind-set,” Candelaria says.

Olson says this is likely just the begin-ning. “With the prevailing atmosphere cen-tered on healthcare, we will continue to see changes to covered diagnosis codes from payer to payer,” she says. “Now more than ever, it is important that all payers be on the same page as far as coverage is concerned.”

Electronic health records (EHR) will be a real boon in this overhaul. “The Blue Cross change seems like a big process, but it’s more like us making a change in the soft-ware and then training clients,” says Jenni-fer Woodward with MediSYS.

When it comes to adding more diagno-sis codes, many EHRs already show past di-agnoses for a patient with just one click. It is the same with any chronic conditions. That allows physicians to easily see the codes that might be pertinent to the current visit and quickly apply them.

“It’s not necessarily that they’ll see dra-matic changes in the look of the software. It’s more like them changing what they’re looking for in what’s already there,” Wood-ward says. From a billing standpoint, many EHRs build checks and balances at both ends — from initial input to claims submis-sion, which will help with both the Blue Cross and the ICD-10 transitions.

Many EHRs also let users group to-gether specific codes by treatment plan, tailoring it to their specialty or common practice treatments. “That could help with additional codes needed with Blue Cross, but it can certainly help with more accurate coding,” Woodward says. EHRs often dis-play which diagnosis codes pay for the pro-cedure entered by the physician.

Blue Cross says they’re working on various value-based payment programs to reward physicians for appropriately coding claims that help reflect the complexity of their patient population. “There also may be an audit function in the future, as our company is accountable for all diagnosis code information passed on to the federal government. We will be audited by the federal government on an annual basis,” Mackin says.

Management Resource Group’s Olson thinks the mammoth coding changes are good for the industry and the patients. “We were always supposed to code to the highest level of specificity. Due to the limitations of ICD-9, we have been allowed to use non-specific codes, and this has allowed providers to become lax on their documentation, yet we were still being reimbursed,” she says.

The additional and more detailed cod-ing will aid practitioners by helping to prove medical necessity. “It will force providers to improve their documentation, which should improve their reimbursement. We will see procedures that previously would have been denied by insurance companies, paid for,” Olson says. “It will also ultimately improve the quality of care given to each patient.”

EHRs Help with Upcoming Diagnosis Coding Changes, continued from page 1

Tammie R. Olson


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By CinDy SAnDerS

To see something in a different light often requires a shift in perspective. David A. Williams, CPA, MPH, FHFMA, leader of healthcare reimburse-ment and advisory ser-vices for HORNE LLP, believes this certainly holds true for practices and facilities facing ever-increasing budget pressures.

Glass Half EmptyWilliams, a partner in HORNE’s

Ridgeland, Miss. office, noted for many healthcare providers, any incremental increase in revenue is eaten up by rising costs — from increased wages to higher prices for supplies to hikes in rent and utilities.

He pointed out that for hospitals, the largest revenue stream is for inpatient stays, and the largest single payer is Medi-care, which can represent from the low 40s to the high 60s in terms of percentage of patients. “There has been a market bas-ket update, but for the last couple of years,

it’s been less than 2 percent,” he said. Williams noted the government

puts in the full market basket update but then begins reducing the rate by looking at adjustments tied to value-based pur-chasing, readmission rates and acquired conditions, in addition to other factors. “Normally you’re seeing very minimal in-creases. It’s caused a flattening of revenue per patient,” he said. Then, Williams con-tinued, after payment increases are netted out, “Medicare is subject to a 2 percent re-duction to fulfill the sequestration order.”

He added that Medicaid, which typi-cally covers anywhere from 5-15 percent of patients … or higher depending on lo-cation and a hospital’s safety net status, is not currently subjected to sequestra-tion. Yet, he said, hospitals are faced with mounting concerns about Medicaid ex-pansion, uncompensated care, and cuts to disproportionate share hospital payments.

For hospitals in states that didn’t opt to expand Medicaid rolls, administrators are worried about rising levels of uncom-pensated care for those that fall into the gap in the Affordable Care Act between traditional Medicaid eligibility and quali-fying for federal subsidies on the health-care exchange. Even for providers who

are in states that did expand Medicaid, Williams said uncertainty still exists about how reimbursement will actually net out.

Traditionally, Medicaid has reim-bursed providers at a set match rate for di-rect patient services and a 50 percent rate for the administrative portion of the epi-sode of care. Although the ACA Medicaid expansion plan covers 100 percent of pa-tient services for three years and then rolls down incrementally to 90 percent over sub-sequent years, the administrative match re-mains at 50 percent so the state does incur additional cost by expanding rolls. Addi-tionally, Williams said certain provisions of the ACA require mandatory changes for states regardless of expansion, includ-ing: welcome mat population or those who were eligible for Medicaid but had not en-rolled previously, foster children expansion to age 26, expanded eligibility for children, primary care physician fee increase, and health insurer fee. In Mississippi, a non-expansion state, the estimated amount of the mandatory changes is between a $272 - $436 million increase in spending. With this amount of growth, the state is not ex-pected to increase the reimbursement rate for a full episode of care.

Medicare DSH payments also are

causing administrators to lose sleep at night. Initially, the ACA plan called for a 75 percent reduction in Medicare DSH payments. However, Williams said part of the final regulation that went into effect Oct. 1 of this year moderated that number a bit by moving to an empirical DSH pay-ment for uncompensated costs … a com-plex, calculated cut that softens the blow some by looking at a hospital’s relative share of Medicaid inpatient utilization as a proxy for uncompensated patients.

Williams said that for one hospital in the Mississippi Delta, the original Medi-care DSH reduction would have meant a loss of $5.6 million. “But,” he contin-ued, “because of the additional payment to fund the uncompensated cost, it was actually a reduction of $2 million.” While that is still a significant loss, “It could have been worse,” Williams noted.

Still, he continued, “You’re faced with the fact your revenue isn’t growing as fast as your expenses. It’s very concerning to most every healthcare organization around.”

Glass Half FullSo if revenue isn’t going up, the logi-

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Gaining Perspective on the Reimbursement Landscape: Glass Half Empty … or Half Full

David A. Williams


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Asthma 101! Causes, Treatment & Triggers

by Jane ehrhardt “It used to be that the doctor did the

work, documented the chart, produced the CPT code, and they got paid,” says Jim Stroud, CPA, with War-ren Averett Kimbrough & Marino. “That’s an oversimplification. But the point is, that’s chang-ing now.”

Reimbursements have begun reflecting outcomes and pa-tient satisfaction rather than procedures. “We’re moving away from ‘you had an office visit, now here’s your fee’,” says Mary Elliott, CPA, with Warren Av-erett Kimbrough & Ma-rino.

To facilitate that new assessment, payers have begun requiring far more diagnosis codes to better evalu-ate their relevancy to the treatment and the overall health of the patient. For in-stance, Blue Cross Blue Shield of Alabama (BCBS) recently tripled their requested

number of diagnosis codes from four to twelve. “They want to see the patient the way the doctor sees the patient,” Stroud says.

More diagnosis codes also label the patient as sicker. And sicker patients have greater value to Medicare. Stroud has had clients with numerous audit requests by Medicare Advantage Plan providers to re-view charts for potentially more diagnosis codes not documented in the claims.

That new detailed level of diagnosis codes also lets payers assess the accuracy and necessity of the resulting treatment codes or Current Procedural Terminol-ogy (CPT) codes. “That’s been a growing trend,” Stroud says.

But the outcomes for physicians are changing beyond simple reimbursement adjustments. “Insurance companies are now keeping scorecards on the doctor,” Elliott says. For instance, they use the negative outcome rate on tests to evaluate a physician’s diagnosis skill.

In the past, a cardiologist would use her own judgment in making referrals to the cath lab for tests to determine block-ages. “But if a high percentage of those tests return negative, that proves that nothing was there which means the pa-

tient didn’t need the test,” Elliott says. Stroud says insurance companies

don’t want patients to go straight to the cath lab. They want less expensive, non-invasive procedures first. But if a cardi-ologist chooses the inexpensive test and it shows that 70 percent of his patients have no blockage, it proves that only 30 percent needed further treatment. “So now your medical judgment is called into question,” Stroud says.

“Payers want the treatment to cost as little as possible and the findings as near to 100 percent as possible,” Stroud says. “They want you to give the patients who need it only what they need with a limited error rate. In other words, you’ll need a crystal ball.”

“We’re moving away from episode reimbursements,” Elliott says. “We’re moving to a payment system that is going to reward on outcomes and patient satis-faction while reducing cost.”

Blue Cross of Alabama already has an electronic survey mechanism in place asking patients about their experience at a doctor’s office. The final question asks if the patient would recommend that physi-cian to family and friends. “If the physi-cian don’t reach a certain percent of ‘yes’,

they don’t qualify for the increased reim-bursement,” Elliott says.

Blue Cross also rewards physicians for participating in another program based on improving quality of care. The Patient Centered Medical Home (PCMH) model of care is designed to coordinate commu-nication between patients and their spe-cialists using the primary care physician as the nexus. PCMH certification, awarded by the National Committee for Quality Assurance (NCQA), runs about $1,180 every three years for two practitioners.

“The idea is to get a more efficient form of healthcare,” says Jordan Cockrell with Cockrell and Associates. She’s the first PCMH Certified Content Ex-pert in Alabama. “The point is to cut down on the overlap of care and to involve the patient in their own care.”

At Blue Cross, physicians in the Pri-mary Care Value-Based Payment Pro-gram (PC-VBP) can earn additional points if they’re certified as a PCMH. Those points can raise their reimbursements on

REIMBURSEMENT

Coding Detail Will Define Patients and Score Physicians

Mary Elliott

Jim Stroud

Jordan Cockrell



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costs. Yet, healthcare providers want to make sure they provide the best care pos-sible without sacrificing a patient’s well being simply to save a few dollars.

“A lot of people equate higher quality with higher cost, but that’s not necessar-ily true,” Williams pointed out. In fact, he said, doing the right thing in the right way is often significantly more cost efficient.

“A major cost in providing care to pa-tients is variation in the clinical process of care,” Williams said. He added it is easy to find real world examples of this type of variation where one hospital’s cost for an average hip replacement is $45,000, yet another one might have an average cost of $22,000. “What’s the disconnect?” he asked of the two cost scenarios. “A lack of standardization of using evidence-based protocols,” he answered.

By using data available through elec-tronic health records coupled with a part-nership with technology company Health Catalyst, Williams said HORNE is able to mine the available information to look at clinical pathways and search out deviation from standard protocols that adds to the cost of care. He was quick to add that the technology doesn’t seek to stop physicians from exercising their medical judgment but does highlight where there are outliers when it comes to following clinical proto-cols. “Best practices and evidence-based medicine say that these are the best proto-cols out there,” he pointed out.

Following those protocols not only saves money, but also should optimize quality. With increased transparency, pay-ers and patients will have access to infor-mation regarding those positive outcomes and lower costs, which could ultimately drive volume.

A Foot in Both BoatsAdministrators and chief financial

officers are caught between the fee-for-service and value-based payment worlds right now. Williams said they are trying to keep their heads above water in the current payment system … and now re-imbursement experts want them to shift their focus to population management. Although making the move is understand-ably frustrating, Williams believes it is also the best option to ultimately improve the bottom line.

“There has to be a change in cul-ture from what it’s been in the past,” he noted. “We tell them, ‘Let’s prepare for it by being the most efficient, effective deliv-erer of care and eliminating patient waste.’ That puts you in a competitive advantage over those providers that have a higher cost structure.”

It is a different mindset, Williams continued, to stop attacking reimburse-ment from the top and instead improve revenue by cutting costs. “If you deliver high quality at a lower cost, then your margins are going to be greater. We see opportunities,” he concluded.

Gaining Perspective,continued from page 8


NURSING

By lAurA FreeMAn

Some people spend their lives working at a job that is just a job.

For nurses with a true call-ing, however, helping patients and their families get through what may well be the most dif-ficult days of their lives isn’t just their work. It’s their passion.

Working at the bedside and in clinics, as they get to know their patients, that passion for nursing can inspire a compassion that goes beyond duty. They be-come advocates for their patients, championing their care, encour-aging them in the tough times, and helping with the small, everyday things that add so much to the quality of life.

Too often, when nurses go above and beyond to deliver exceptional care, their ef-forts are known only to patients and their families. Through the Daisy Award pro-gram at Children’s Hospital of Alabama and more than 1500 other hospitals around the world, patients have the opportunity to bring nurses who have made a difference in their lives into the spotlight.

“The Daisy Award program was es-tablished through the Daisy Foundation (Diseases Attacking the Immune System), by the Barnes family in memory of their son Patrick and the nurses who cared for him,” Lori Moler, Vice president of Customer Service at Children’s Hos-pital said. “Since Chil-dren’s Hospital became involved with the program last spring, we have been receiv-ing 20 to 30 nominations a month, and 95 percent have come from patients and their families.”

Moler and Marilyn Prier, Director of Patient Health and Safety, facilitate the program and work with the hospital’s Daisy Award committee, which reads nominations and votes for each month’s winner.

Prier said, “Our in-teractive patient care sys-tem provides computer access in every room. Patients and their families can nominate a nurse online. It gives them an opportunity to express how they feel about a nurse whose care had been especially meaningful to them. If the nurse they nominate wins, we let them know and invite them to the award ceremony.”

For a nomination to win, the com-ments have to be more than “she was nice.” With so many strong competing nomina-tions, choosing a winner can be difficult.

“There has to be a story,” Moler said. “What did the nurse do, and how did that

make a difference? We pass the stories on to the Daisy Committee with names removed so they can vote objectively based on the strongest content to choose the winner.”

In considering criteria for nomina-tions, the committee looks for nurses who can serve as a role model for the nursing profession; demonstrate a caring attitude in all situations; communicate with compas-sion, using words the patient and family un-derstand; and make a significant difference in the life of a patient.

“We’ve had winners from every shift and several different departments, includ-ing both inpatient nurses and nurses from our outpatient clinics,” Prier said. “After

the voting, the name of the win-ner is kept under wraps till the day of the award so it will be a surprise. Only the head of the winner’s departments is told, and we swear them to secrecy while they call a department meet-ing at a time the winner will be there.”

When the department is as-sembled, members of the Daisy Committee arrive, bearing the award, a banner and a box of cin-nabons—a favorite treat Patrick Barnes enjoyed during his illness, with a “heavenly sweet aroma” as a reminder of how special the work is that nurses do.

“Our Chief Nursing Offi-cer Deb Wesley is always there to read the nominating story,” Prier said. “Sometimes the winners begin to cry as they recognize the story and realize the award is for them and that they were nominated by patients who appreciate what they have done.”

Moler said, “In addition to a Daisy pin and a certificate, the winner receives a hand-carved stone statue called ‘A Healer’s Touch.’ Each one is created by artisans in a village in Zimbabwe. The statues are very special, like the nurses who receive them.

“At Children’s Hospital, we believe in patient and family-centered care, and com-passionate nurses play a tremendous role in carrying out that mission.”

Deb Wesley presents the Healers Touch statue to DAISY Award winner Geni Crawford.

A Daisy for NursesRecognizing Compassionate Care

Sanders Inducted Into Nursing Hall of Fame

Nena Sanders, BSN, MSN, DSN, Samford University vice provost and dean of the Ida V. Moffett School of Nursing, was in-ducted into the Ala-bama Nursing Hall of Fame in October.

Established by the University of Alabama’s Capstone College of Nursing, the Hall of Fame honor cited Sanders was for her expertise in clinical nurs-ing, nursing education, administration and consultation that has impacted the profession both in Alabama and across the nation, and her legacy of commit-ment, vision and enduring spirit that is reflected in those she has influenced.

In addition to the growth and advances she has achieved as dean, earlier this year, Sanders was named vice provost and will oversee planning for and implementation of Samford’s new College of Health Sciences.

“It is truly an honor to be recog-nized for achievements in your field, but it is particularly humbling to be acknowledged by your peers,” Sand-ers said.

“As I think back through my career, I have been blessed to have had wonderful mentors who have sup-ported me at critical junctures in my career and life,” she said. “I count it a privilege to have served the patients charged to my care, and for the op-portunities to work with knowledge-able and skillful nurses in practice, administration and education.”

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NURSING

By lAurA FreeMAn

When the patient is a child, nursing is definitely not a one-size-fits-all prop-osition. Medical equipment is different. Dosages are different. Even the patient’s level of understanding and communication skills can require a completely differ-ent approach.

However, pediatrics is one area where nursing students may not receive extensive training, often because opportunities for clinical experience can be limited.

“When we recruit nursing graduates or any nurse who doesn’t have a strong background in pe-diatric nursing, they spend their first 14 weeks here in a concentrated program of classroom and clinical training to thoroughly prepare them to be pediatric nurses,” Deb Wesley, senior vice presi-dent and chief nursing officer at Chil-dren’s Hospital of Alabama, said.

“We offer the program three times a year, and it is always full. We even get re-quests from out of state schools and hospi-tals looking for pediatric training for their nurses,” Wesley said. “We cover every as-pect of pediatric nursing, from differences in anatomy to the nuances of how chil-dren can respond differently to illnesses

and treatment. We discuss developmental issues, along with cognitive and language differences.

“Especially when working with neo-nates and very young children, nurses have to use a whole different skill set to as-sess the patient’s condition,” Wesley said. “You can’t ask patients without language skills about their symptoms and how they are feeling. That means you have to learn to listen and distinguish between cries of pain and fear, and look at body language and behaviors to identify problems and judge how they are responding.”

Since pediatric patients range from

newborns to age 21, the skill sets needed within the field can vary from patient to patient.

“Blood pressure cuffs come in differ-ent sizes, the needles and blood draws and medication dosages may be smaller. Even the beds are different, ranging from iso-lets and bassinettes to toddler cribs, junior beds and full size beds,” Wesley said.

Since Children’s Hospital draws young patients from across Alabama as well as surrounding states, the types of cases nurses are likely to see are also widely varied.

“Some of our cases from the local

area are less acute, but we also see the sickest of the sick,” Wesley said. “That includes burns, trauma and very complex illnesses with different co-morbidities and underlying conditions.

“Illnesses that may not be severe in adults can quickly become serious in a child because of their anatomy or the fact that their immune system is less experienced in fighting off an illness,” Wesley said.

Another factor is that, unlike adults who are usu-ally able to use a call button when they need help, small children can’t be left unat-tended.

“Parents usually try to stay with the child, and

relatives and friends often fill in when they can, but it’s difficult to have some-one there every minute of the day and night. There are also parents who face the economic realities of being unable to take time off work, and children who have only one parent or none,” Wesley said. “In those cases, we staff differently to meet the specific needs of the patient.”

Some pediatric patients come to Chil-dren’s Hospital for outpatient treatment and short-term admissions. Others are there for an extended period, waiting for a transplant or undergoing specialized care.

“We have teachers on staff to help children with their school work, and our child life specialists work to make life as normal as possible. They use play therapy and interaction to reduce fear and distract the children from treatments that may be uncomfortable,” Wesley said.

New hospital facilities that opened last year are also helping to streamline care.

“Everything is state of the art and designed with patient care flow in mind. All the things we need to take care of the patient are adjacent, so we don’t waste a lot of hunting-and-gathering time look-ing for equipment. We have a touchdown space outside the room with a computer and phone, and we can see into the room while we are working with records,” Wes-ley said.

“Pediatric nurses are very special people. I’ve learned that people are either pediatric nurses or they are not. If they are, they tend to stay with it,” Wesley said. “We have a very tenured staff. Many re-tire after 30, 35 or even 40 years in the field. Those who love pediatric nursing love it with a passion.”

Small Patients. Big Differences.

“Those who love pediatric nursing, love it with a passion,” Deb Wesley said.

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By lAurA FreeMAn

When the topic turns to the short-age of primary care physicians, it soon becomes obvious that the numbers aren’t adding up. Despite the best efforts to at-tract more medical students to primary care, it isn’t likely to happen fast enough to deal with the double strain of an aging population needing more care and more people looking for doctors now that they have access to health coverage.

One of the most frequently proposed strategies for coping with the shortage is training more nurses to move into ad-vanced practice. Nurse practitioners could be a tremendous asset in meeting the de-mand for routine care, especially among underserved populations. RNs trained as health managers could help physicians make more efficient use of their time, and nurse navigators can guide patients to the services they need without time and resource-consuming duplication.

However, the next question is, with more nurses moving into advanced prac-tice, will we still have enough nursing shoes on the ground to take care of pa-tients at the bedside and in clinics?

“We will always need more nurses, but we also have more pathways into nurs-ing and accelerated routes of entry that are bringing people into the field faster,” Cynthia S. Selleck, DSN RN FNP and As-sociate Dean for Clinical Affairs and Part-nerships at UAB said.

“In addition to people who begin their college studies as nursing students, we offer programs for people who already have degrees in other areas and want to transition into nursing. After a year of in-tense study and over 50 credit hours, they will be ready to sit for a license exam. We also offer an accelerated program for a master’s degree in nursing,” Selleck said.

Strong job opportunities are attract-ing more people who are changing ca-reers, including more men. The definition of nurse is also changing, with changing job descriptions that include a broader range of more advanced and more spe-cialized work.

“We need nurses who are prepared to take on a greater leadership role and more responsibility,” Selleck said. “That’s why a priority for nursing education in Alabama is the 80 by 20 recommendation in the Institute of Medicine’s report on nursing. Our goal is to have 80 percent of our nurses with a baccalaureate degree by 2020. Right now, we’re at 40 percent. We need to double that number.

“To do that, nursing schools are working to help nurses transition from one degree program to the next—to BSN, MSN, and DNP so as they advance in nursing they can be ready for new oppor-tunities.”

Another change in medical educa-tion is a trend toward educating students in different health disciplines together from the start so they can become more experienced in working as a team. As they

get to know each other and see students from other disciplines at work, they should gain a better understanding of the value of what those in other areas of health care do and how it fits into their own work.

Helping nurses stay in nursing is another es-sential part of making sure there are enough nurses to care for the patients who need them. Nursing can be a de-manding profession. Nurses are at risk of back injury, foot, leg and joint pain from being on their feet, and the physical and emotional ef-fects of stress that can limit their career.

“It’s important for nurses to learn to take care of themselves,” Selleck said. “Knowing about body mechanics and how to use your body can make a dif-ference. The average patient is getting heavier. Better equipment is available for moving patients. It’s good to have it and know how to use it.”

Another valuable strategy for nurses to stay in nursing is planning their career path so they will be ready to transition to another area of nursing if the need arises. For example, nursing education, patient education, research nursing and nursing management offer opportunities to put the experience nurses gain through the years to good use while also being less physically demanding.

Whether at the bedside in a big city hospital, or working solo as a nurse prac-titioner in an underserved rural neigh-borhood, nurses play an essential role in America’s health care system.

However, in Alabama, some laws governing advanced practice nursing put our state at a disadvantage in focusing the capabilities of nurses to help bridge the primary care gap.

“This year, nurse practitioners were legally authorized to prescribe controlled substances, which will help to streamline care,” Selleck said. “However, the larg-est barrier is that Alabama—unlike many other states--requires nurse practitioners to be co-located with physicians at least

NURSING

The Primary Care Conundrum

Cynthia S. Selleck, DSN

RN FNP


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For healthcare enti-ties seeking to avoid costly and time-consuming court battles, Alabama’s Private Judging Act could be the answer. Effective for over a year now, the Alabama legislature passed the Act in July 2012, allowing par-ties involved in state civil or domestic litigation to hire a qualified retired or former judge to try their cases.

It’s been slow to catch on. “As far as I know, no civil case has been tried under the Act,” says Scott Vowell, a retired Jefferson County circuit judge now at Vowell and Goldsmith. He was one of the first to hang out his shingle as a private judge.

Vowell says domestic relations cases have already utilized the law. “I think one of the issues for civil cases is getting the lawyers used to the idea, and also both sides have to be willing to waive the trial by jury and that makes people a little ner-vous,” he says. “One side would be more likely to want to retain that option.”

But advantages do arise from procur-ing a private judge. The waiting time no longer depends on the court system. “Un-like an actively serving judge, a private

judge doesn’t have hundreds of pending cases,” Vowell says. That can dramatically cut lawyer costs as well as time away from the medical practice. “The advantage is that you can get a trial as quickly as the participants are ready.”

The litigants also get to choose the judge. To qualify as a private judge, the judge must have served at least one full six-year term of office and cannot be cur-rently serving on the bench. They must also be an active member of the Alabama State Bar and qualified by the Alabama Center for Dispute Resolution.

“This means litigants can choose a re-tired judge who may have some special ex-

pertise which makes them particularly well suited to resolve the issues in their case,” Vowell says. Cur-rently, the Alabama Center for Dispute Resolution lists 31 qualified private judges throughout the state.

Uti l iz ing judges with an understanding of healthcare provider con-cerns could present an ad-vantage. And unlike some other arbitration options, private judging cases still retain their right to appeal. “If you arbitrate a case, like in nursing-home cases, there’s no real chance for

an appellate review. Parties are pretty well stuck with the outcome. But in private judging, you can have the judge’s decision appealed,” Vowell says.

Also, unlike with arbitration, during private judging proceedings, the Alabama Rules of Civil Procedure and the Alabama Rules of Evidence still apply to the case. At the conclusion, the judge enters a final judgment that can be reviewed by the appellate courts, just like any other final judgment. “You’re still bound by all the rules of civil procedure and evidence, so that also gives lawyers a sense of certainty they don’t have in arbitration cases,” Vowell says. “Essentially, the trial is ex-

actly the same as a regular trial.”One big difference would be the cost

of hiring the judge. “There’s no fixed rule for the fee,” Vowell says. “It’s whatever the special judge and attorneys who hire him agree to. It’s starting out about the same as the hourly rate a mediator would charge.”

For some cases, the ability in private judging cases to hold the trial in private quarters away from the exposed venue of a public courtroom could be highly ap-pealing. “You do lose that security of the courthouse, but if you have very high feel-ings and emotions in a case, you could find an unused courtroom to engage,” Vowell says.

Vowell says he could see private judg-ing as useful in almost any legal dispute involving a healthcare provider. “I think it would be ideal for complex medical malpractice cases, especially with a judge who has experience trying those cases,” he says, though the right to a jury might in-terfere in some of those situations.

For cases where discretion reigns as a primary concern by both parties involved, private judging could be ideal. “It would be a great advantage in business disputes among medical partners where they would not want to air that situation in a public court hearing,” Vowell says.

A common criticism of the judge-for-hire option concerns the risk of creating

Judge for Hire

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ACA marketplaces which was making it difficult for them “to handle even the first wave of consumers who were able to sign up for health insurance using federally- run exchanges during the glitch-ridden rollout of the new law.”

The report further stated that more than a dozen health insurance companies have re-ceived data from online mar-ketplaces that is “riddled with errors, including duplicate en-rollments, missing data fields, and spouses reported as chil-dren.”

According to an Associated Press poll, the bumpy start re-sulted in only about one in 10 people being able to buy health insurance during the first week of enrollment. Blue Cross and Blue Shield officials did not report major problems from their end. Calls to Humana and United Healthcare in Birmingham were not returned.

Blue Cross and Blue Shield spokes-person Koko Mackin says that call volume at their company has tripled compared to call volume from this same time last year. “It is too early to report enrollment num-bers, but we have received thousands of calls from interested Alabamians who are looking at their options,” she says. “We

understand there have been some glitches on the site, but these connectivity issues will get resolved.”

Mackin says the Blue Cross and Blue Shield staff has worked hard to develop the new ACA-compliant health plans that are on and off the exchanges. “We also made significant changes to our claims processing and customer service functions in order to meet the requirements of the

new law,” she says.

The Marketplace Exchanges

Sixteen states are operat-ing their own exchanges, while 34 states are either partnering with the federal government or are having the federal govern-ment run their exchanges. Ala-bama’s exchange is run by the federal government.

Following the Supreme Court ruling that upheld the individual mandate, which re-quires taxpayers to maintain qualifying health insurance or pay a penalty, and eliminated the requirement that all states expand Medicaid, Alabama Governor Robert Bentley de-cided that Alabama would not set up a state exchange.

“Alabama’s decision not to expand Medicaid and not to establish a state exchange

are in line with a majority of the states,” says Bruce “Andy” Andrews, an attorney with Sirote & Permutt PC in Birmingham. “The governor stated his reason for not establishing a state-based exchange was the additional tax burden. His decision not to expand Medicaid was likewise due to cost. He said the state simply cannot afford to expand Medicaid under its cur-rent structure. By going with the federal

exchange, the state avoids the associated administrative costs for equipment and personnel.”

Andrews says the essential difference between a federal and state exchange is who has control over it and where the cost lies. “If our state managed its exchange, the state government would be more heavily involved. As it is, the federal gov-ernment performs the exchange functions, such as evaluating and approving the plans offered in the marketplace,” he says.

According to the ACA, all approved insurance plans must contain 10 “essential health benefits:”

• Ambulatory services• Prescription drugs• Emergency care• Mental health services• Hospitalization• Rehabilitative and habilitative

services• Preventive and wellness services• Lab services• Pediatric care• Maternity and newborn careThe exchanges are set up to serve

people who are currently uninsured or who buy individual health insurance. Small businesses also will shop for plans on the exchange through the Small Busi-ness Health Options Program (SHOP). To start the process of searching for in-formation about available plans and to enroll, log in to www.healthcare.gov.

Navigating the Affordable Care Act, continued from page 1

Attorneys Bruce “Andy” Andrews, right, and David Drum of Sirote & Permutt discuss the policies of the ACA.



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SOLUTIONS

By lynne Jeter

Editor’s note: The Solutions series is a new feature of the Birmingham Medical News, focusing on innovative answers to the growing chasm between the number of medical graduates and residency slots.

While the gap between medical graduates and the number of residency slots nationwide continues to challenge industry leaders, the University of South Florida (USF) Health Morsani College of Medicine (COM) in Tampa is bucking the trend. Within the next couple of years, the number of residency slots will nearly double to 1,400.

“We have one of the nation’s largest distributive residency programs, with 730 USF residents at seven sites, and a pro-posal to add another 700 residents,” for-mer USF Health CEO Stephen Klasko, MD, also former dean of the Morsani COM, said before he left the school in Au-gust to become the first executive selected to head both Thomas Jefferson University and the TJUH System in his home state of Pennsylvania. Klasko significantly contrib-uted to the medical school infrastructure expansion, allowing meaningful strategic growth of the residency program.

The ambitious plan fits the distribu-tive model, allowing USF Health Morsani COM the ability to sponsor or participate in residency programs as “civilians,” ex-plained Charles Paidas, MD, vice dean for clinical affairs and GME for the USF Health Morsani COM.

“We’re offering a shopping list of educational and research initiatives that are required for GME certification,” said Paidas, noting that Naples Community Hospital in Naples, located more than 150 miles away, represents the school’s most recent affiliate addition, and that a pact for other affiliations is in the works.

When Paidas, the plan’s architect, be-came associate dean for GME in 2009 after five years with the school, the residency program faced governance and operation issues that required improved oversight. He assembled a strategic committee that allowed the school to garner impeccable institutional review commendations from the Accreditation Council for Graduate Medical Education (ACGME). In 2011, he was promoted to his current post.

At the suggestion of USF medical students, Paidas also brought together As-sociation of American Medical Colleges (AAMC) executives, GME leaders and medical school deans to the USF Health

GME Summit last year. The well attended event “begs the

issue of a replay this year,” he said. “Our goal was to characterize the state of GME in Florida. For example, the average num-ber of residents per 100,000 population in the U.S. is 35.9. Florida’s at 17.5. That’s a raw data point that tells you we need to double the workforce. That translates to 2,900 residency slots in the state.”

Boosting the number of residency slots also improves the chances of keeping new doctors in Florida.

“Florida had nearly a 59.6 percent retention rate of residents who com-plete their training and stay here,” noted Paidas. “The mantra around the country is: wherever you do your residency – not where you attended medical school – is likely where you’ll practice. USF pushes that to 68 percent.”

Of 128 total first-year resident slots, USF Health Morsani College of Medicine placed medical graduates in the following specialties, according to the National Resi-dent Match Program:

Dermatology: 4

Emergency Medicine: 10

Family Medicine: 8

Internal Medicine: 29

Medical-Preliminary/Ophthalmology: 1

Neurological Surgery: 2

Neurology: 5

Obstetrics-Gynecology: 5

Orthopedic Surgery: 4

Otolaryngology: 3

Pathology: 4

Pediatrics: 15

Physical Medicine & Rehabilitation: 2

Plastic Surgery (integrated) 3

Psychiatry: 8

Radiology-Diagnostic: 8

Radiation Oncology: 1

General Surgery: 6

Surgery-Preliminary: 2

Surgery-Preliminary/Urology: 3

Vascular Surgery: 2

Medicine-Pediatrics: 3

“This past year, we matched all 128 first-year slots in the first round of Match,” said Paidas. “We haven’t done that in 20 years!”

Doubling Residency Slots USF Health Morsani COM hosts one of the nation’s largest distributive residency programs; maintains high retention rate of new doctors


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Navigators are available throughout the state to assist those who are shop-ping for and enrolling in plans in the exchanges. The federal government pro-vided grant money for these positions in each state. Alabama’s grant recipients are Ascension Health; AIDS Alabama, Inc.; Samford University; Catholic Social Ser-vices – Archdiocese of Mobile; and Tom-bigbee Healthcare Authority.

Alabama’s PlansThe ACA groups health plans into

four standard levels of coverage – Plati-num, Gold, Silver, and Bronze. There is also a fifth category, catastrophic cov-erage, available to people under age 30 and to some people with limited incomes. These “metal levels” of coverage are based on the average amount of health care costs paid annually by the health plan. “For example, for a Platinum level plan, Blue Cross will pay throughout the year an average 90 percent of the cost of a member’s covered benefits. The member pays the remaining 10 percent,” Mackin says. “Similarly, for a Gold plan, we pay 80 percent and member pays 20 percent; for a Silver plan, we pay 70 percent and the member pays 30 percent; for a Bronze plan, we pay 60 percent and the member pays 40 percent.”

Blue Cross and Blue Shield, which writes more than 80 percent of the health insurance policies in Alabama, and Hu-mana are offering individual policies

through the exchange. Blue Cross and United Healthcare are offering policies to small businesses.

“We have been implementing the re-quirements of the ACA since its passage in March 2010,” Mackin says. “We want to make sure Alabamians can access health coverage and get all the help they need to navigate this new environment.”

According to Terry Kellogg, CEO of Blue Cross and Blue Shield of Alabama,

his company and United Healthcare will offer plans statewide while Humana will offer plans in the counties of Jefferson, Madison, and Shelby.

“Blue Cross is offering 20 new health and dental plans in all metal levels in all 67 counties of Alabama, on and off the federally facilitated Health Insurance Marketplace,” Mackin says. “Blue Cross will offer individuals and small businesses 14 new health plans in the catastrophic,

bronze, silver, gold and platinum levels and six new dental plans.”

Individuals can choose from nine health plans and three dental plans, and small businesses can choose from five health plans and three dental plans. “We are offering new health plans with broad physician and hospital networks,” Mackin says. “We do not plan to offer health plans with smaller, restricted provider networks. For individuals and small businesses, these are new health plans as required by the ACA.”

The ACA includes a grandfathering provision that allows people to keep plans they had on the date the law was enacted provided the plans are amended to meet some ACA requirements:

• Reduce the waiting period so that it is no longer than 90 days;

• Remove lifetime limits;Comply with the limitation on annual

limits;• Allow the extension to age 26 but

limited to an adult child who is not eligible for enrollment in an employer-sponsored plan until 2014;

• Provide the uniform coverage docu-ments; and

• Apply the standard definitions.Of course, given that most plans did

not have these features, very few plans will actually be grandfathered, meaning that most individuals will lose their current plan and be forced to buy another one.




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vertebral compression fractures in the United States each year. Compression fractures are usually very painful and become debilitating with severe postural change over time. Unfortunately, compression fractures are not detected timely. Historical management for a compression fracture is rest. However, this approach does not solve the loss of vertebral body height and usually results in chronic pain. In addition, rest and activity loss leads to further demineralization and bone weakening, thus

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Often times it seems that com-pounding pharmacies operate in a “gray area” between state legisla-tive oversight and federal legisla-tive oversight. However, due to the attention created by several sterile compounding pharmacies, the federal government is once again proposing ways to regulate the compounding pharmacy industry.

The U.S. Senate recently drafted proposed legislation (“Sen-ate Proposal”) targeting compound-ing pharmacies. The Senate Proposal contains some fundamental changes to compounding pharmacies. For example, the proposed legislation includes com-pounded drugs within the definition of a “new drug” under the Federal Food, Drug and Cosmetic Act (“FDCA”). This inclu-sion would create a presumption that com-pounded drugs have to comply with the burdensome requirements of the FDCA for registration of a new drug and complying with certain manufacturing process.

The Senate Proposal also creates two categories of compound pharmacies, “tra-ditional compounders” and “compound-ing manufacturers.” While the definition

of “traditional compounder” is very simi-lar to the historical use of the term “com-pounding pharmacy” and would continue to be licensed by state boards of pharmacy, a “traditional compounder” would be sub-ject to additional federal requirements. On the other hand, “compounding manu-facturer” is a new category. “Compound-ing manufacturer” would mean an entity that compounds any sterile drug without receiving a prescription order prior to be-ginning compounding and introduces the compounded drug into interstate com-merce or that repackages a drug using sterile preservative-free single-dose vials or by pooling sterile drugs. Under the Senate

Proposal, “compounding manu-facturers” cannot be licensed as pharmacies under state laws. It is interesting that the definition of “compounding manufacturer” is specifically limited to the com-pounding of sterile drugs.

On September 12, 2013 Reps. Morgan Griffith (R-VA), Gene Greene (D-TX), and Diana DeGette (D-CO) introduced a compounding pharmacy bill named the Compounding Clarity Act (“CCA”) that is intended to clarify FDA authority over com-

pounding in the wake of the recent issues involving sterile compounding pharmacies. The CCA attempts to distinguish between small-scale and large-scale compound-ers by clarifying the roles that individual states and the FDA have in regulating such compounders. According to the CCA, tra-ditional pharmacies will remain under the jurisdiction of state boards of pharmacy and remain exempt from the FDA’s manu-facturing authority. The FDA, on the other hand, will have authority over “compound-ing manufacturers” that provide over 5% of their compounded medications for use in a facility such as a hospital, as well as “outsourcing facilities” that ship medica-

tions across state lines. The CCA seeks to preserve the current physician-patient-pharmacist relationship by allowing all compounding to be done pursuant to a patient-specific prescription, and allowing for anticipatory compounding based on a pre-existing relationship with a patient or doctor. The CCA also proposes to establish a safety standard for all compounded drugs to follow. Additionally, the practice of office use where drugs are dispensed in a health-care setting will be permitted, provided a prescription or patient name is reconciled back to the pharmacy within seven days.

The Senate Bill seems to have a more significant impact on compounding phar-macies than the CCA especially the provi-sion that treats all “compounded drugs” as “new drugs” under the FDCA. Al-though as of the publishing of this article, no new legislation has been passed, with the increased legislative activity, it is only a matter of time before the federal govern-ment issues new legislation applicable to compounding pharmacies.

Possible Legislative Changes to Compounding Pharmacies

Jim Hoover is a partner in the Health Care Practice Group at Burr & Forman LLP and exclusively represents healthcare providers in regulatory and litigation matters.


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Cyber SecurityProtecting the personal and financial

information of people who are enrolling in plans on the exchanges is vital. Secu-rity experts warn that the exchanges need to protect themselves against cybercrimi-nals. In addition, consumers attempting to enroll in health plans on these online ex-changes need to take precautions, such as making sure they are visiting the genuine insurance marketplaces and not entering personal information into imposter sites.

Blue Cross and Blue Shield employees are working to ensure the security of con-sumers enrolling in the company’s plans. “Blue Cross uses secure user account au-thentication practices, and we enforce secure information exchange protocols to transmit information to and from the federal exchanges,” Mackin says. “Our systems are developed in accordance with secure coding best practices and we use encryption technologies to protect consumer information. In addition, Blue Cross’ systems meet HIPAA Privacy and HIPAA Security regulatory requirements and are secured in accordance with Pay-ment Card Industry Standards that pro-tect credit card information.”

SubsidiesFinancial assistance such as advanced

premium tax credit subsidies and cost sharing subsidies may be available from the federal government for consumers who are purchasing healthcare coverage directly from a plan in the exchange. “Ap-plying for tax credit subsidies is part of the exchange enrollment process,” Andrews says. “The exchanges also function to trigger the employer mandate penalties that go into effect in 2015. If a person is a full-time employee of a company with 50 or more full-time equivalent employ-ees and the company does not offer that full-time employee affordable health in-surance that meets ACA requirements, the company will owe a penalty to the IRS when that employee receives a credit through an exchange.”

To determine eligibility for a pre-mium subsidy, enrollees will provide in-formation about income, household size and access to employer-sponsored health insurance.

For those who don’t qualify for a sub-sidy, plans also will be available outside the exchanges. Those plans will comply with ACA requirements, but may include different plan designs and additional car-riers.

PremiumsAlong with the new health plans are

new premiums because of the law’s re-quirements. The ACA’s impact on premi-ums varies based on several factors:

The health plan you choose – bronze, silver, gold or platinum; the county where you live; the number of members in your family, their ages and whether they use tobacco.

Member level rating is new and re-quired by the ACA. “In the past, we had

one single premium and one family pre-mium — no matter how many people were in the family. The ACA requires that each member on a policy be rated based on their age, address and tobacco use. Then all of these individual rates are added together to determine the family premium. As a result, larger families may experience higher premiums,” Mackin says.

Health underwriting and waiting pe-riods for pre-existing medical conditions have been eliminated by the law. Individ-uals now have access to healthcare cov-erage regardless of their health condition, and premiums cannot vary based on an individual’s health status.

The ACA limits how much insur-ers can vary premiums based on an in-dividual’s age. “Today the law requires a 3:1 maximum ratio for age rating for adults. This means that premium rates for older adults are not allowed to ex-ceed more than three times the rate of a younger person,” Mackin says.

The Act also contains a number of fees and taxes that have been added to premiums.

On the federally facilitated exchange in Alabama, many individuals and fami-lies may qualify for advanced premium tax credits that may lower the amount of premiums they pay for coverage. To be eligible for these premium tax credits, an individual’s annual income must be less than $45,960; for a family of four, their annual income must be less than $94,200.

According to a Sept. 30, 2013, news release from the U.S. Department of Health and Human Services, the average premium nationally for the second lowest cost silver plan on the exchanges is $328 before premium tax credits. “The average premium for the second lowest cost silver plan on the exchange in Alabama is $318 before premium tax credits,” Mackin says. “In addition, among the 50 states, Alabama has the lowest family premiums in the country for employers according to the federal government’s 2011 Medical Expenditures Plan Survey.”

The Cost of No InsuranceBeginning in 2014, most uninsured

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If you’re already covered by a qualify-ing individual policy, an employer group plan, or a government program such as Medicare, Medicaid or the Veterans Health Administration, you’re automati-cally in compliance with the individual mandate.

Those without coverage in 2014 face a tax penalty of one percent of their an-nual income or $95, whichever is greater, and a per-child fine of $47.50, up to a family cap of $285. In 2015, the penalty increases to the greater of two percent of income or $325, and by 2016, the penalty, which is added to the individual’s federal income tax, increases to the greater of 2.5



Birmingham Medical News NOVEMBER 2013 • 2110x6.375_ad2014_2.indd 1 10/25/13 12:30 PM

One Doctor: Close Calls, Cold Cases, and the Mysteries of Medicineby Brendan Reilly, M.D.c.2013, Atria Books; $28.00 / $32.00 Canada; 464 pages

You always hated taking tests.Prepared or not, your hands sweated

when faced with a test, and your stomach felt shaky. Whatever you’d learned, it fl ew from your head the second you sat down.

Today, it’s the same in the hospital as it was in high school: you hate taking tests. But what other way does your doctor have of knowing what’s wrong with you? In the new book One Doctor by Brendan Reilly, MD, you’ll see that moth-eaten methods may beat modern.

“New York doctors don’t work week-ends.”

That’s what one of Brendan Reilly’s patients claimed, surprised to see Reilly at her bedside on an early Saturday morn-ing at New York’s Presbyterian Hospital. He was there because he believes that the doctor who “knows you best” is the one who should assume the majority of

the caregiving. That’s not the way most medical centers work these days, but it’s the way he prefers to practice medicine.

For Reilly, doing things the old-fash-ioned way is often better than technology, when making a proper diagnosis. Ma-chines, he points out, can miss the small-est of symptoms: a non-dilated pupil, an errant refl ex, a hidden blood clot, rare bacteria that mimics something else.

“Diagnosing disease,” he says, “has something to do with patterns.” Good doctors – “grandmasters,” he calls them – know how to recognize those patterns without “wasteful, redundant, or ineffec-tive” medical intercession. Such recogni-tion, near-intuition, and the ability to deal with a day when “doctoring feels like pin-ball” are talents he cultivates in his resi-dents and students.

Even so, there are times when a doc-tor is stumped by a medical mystery that requires rapt attention and sleuthing skills. That’s when it’s mandatory to listen to a patient, the patients’ ailing body, and one’s own subconscious, as well as medi-cal knowledge new and old. Such mys-teries may result in instinctual reaction, and a cure. Other times, they might end

with the surety that it’s time to stop.And on that, says Reilly, doctors

“know about regret. But we don’t talk about it. Ever.”

Broken up into thirds, One Doctor is a mixed bag.

Author Brendan Reilly, MD starts his book in the wee hours of a typical on-ser-vice day in a busy New York hospital, and we’re treated to a whirlwind of intriguing medical cases, AHA! moments, and solu-tions worthy of a Sherlockian novel. The end of that long day, and the cases of his own parents, are where Reilly wraps up.

I would have been more enthusiastic about this book, had that been the sum

of it.No, instead, the middle third here

is taken up by the story of a couple that Reilly knew some 30 years ago, the care of which still resonates in his career. That was interesting at fi rst, but I thought it be-came overly long.

And yet, I did enjoy this book, over-all, and I think lovers of medical dramas will, too. If that’s you, and you’re maybe willing to skip bits that lose your interest, then One Doctor tests out well.

Terri Schlichenmeyer. Terri is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.

The Literary ExaminerBY TERRI SCHLICHENMEYER

of it.

is taken up by the story of a couple that Reilly knew some 30 years ago, the care of which still resonates in his career. That was interesting at fi rst, but I thought it be-came overly long.

all, and I think lovers of medical dramas will, too. If that’s you, and you’re maybe willing to skip bits that lose your interest, then

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percent of income or $695 per individual.Excused from the requirement are

incarcerated individuals, undocumented immigrants, members of American In-dian tribes and congregants of religious groups opposed to health insurance. Those with incomes so low that they are not required to file a federal income tax return -- roughly $10,000 for individuals and $20,000 for families -- and those who would have to pay more than eight per-cent of their annual income for health in-surance also will not be penalized for lack of coverage.

You won’t have to demonstrate that you have coverage, or an exemption from the mandate, until you file your 2014 fed-eral income tax in 2015.

The employer mandate outlined in the ACA has been postponed until 2015. At that time, employers will face a deci-sion of whether to offer insurance for their workers or to pay the penalty for not pro-viding required coverage. Andrews says this is the main issue they are discussing with clients. “In the past, insurance dis-cussions addressed two issues –cost and coverage. Insurance packages are tradi-tionally used by employers to attract and

retain good employees,” he says. “Under the ACA, there are at least four issues to balance – cost and coverage, as well as penalties and participation rates.”

If a company chooses not to provide health coverage at all, the company will be charged a non-deductible penalty of $2,000 per full-time employee except the first 30. If a company does provide cov-erage but it does not meet the ACA re-quirements for a particular employee, the company will be charged a non-deduct-ible penalty of $3,000 for that employee. Employers must decide whether provid-ing insurance is more cost effective than paying the penalty and what effect that might have on retaining good employees.

“If an employer fails to offer health insurance that meets the ACA require-ments to just one employee, the company will have a $3,000 non-deductible penalty. For employers in the top marginal tax rate, that is equivalent to spending approxi-mately $5,000 for health insurance that is deductible,” Andrews says. “When you add the employee’s allowed contribution to the premiums, up to 9.5 percent of their household income, it rarely makes financial sense for employers to pay the penalty.”


various codes by up to five percent in each of three categories.

Medicare and Medicaid also grant some form of reimbursement program for PCMH in 17 states, though Alabama is not yet one of them. “These reimburse-ments can be anything from lump-sum payments to offset application fees and various technological expenses to pay-for-performance reimbursement,” Cockrell says.

Practices need to stay on top of these changes and options for raising reimburse-ments, because what they’re not doing today can impact their income even years in the future. “2013 data will form their Medicare payment adjustment in 2015,”

Elliott says. “So you could be reducing your 2015 reimbursements by one per-cent based on your failure to do things you need to do this year.”

“Practices need to be certain that any information from a payer is being given adequate review,” Stroud says. “It can no longer go into the top drawer of the lady whose job it is to just get today’s charges into the system.” He says staff at the highest level, including doctors, needs to ensure the practice stays sensitive to the concerns of the payers. “More and more practices are going to have to hire certified procedural coders to handle their documentation and claim submission and claims appeal processes.”

Coding Detail, continued from page 9

10 percent of the time. “This is a problem in getting health

care where it is needed. Our nurse prac-titioners were asked to take over The Foundry clinic when the physician oper-ating it left. We were able to staff it four days a week by rotating four nurse prac-titioners. But to meet the requirement to have a collaborating physician, we had to recruit a physician, which added sig-nificantly to our cost. We could have had the clinic open two months earlier if we hadn’t had to go through such an amazing

amount of labor -intensive red tape and fees that impede the process of making care accessible.”

Another problem is that insurance in Alabama tends to reimburse nurse prac-titioners at a lower rate than is typical in other states.

“Florida has around 15,000 nurse practitioners,” Selleck said. “Alabama has 1800. Even though we have very active programs training nurse practitioners, a large percentage go to other states to prac-tice because of the laws limiting practice here and the lower reimbursement.

“We need to make Alabama not only a good place for advanced practice nurses to train, but also a good place to stay. Our people need the care they can provide.”

The Primary Care, continued from page 13

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Mimi Guarneri, MD, FACC, and fellow founding members of the Ameri-can Board of Integra-tive Medicine (ABOIM) spent the lingering days of summer putting the final touches on a new board certification ex-amination for a specialty that’s garnering national attention.

“Creation of inte-grative medicine as a specialty by the American Board of Physician Specialties (ABPS) guarantees excellence in the field and assures consumers of healthcare the practitioner they’re seeing has reached a high standard of practice,” said Guarneri, board-certified in cardiology, internal medicine, nuclear medicine and holistic medicine.

Tampa, Fla.-based ABPS, the first multi-specialty certifying body to offer physician certification in integrative medi-cine, is the official certifying body of the American Association of Physician Spe-cialists (AAPS) and one of three national certifying organizations of MDs and DOs. The ABPS has led industry response to trends in urgent care, disaster medicine, hospital medicine and family medicine obstetrics.

Andrew Weil, MD, said the forma-tion of ABOIM – one of 18 ABPS boards – marks an important milestone in the development in the field of integrative medicine.

“Finally, there’s a way for qualified physicians to present themselves as experts in offering competent integrative care to patients,” said Weil, who helped establish integrative medicine as a specialty.

Of the other two national certifying organizations, the American Board of Medical Specialties (ABMS) represents the largest national organization certify-ing MDs and DOs. The American Osteo-pathic Association Bureau of Osteopathic Specialists (AOABOS) certifies DOs only.

“Integrative medicine focuses on get-ting to the underlying cause of disease and implementing personalized programs that help people achieve optimal health,” said Guarneri. “In conventional medicine, we’re taught to make a diagnosis and pre-scribe a treatment. In integrative medi-cine, we look for the underlying cause of the problem or health challenge. For ex-ample, in conventional medicine, we may

diagnose diabetes and prescribe a medica-tion. In integrative medicine, we look at what a person is eating (to determine if) they’re deficient in micronutrients linked to diabetes. If they’re physically fit, are they exposed to toxins? Are they under stress? All of these can cause diabetes. We may prescribe medicine, but we also look to correct the underlying cause. We treat the whole person – body, mind and spirit – and we look at an individual’s relation-ships to family, community and planet.”

ABOIM and the Consortium of Ac-ademic Health Centers for Integrative Medicine define integrative medicine as “the practice of medicine that reaffirms the importance of the relationship be-tween practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeu-tic approaches, healthcare professionals, and disciplines to achieve optimal health and healing.”

Guarneri, founder of the Scripps Center for Integrative Medicine in La Jolla, Calif., and president of the Ameri-can Board of Integrative Holistic Medi-cine (ABIHM), pointed out that as a cardiologist, her goal is to also reverse the patient’s health challenges.

“Integrative medicine provides me the tools that weren’t available in my con-ventional medical training,” she said. “As a cardiologist, I’m well versed in the role of medication, surgery and stenting for treatment of cardiovascular disease. But, it’s my training in integrative medicine that’s taught me the principles of nutri-tion, the evidenced-based use of natural supplements, and the role of the mind-body connection. Integrative medicine allows me to complete the circle of care.”

Eudene Harry, MD, medical director of Oasis Wellness & Rejuvenation Cen-ter in Orlando, Fla., was thrilled to learn about the new board certification in inte-grative medicine.

“It’s very good that integrative medi-cine is being acknowledged as a specialty,” said Harry. “The message is: let’s not be exclusive. Let’s be inclusive. Let’s look at all evidence-based material and treat it equally.”

Harry, who specializes in both holistic and emergency medicine, said integrative medicine allows “more focus on informa-tion-gathering.”

“That’s going to be helpful,” she said. “Medications don’t address the issue that’s driving the patient to the doctor’s office.”

Integrative Medicine Goes MainstreamABOIM finalizes board certification exam for emerging specialty

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What if a simple blood test could pro-vide information that your patient had a significantly elevated risk of developing diabetes within the next decade? What might that mean from the standpoint of early intervention and prevention? While it’s much too soon for this type of clinical application, researchers at the Vander-bilt Heart and Vascular Institute (VHVI) and Massachusetts General Hospital have identified a novel biomarker that lends it-self to such intriguing questions.

Led by Thomas J. Wang, MD, di-rector of the Division of Cardiovascular Medicine at Vanderbilt and physician-in-chief for VHVI, the team recently pub-lished results of their discovery of elevated 2-aminoadipic acid (2-AAA) as a precur-sor to diabetes in The Journal of Clinical Investigation. Tapping into the rich data source of the Framingham Heart Study, which is now following its third generation of participants, the Wang research team studied blood samples gathered more than a decade ago from 188 individuals who ul-timately developed type 2 diabetes and 188 who did not develop diabetes.

Using these blood samples, the inves-tigators were able to compare levels of me-tabolites to see if there were any differences between the group that went on to develop diabetes and the group who did not. Wang noted newer technology now makes it pos-sible to profile hundreds of metabolites at one time.

“One of the things that really lit up when we looked at the people who devel-oped diabetes was 2-aminoadipic acid,” he said. “Having elevated levels of 2-AAA pre-dicted risk above and beyond their blood sugar at baseline, their body weight, or other characteristics that put them at risk.” Wang added there doesn’t appear to be a specific threshold of risk at this point … the higher the levels of 2-AAA, the higher the risk of developing diabetes. In fact, those in the top quartile of 2-AAA concentrations had up to a fourfold risk of developing dia-betes during the 12-year follow-up period compared to those in the lowest quartile.

Interestingly, the researchers found 2-AAA might not be just a passive marker. As part of the same study, the team con-ducted mouse model testing and discov-ered giving 2-AAA to the mice actually altered the way the animals metabolized glucose.

“It suggests the molecules might be playing a direct role in how the body pro-cesses glucose rather than being an inno-cent bystander in the process,” Wang said. He added that elevated levels of 2-AAA don’t necessarily mean the molecule is bad for the body. Instead, it could be a defense mechanism where the body is producing higher levels to fight risk from another, as yet unknown, source.

Figuring out the metabolite’s exact role in the functioning of pancreatic cells is one area for future research. If, indeed, 2-AAA

turns out to be a defense mechanism to stave off diabetes, the good news is that the metabolite could be given to humans in the form of nutritional supplements. On the other hand, if 2-AAA turns out to be harm-ful to the body’s glucose regulation system, further research could reveal methods to lower the metabolite’s presence.

Wang was quick to say the next step is to conduct additional research to mea-sure 2-AAA in other human populations outside of the Framingham study through both retrospective and prospective stud-ies. More in depth animal model studies are also in the pipeline. “A lot of the effort will be focused on trying to understand the biologic effect of 2-AAA in developing dia-

betes,” he said of the work going forward.However, Wang said the current re-

search results at least raise the possibility that somewhere in the future knowing how high a person’s circulating 2-AAA levels are could impact clinical practice by allow-ing providers to adopt a more aggressive intervention posture among those at high-est risk, whether that be through exercise, weight loss or pharmacologic measures. It is conceivable that 2-AAA might be the type of red flag for diabetes that high cho-lesterol is for heart disease.

“Understanding why diabetes oc-curs and how it might be prevented is a very intense area of investigation because of the serious consequences of having the

disease,” Wang said. “Down the road, this might be one part of the armamentarium of tests that could be considered. If this were proven useful in further studies and could be used clinically, it would be an easy test to administer.”

As for the impact of the findings right now, Wang added, “In 2013, it highlights a specific pathway that might be related to diabetes risk that we previously didn’t know about.”

Considering the prevalence of type 2 diabetes and growing obesity epidemic in the United States, that is an important lead for researchers working to develop strate-gies to interrupt the disease progression and stop risk from becoming a reality.

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As another dismal economic year draws to a close, addiction and substance abuse clinics are gearing up for an infl ux of patients.

“We say in our business that the drink-ing season begins at Thanksgiving and ends on Super Bowl Sunday,” said Percy Menzies, M. Pharm., founder of As-sisted Recovery Centers of America (ARCA), based in St. Louis, Mo. “We opened in February and just recently had to turn away patients for the fi rst time. It’s that busy. We’re also dealing with a huge iatrogenic epidemic of addiction to prescription pain drugs. For the fi rst time, more people have died of drug overdose than automobile ac-cidents. Heroin has become the cheap ‘ge-neric’ form of opioid pain killers.”

Despite the revolving door headlines about celebrities frequenting rehab clinics, addiction medicine remains one of the most underfunded diseases in the United States. According to a 2012 report published by The National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia), “Addiction Medicine: Closing the Gap between Science and Practice,” 15.9 percent (40.3 million) of Americans have the disease of addiction. That’s more than heart conditions (27 mil-lion), diabetes (25.8 million) or cancer (19.4 million). Even though one in fi ve deaths is attributable to tobacco, alcohol and other drug use, the U.S. spent $107 billion to treat heart conditions, $86.6 billion to treat cancer, and $43.8 billion to treat diabetes in 2010. But only $28 billion was spent on addiction treatment.

Another eye-opening statistic: Of every dollar spent by federal, state and local governments on risky substance use and addiction, 95.6 cents pay for conse-quences; only 1.9 cents go to prevention and treatment.

Genetic predisposition, structural/functional brain vulnerabilities, psychologi-cal and environmental infl uences are clear risk factors for addiction, as is the age of fi rst use. Ninety-seven percent of addiction cases start with substance abuse before the

age of 21, while the brain is still developing. As a result of all risk factors, one-third of the population over the age of 12 is suscep-tible to substance abuse.

“This clearly articulates the monu-mental challenge ahead of us,” said Men-zies, who left an executive role with DuPont Pharmaceuticals to open ARCA’s fi rst in-tegrated outpatient clinic in 2001, and in early 2013, a 25-bed residential substance abuse clinic. He’s on a campaign to move addiction into the mainstream of medicine.

“For too long,” he said, “we’ve been on the outside of the margins.”

Addiction Medicine Challenges

Various factors keep addiction and substance abuse programs in the shadows of medicine: the professional stigma that makes it diffi cult to recruit healthcare pro-viders, the social stigma that pervades so-ciety and the fi eld of addiction medicine, misconceptions among other healthcare providers, and the often unbalanced mix of medications and treatment.

“When I give talks to medical school students, and ask who wants to specialize in addiction medicine, not one hand goes up,” said Menzies, noting that of 985,375 active physicians nationwide, only 1,200 are prac-ticing addiction medicine specialists and 355 are practicing addiction psychiatrists. “They don’t see it as a very lucrative busi-ness.”

The report also noted a signifi cant differential in requirements for addiction counselors by state. Only one state has a minimum requirement of a master’s de-gree, six states require an undergraduate degree, and 10 states require an associate’s degree. Fourteen states require only a high school degree or GED equivalent, six states have no minimum degree requirements, and 14 states don’t require any licensure or certifi cation. Only 10 states mandate a phy-sician as a medical director or staff member of residential treatment programs.

“The majority of people who work in addiction treatment are in recovery and lost everything to their addiction and want to give back to society,” he said. “Part of the challenge is that they come with their own baggage. Being in recovery doesn’t make them an expert. That’s one of the major obstacles we face in this fi eld.”

Menzies, who is not in recovery, re-called how his relatives – many are health-care professionals – questioned his decision to move into addiction medicine.

“Others ask me if my practice failed, because they believe no self-respecting healthcare professional would go into this fi eld voluntarily,” he said, with a chuckle.

The social stigma of the disease exac-erbates misconceptions of addiction.

“If you go to your physician and say, ‘doc, I’m drinking too much,’ he’s likely to say ‘stop drinking’ and maybe advise you

Managing AddictionsAddiction medicine professionals prepare for ‘busy season’

Dr. Percy Menzies






to go to AA,” he said. “If you go to a psy-chiatrist and say, ‘I’m drinking too much,’ he’s likely to say, ‘you’re depressed. Let me give you an anti-depressant.’ If you go to your pastor and say, ‘I’m into drugs and alcohol,’ he may say, ‘you should come to church more often.’ My goal is to treat addiction like any other chronic medi-cal condition, such as diabetes or asthma, through the right combination of medica-tions, counseling, behavioral therapies, and psychiatric care.”

Drug Intervention ChallengesIronically, drug and alcohol treatment

has a dark and checkered history, noted Menzies.

“Highly dangerous and addicting drugs were touted as ‘cures.’ This has resulted in a very unhealthy segmentation of treatment,” he explained. “Only a small percentage of alcoholics are treated with medications, but addiction to opioids is predominantly treated with addicting and abusable drugs like methadone and buprenorphine, which adds to the stigma and deters many physi-cians from getting into this field.”

Nearly 35 years ago, the federal gov-ernment developed naltrexone as the first non-addicting medication to prevent de-toxed heroin addicts from relapsing, added Menzies.

“DuPont introduced this medication in 1984; in 1994, the same medication

was approved for the treatment of alco-holism,” he said. “Naltrexone faced op-position from many treatment providers and the practical challenge of medication compliance.” Vivitrol, a monthly injection of naltrexone, was introduced in 2006 but has yet to gain significant use.

“It’s an amazing medication to prevent relapse to alcohol or opioid use, but there’s so much opposition to it,” he said. “It gives patients a fighting chance of not relapsing when they return home to the familiar envi-ronment of past drug and alcohol use. The true test of any treatment program is how well patients do when they return home. Vivitrol is a potent tool to keep patients en-gaged in long-term treatment.”

Improving the EnvironmentIn 1956, the American Medical As-

sociation (AMA) referred to alcoholism as an illness that should be treated within the medical profession. In 1989, the AMA adopted a policy naming addiction as a disease. Yet less than 6 percent of referrals to publically-funded addiction treatment emanates from healthcare providers.

Addressing the education, training and accountability gap is paramount to moving addiction medicine into the main-stream. Among the report’s next-step rec-ommendations, improved screening and assessment tools need to be developed, national accreditation standards for all ad-diction treatment facilities and programs that reflect evidence-based care need to be established, addiction medicine workforce

needs to be expanded, addiction treatment facilities should be licensed as healthcare providers, and research and data collection to improve and track progress and search for a cure needs a financial shot in the arm.

“The stigma of addiction,” said Men-zies, “can only be removed with better out-comes.”

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Basically, says Vowell, private judging should be viewed as an additional option in alternative dispute resolution. “We have mediation and arbitration, and this just goes a step further to resolve disputes out-side the formal court system,” he says. Cali-fornia has been employing private judging for more than 30 years and at least five other states allow it as well, including Colo-rado, Indiana, Florida, Texas and Ohio.

But Vowell knows this level of break from tradition will be a slow transition for the Alabama legal system. “It’s a matter of educating the Bar about it and getting people used to it. The court system is in-herently conservative and things are slow to change.”

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Editor’s note: This article fi rst appeared in the Birmingham Medical News blog on October 3.

Completing the screening and re-screening cycle for colorectal cancer is a daunting task for medical practices across the state. The U.S. Preventative Services Task Force recommends colonoscopy every 10 years or a fl exible sigmoidos-copy every fi ve years or an annual stool test for average risk patients. Identifying patients who need screening, encouraging compliance with recommended screening methods, and repeating FIT/iFOBT tests annually are just a few of the necessary, but challenging steps in reducing inci-dence and mortality of Alabama’s second-leading cancer killer.

The ideal patient panel for annual screening with FIT/iFOBT is average risk, compliant and in the provider’s offi ce multiple times per year. That population exists in Alabama and it has a 30 percent higher risk for colorectal cancer: people with diabetes.

One in 10 Alabamians have been di-agnosed with diabetes, an illness that neg-atively impacts quality of life and lifespan and brings with it a host of other health issues. Those at risk for type 2 diabetes often mirror those at risk for colorectal cancer: patients over 50 years old or Afri-can Americans, for example. Many of the risk factors for colorectal cancer overlap with diabetes including obesity, sedentary lifestyle, and western diet.

In addition to sharing risk factors and at-risk populations, diabetes may also contribute to colorectal cancer through chronic insulin treatment, increased pro-duction of bile acids, and slower bowel transit.

While data show that diabetic pa-tients in Alabama are more likely to be screened for CRC than the general popu-lation, approximately 29 percent of the diabetic population in Alabama is not up to date on CRC screening.

Tracking screening within the chronic patient pool.

One way to target diabetic patients and other chronic disease sufferers for colorectal cancer screening is through electronic health records (EHR). By

choosing colorectal cancer screening as one of your clinical quality measures (NQF 0034/PQRI 113) you can improve patient care, earn incentives up to $44,000 for Medicare or $63,750 for Medicaid de-pending on your patient population, and achieve three EHR objectives at once.

Providers can achieve the profes-sional core objective by reporting am-bulatory clinical quality measures. Two eligible professional menu objectives can be achieved by generating a list of patients by specifi c condition to use for quality im-provement and sending patient reminders as needed for preventative and follow-up care.

A recent study published in the Annals of Internal Medicine showed that patients completed recommended screening more often when EHR-linked reminders and fecal occult blood testing kits were sent to them. Primary care facilities in the study created a registry through EHR which tracked when a screening was due and automatically generated mailings. Patients who received automated reminders and mailouts were 26.3 percent more likely to be screened even without direct contact from a nurse or physician. The study also showed drastic increases in screening rates for patient groups who received automated information and staff follow-up.

For help setting up clinical deci-sion support rules and patient alerts for colorectal cancer screening, physicians can contact the Alabama Regional Exten-sion Center at (251) 414-8170.

Screening more patients overall.Screening with a FIT test is a great

way to increase screening in your practice by offering an easier, convenient method of screening for your patients. Patients of-fered a choice between colonoscopy and a stool test are more likely to be screened. Patients often have barriers to colonoscopy like fear, lack of adequate insurance cover-age, inability to provide transportation or time off from work. Those barriers can be overcome with take-home stool tests.

Only high-sensitivity tests, like the FIT/iFOBT and high-sensitivity guaiac are recommended by the USPSTF as ac-ceptable stool tests. Older, low-sensitivity guaiac FOBT should no longer be used.

Take-home FIT/iFOBT screening is also covered by major insurers in Alabama including Blue Cross and Blue Shield of Alabama, Medicaid, and Medicare. Medi-care reimburses $21.86 for a completed test (CPT Code: G0328QW).

To get more information on screen-ing with the FIT contact the Alabama Department of Public Health Cancer Pre-vention Program: Ashley Vice 334-206-3336, [email protected]

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Ashley Vice is the Public Information Specialist for the Alabama Department of Public Health FITWAY Colorectal Cancer Prevention Program.




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Editors Note: This article first appeared in the Birmingham Medical News blog on October 14.

The Centers for Disease Control estimates there are 25.8 million diabetic American as of 2011, with 1.9 million new cases being diagnosed annually. Medicare FFS data from 2008 showed diabetic foot ulcers in these patients. 20 to 25 percent of these patients went on to some form of amputation (toe, foot, or leg). “Up to 83 percent of lower limb amputations in dia-betic patients are preceded by foot ulcers that fail to heal.”

Sadly, the five-year death rate on a diabetic patient following a below-the-knee amputation is 47 percent. (In con-trast, only 28 percent of Stage III breast cancer patients die within five years). Both the in-hospital and in-home healthcare costs skyrocket after a major amputation. Surprisingly, virtually all insurers are will-ing to invest significant monies in order to heal diabetic foot ulcers (DFUs).

As most physicians are aware, chron-ically elevated glucose levels can lead to neuropathy, peripheral vascular disease,

and impaired white blood cell function. It is estimated that 30 to 50 percent of diabetics will develop neuropathy in their feet. Unsurprisingly, 60 percent of DFUs occur in patients with neuropathy only, 15 to 20 percent in diabetics with peripheral vascular disease, and 15 to 20 percent in DFU patients with both neuropathy and peripheral capsular disease.

Rare is the physician who hasn’t see a foot ulcer in a diabetic patient whose poorly fitting shoe and lack of sensation have resulted in callus build up, followed by pressure necrosis, followed by infec-tion. Cellulitis, deep space infections, and even osteomyelitis result all too commonly from this scenario. Frequently, a multi-disciplinary team treating the many com-ponents of these lesions will be required. Such resources often exceed the office capabilities of our hard working primary care physicians.

The initial patient encounter in a dedi-cated wound care center (WCC) involves wound measurement, evaluation of blood sugar control, assessment of arterial blood inflow/wound tissue oxygenation, evalua-tion for infection, as well as determining the correction of the cause of the chronic foot

trauma. Typical initial treatments involve off-loading the ulcer (total contact cast, walking boot, temporary diabetic shoe, and ultimately, a custom designed orthotic shoe insert to prevent further ulcers); regular wound debridement that rids the ulcer of callus, dead tissue, and the bacteria-laden biofilm which so often covers the surface of the ulcers; and a specialized wound dress-ing helps provide enough moisture to pro-mote healing but not so much as to cause wound maceration.

When these primary therapies aren’t enough (i.e. the wound is less than 40 per-cent healed after four weeks of these initial treatments), more advanced therapies are indicated.

Many physicians are familiar with the Wound VAC wound closure system. Some may not be as familiar with topical vascular endothelial and human platelet derived growth factors. Also human skin substitutes from tissue cultured neo-natal foreskin contain a number of growth fac-tors which stimulate ingrowth of the pa-tients own skin calls in order to heal the wound.

Revascularization via stenting or leg artery bypass can improve oxygen deliv-

ery to the wound when peripheral vascu-lar disease is an issue. Hyperbaric oxygen is another advanced therapy to improve DFU oxygen level. 100 percent oxygen under two atmospheres of pressure for 90 minutes at a time is demonstrated to kill bacteria (even osteomyelitis), stimulate the growth of new arterioles into the ulcer, and stimulate the proliferation of wound healing cells.

Thus, according to the American Di-abetic Association, examples of wound pa-tients who should be referred to a Wound Care Center include:

1) A wound that had failed to show significant progress after four weeks of standard care

2) A wound that involves deep tissue structures or is limb-threatening

3) A wound complicated by signifi-cant comorbidities including peripheral vascular disease, vascular disease, persis-tent edema, persistent infection, or prior radiation to the area

How a Wound Care Center Helps Diabetic Foot Ulcer

G. Blaine Bishop, Jr., MD is a general surgeon with Advanced Surgeons, PC and a member of the medical staff at Trinity Medical Center.


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Frederic Jones, MD, medical director for the Emergency Department at DCH Regional Medical Center, has been named a 2013 Medical Director of the Year for Emergency Medi-cine by TeamHealth, one of the nation’s largest pro-viders of outsourced physi-cian staffi ng solutions for hospitals.

Jones was one of 13 professionals rec-ognized for excellence in physician leader-ship by TeamHealth’s operating division presidents. The winners are among more than 8,900 health care professionals affi li-ated with TeamHealth.

Jones has worked with TeamHealth since 2005, and he came to Tuscaloosa when TeamHealth began providing physi-cians for the DCH emergency department in 2011. Before coming to DCH, he was medical director at Decatur General Hospi-tal and was assistant medical director at St. Vincent’s Medical Center in Birmingham.

Samford Nursing Graduates Honored

Samford University’s Ida V. Moffett School of Nursing honored 17 alumni at its annual Courage to Care awards gala. The honorees, including Living Legacy award recipient Frances Mellett Robinson, were cited for their adherence to the maxims of the school’s namesake, the late Ida V. Mof-fett.

Courage to Care honorees are:Rosemary Cox Bamberg; Roxane

Cobb; Audrea A. Dooley; Frances Dobynes Ford; Yvonne Harper; Robbie Smith Hea-ton; Susan Tucker Hornsby; Lisa A. Jones; Lisa Kuntz; Rebecca G. McAnnally; Ann Hughes McEntire; Pennie Nichols; Re-becca Dick Peinhardt; Kelly Snow Preston; Molly Shaw; Joan Wolfe Williamson.

St. Vincent’s Receives MASA Accreditation with Commendation

St. Vincent’s Health System (STVHS) has received accreditation with commen-dation as a provider of continuing medical education (CME) by the Medical Associa-tion of the State of Alabama (MASA). Ac-creditation with commendation, or “Level 3,” means that STVHS has received a six-year accreditation and is among the top 25 percent of providers offering CME in the United States.

STVHS is one of only two organiza-tions in Alabama to achieve this prestigious accreditation.

The Accreditation Council for Con-tinuing Medical Education (ACCME) and state medical associations, such as MASA, rigorously evaluate the overall CME pro-grams of institutions according to standards adopted by all seven sponsoring organiza-tions of the ACCME.

“This accreditation with commenda-tion designation recognizes that our CME program has an infl uence on quality, safety and improvement in professional practice

and affects the quality of care offered to our patients,” said Kathy Loyd, RN, MSN, JD, human resources director of clinical ser-vices at STVHS.

Harding University Dedicates Health Sciences center to Swaids

Birmingham neurosurgeon Swaid N. Swaid, MD and his wife, Christy, were recently honored by Hard-ing University at a build-ing dedication ceremony. The University named the newly constructed health sciences center the Swaid and Christy Swaid Center for Health Sciences.

The 44,000-square-foot building is home to the University’s Carr College of Nursing and the department of communi-cation sciences and disorders.

Born in Galilee in 1952, Swaid came to the United States in 1969 to attend Hard-ing University. After graudating summa cum laude, he earned his medical degree from the UAB School of Medicine. He is a world-renowned neurosurgeon with vast experience in treating complex brain and spine disorders and he has been named one of America’s Top Doctors.

Christy Swaid is a six-time world champion professional watercraft racer. She was recognized as “one of the fi ttest women in America” by Competitor Maga-zine and Muscle and Fitness.

BHS Hospitals Earn “A” in Patient Safety

When the national, nonprofi t Leapfrog Group released its latest Hospital Safety Scores recently, three Baptist Health Sys-tem (BHS) medical centers once again were recognized with an “A” rating.

Princeton, Shelby and Walker Baptist Medical Centers were each awarded an “A” score. Only one non-Baptist hospital in the area received an “A” rating.

In the ratings, the Leapfrog Group assigned a Hospital Safety Score (A, B, C, D or F) to 2,539 hospitals through the U.S. Letter scores – A, B, C, D or F – were determined by the hospitals’ performance on 28 safety measures. Only 813 of those hospitals, including Princeton, Shelby and Walker Baptist, received an “A” score.

“At BHS, we believe hospitals should be transparent with their quality and safety information and that the communities they serve should know the efforts we are mak-ing to protect our patients,” said BHS Presi-dent and CEO Shane Spees.

The latest Leapfrog safety scores were also used to rank U.S. states based on the percentage of hospitals in each state that received an “A” grade. With a third of its reporting hospitals rated “A,” Alabama ranked number 20 on the list.

Frederic Jones, MD

Swaid N. Swaid, MD


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Grand Rounds

UH-Clear Lake Awards SpeesBaptist Health System President and CEO M. Shane Spees received the University of

Houston-Clear Lake Alumni Association Early Achievement Award in October. The award is presented to a UHCL alumnus age 45 or younger with notable accomplishments in her/his business, community service, or involvement in the Alumni Association.

Spees has led Baptist Health System since 2007. The system produces approximately $600 million in revenues and includes four hospitals, 45 physician practices and more than 800 physicians throughout central and north Alabama. In 2011, Spees was appointed by the governor to the State of Alabama Health Insurance Exchange Study Commission and served as president of the Birmingham Regional Council of the Alabama Hospital Association. He also serves as a member of the Board of Directors for the Alabama Hospital Association and the American Heart Association, and as a member of the United Healthcare Hospital Execu-tive Advisory Board.

Prior to joining Baptist, Spees held executive positions with Valley Baptist Hospital in Harlingen, Texas, and Memorial Hermann Healthcare System in Houston. Under his lead-ership, recognitions have included being named by the Birmingham Business Journal as one of the Top Ten Best Places to Work in Birmingham for four years running and one of the 2013 Best Companies to Work for in Alabama by Business Alabama. Hospitals within Baptist Health System have been named “Top Hospitals” by their accrediting body, the Joint Com-mission, as well as being named one of the “Best Hospitals” in their market by U.S. News and World Report.

Spees received his Master of Healthcare Administration from UHCL in 1997.

Spees (middle) accepts the award.

$1 Billion Goal for UAB’s Largest Fundraising Campaign

UAB today has kicked off the public phase of The Campaign for UAB: Give Something, Change Every-thing, the university’s larg-est fundraising campaign to date, with an ambitious $1 billion goal.

The campaign will run through 2018.

“The theme reflects the fact that, when you give to UAB, you help us change our community and our world for the better, whether by fi nding the cure for a disease, enabling a bright young person to go to college or lighting the spark for a new innovation,” UAB President Ray L. Watts said.

Donors can:• Fund scholarships that remove fi nan-

cial barriers to a UAB education• Create endowments that attract fac-

ulty at the top of their fi elds• Expand facilities to accommodate

increasing enrollment and new or growing programs

• Invest in new technologies that sup-port teaching, research and global outreach

• Underwrite efforts to commercialize discoveries

• Expand patient-care facilities to im-prove the health of residents

• Support arts and cultural programs that enrich our lives and strengthen the fab-ric of our community

Participation will also come from within; at least $35 million of the $1 bil-lion goal is expected from UAB faculty and staff.

“I anticipate that the UAB family, who knows more than anyone the great contri-butions this institution makes, will step up in a big way,” Watts said.

To learn more about the Give Some-thing, Change Everything campaign, visit uab.edu/campaign.

Ray L. Watts


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Mathis Announces for CongressChad Mathis, MD, part owner of Alabama Bone and Joint Clinic in Pelham, an-

nounced his campaign for Congress in Alabama’s 6th Congressional District last month. The news comes after Representative Spencer Bachus announced recently that he would not seek reelection next year.

Mathis, an orthopedic surgeon, decided to run because he wants to do something about the Affordable Care Act (ACA), and the out of control spending in Washington. He believes that the ACA is the wrong approach for America’s healthcare system. He thinks reforms that focus on improving the doctor/patient relationship like strengthening health savings accounts are a better way forward. He also thinks SGR needs to be reformed with regard to Medicare and worries how changes in scope of practice rules are affecting the quality of healthcare patients receive.

Mathis, a member of Mountaintop Community Church, lives in Indian Springs with Angie, his wife of 19 years, and their two children.

Grand Rounds

MagMutual Launches Patient Safety Institute

MagMutual Insurance Company has announced the establishment of the Mag-Mutual Patient Safety Institute. Underscor-ing its commitment to improving quality across care delivery settings, MagMutual’s $50 million investment offers physicians a wide range of tools that facilitate the adop-tion of best practices to improve safety and decrease exposure to risk.

“We believe the best defense against medical error is to assist our policyholders in the creation of environments conducive to optimal care and outcomes,” says Joseph Wilson Jr., MD, MagMutual’s chairman of the board. “Patient safety is one of the most pressing healthcare challenges facing our physicians, making it a priority for us to invest in helping them improve their qual-ity of care as well as reduce risks associated with that care delivery.”

The MagMutual Patient Safety Insti-tute will compile a database of information from more than 18,000 physician policy-holders and compare those fi ndings with those from other national databases. This data will enable the Institute to craft con-tinuing medical education from evidence-based research and offer MagMutual policyholders access to successes achieved by their peers in the fi eld of patient safety. The Institute will also assist policyholders

with self-assessments based on root-cause taxonomy.

Future plans for the Institute include a state-of-the-art simulation lab that will model patient safety best practices in a sim-ulated real-life environment.

With more than 25 years of experi-ence in cardiac surgery, patient safety and hospital administration, Mary Gregg, MD, FACS, MHA, MagMutual’s chief medical offi cer and senior vice president, has been named president of the MagMutual Pa-tient Safety Institute. “Dr. Gregg’s passion for advocating the safe practice of medicine makes her the perfect fi t for this role,” Wil-son says.

Tinney Joins Medical WestSean Tinney has joined Medical West

as Senior Vice President and Chief Operat-ing Offi cer.

Sean received his bach-elor’s degree from Auburn University and his master’s in Health Administration from UAB.

Before joining Medi-cal West, Tinney served as President of Rural Hospital Operations for St. Vincent’s Blount, St. Vincent’s St. Clair, and St. Vincent’s East

Sean Tinney


Trinity Names Assistant CFOMichael J. Breault has been named the

Assistant Chief Financial Offi cer at Trinity Medical Center.

Most recently, Breault was Controller for Cedar Park Regional Medical Center in Cedar Park, Texas. Prior to that, he served in various fi nance roles for several health-care facilities including Seton Healthcare Family in Austin, Texas; Saint Joseph Mercy Health System in Ann Arbor, Mich-igan; and Oakwood Healthcare in Dear-born, Michigan.

Breault received a bachelor’s degree in Business Administration from the Univer-

sity of Michigan and a master’s of Business Administration degree from the University of St. Thomas in Minneapolis, Minnesota.

UAB Becomes Largest Cancer Study Enrollment Site in U.S.

With 1,209 participants, UAB has become the largest single-site enrollment location in the United States for the Cancer Prevention Study-3 (CPS-3). This surpasses the previous record set in Albany, New York where 1,200 people enrolled at

one site.“We’re thrilled to break this national

record,” said Edward Partridge, MD direc-tor of the Comprehensive Cancer Center and past-president of the American Cancer Society.

“I would venture to say that this cur-rent effort at UAB is one of the most sig-nifi cant enrollments in the history of our enrollment period, and it may very well be what helps push us over our 300,000 goal nationwide,” said Alpa Patel, PhD, princi-pal investigator for the CPS-3 study.

Ramsey Begins Term as President of Pediatrics Society

Michael J. Ramsey, MD, FAAP began his term on October 1st as president of the Alabama Chapter of the American Academy of Pediatrics (AL-AAP), a statewide society of pedia-tricians.

Ramsey attained his medical degree at UAB in 1994 and completed his pediatric internship and residency at Children’s of Alabama. He joined Dothan Pediatric Clinic in 1997, where he has served as medical director and fi nancial director.

Ramsey has held numerous roles within the leadership of the AL-AAP. His expertise on payor issues prompted his serving as an advisor to Blue Cross Blue Shield of Alabama’s Medical Home Demonstration Pilot, during which he led his practice’s transformation to become the fi rst Alabama practice recognized by the National Committee on Quality Assurance as a Patient-Centered Medi-cal Home. He was also a member of the American Academy of Pediatrics’ (AAP) Accountable Care Organizations work-group, and more recently, he has served on Governor Robert Bentley’s Medic-aid Advisory Commission and Medicaid Pharmacy Advisory Commission.

Trinity CEO Keynote SpeakerKeith Granger, President & CEO

of Trinity Medical Center, was a key-note speaker at the Studer Group’s 11th annual What’s Right in Health Care conference held in Atlanta. Granger’s topic was Elevating Results through Systems, Processes and Accountability.

More than 1,200 health professionals attended the confer-ence designed to share best practices and tools to help an organization achieve and sustain clinical, service and operational excellence.

Granger was asked to share the story of how Trinity Medical Center, in a short period of time, has achieved top-tier rank-ings for quality initiatives and patient ex-perience. He was the only hospital CEO to serve as a keynote speaker.

EDITOR & PUBLISHER

Steve Spencer

VICE PRESDIENT OF OPERATIONS

Jason Irvin

CREATIVE DIRECTOR

Susan Graham

STAFF PHOTOGRAPHER

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CONTRIBUTING WRITERS

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Cindy Sanders

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Grand Rounds

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Mutual Interests. Mutually Insured.

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“ Like me, you’ve probably noticed some professional liability insurance providers recently offering physicians what seem to be lower rates. But when I took a closer look at what they had to offer, I realized they simply couldn’t match SVMIC in terms of value and service. And SVMIC gives me the peace of mind that comes when you’re covered by a company with more than 35 years of service and the financial stability of an “A” (Excellent) rating. At SVMIC, I know it’s not just one person I rely on… there are more than 165 professionals who work for me. That’s because SVMIC is owned by you, me, and over 14,000 other physicians across the Southeast. So we know our best interests will always come first.”

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Grand Rounds

Colin Luke Joins WallerVeteran healthcare attorney Colin H.

Luke has joined Waller in the Birmingham offi ce.

“Colin is respected throughout the Southeast as a leader in healthcare law,” said Waller chairman John Tishler. “Our goal is to build world-class healthcare practices in our Birming-ham and Austin offi ces that complement the skills we’ve developed over 40 years in Nashville.”

“I have always held Waller and its at-torneys in high regard for the work they do in the healthcare industry,” said Luke.

The former chair of the Alabama Bar’s Health Law Section, Luke’s healthcare ca-reer spans more than two decades. He ad-vises hospitals, physicians and outpatient service providers on regulatory compliance matters involving the federal Anti-Kickback Statute and Stark law, HIPAA, state health-care regulations and the development of effective corporate compliance programs. Luke also counsels healthcare clients on op-erations issues, such as provider and payor certifi cations, facility licensure and certifi -cates of need and in transactional matters.

Luke earned his J.D. from the Univer-sity of Chicago Law School and his B.A., summa cum laude, from Vanderbilt Uni-versity. He has been named “Best of the Bar” by the Birmingham Business Journal, and he is listed in Best Lawyers and Ala-bama Super Lawyers. Luke is a member of the American Health Lawyers Associa-tion and the Health Law and Business Law Sections of the Alabama State Bar and the American Bar Association.

Cerfolio Closes Association Presidency with Annual Address

UAB Chief of Thoracic Surgery Rob-ert Cerfolio, MD, gave the 60th annual presidential address at this year’s Southern Thoracic Surgical Association meet-ing which marked his last duties as 2012-2013 presi-dent of the organization.

Cerfolio, a world-re-nowned thoracic surgeon who has performed more than 15,000 operations, is a leader in devel-oping new ways to reduce pain, reduce air leaks, and make operations more effi cient for patients, with less morbidity.

Cerfolio has hosted more than 200 visiting surgeons from around the world to observe his novel surgical techniques. He has written more than 154 original peer-reviewed articles and more than 50 book chapters, and he is scheduled to release his fi rst nonmedical book, The Athleticism of Surgery, in 2014. In addition, he will com-plete his MBA degree in December.

At age 51, Cerfolio is one of the young-est presidents of any major cardiothoracic society.

Colin H. Luke

Robert Cerfolio, MD

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