BY TED GRIGGS Each year, for the past five years, Louisiana’s hospitals have gone to the Jindal admin- istration and the state Legislature and asked for Medicaid funding help. And each year, the cash-strapped state government’s answer has been more cuts, roughly $260 million, or 26 percent, since 2009. But this year, the Legislature overwhelmingly approved two measures that will let voters decide whether hospitals can put up the money to draw down federal funds for Medicaid. Hospitals and their supporters say the bills will help stabilize funding through constitutional protections. Opponents, who included the non-partisan Public Affairs Research Council and the liberal Louisiana Budget Project and Gov. Bobby Jindal’s administration, say constitutional protection means the state will have even less flexibility in budgeting matters. Opponents argued that if voters approve the amendments, higher education will suffer because it BY BARBARA MCCONNELL What do Angelina Jolie and 2013 Miss America Pageant con- testant, Allyn Rose have in common? They are young, beautiful, and both have elected to have bilateral mastectomies without an actual diagnosis of breast cancer due to a combination of family history and possession of the BRCA-1 gene mutation. And that has put the younger breast cancer patient in the cen- ter of a national news frenzy and increased public curiosity. People don’t always think about a young woman developing the disease, especially since both incidence and mortality rates increase expo- nentially with age, with the median age being 61 years at time of diagnosis. The younger patient has unique priorities from an older woman including: bearing and nursing children, body image, jug- SOUTH LOUISIANA EDITION YOUR PRIMARY SOURCE FOR PROFESSIONAL HEALTHCARE NEWS On Rounds Read Louisiana Medical News online at www.louisianamedicalnews.com JULY 2013 / $5 Louisiana Hospitals Seek Funding Protection Dr. Christy Valentine Rising Phoenix From the devastation of a barrage of hurricanes arose a phoenix, bringing renewed hope to New Orleans residents facing the upcoming storm season. Lessons learned from Hurricanes Katrina, Gustav and Isaac spurred local physician Christy Valentine to create PhoenixLink Solutions, an online portal for patients and physicians to stay connected during disasters ... page 3 Conference Offers PAD, CLI Solutions Fourteen years ago, when Dr. Craig M. Walker organized the first New Cardiovascular Horizons conference, he had a number of goals ... page 6 Physician Spotlight PRINTED ON RECYCLED PAPER PRSRT STD U.S. POSTAGE PAID FRANKLIN, TN PERMIT NO.357 (CONTINUED ON PAGE 11) (CONTINUED ON PAGE 5) SurviveDAT! A program for younger breast cancer survivors in Louisiana Britney Temple, fitness trainer and SurviveDAT! audience
Transcript
By TED GRIGGS
Each year, for the past fi ve years, Louisiana’s hospitals have gone to the Jindal admin-istration and the state Legislature and asked for Medicaid funding help. And each year, the cash-strapped state government’s answer has been more cuts, roughly $260 million, or 26 percent, since 2009.
But this year, the Legislature overwhelmingly approved two measures that will let voters decide whether hospitals can put up the money to draw down federal funds for Medicaid. Hospitals and their supporters say the bills will help stabilize funding through constitutional protections.
Opponents, who included the non-partisan Public Affairs Research Council and the liberal Louisiana Budget Project and Gov. Bobby Jindal’s administration, say constitutional protection means the state will have even less fl exibility in budgeting matters. Opponents argued that if voters approve the amendments, higher education will suffer because it
By BARBARA mCCoNNELL
What do Angelina Jolie and 2013 Miss America Pageant con-testant, Allyn Rose have in common? They are young, beautiful, and both have elected to have bilateral mastectomies without an actual diagnosis of breast cancer due to a combination of family history and possession of the BRCA-1 gene mutation.
And that has put the younger breast cancer patient in the cen-ter of a national news frenzy and increased public curiosity. People don’t always think about a young woman developing the disease, especially since both incidence and mortality rates increase expo-nentially with age, with the median age being 61 years at time of diagnosis.
The younger patient has unique priorities from an older woman including: bearing and nursing children, body image, jug-
SOUTH LOUISIANA EDITION
YOUR PRIMARY SOURCE FOR PROFESSIONAL HEALTHCARE NEWS
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On Rounds
Read Louisiana Medical News online at www.louisianamedicalnews.com
From the devastation of a barrage of hurricanes arose a phoenix, bringing renewed hope to New Orleans residents facing the upcoming storm season. Lessons learned from Hurricanes Katrina, Gustav and Isaac spurred local physician Christy Valentine to create PhoenixLink Solutions, an online portal for patients and physicians to stay connected during disasters ... page 3
Conference Offers PAD, CLI SolutionsFourteen years ago, when Dr. Craig M. Walker organized the fi rst New Cardiovascular Horizons conference, he had a number of goals ... page 6
Physician Spotlight
PRINTED ON RECYCLED PAPER
PRSRT STDU.S.POSTAGE
PAIDFRANKLIN, TN
PERMIT NO.357
(CONTINUED ON PAGE 11)
(CONTINUED ON PAGE 5)
SurviveDAT! A program for younger breast cancer survivors in Louisiana
Britney Temple, fi tness trainer and SurviveDAT! audience
2 • JULY 2013 Louisiana Medical News
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From the devastation of a barrage of hurricanes arose a phoenix, bringing renewed hope to New Orleans residents facing the upcoming storm season. Les-sons learned from Hurricanes Katrina, Gustav and Isaac spurred local physician Christy Valentine to create PhoenixLink Solutions, an online portal for patients and physicians to stay connected during disasters.
Shortly after Hurricane Katrina hit in 2005, Valentine incorporated her prac-tice, Valentine Medical Center. But, she was unable to open an offi ce right away. “It took some time to get it up and run-ning with the conditions in our area,” she recalled.
A couple of months after the storm, she gave birth to a daughter, Phoenix, who became her glimmer of hope dur-ing the chaotic recovery period. “She just helped in the whole healing process,” Val-entine said. “She was a great gift.”
In 2007, Valentine opened her fi rst location in Belle Chase with a complete electronic medical records system. A year later, Hurricane Gustav delivered another destructive blow to Belle Chase. Valen-tine’s offi ce building sustained a major loss, sparking her to develop a hurricane
plan. Before Hurricane Isaac hit in Au-gust, 2012, her staff started preparing – packing up and labeling computers, offi ce machines and lab equipment and plac-ing them in a central room up off of the ground. Unfortunately, when the storm made landfall, strong winds blew off the roof. Torrential rains ravaged inside, com-pletely destroying the contents.
Fortunately, Valentine found an al-ternate location nearby, allowing her to maintain her patient base and continue serving the area. Last August, Valentine opened a second location in New Orleans. “Having an awesome team that I work with, everybody just really pitched in and we pulled it all back together,” she said.
During these emergencies, Valen-tine’s offi ce had a diffi cult time commu-nicating with displaced patients. This
motivated Valentine to take action. “Hav-ing an electronic offi ce, I keep my pa-tients’ information safe and secure,” she said. “We originally had a server-based electronic records system, and I had to evacuate the server twice. So, what I rec-ognized was that the patients’ information was all safe, but we had no way to connect with the patients when they evacuated.”
So, on June 1, the fi rst day of hurri-cane season, Valentine launched Phoenix-Link Solutions, a brand new online health information system. Named after Valen-tine’s daughter, PhoenixLink allows pa-tients to access all of their medical records, including immunizations, tests, prescrip-tions and physician information, from any Internet connection. The HIPAA-compliant system also creates a forum for physicians to post their updated contact information during emergency situations. “I’m so excited about it, because it is really something that I think will empower the people in our area,” she said. “Every part of our nation has something that happens, whether it is a tornado, fi re or hurricane. So, knowing that you are able to have access to your information and maintain some sort of control in a truly chaotic time will bring a level of peace. And then, if you have to evacuate, you’ll have access to your medical records and can give the information to the provider in your new location.”
Being reared in a storm-prone area obviously impacted the New Orleans-bred Valentine. The fi rst in her family to be-come a doctor, Valentine was inspired by her parents’ care of her autistic brother, Darrell. “Growing up in a home with him, I really appreciated the things that my parents did to keep order in the house,”
she said. “He still had to listen; he still had to do his chores. It just fascinated me.”
After graduating from Ursuline Acad-emy, Valentine attended college at Xavier University of Louisiana. She remained in New Orleans for her medical studies, beginning at LSU for medical school fol-lowed by Tulane University for residency. Her specialties are in internal medicine and pediatrics. “I like the fact that I can have a patient from birth through child-hood and adolescence, and totally see the transition of that individual,” she ex-plained. “I love being able to see entire families, and I have a lot of families where I see the mom, dad, children, aunt, uncle and the grandparents. I just love the fact that you have one place where the whole family can get service and really help make healthy choices in their lives.”
When not juggling her two offi ces, Valentine enjoys spending time with seven-year-old Phoenix and fi ancé, Saton Wilson. The couple is planning a Febru-ary wedding. In her off time, Valentine indulges in her favorite activity – fi shing. “I love to fi sh,” she said. “I love going out and catching redfi sh. I would do that all of time, especially growing up with my fam-ily. I love the whole, you know, waking up before the break of dawn to get out there. It makes you appreciate how beautiful our city is.”
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4 • JULY 2013 Louisiana Medical News
Read Louisiana Medical News Online:
LOUISIANAMEDICALNEWS.COM
By LyNNE JETER
Not long ago, hospice referrals for end-of-life care were typically made only a few weeks before the patient’s death. Now, good hospice referrals are made six months to a year in advance to allow time for patients and their families to transi-tion to the fi nal phase of life. Palliative care comes in sooner for patients suffering from serious illness, with specialists having the advantage of focusing on the patient, not the disease.
“Just about any patient with a seri-ous, life-limiting illness can benefi t from palliative care,” said Robert Lehmberg, MD, FACS, assistant professor of hospice and palliative medicine at the University of Arkan-sas for Medical Sciences (UAMS). “It improves the patient’s quality – and sometimes length – of life.”
Hospice is defi-nitely underutilized in the United States, said Derrick O’Connell, RN, MBA, chief quality of-fi cer for Esse Health, a St. Louis-based practice group with nearly 100 physicians and special-ists.
“There are barriers to hospice be-cause of the inability to confront mortal-ity as a psycho-social issue,” he said, “and barriers within the medical community to refer patients to hospice because phy-sicians and their teams may feel they’ve failed in the medical management of a patient.”
Miguel A. Paniagua, MD, FACP, concurs. Because so many great techno-logical advances in medi-cine have been made, he said a patient’s treating physician may view their death as failure.
O’Connell, a former hospice manager, said the emerging Patient Centered Medical Home
(PCMH) model has a mechanism in place to assist primary care providers (PCPs) with the transition of patients to hospice and palliative care.
“Primary care providers and their teams can facilitate the documentation of advanced directives for each patient,” he explained. “Each patient is counseled on choices in the event of a life-ending medical condition or event. It’s impor-tant when provider teams recognize that the patient is nearing the end of their life cycle and can begin the patient-centered collaboration for appropriate end-of-life care with a statement like: ‘there’s noth-ing more medicine can do for you. We’d like to refer you to hospice care because they’re experts at keeping you comfortable at end-of-life care and can enable you to die with dignity.’”
Paniagua, associate professor and director of the Department of Internal Medicine Residency Program at Saint Louis University (SLU) School of Medi-cine in Missouri, said a smooth transition is easier when the primary care provider (PCP) team clearly communicates the end-of-life plan with patients.
“We similarly teach many high-tech and high-reimbursing procedures in med-icine, but in my view, the most delicate and nuanced procedure we can teach and learn is the bedside conversation about goals of care and treatment planning,” he said. “Like any procedure in medicine, there are effective and ineffective ways of doing it. Unfortunately, not enough emphasis is placed on teaching and learn-ing this procedure, which leads to much variability in the way it’s delivered, as well as providers’ discomfort and unease with doing it.”
Paniagua also noted that mainstream media’s sensationalized coverage of eutha-nasia and physician-assisted suicide issues
has hindered progress in the advancement of the specialty and public perception.
“In reality, (euthanasia and physi-cian-assisted suicide) is such a miniscule practice, and in only three states,” he em-phasized. “But my view is that too often patients feel they have no other way out of their suffering. More often than not, we providers don’t do an adequate job pro-viding palliative care to most of the suf-fering.”
Lehmberg, who switched specialties to hospice and palliative medicine after a neck injury prevented him from con-tinuing his nearly 30-year plastic surgery practice, said the most common misper-ceptions about the specialty are the differ-ences between palliative care and hospice, and getting the team involved early
enough to “truly assist the patients, their families and the treating physicians.”
“Most people, physicians included, think of us only in terms of hospice and end of life,” said Lehmberg. “However, palliative care improves the quality of life of patients and their families with life-threatening conditions through the pre-vention and relief of suffering, and also the treatment of pain and other problems – physical, psychosocial and spiritual.”
Palliative care may be extremely helpful to physicians and patients in con-junction with therapeutic treatments, such as chemotherapy and radiation, said Lehmberg, noting that requests for hos-pice and palliative care consultations for the UAMS Department of Hematology and Oncology has increased signifi cantly – from 400 in 2007 to more than 2,200 estimated this year.
“As evidenced by our program growth, an awareness of the role of pal-liative care is increasing,” he said. “Still, I’d like to continue to contribute to a better understanding of our subspecialty and how we can help. Once a patient has been diagnosed with a life-threatening ill-ness, it’s really never too early to involve a multi-disciplinary palliative care team.”
Palliative care transitions to hospice care when the illness progresses to the point that therapeutic treatments are no longer applicable, explained Lehmberg.
“In palliative care, an experienced team is best at fi tting in with the primary medical approach, not rivaling it,” said Lehmberg. “As consultants, the palliative care team … complements the treatment and care provided by the primary physi-cians.”
Tapping into Hospice and Palliative MedicinePCPs benefi t from services of underutilized specialty
Palliative v. Hospice CarePalliative care:• provides comfort and relief from pain and other distressing symptoms;• is meant to neither hasten nor postpone death;•integrates the psychological and spiritual aspects of patient care;• affi rms life while regarding dying as a normal process;• assists patients in living as actively as possible until death;• helps the family cope during the patient’s illness;• uses a specialized team approach including physician, nursing, chaplaincy and
social work; and • is provided in conjunction with therapeutic treatments such as chemotherapy
and radiation.
Hospice:• focuses on caring, comfort and dignity at end of life;• provides relief from pain and other distressing symptoms;• is meant to neither hasten nor postpone death;• integrates the psychological and spiritual aspects of patient care;• helps the family cope with the patient’s end of life and their own bereavement• uses a specialized team approach including physician, nursing, chaplaincy and
social work.
Outside the Box When it was established 25 years ago, the American Academy of Hospice
and Palliative Medicine (AAHPM) had 250 charter members. Now, the professional organization has 5,000 members.
Yet even though four of fi ve larger U.S. hospitals now have palliative care programs, and consultations for the specialty have spiked, new growth isn’t keeping pace with the coming demand. New hurdles hinder progress – a rapidly aging baby boomer generation coupled with the existing senior population, continued segmentation of care, and limited funding for specialty training programs.
AAHPM leaders recently proposed a solution to the specialty shortage problem: Timothy E. Quill, MD, FACP, and Amy P. Abernethy, MD, FACP, president and president-elect of the AAHPM, respectively, suggested reserving palliative medicine physicians for more challenging cases, while also increasing the palliative skills of primary care providers (PCPs) and specialists who see patients daily.
Using their model, PCPs would receive appropriate education to address management of pain and other symptoms and other basic palliative care needs. Palliative medicine physicians would be called in to manage diffi cult-to-treat pain, complicated depression, anxiety and grief and other more complex needs.
SOURCE: AAHPM. Dr. Robert Lehmberg
Derrick O’Connell
Dr. Miguel A. Paniagua
Louisiana Medical News JULY 2013 • 5
By CINDy SANDERS
In October 2004, member schools of the American Association of Colleges of Nursing (AACN) voted to endorse the or-ganization’s position statement calling for the transition of the level of preparation needed for advance practice nursing from the master’s degree to the doctorate level by 2015 through the addition of the DNP — Doctor of Nursing Practice.
“Will we have all of our APRN pro-grams transition to DNP by the 2015 dead-line? Probably not … but we will have a critical mass that are,” said Jane Kirsch-ling, PhD, RN, FAAN, dean of the School of Nursing for the University of Maryland who serves as 2012-2014 board president for AACN. “I feel like we’ve reached the tip-ping point,” she added.
Indeed, the growth of DNP programs na-tionwide has been re-markable. By spring 2013, programs existed in 40 states and the Dis-trict of Columbia. “We are extremely pleased that we currently have 217 Doctor of Nursing Practice programs up and running in the United States. If you go back to 2004, we only had seven programs,” Kirschling noted. “In addition, we have 97 new programs under development.” She
added enrollment has jumped from 170 DNP students in 2004 to 11,575 last year.
Rooted in the desire to deliver the highest quality of care in the practice set-ting, Kirschling said the addition of the DNP was consistent with what is happen-ing in other healthcare disciplines including pharmacy, audiology and physical therapy. Grounded in evidence-based practice, she said the hope is that these doctoral-pre-pared nurses will take existing discoveries and more rapidly drive that knowledge to the bedside. Additionally, she said the de-gree is anticipated to prepare these nurses to provide leadership in an increasingly multifaceted healthcare environment.
“What I project we’ll see with time as we graduate more from the DNP pro-gram is they will actually partner with PhD nurses to create some really interesting synergy to solve really diffi cult clinical is-sues and to solve them in a quicker timeline that directly impacts patient care,” stated Kirschling.
The reason for the DNP movement is multifactorial. In addition to aligning with other health profession disciplines that offer a clinical doctorate, Kirschling said the degree also recognizes the complexity of the nation’s evolving healthcare delivery system.
The number of hours and amount of academic work required to become an advanced practice registered nurse pro-
vided another impetus behind the DNP movement, Kirschling noted. Nursing had already moved to increase and expand practical knowledge in APRN master’s programming. Where many master’s de-grees in other fi elds require 30-36 credit hours, the four recognized APRN master’s programs — Nurse Practitioner, Clini-cal Nurse Specialist, Nurse Anesthetist, and Nurse Midwife — already required a minimum of 40-55 credit hours. With the
newer doctoral degree, students need, on average, 80 credit hours in the baccalaure-ate to DNP program and an additional 39 credits in the master’s to DNP path.
“Healthcare in the county has changed dramatically,” Kirschling concluded. “The depths of knowledge and the skill set any provider needs have just increased over time. We, as a discipline, felt it was critical that our graduates be prepared to meet the demands of the future.”
The Move to DNPNurses embrace advanced degree program to address the increasingly complex healthcare practice environment
PhD vs. DNP
Jane Kirschling, PhD, RN, FAAN, president of the American Association of Colleges of Nursing, said the addition of the Doctor of Nursing Practice (DNP) degree was the clinical complement to the long-standing Doctor of Philosophy (PhD) or Doctor of Nursing Science (DNSc) degrees, which prepare students for scientifi c research.
The PhD, she noted, “is really intended to prepare the next generation of scientists for new discovery so they are generating new knowledge for the discipline.” In addition to an interest in a nursing faculty career with a research component, Kirschling said it was fairly common for nurse executives to obtain a PhD as they sought to increase leadership roles. With the addition of the DNP, nurses now have two terminal degree tracks from which to choose — re-search and practice.
The newer DNP quickly overtook PhD and DNSc programs in terms of the number being offered across the country. Currently, there are 131 research-focused programs in the U.S. The number of research doctoral programs grew from 103 to 131 be-tween 2006 and 2012. During that same time period, DNP programs grew from 20 to 217.
As the fi eld looks to increase the number of doctoral-prepared nurses, the good news is enrollment is up in both research-based and practice-based doctorate programs, although the newer DNP degree has seen much more rapid growth as more academic institutions have begun offering the option. Between 2004 and 2012, the number of students en-rolled in DNP programs increased from 170 to 11,575. The number of students seeking a PhD in nursing grew from 3,439 to 5,110 dur-ing the same timeframe.
Dr. Jane Kirschling
focused programs in the U.S. The number of research
will be the only other major, unprotected chunk of the budget left.
John Matessino, president and chief executive offi cer of the Louisiana Hospital Association, said he knew the bills had a good chance of passing but the amount of backing was something of a stunner.
“Are we surprised at the overwhelm-ing majority we got? I’d be lying if I said I wasn’t,” Matessino said.
However, Matessino said hospitals and nursing homes did a good job of lob-bying their respective legislators.
And the providers made legislators’ decision easier by offering a solution – put-ting up their own money to draw down the federal match for Medicaid – rather than asking for more funding, he said. Polls show-ing members of the public understood the impact that Medicare and Medicaid fund-ing cuts have on hospitals and the state’s economy also helped infl uence legislators.
“When you cut Medicaid and Medi-care, insured people and employers make up the difference. It’s almost like a hidden tax,” Matessino said.
One bill allows the hospitals to pool their money for their share of the Medic-aid match. The bill limits cuts to Medicaid payments and requires a vote of the legis-lature to do so.
The second bill sets a fl oor on Med-icaid patient payments to nursing homes, pharmacies and intermediate care facilities, or institutions for the developmentally dis-abled. Cuts to those payments would also require a vote by legislators.
Matessino said the fi scal picture for healthcare providers was not good head-ing into the session.
The Medicaid programs that hospi-tals and the state have relied on in the past, such as the disproportionate share-hospital and upper payment limit funds, have ques-tionable futures, he said.
The hospitals had to fi gure out a way to get a more stable funding stream and re-imbursement rate.
“We’re not trying to leapfrog over the Medicare rates or anything like that,” Ma-tessino said. “We’re just trying to get a little bit closer to where those are … so it puts hospitals in a better position to be able to provide care to everyone.”
Right now, the larger non-state, non-rural hospitals, like those in Baton Rouge and Lafayette, get paid about 60 cents on the dollar for the cost of treating Medicaid patients, Matessino said.
“If and when Medicaid expansion comes in, that could paint a pretty red cloud over a hospital, and physicians for that matter,” Matessino said.
Until now, the state Department of Health and Hospitals, with the governor’s approval, has set Medicaid payments. But the amendments, if passed, mean DHH couldn’t cut rates without legislators’ ap-proval.
Matessino said Gov. Jindal’s position against new fees, taxes or assessments is well-known.
The proposed constitutional amend-ments offered a veto-proof solution.
The hospitals and nursing homes approached members of the Legislature about the proposals, Matessino said. House Speaker Chuck Kleckley, R-Lake Charles, agreed to author both bills.
The next step was getting the Legisla-ture to pass the measures. The next step, which will take place in 2014, is to get vot-ers to pass the amendments, Mattesino said. The third step will be for the Legisla-ture to set up the specifi cs; the assessments will probably be based on hospital revenue.
Hospitals’ base payment rates now are the same as they had in 1993, Matessino said.
“We don’t want the state to go below that,” Matessino said.
The hospitals would be pretty happy to see Medicaid payments at 80 percent of the actual costs for treatment, he said. Medicaid payments at that level would en-courage members of the Hospital Associa-tion to do more in the Medicaid arena.
Matessino said hospitals also wanted to make sure that the hospital stabilization fund didn’t end up like the state gasoline tax.
The tax was intended to pay for high-way repairs, but the Legislature ended up backing that amount of money out of the state Department of Transportation and Development’s budget, and the repairs didn’t get done.
Louisiana Hospitals Seek Funding Protection, continued from page 1
6 • JULY 2013 Louisiana Medical News
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By TED GRIGGS
Fourteen years ago, when Dr. Craig M. Walker organized the first New Car-diovascular Horizons conference, he had a number of goals, in-cluding:
• To draw attention to peripheral arterial disease (PAD), a preva-lent and deadly malady, and help providers do a better job of diagnos-ing PAD and making the connection to other health issues; and
• To show providers there were other, better options for patients with critical limb ischemia than amputation.
The first conference drew around 200 people, most of them podiatrists who didn’t really know what to do for their patients with peripheral artery disease, Walker said. The conference, most re-cently held June 5-7 in New Orleans, is now the largest peripheral intervention conference in the United States and at-tracts more than 2,000 physicians, sci-entists, allied professionals and industry professionals.
At this year’s conference, Drs. Nick Cavros, Christopher Daniels, Raghotham Patlola, and Kalyan Veerina of Cardio-vascular Institute of the South performed
six, intricate interventional cases at Re-gional Medical Center of Acadiana. The procedures were among the more than 30 broadcast live at the conference.
Walker said the goal of this year’s conference wasn’t to pit one therapy against another but to find the best ther-apy and make sure that all of the patients get treated appropriately.
“What we don’t want to see is ampu-tation first,” Walker said. “We think that’s bad therapy.”
This approach, championed by Walker and his colleagues at Cardiovas-cular Institute of the South, is gaining in popularity nationally and globally, he said. New Cardiovascular Horizons also holds conferences each year in China, Latin America and 10 or so regional meetings throughout the United States, with lots of requests for additional locations.
Still, it hasn’t been that long since the first option for a CLI patient was ampu-tation, Walker said. Historically, and at the time of the first conference, anyone who attempted to revascularize the leg of a CLI patient was looked on as “aggres-sive, i.e. bad,” Walker said. Cutting off the patient’s leg was considered conservative, or good.
The problem with the conservative approach, Walker said, is that amputation involves a number of drawbacks, such as phantom limb pain, which never goes away.
The patients with PAD or CLI are usually older, Walker said. Almost 30 percent of people over age 70, and almost 30 percent of the people over age 50 who have either smoked or have diabetes, have peripheral arterial disease.
What people don’t realize is how dan-gerous amputation is, Walker said.
“If you get your leg cut off below the knee at the best centers in America, at centers like the Mayo Clinic and the Cleveland Clinic, you have a five to eight percent 30-day mortality,” Walker said.
Below the knee, the 30-day mortality rates range from eight to twelve percent.
“Fully one-third of people who get a major amputation from ischemic limb dis-ease go straight to a nursing home, never to leave again,” Walker said.
The annual cost for those nursing home patients is more than $100,000, he said. The patients that do return home also face their own challenges and ex-
penses, including medicines, prosthetics and bathroom modifications.
In the mid-2000s, Dr. David Allie and Walker published an article in Euro-Intervention that estimated society could save $4 billion a year by reducing the number of amputations by 20 percent.
Those savings would be much greater today, Walker said, thanks to rising num-bers of people stricken by PAD and CLI and healthcare costs.
And that’s with only a 20 percent re-duction in amputations. With limb salvage rates of better than 95 percent, which Walker said are achievable, “we’re talk-ing about a whole lot more money than $4 billion.”
So it’s important in every way, shape or form to save limbs, he said.
Walker points to a former patient, 28-year-old Angela Mullins of Ocean Springs, Miss., as proof of that. Last fall, Mullins, an RN, learned that both her legs were again blocked. Mullins had already had seven bypasses on her legs.
She was told, by more than one doc-tor, that her only option was to amputate both legs.
Mullins said she visited many doctors before eventually being referred to Car-diovascular Institute of the South. Walker performed three laser treatments on Mul-lins’ legs. Afterward, Mullins began walk-ing two miles a day and says she no longer experiences pain.
Walker said amputation can be a very, very important and lifesaving proce-dure for certain people.
“But in my opinion, it should never be called first step. It should be called last step. It should be called the step you take only when there is no other option,” Walker said.
Conference Offers PAD, CLI Solutions
Angela Mullins
Dr. Craig M. Walker
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Louisiana Medical News JULY 2013 • 7
Become a Part of the Journal of the LSMS
by LSMS Communications, Publications, and Social Media Manager Joshua Duplechain
LSMS Communi-cations, Publica-tions and Social Media Manager Joshua Duplechain
LSMS Making Louisiana a Better Place to Practice Medicine Since 1878
For more than 160 years, the Journal of the Louisiana State Medical Society has provided valuable scientific articles and information to physicians. Estab-lished in 1844, the Journal is one of the oldest periodicals of its kind in the country and fea-tures clinical trials and cutting edge research being conducted by some of the top physicians and researchers in the state.
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By LyNNE JETER
No RTP (return to play) on the same day, regardless of circumstances. An ear-lier return to light exercise, recommended. And the differential between pediatric and adult patients, clarified.
Those are among the highlights of the 2012 Concussion Consensus Statement derived from the 4th International Consen-sus Conference on Concussion in Sport, held last November in Zurich.
Every four years, the International Ice Hockey Federation, International Olympic Committee, International Rugby Board, International Federation for Equestrian Sports, and FIFA (Interna-tional Federation of Association Football) host the conference, which results in an updated concussion consensus statement.
“The new statement shows that we basically still don’t understand concus-sions, and there are many opinions on how to diagnose and treat them,” said William Feldner, DO, a sports medicine specialist at South County Family & Sports Medicine and St. Anthony’s Medical Cen-ter in St. Louis, Mo., and team physician for Lindenwood University and USA Vol-leyball. He’s also a board member of the Joint Commission for Sports Medicine and Science, an editorial board member of the Clinical Journal of Sports Medicine, and past president of the American Osteopathic Academy of Sports Medicine. “And, while it’s not in the (consensus) statement, there’s some interesting genetic research going on. We may eventually be able to prede-termine if someone is more susceptible to concussion based on their genetic makeup.” Marc Hilgers, MD, PhD, director for sports medicine fellowship, sports medicine research, and a sports medicine physician at Level One Orthopedics with Or-lando Health in Cen-tral Florida, said he didn’t expect major changes in the 2012 consensus statement.
“I’ve been keeping my finger on the pulse of knowledge and I knew what was coming down the pike,” said Hilgers, also the team physician for Orlando City Soc-cer and the Minor League Umpire As-sociation, medical advisor for the Florida Orthopaedic Institute, and assistant pro-
fessor of family medicine at the University of South Florida. “That’s why I wasn’t sur-prised, especially with the broad spectrum of specialists from all over the world who met to write the updated statement, that it was kept general and not too progressive.”
Bill Hefley, MD, an orthopedic sur-geon and partner at OrthoSurgeons based in Little Rock, Ark., said the latest consen-sus statement showed “great development in the CRT (concussion recognition tool) for lay use.” The 2008 confer-ence resulted in the de-velopment of the Sport Concussion Assessment Tool (SCAT2), a standardized method of evaluating ath-letes ages 10 years and older for concus-sions.
“This tool takes out the ‘guesswork’ and interpretation for laymen,” said He-fley. “The SCAT3 has a background section, which is a great addition to the SCAT2. Also, the SCAT3 is much more streamlined with clinician instructions on its own page, rather than after each sec-tion. The Child-SCAT3 is a great new tool for younger athletes who may sustain concussions.”
Todd Ross, MS, ATC, an athletic trainer for Pulaski Academy with Or-thoSurgeons, highlighted the 2012 con-sensus statement’s importance “because it continues the worldwide awareness of concussions (and) shows the dedication the medical society has for learning more about concussions, how to recognize con-cussions, how to properly manage athletes with concussions, and how to properly and safely return an athlete to play after a con-cussion has subsided.”
The only major blip noted repeatedly: the altered position on CTE (chronic trau-matic encephalopathy). Hilgers called it “an interesting update … on an issue that had ‘percolated up’ since 2008.”
• The 2008 section on chronic trau-matic brain injury (TBI) notes: “Epi-demiological studies have suggested an association between repeated sports concussions during a career and late life cognitive impairment. Similarly, case re-ports have noted anecdotal cases where neuropathological evidence of CTE was observed in retired football players. Panel discussion was held, and no consensus was reached on the significance of such obser-vations at this stage. Clinicians need to be mindful of the potential for long-term
Sports Medicine Community Weighs InZurich 2012 Concussion Consensus Statement clarifies issues, muddles others, exemplifies mystery of TBI
Dr. William Feldner
Dr. Marc Hilgers
Dr. Bill Hefley
(CONTINUED ON PAGE 8)
8 • JULY 2013 Louisiana Medical News
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problems in the management of all ath-letes.”
• The 2012 TBI section notes that “clinicians need to be mindful of the po-tential for long-term problems in the management of all athletes. However, it was agreed that CTE represents a distinct tauopathy with an unknown incidence in athletic populations. It was further agreed that a cause and effect relationship has not as yet been demonstrated between CTE and concussions or exposure to contact sports. At present, the interpretation of causation in the modern CTE case studies should proceed cautiously. It was also rec-ognized that it’s important to address the fears of parents and athletes from media pressure related to the possibility of CTE.”
“It seems unclear what their true po-sition is between the two consensus state-ments and needs to be better explained,” said Ross, particularly given the unfortu-nate trend of former and current profes-sional athletes taking their own lives for their families “to donate their brain … to prove CTE is in fact an issue.”
Among high-profile, self-inflicted deaths in recent years are professional ath-letes Junior Seau, Derek Boogard, Dave Duerson, who may have been the only one to commit suicide and leave instruc-tions donating his brain for the study of CTE. Former NFL Chicago Bears quar-terback Jim McMahon has agreed to do-nate his brain to science after his death.
Another point of controversy: con-cussion determination. A neuropsycholo-gist in the field of treating concussions
pointed out the 2004 consensus statement was driven largely on a grading scale (1-3) for concussion with loss of consciousness serving as a means of grading the severity of concussion, from which the 2008 con-sensus statement began to deviate.
“My take is that a concussion is more black and white,” he said. “Either you have a concussion or you don’t. When you get into grading scales and severity ratings, you oftentimes relay misinforma-tion to patients and the other providers involved in the case. Calling it a yes-or-no decision takes that away. Oftentimes, ath-letes get caught up in whether their con-cussion was mild or severe, which leads to poorly-based expectations about recovery. A concussion is a concussion and every-body recovers differently.”
In the clinical treatment and man-agement of concussion, the clinician is the key, said the neuropsychologist.
“The consensus statements, the most recent one included, spend a lot of ef-fort discussing sideline assessment tools, baseline testing, cognitive assessment tests, balance testing, RTP decisions, and preferred means of assessment or treat-ment,” he said. “All these components are tools that, when used correctly by a well-trained clinician, can be extremely valuable. But the clinician remains the most important piece in terms of con-cussion treatment and management. The consensus statements do very little in terms of providing practical guide-lines for the clinical care of concussion with respect to the individual clinician.”
Sports Medicine Community Weighs In, continued from page 7
Notable HighlightsTodd Ross, MS, ATC, an athletic trainer for Pulaski
Academy with OrthoSurgeons in Little Rock, Ark., emphasized other notable 2012 Concussion Consensus Statement highlights:
• In the preamble, “ … therapists, certified athletic trainers … coaches and other people” were replaced with “primarily for use by physicians and healthcare professionals,” which better addresses who should be diagnosing concussions and handling RTP decisions concerning concussions.
• “Brain injury” was added to the first sentence to read: “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain induced by biomechanical forces.” “One could argue the point of, by definition, a concussion isn’t an injury but a process,” he said. “Adding the language of brain injury nullifies this objection.”
• A timeline for concussion status was identified as “in some cases, symptoms and signs may evolve over a number of minutes to hours,” which could broaden the clinician’s interpretation of signs and symptoms.
• The “Classification of Concussion” subtitle was changed to “Recovery of Concussion.”
• In the neuropsychological assessment subtitle, the second and third paragraphs were rewritten and show less of an emphasis on the patient seeing a neuropsychologist. However, the emphasis changes to neuropsychological (NP) testing and a multidisciplinary approach to concussion management.
Todd Ross
Louisiana Medical News JULY 2013 • 9
(CONTINUED ON PAGE 10)
By CINDy SANDERS
As healthcare continues to transform and evolve, the skill sets needed to be an effective leader and provider are chang-ing, too. From HIPAA and HITECH to the Affordable Care Act, the regula-tory and reimbursement environments have impacted the recruiting process by demanding that physicians, nurses and management teams be able to provide the best outcomes in the most efficient man-ner possible.
“The hospital model is changing so those leaders don’t look the same any-more,” said Brian Kelley, a partner with The Buffkin Group, LLC. “You better have a deep bench,” he contin-ued of the need to have an executive team with different areas of exper-tise.
Just as the ideal ap-plicant is changing, the most effective way to recruit that candi-date is also undergoing a transformation. “We’re doing a lot of things differently than we did five or six years ago,” noted Susan Masterson, national vice president of provider recruitment for TeamHealth. “The day of placing an ad and waiting
for the right candidate to appear is long gone.”
As for the true impact of health re-form on job recruitment, the experts all agreed that has yet to fully play out. “We’re building the plane engine as we fly it,” Masterson said wryly.
So how are recruit-ing and management firms attracting and re-taining the right people in a period of great transition, and what skills should candidates hone to answer new challenges posed by the nation’s com-plex healthcare system? Medical News asked a number of recruiters to share their insights.
PhysiciansIn addition to her national provider
recruitment duties with TeamHealth, Masterson is a past board member and committee chair for the National Associa-tion of Physician Recruiters and a current committee member for the Association of Staff Physician Recruiters.
On the national front, she said the need for primary care physicians is antici-pated to rise dramatically. Yet, she contin-ued, only about a quarter of the applicants
coming out of training are headed that direction. “We need more family practice and internal medicine physicians,” she said.
“The government is going to have to make more slots for internship and residency, and they’re going to have to incentivize physicians to be primary care doctors,” Masterson added of anticipated demand in the wake of ACA.
“Regardless of the specialty,” she continued, “I think there are different competencies for doctors that are a ‘must have’ today than (were necessary) years ago.” A focus on quality, prevention and evidence-based medicine were included on her list. Masterson also noted the need to be comfortable with technology and said two of the biggest skills were to be team-oriented and effective in mentoring and working alongside advanced practice clinicians (APCs).
“Another thing I think we’ll see is there will be a lot of physicians that are in small, private practices that will choose to join larger companies or hospitals,” Masterson said. She added that her com-pany is recruiting many physicians who are ready to hang up their shingle because of heavy workload, decreasing reimburse-ments, increased regulation and uncer-tainty over how healthcare reform will
impact their practice. Another factor driv-ing this trend, she added, is that the ‘new millennials’ (born between the early 1980s and 2000s) are very focused on a work-life balance and value personal time as much as career … which often translates into a willingness to be hospital employees rather than taking on the stress of owning their own practices.
In her own company, Masterson said they have taken a much more pro-active strategy to recruit residents for their key focus areas of emergency medi-cine, anesthesiology, urgent care and the ‘ists’ — hospitalists, laborists, surgicalists. TeamHealth has created a number of sup-port services … from online resources to shadowing opportunities to hosting disci-pline-specific boot camps … to help the young recruits settle into their new roles.
“We’re also signing many more APCs … probably three or four times more than we did just four or five years ago,” she noted of the increased demand for physi-cian assistants, nurse practitioners, nurse anesthetists and other mid-level providers.
As demand increases for providers, it has become increasingly competitive to fill open spots. Locum tenens companies have been springing up, said Masterson. Where those temporary providers had been filling
Recruiting in an Era of ReformNew Landscape Requires Different Leadership Skills
Brian Kelley
Susan Masterson
10 • JULY 2013 Louisiana Medical News
Recruiting in an Era of Reform, continued from page 9
in for short periods during vacation or ma-ternity leave, Masterson said it is increas-ingly common to see them in place for months at a time while the search contin-ues for a permanent hire. TeamHealth has their own internal group known as Special Ops physicians to answer this need.
Hiring, however, is only one part of the puzzle. “It’s one thing to recruit the doctors, but then we have to retain them so there is a tremendous focus on reten-tion,” Masterson said.
Advanced Practice ProvidersMedPlacer, a national recruitment
and operational process improvement firm, places healthcare providers and executives in a variety of positions. How-ever, said Jeff E. Mc-Cracken, founder and managing director, the company’s core business is on emergency, surgical and cardiovascular ser-vice placement. “When we originally founded our company, we had a broader approach,” he noted. Over time, he continued, “We’ve really focused in more on a couple of key niche areas, and it’s really driven by the market.” McCracken added, “About 90 percent of the professionals we place have a nursing background of some sort.”
The company, he explained, has three main divisions — permanent nurs-ing leadership recruitment, staff nursing recruitment, and interim departmental leadership. Although MedPlacer doesn’t always put an interim director on site, when the company does have a leader on the ground, that person helps clients assess operations, identify weaknesses, outline process improvements, set departmental objectives and align staff appropriately to achieve those goals.
McCracken said the strategy has been to not only glean the technical needs of a department but to understand the culture
to recruit the right person. “The retention rate has been much higher because we’ve had an on-the-ground experience within the hospital,” he noted.
Like physicians, McCracken said nurses are now recruited nationally. As the housing market has improved, he has found an increased willingness among nurses to consider positions in other parts of the country. An area of rapid growth has been placing staff level nurses in de-partments to help alleviate dependence on travel nurses. He was quick to add that travel nurses play an important role in helping a facility staff up for seasonal peaks or to meet the needs of increased patient populations for short periods of time. However, he added, hospitals ulti-mately want staff members who are en-grained in their community.
Kipper Latham, RN, chief clinical of-ficer for MedPlacer, is the person on the inside. “It helps the nurse understand that hospital before they pick up and move from Pittsburgh to Texas,” he said of being embedded in the hospital while as-sessing a department’s operations, staffing and processes.
Additionally, he spends his time learning about the area … schools, activi-ties, the housing market, and quality of life … to best match a job candidate with both the hospital and community. He added finding the right match is more than just aligning skill sets. “You have to look not only on paper but also understand that professional’s long-range goals and moti-vation,” he said.
Like McCracken, Latham said travel nurses play an important role in staffing solutions but likened them to renters vs. owners. “Travelers are needed, but it’s not the same as if 80-90 percent of your nurses are part of the community,” he explained.
During a seven-month stint in the emergency department at a Texas hos-pital, Latham saw the number of travel nurses decrease from 25 to two, and the Press Ganey hospital scores rise from
the bottom 25th percentile to the top 15 percent. “Patient satisfaction scores went through the roof because now you had ownership in the community,” Latham noted.
As with physician recruitment, reten-tion is a key to success. McCracken reiter-ated turnover not only hurts the bottom line, but it takes a heavy toll on key areas impacting quality and efficiency including morale, institutional knowledge, cultural sensitivity, and patient and employee sat-isfaction.
He added there is no crystal ball to know exactly how ACA will impact hos-pital staffing, but McCracken pointed out increased volumes are often seen in the Emergency Department first and then have a domino effect in other areas of operation. He said MedPlacer is working collaboratively with colleagues in other firms to try to prepare for increased de-mand. “We’re continuing our strategic al-liance with other recruitment companies nationally. That way we can scale appro-priately,” he concluded.
The Executive SuiteThe Buffkin Group focuses primar-
ily on placements at the C-suite level for service providers and end payers. The landscape … and the skills needed to suc-cessfully navigate the new terrain … are definitely changing.
“When you’re in the heat of your business, it’s sometimes difficult to take a strategic look at your executive team and ask, ‘Do we have the team in place to meet the regulatory demands that take place in 2014?’” said Craig Buffkin, manag-ing partner and founder of the firm.
For non-profit hos-pitals, he added, that could mean a shift in at-tention. Previously, these facilities were much more focused on outcomes than on cost factors.
Now, both must be equally weighed. “It’s put a lot of pressure on having a different type of leader in different parts of their or-ganizations that didn’t exist five years ago because not only do they have to worry about outcomes but also on driving costs and efficiencies,” Buffkin said.
The new regulatory environment and shifts in reimbursement models have brought about some consolidation of acute care facilities and hospitals taking over physician practices. In the short run, said Buffkin, consolidation shrinks the leader-ship market. However, he continued, “In the long term, it typically increases the need as companies get bigger.”
In fact, he continued, “We’ve dou-bled the number of searches we’ve been completing on an annual basis in the last several years, and the majority of that de-mand has come from our healthcare cli-ents because of regulatory pressures.”
Brian Kelley, a partner based in the firm’s Connecticut office, added the com-plex delivery and regulatory environment has made it nearly impossible for one person to have all the skills necessary to meet the hospital’s or practice’s needs. Three areas he identified as ‘critical in any management setting’ are knowledge and experience of healthcare services, profit and loss expertise to understand re-imbursement challenges and a robust un-derstanding of IT from both a quality and efficiency perspective.
“You have to have a team … it’s not one person,” he said. “For one person to have all three of those skill sets is
Jeff McCracken
Craig Buffkin
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Louisiana Medical News JULY 2013 • 11
gling work, studies and family. They need specific answers and solutions that pertain to their stage in life, but much of the infor-mation available to them is geared toward women over 40.
Louisiana ranks at the top in the na-tion for deaths from breast cancer, though our incidence rate is lower than the na-tional stats, suggesting that our women wait too long to be treated, have limited access to information and medical care, and don’t go for mammography.
And so SurviveDAT! was conceived. It has a cute name, but a serious purpose – provide breast cancer information for young breast cancer survivors ages 18-44.
A partnership between the LSU Health Sciences Center School of Public Health, and Mary Bird Perkins Cancer Center (MBPCC), SuriviveDat! was writ-ten as a three-year grant and funded by the Centers for Disease Control and Preven-tion.
Donna Williams, assistant professor at the LSUHSC School of Public Health, who is also director of the Louisiana Can-cer Prevention and Control Program, “Young breast cancer survivors have needs which can differ substantially from those of older women with breast cancer. It’s vitally important that we respond to these needs and assist these women, their families and their caregivers in the cancer journey.”
Specifically there are three integrated parts to the program: The www.survive-dat.org website is packed with both local and national breast cancer resources for
the younger breast cancer survivor; a monthly support group meeting at Cancer Services of Baton Rouge where they can network; and quarterly workshops, often with the topics tied to information from the website.
The SurviveDAT! participants come from a combination of physician contact and community outreach by representa-tives making regular visits to Baton Rouge physicians’ offices to let both doctors and patient navigators know about the pro-gram, and taking part in community events like the Susan G. Komen Race for the Cure.
Younger survivors can come from anywhere or be referred by their doctors from other parts of the state. They don’t have to live in Baton Rouge to attend.
Since the program’s kick-off last fall, there have been two quarterly sessions; ge-netics in January, with Dr. Duane Super-neau and fertility in March with Dr. Sissy
Sartor.Chiquita, a 37-year old breast can-
cer survivor said she first knew about the program when taking treatment for her breast cancer at MBPCC last year, and has been to everything since. “I was so impressed with the strong connection with others, and the program is geared toward the younger patients in an atmosphere of sharing the same feelings and concerns that we all have, especially in the begin-ning when the group was smaller and more intimate.”
She added that the positive and sup-portive group of nurses and doctors at MBPCC and the SurviveDAT! program “made my journey not nearly as bad as it could have been or I anticipated.”
Bold, Beautiful You!And in May 2013 the event was,
‘Bold, Beautiful You!’ an uplifting, fun but informative, well-attended evening held at the U-WINK Eyelash Studio at the Mall of Louisiana. A reception in a sea of pink color-cupcakes to boas started off the eve-ning, which was geared to the young sur-vivors’ emotional side – it was all about looking good, feeling good and being re-energized.
“We wanted to host a fun event that addressed the specific body image concerns of young breast cancer survivors,” said Renea Duffin, vice president of cancer sup-port and outreach for Mary Bird Perkins Cancer Center. “Our goal is for survivors to feel bold, beautiful, and supported by
their community.”The first speaker, Britney Temple of
Fit Lab Fitness, discussed basic nutrition of lean meats, fruits and veggies and water consumption, but added that a chemo pa-tient might try spices and seasoning (but not extra salt!) to put taste back in food. And she advised exercise three-four times a week – anything goes!
Phyllis Sales, owner of Still Me Bou-tique, showed many examples of post mastectomy care garments, from the immediately-worn, frankly utilitarian, compression items, and ‘balancers’ and prostheses, to later stage beautiful lingerie, lace-decorated bras and camisoles. She pointed out that there are many products available for all stages of pre- and post-sur-gery, and that active women need the right clothes to achieve body balance, symmetry and emotional well-being.
The make-up sessions were saved until last and models from the audience had fun, but were given good advice for post radiation and chemo hair loss from La-Trice Pinkins, the evening’s hostess. Shana Ballard, one of the participant/models, exclaimed after make-up was expertly ap-plied, “I have eyebrows!”
The event for July is “Getting to Know the New You: Renewing Healthy Relation-ships after Breast Cancer Diagnosis.”
Though all the sessions at this time take place in and around Baton Rouge, there are plans for expansion into New Orleans, both for local website information and eventually area meetings.
SurviveDAT! continued from page 1
“I have eyebrows!”
12 • JULY 2013 Louisiana Medical News
The 2013 Regular Ses-sion of the Louisiana Legislature ended on Thursday, June 7th. In next month’s report we’ll feature some of the highlights of this past session. Below is a recap of selected heal thcare-re lated measures that made it through the entire leg-islative process.
HB 10, PearsonAdds certain hallucinogenic substances to the list of Schedule I controlled dangerous substances; 5/23/2013; Becomes Act 7; Effective August 1, 2013
HB 15, MackAdds certain compounds to the Schedule I clas-sifi cation of controlled dangerous substances; 5/23/2013; Becomes Act 8; Effective August 1, 2013
HB 21, Burns, HProvides with respect to reporting of mental health information regarding the purchase of fi re-arms; 4/18/2013; Substitute bill adopted: HB 717
HB 120, PughAuthorizes the La. State Board of Nursing and the La. State Board of Practical Nurse Examiners to ac-cept certain accreditations for nurses.; 4/8/2013; Referred to committee on Health & Welfare
HB 150, GreeneRequires recognition of assignment of health insurance benefits to health care providers; 4/8/2013; Referred to committee on Insurance
HB 216, ShadoinProvides relative to the ability of the Patient’s Compensation Fund Oversight Board to invest certain funds; 5/30/2013; Becomes Act 80; Effec-tive August 1, 2013
HB 221, ConnickAuthorizes certain dual employment and dual offi ce-holding for physicians; 6/6/2013; Enrolled in the House
HB 228, FanninProvides relative to balance billing by and reim-bursement of noncontracted facility-based physi-cians for covered health care services rendered in an in-network health care facility; 4/8/2013; Referred to committee on Insurance
HB 275, WillmottAuthorizes podiatrists to obtain patient histories and perform physical examinations under certain conditions; 4/8/2013; Referred to committee on Health & Welfare
HB 322, ThierryRequires birthing facilities to perform pulse oxi-metric screening for certain heart defects on each
newborn in the care of those facilities; 5/29/2013; Enrolled in the House
HB 342, HuvalProvides relative to balance billing by and reim-bursement of noncontracted health care provid-ers of emergency medical services; 4/8/2013; Referred to committee on Insurance
HB 392, Bishop, S.Provides relative to credentialing and claims pay-ment functions of managed care organizations participating in the La. Medicaid coordinated care network program; 6/6/2013; Enrolled in the House
HB 393, AndersProvides relative to prescription drug benefi ts of managed care organizations participating in the La. Medicaid coordinated care network program; 6/4/2013; Enrolled in the House
HB 449, BurrellProvides for a time-limited expansion of Medicaid eligibility standards in La. to conform such stan-dards to those provided in the Affordable Care Act until Dec. 31, 2016; 4/8/2013; Referred to committee on Health & Welfare
HB 451, BarrowRequires hospitals to offer pertussis (whooping cough) vaccinations to parents of newborns; 5/28/2013; Enrolled in the House
HB 479, BarrasProvides an exception to annual ethics training requirements for certain hospital employees; 6/4/2013; Enrolled in the House
HB 508, CromerCreates an income and corporation franchise tax credit for manufacturers, producers, and import-ers of medical devices for amounts paid as fed-eral excise taxes on the sale of medical devices; 4/8/2013; Referred to committee on Ways and Means
HB 532, KleckleyProvides for a hospital stabilization formula and assessment and creates the Hospital Stabiliza-tion Fund and provides for uses of the fund; 5/29/2013; Enrolled in the House
HB 533, KleckleyCreates the Medical Assistance Trust Fund as a constitutional fund, creates accounts for each provider paying fees into the fund, and provides for uses of the fund; 6/3/2013; Enrolled in the House
HB 549, LegerEstablishes the MediFund for statewide advance-ment of biosciences and medical centers of excel-lence; 6/6/2013; Enrolled in the House
HB 569, BrownEliminates restrictions on performance of physical therapy services without a prescription or refer-
ral; 4/8/2013; Referred to committee on Health & Welfare
HB 592, ThibautProvides for the adequacy, accessibility, and quality of health care services offered by a health insurance issuer in its health benefi t plan net-works; 5/29/2013; Enrolled in the House
HCR 4, NortonDirects the secretary of DHH to expand eligibility standards for the La. Medicaid program to con-form to those established in the Affordable Care Act; 4/8/2013; Referred to committee on Health & Welfare
HCR 8, EdwardAmends administrative rules to provide that La. Medicaid eligibility standards conform to those established in the Affordable Care Act; 4/8/2013; Referred to committee on Health & Welfare
HCR 90, SmithCreates a task force to study and evaluate the ef-fectiveness of sexual health education programs used throughout the state and other states; 6/2/2013; Enrolled in the House
HCR 139, BarrowDirects certain state entities to report to the leg-islature concerning operation and management of state hospitals by private entities; 6/6/2013; Enrolled in the House
HCR 140, HunterDirects implementation of certain require-ments for private contractors as conditions for privatizing the operation of any state hospital; 5/21/2013;Referred to committee on Health & Welfare
HR 47, HunterRequires submission for approval by the House Committee on Appropriations of any coop-erative endeavor agreement between the Louisiana State University Board of Supervisors and a private entity involving the change in management of a public hospital; 4/18/2013; Referred to committee on Appropriations
SB 185, MurrayProvides relative to Medicaid and certain man-aged health care organizations providing health care services to Medicaid benefi ciaries; 6/6/2013; Enrolled in the Senate
SB 189, HeitmeierProvides relative to the practice of optometry; 4/8/2013; Referred to committee on Health & Welfare
SB 198, WhiteConsolidates the functions of the Louisiana Emergency Response Network and the Bureau of Emergency Medical Services into the Louisiana Emergency Medical Services and Response Net-work; 5/13/2013;Substitute bill adopted SB 262
SB 220, WalsworthProvides for the “Louisiana Has Faith in Families” Act; 5/31/2013; Becomes Act 66; Effective May 31, 2013
SB 262, WhiteProvides for the Louisiana Board of Emergency Medical Services; 5/20/2013; Referred to com-mittee on Health & Welfare
SCR 25, GallotRequests the LSU Board of Supervisors and the governor to keep the Huey P. Long Medical Cen-ter open and viable; 6/5/2013; Enrolled in the Senate
SCR 41, BroomeRequests DHH to examine the benefi ts of rou-tine nutritional screening and therapeutic nutri-tion treatment for those who are malnourished or at risk for malnutrition, as well as examine the benefi ts of such actions as part of the standard for evidenced-based hospital care; 5/29/2013; Enrolled in the Senate
SCR 42, BroomeAcknowledges the role of optimal infant nu-trition during fi rst year of life and that new
mothers require assistance to provide the best nutritional start for their babies and urges DHH to facilitate maternal and infant nutrition aware-ness and provide access to nutritional programs.5/29/2013; Enrolled in the Senate
SCR 57, MartinyRequests various state and local departments to take certain actions regarding the commercial construction and operation by Planned Parent-hood Gulf Coast of a facility to provide abortions in Louisiana; 6/5/2013; Enrolled in the Senate
SCR 87, HeitmeierDirects the Department of Health and Hospitals to submit a Section 1115 demonstration waiver to the Centers for Medicare and Medicaid Services that replaces upper payment limit funding and creates funding pools to replace upper payment limit payments; 6/5/2013; Enrolled in the Senate
SCR 98, JohnsExpresses support of and provides authority for actions by the Board of Supervisors of the Louisi-ana State University and Agricultural and Mechani-cal College for the strategic collaboration with the the division of administration and the Department of Health and Hospitals in planning for a new model of health care delivery throughout the Lake Charles region; 6/5/2013; Enrolled in the Senate
SCR 101, WhiteRequests the Department of Health and Hospi-tals to protect certain hospitals from the nega-tive fi nancial consequences of the closure of the Earl K. Long Medical Center by adequately compensating such hospitals for their increased burden of providing health care to the poor and uninsured residents of the greater Baton Rouge region; 6/5/2013; Enrolled in the Senate
SCR 108, HeitmeierDirects the Department of Health and Hospitals to submit a request to the Centers for Medicare and Medicaid Services to extend Louisiana’s Sec-tion 1115a demonstration waiver for the Greater New Orleans Community Health Connection and authorizes the governor and the secretary of the department to identify a source or sources for matching of non-federal funds required under the extended waiver; 6/5/2013; Enrolled in the Senate
SR 18, BroomeDesignates April 15, 2013, as Earl K. Long Medi-cal Center Day; 4/29/2013; Enrolled in the Senate
SR 28, MurrayRequires submission for approval by the Senate Committee on Finance of any cooperative en-deavor arrangements between the LSU Board of Supervisors and a private entity involving the change in management of a public hospital; 4/29/2013; Enrolled in the Senate
SR 51, MillsDesignates April 25, 2013, as “School-Based Health Center Awareness Day.”; 5/13/2013; En-rolled in the Senate
SR 106, ThompsonUrges and requests the Department of Education and the Board of Elementary and Secondary Edu-cation to expand and enhance oral health care education in Louisiana public schools; 6/6/2013; Enrolled in the Senate
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Louisiana Medical News JULY 2013 • 13
By CLAy J. CouNTRymAN, ESq.
On March 26, 2013, the Office of In-spector General (OIG) of the U.S. Depart-ment of Health and Human Services issued a Special Fraud Alert on Physician-Owned Entities. In the introduction, the OIG pro-vided that this Special Fraud Alert addresses physician-owned entities (i.e., referred to as physician-owned distributorships or “PODs”) that derive revenue from selling implantable medical devices ordered by their physician owners for use in procedures the physician-owners perform on their own patients at hospital and ambulatory surgical centers (ASCs).
The OIG also emphasized in the intro-duction to this Special Fraud Alert that the OIG has previously issued several “general” guidance documents on the topic of physi-cian investment to entities to which they refer, and that they have specifically issued previous guidance addressing physician in-vestments in medical device manufacturers and distributors in a Oct. 6, 2006 letter to the health care industry. In this particular Special Fraud Alert, the OIG noted that this Fraud Alert focuses on “the special at-tributes and practices of PODs that we be-lieve produce substantial fraud and abuse risk and pose dangers to patient safety.”
Application of the Anti-Kickback Statute to Physician Investments
The OIG emphasized its position in “longstanding” OIG guidance that the op-portunity for a referring physician to earn a profit, including through an investment in an entity for which a physician investor generates business, could constitute illegal remuneration under the Anti-Kickback Statute. The OIG also listed the following aspects that the OIG has “repeatedly ex-pressed” concerns under the Anti-Kickback Statute in arrangements (i.e., joint ventures) with physicians:
Selecting investors because they are in a position to generate substantial business for the entity;
Requiring investors who cease practic-ing in the service area to divest their owner-ship interests;
Distributing extraordinary returns on investment compared to the level of risk involved.
The OIG commented that PODs that exhibit any of the above aspects or other questionable features potentially raise four major concerns typically associated with kickbacks, including: (1) corruption of medical judgment, (2) overutilization, (3) increased costs to the Federal health care programs and beneficiaries, and (4) unfair competition. The OIG stated that they were particularly concerned about the pres-ence of financial incentives in the implant-
able medical device context because devices typically are “physician preference items,” meaning that both the choice of brand and the type of device may be made or strongly influenced by the physician, rather than being controlled by a hospital or ASC where a procedure is performed.
Hospitals and other providers should note that the OIG commented that a dis-closure to a patient of the physician’s finan-cial interest in the POD (which is commonly required by certain state laws) “is not suffi-cient” to address fraud and abuse concerns.
This OIG Special Fraud Alert on Phy-sician-Owned Entities listed the following concerns of which the OIG is “particularly concerned”:
The size of the investment offered to each physician varies with the expected or actual volume or value of devices used by the physician.
Distributions are not made in pro-portion to ownership interest, or physi-cian-owners pay different prices for their ownership interests, because of the expected or actual volume or value of devices used by the physicians.
Physician-owners condition their refer-rals to hospitals or ASCs on their purchase of the POD’s devices through coercion or promises, for example, by stating or imply-
ing they will perform surgeries or refer pa-tients elsewhere if a hospital or an ASC does not purchase devices from the POD, by promising or implying they will move sur-geries to the hospital or ASC if it purchases devices from the POD, or by requiring a hospital or an ASC to enter into an exclu-sive purchase arrangement with the POD.
Physician-owners are required, pres-sured or actively encouraged to refer, recommend or arrange for the pur-chase of the devices sold by the POD or, conversely, are threatened with, or experience, negative repercussions (e.g., decreased distributions, required di-vestiture) for failing to use the POD’s de-vices for their patients.
The POD retains the right to repur-chase a physician-owner’s interest for the physician’s failure or inability (through re-location, retirement or otherwise) to refer, recommend or arrange for the purchase of the POD’s devices.
The POD is a shell entity that does not conduct appropriate product evaluations, maintain or manage sufficient inventory in its own facility, or employ or otherwise contract with personnel necessary for opera-tions.
The POD does not maintain continual oversight of all distribution functions.
In its conclusion, the OIG noted that the Anti-Kickback Statute is not a prohibi-tion on the generation of profits; however, PODs that generate disproportionately high rates of return for physician-owners may trigger heightened scrutiny. These com-ments imply the OIG does not consider suc-cessful physician investments in other health care providers to be illegal; however, other factors associated in a physician’s invest-ment and the structure of PODs may result in the OIG taking a position that distribu-tion of profits closely aligned with a POD providing implantable medical devices or-dered by a physician investor may constitute illegal remuneration for the orders.
Hospital’s should pay close attention to this Special Fraud Alert because it highlights the increasing potential for scrutiny and en-forcement action by the OIG and other en-forcement agencies.
A copy of the OIG Special Fraud Alert on Physician-Owned Entities is available on the OIG’s web site at www.oig.hhs.gov/ under “What’s New.”
OIG Issues Warning to Hospitals and Other Providers In Special Fraud Alert on Physician-Owned Distributorships for Implantable Medical Devices
(CONTINUED ON PAGE 14)
Clay J. Countryman is a partner in the Baton Rouge, LA office of Breazeale, Sachse & Wilson, LLP. [email protected]
14 • JULY 2013 Louisiana Medical News
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First MDA/ALS Clinic in Louisiana Located at LSUHSC Medical School
NEW ORLEANS — The Muscular Dystrophy Association announced the designation of the Louisiana State Univer-sity Health Sciences Center New Orleans School of Medicine as an MDA/ALS clinic. The designation makes LSUHSC the fi rst MDA/ALS clinic in Louisiana and recognizes the high standards of care offered by a team of specialized physicians and therapists for people in the greater New Orleans area who are living with ALS (amyotrophic lateral sclerosis, or Lou Gehrig’s disease).
LSUHSC is the 44th MDA/ALS center in the country, joining a national network of MDA/ALS centers that pro-vide a multidisciplinary team of medical professionals skilled in the diagnosis and treatment of ALS. LSUHSC has built a comprehensive medical team of clinicians including a board-certifi ed neurologist, a pulmonologist, and respiratory, physical and speech therapists.
“This designation of the MDA/ALS clinic is a very important step in improving patient care for those who are diagnosed with ALS or a neuromuscu-lar disease,” said clinic director Amparo Gutierrez, M.D. “This will allow us to provide specialty care to patients in Loui-siana and other states in the southeastern region. Our clinic will continue to provide patients access to care regardless of their economic background. And we also look
forward to working with other MDA/ALS clinics around the country to grow our ALS research program.”
MDA/ALS centers are an integral part of MDA’s commitment to developing effective treatments and working toward fi nding a cure. One of the ways in which they do this is by participating in ongoing ALS clinical research trials.
“We welcome the exceptional exper-tise in ALS care provided by the health care specialists at Louisiana State Univer-sity to our network of clinics,” said MDA Executive Vice President and Chief Medi-cal and Scientifi c Offi cer Valerie A. Cwik, M.D. “We know that the team at LSU will provide help and hope to families who are on the challenging journey that is ALS.”
Currently, MDA is funding 63 inter-national ALS research projects at a cost of more than $20 million.
For more information, see “New MDA/ALS Center Opens at LSU.”
Touro Rehabilitation Center Earns Three-Year CARF Accreditation
NEW ORLEANS – The Commis-sion on Accreditation of Rehabilitation Facilities (CARF) recently presented Touro Rehabilitation Center with a three-year accreditation for Comprehensive In-tegrated Inpatient Rehabilitation, Spinal Cord System of Care, and Brain Injury Rehabilitation.
“This accreditation validates Touro
Rehabilitation Center’s standing as one of the premiere destinations for patients seeking rehabilitative services in New Or-leans and throughout the Gulf South,” said Gary Glynn, M.D., Touro Rehabili-tation Center Medical Director. “By pur-suing and achieving accreditation, Touro has demonstrated once again that it meets international standards for quality and is committed to pursing excellence.”
This decision represents the highest level of accreditation that can be awarded to an organization and shows Touro Reha-bilitation Center’s substantial conformance to the CARF standards. An organization receiving a Three-Year Accreditation has put itself through a rigorous peer review process and has demonstrated to a team of surveyors during an on-site visit that its programs and services are of the highest quality, measurable, and accountable.
Dr. Wilson Receives Tulane Medical Alumni Award
SHREVEPORT- Dr. John T. Wilson, professor of pediatrics, section chief and di-rector of the Children’s Clinical Research Center at LSU Health Shreveport, was recently honored by the Tulane Medical Alumni As-sociation as the 2013 Life-time Achievement Award recipient.
“Dr. Wilson has made a remarkable contribution to the fi eld of pediatrics and child public health not only in our country but worldwide,” says Dr. Benjamin Sachs, dean of Tulane University School of Med-icine. “He is truly a pioneer of pediatric therapeutics.”
Early in his career Wilson’s research fi ndings showed that 78% of drugs lacked suffi cient information for use in children. This prompted Wilson to ask a funda-mental question “How do we know what medications are safe for our children?”
This questioning and the ensuing 40 years of advocacy by the American Acad-emy of Pediatrics helped to support leg-islative efforts to get products and drugs studied for safety in both adults and chil-dren. The congressional passage of the 2012 FDA Safety and Innovation Act sig-nifi es Wilson’s lasting impact on the safety of children and our society. This act se-cures enhanced drug labeling for children making sure that drugs used for children have the same safety standards as those found in adults.
Upon receiving the Lifetime Achieve-ment Award at the Class of 1963 50th reunion celebration, Wilson credited his medical education with giving him the basis to achieve such success in his career. Dr. Paul Winder, a former Tu-lane graduate and Shreveport physician, sponsored Wilson for the award. Wilson complimented his fellow classmates as a strong group of achievers that pushed him to better himself and strive further in his academic studies. Borrowing a quote from Alice in Wonderland, Wilson told his classmates, “I had to run twice as fast just to stay in the same place with you.”
Dr. John T. Wilson
Louisiana Medical News JULY 2013 • 15
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In the News
Our Lady of the Lake Physician Group Welcomes Drs. Garner and Walker
BATON ROUGE – Our Lady of the Lake Physician Group Walker Clinic is now open and staffed by Gregory Garner, MD and Patrick Walker, MD who are accepting new patients.
Dr. Garner received his medical degree from In-diana University School of Medicine in Indianapolis, IN. He completed his resi-dency in Family Medicine at Louisiana State Univer-sity Health Sciences Center in Shreveport.
Dr. Walker received his medical degree from Louisiana State University
School of Medicine in Shreveport, LA. He also completed his residency in Family Medicine at Loui-siana State University Health Sciences Center in Shreveport.
Drs. Garner and Walker treat com-mon disorders of the cardiovascular, respi-ratory, gastrointestinal and reproductive systems including diabetes, hypertension, hyperlipidemia, asthma, chronic obstruc-tive pulmonary disease and chronic kid-ney disease. They also perform routine childhood and adolescent health exams.
The Walker Clinic is located in the physician tower at OLOL Livingston in Walker.
First Practices Join Quality Blue Primary Care
BATON ROUGE- Three primary care practices—West Monroe Family Clinic, West Calcasieu Virtual Medical Home and Baton Rouge General Physi-cians—have signed up for Quality Blue Primary Care (QBPC), Blue Cross and Blue Shield of Louisiana’s innovative population health and quality improve-ment program. QBPC is designed to get better outcomes for patients with chronic diseases, support doctors and transform healthcare delivery.
Blue Cross is implementing QBPC in primary care physicians’ offi ces and clinics, and will roll it out statewide over two to three years. In the early months of QBPC, Blue Cross is signing up network primary care practices that treat the high-est number of members with chronic dis-eases such as diabetes.
“We were the fi rst provider group in the state to sign on with QBPC, and we believe this will create a truly collabora-tive care environment. Our staff will work closely with Blue Cross so that together, we can help our patients become healthier and remain well,” said Steven McMahan, M.D., physician with West Monroe Fam-ily Clinic in West Monroe, La.
“Partnering with Blue Cross and Blue Shield to offer this program in our commu-nity demonstrates the benefi ts of working together to improve health outcomes, while reducing cost,” said Bill Hankins, chief ex-ecutive offi cer at West Calcasieu Cameron
Hospital and president of the West Calca-sieu Virtual Medical Home in Sulphur, La.
Hankins said that while the West Calcasieu Virtual Medical Home is cen-tered around the QBPC, it is unique in that seven primary care sites in Calcasieu Parish have joined together and will be part of the program. These sites are The Cypress Clinic, Schlamp Family Medical, Calcasieu Family Physicians, Gamborg and Cavanaugh Family Medicine, The Family Care Center of SWLA, The Fam-ily Practice Center of Sulphur and Maple-wood Family Medicine.
“We are excited to be one of the fi rst QBPC providers and are enthusiastic about working with Blue Cross and Blue Shield to implement this new population health-focused program,” Hankins said.
David Carmouche, M.D., chief medical offi cer for Blue Cross and Blue Shield of Louisiana, said that Quality Blue Primary Care is the next generation of population health management. “This model will signifi cantly improve patient outcomes and support providers. We are making a substantial investment by paying for software and helping the participating
practices through the transformation,” Carmouche said. “This will give our pro-viders the data and support they need to improve both overall healthcare quality and the lives of their individual patients with chronic diseases.”
Two years ago, Blue Cross began using a model for primary care called the patient-centered medical home, or PCMH. It focused on improving patients’ health and lowering costs. Both QBPC and PCMH offer organized, team-based, proactive care that works to prevent dis-ease and protect or restore health.
Dr. Gregory Garner
Dr. Patrick Walker
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