Mississippi Medical News July 2014

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Incorporating the New Telemedicine Model PolicyFederation of State Medical Boards releases long-awaited model policy In mid-spring, the Federation of State Medical Boards released a long-awaited model policy that provides the group’s fi rst guidance on telemedicine since the early 2000s ... 3

UMMC Senior Leader Announces Transition PlansJACKSON, Miss. – Dr. James E. Keeton, vice chancellor for health affairs and dean of the School of Medicine, has announced he will step down from his role at the end of the next academic year, June 30, 2015. Keeton has served in the position since July 2009, the fi rst six months on an interim basis ... 4

July 2014 >> $5

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Troy E. Rhodes, MD, PhD

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PHYSICIAN SPOTLIGHT

ONLINE:MISSISSIPPIMEDICALNEWS.COMNEWS.COM

New Laws Taking Effect July 1Healthcare leaders report successful session for medical-related bills

Balancing a Fruitful PlateTim Moore brings fresh energy to role as state’s lead hospital advocate

By LyNNE JETER

MADISON—Tim Moore is constantly fi ring on all cylinders, with an energy that moves seamlessly from one controversial issue to another concerning Mississippi hospitals.

On the job since last September, Moore, who gave up the post of CEO of North Mis-sissippi Medical Center to lead the Mississippi Hospital Association (MHA), has little time to sit still.

“Declining reimbursement remains the most pressing matter from a hospital stand-point,” said Moore, who took over the top post representing more than 100 healthcare orga-nizations from long-serving MHA CEO Sam Cameron, who retired last summer. “We’re seeing the resulting fi nancial challenges hospi-tals are facing. The picture’s not going to get a lot brighter anytime soon, I’m afraid.”

Moore, a native of Forest, with leadership experience at Rush Health System in Meridian, Greenwood-LeFlore Hospital and

North Mississippi Medical Center (NMMC), was poised to become chairman-elect of the MHA board. At NMMC, he’d been hand-picked to replace departing Steve Altmiller as the fi rst president selected from the NMMC family since the 1970s. Moore called it “the most amazing health system in this region” that he “would’ve loved to have been a part of.”

But, Moore emphasized, there’s much work to be accomplished at the state level.

“For example, from MHA’s perspective, we believe the healthcare delivery model for Mississippi has got to evolve into an entirely different delivery model and payment model,” emphasized Moore, who spent last fall building and strengthening relationships with elected state offi cials. “We have ideas for doing that, which gets me really excited. That’s why I’m here, and that’s what led me to make the deci-

sion to take a statewide role, to have an impact on redeveloping or causing a state of evolution in healthcare in Mississippi.”

(CONTINUED ON PAGE 6)

By LyNNE JETER

The 2014 Mississippi Legislature kept pace with a steady diet of healthcare bills during the 90-day session.

New Laws Policy changes on sports-related concussions will impact the

orthopedic community this fall, particularly as football play gets underway. Partially as a result of the updated sports concussion statement resulting from the 4th International Conference on Concussion in Sport in 2012, held internationally every four years,


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Tim Moore

2 > JULY 2014 m i s s i s s i p p i m e d i c a l n e w s . c o m

By LUCy SCHULTZE

From the young patient with an ab-normal heart rhythm to an older one needing a pacemaker, it’s the diversity of patients and procedures that keeps Troy E. Rhodes, MD, PhD, engaged.

“Even within a subspecialty of cardi-ology, I perform a lot of different proce-dures day-to-day,” said Rhodes, a cardiac electrophysiologist (EP) who joined the University of Mississippi Medical Center in January as an assistant professor.

Despite the focused nature of his practice — “all electrical, no plumbing,” as he puts it — Rhodes has found the fi eld to offer a world of variety.

“Every issue is electrical, whether the heartbeat is too fast, too slow, or irregu-lar,” he said. “I have the opportunity to see very different patients and perform di-verse procedures all within the same day.”

Among those procedures is the im-plantation of the new subcutaneous im-plantable cardioverter-defi brillator system (S-ICD), approved by the FDA in 2012 and Rhodes brought several years of ex-perience with the device to UMMC after participating in the research trials prior to approval.

Traditional defi brillators and pace-makers monitor the heartbeat with wires that run through blood vessels and into the heart itself. The S-ICD system, by contrast, has a wire that is completely con-tained under the skin.

“This tends to be a good option for younger patients who are at risk for sud-den cardiac death due to a heart condition but don’t have trouble with a slow heart rhythm,” Rhodes said. “It can also be bet-ter for younger people who will have an ICD for decades and may be susceptible

to lead failure over the years.”Likewise, he said, the new S-ICD

system can be a better choice for patients with higher-than-normal risk for infec-tion such as patients on dialysis or with infusion ports. “This option should lower their risk of infection, since the lead is not in the bloodstream,” he said.

Rhodes was trained in the procedure at Ohio State University, one of the fi rst centers to begin using the S-ICD system. He spent more than fi ve years at Ohio State, for his fellowship and then as part of the medical faculty, before being recruited to Mississippi.

“UMC was looking for an additional cardiac electrophysiologist who could do advanced ablation as well as lead extrac-tion — removing old pacemaker and de-

fi brillator wires,” Rhodes said. “Although in some regards it’s a slightly smaller med-ical center, I was attracted by the opportu-nity for growth and how closely the faculty work together.”

Just as important, UMC proved to be a good match as well for his wife, Melissa M. Rhodes, MD, who accepted a post as associate professor of pediatric hematol-ogy and oncology at Batson Children’s Hospital.

“The big thing was the way they worked with us in making sure both of us had a position,” he said. “We’ve had some diffi cult transitions before, in terms of bal-ancing two medical careers in completely different fi elds. But UMC made this tran-sition very smooth for both of us.”

As he came aboard the medical fac-ulty, Rhodes joined fellow cardiac elec-trophysiologists E. Matthew Quin, MD, and Santo M. Borganelli, MD. With both of them stepping down this year, Rhodes is recruiting a new colleague from Johns Hopkins University but will bridge a brief gap as UMC’s only invasive cardiac elec-tophysiologist.

Rhodes spends the bulk of his time performing procedures, with a day or so each week devoted to seeing patients in clinic. Those visits include both new pa-tients and those whom he monitors on an ongoing basis, checking in once or twice a year to ensure their device is functioning properly or that the antiarrhythmic medi-cations he prescribes are doing a suffi cient job.

“With some younger patients who re-ceive a curative ablation, I see them once following their procedure and they ‘gradu-ate’ from EP clinic,” Rhodes said.

“Then there are a lot of patients who have multiple issues. They may have a de-

vice and require antiarrhythmic medica-tions, so they need to follow up regularly for monitoring. I work closely with their primary cardiologist to monitor their de-vice, arrhythmias, and antiarrhythmic medications.”

Rhodes came to cardiac electrophysi-ology through an interest in excitable cells, the focus of his research during doctoral studies at Eastern Virginia Medical School and Old Dominion University.

A native of Norfolk, Va., Rhodes holds an undergraduate degree in biology from Old Dominion University.

After receiving a PhD in biomedical sciences with a focus on neuroscience, he went on to complete a medical degree from Eastern Virginia Medical School. He completed his internship and residency along with a fellowship in cardiovascular medicine at Vanderbilt University Medi-cal Center.

At Vanderbilt, Rhodes was selected as a postdoctoral fellow in clinical phar-macology through the Physician-Scientist Training Program of the American Board of Internal Medicine. He is board certi-fi ed in internal medicine, cardiovascular disease and clinical cardiac electrophysiol-ogy, and is a certifi ed cardiac device spe-cialist.

In his practice today as part of Uni-versity Physicians, his areas of clinical in-terest include electrophysiologic testing; ablation of supraventricular and ventricu-lar arrhythmias; pacemaker and defi bril-lator implantations, revisions and lead extractions; evaluation of syncope; and genetic arrhythmias.

While most of his patients come from central Mississippi, Rhodes also sees pa-tients from other parts of the state.

“In the brief time I’ve been here, we’ve had patients they’ll send up from the Gulf Coast or elsewhere for a proce-dure,” he said. “For patients in some areas of Mississippi, we can offer procedures that may not be available closer to home, then have them follow up with their home cardiologist.”

Outside of work, he enjoys tennis and golf.

Troy E. Rhodes, MD, PhDPhysicianSpotlight

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Dr. Ley is board-certified in general surgery and is a Fellow of the American College of Surgeons, a Fellow of the Society of Surgical Oncology, a member of the American Society of Clinical Oncology and a member of a large number of societies and associations dedicated to the highest standards of surgical and oncological care. Dr. Ley completed formal fellowship training in surgical oncology at The University of Texas MD Anderson Cancer Center.

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By LyNNE JETER

In mid-spring, the Federation of State Medical Boards released a long-awaited model policy that provides the group’s first guidance on telemedicine since the early 2000s.

Even though some healthcare pro-viders may underrate its significance, it’s widely assumed that all licensing boards will soon adopt or borrow liberally from the federation’s “Model Policy for the Appro-priate Use of Telemedicine Technologies in the Practice of Medicine,” which covers details from e-prescribing, to patient disclo-sures, to charting/record keeping.

More specifically, the new policy pro-vides guidance to state medical boards reg-ulating the use of telemedicine technologies and the practice of medicine, and educates licensees to the appropriate standards of care in the patient-direct delivery of medi-cal services via telemedicine technologies, noted Mike Sacopulos, JD, president of Medical Risk Institute.

“This model policy casts a broad net,” he emphasized, “and will impact tens of

thousands of physicians.”

Application of the Model Rule

This policy applies to “…the practice of medicine using electronic communication, informa-tion technology or other means of interaction be-tween a licensee (physician) in one location and a patient in another location with or without an intervening healthcare pro-vider,” said Sacopulos.

“The rule then goes on to state that typically it involves the application of the secure video conference technology,” he said. “However, video conferencing isn’t a mandatory element of telemedicine under the model rule. What’s clearly excluded: communication between physicians. It seems that certain uses of a patient portal would fall under the model policy.”

Establishing Physician Patient Relationship

The model policy begins by stating

that it may be difficult in some circumstances to pre-cisely define when a physi-cian-patient relationship is established. It then goes on to state that a relationship “… is clearly established when a physi-cian agrees to undertake a diagnosis and treatment of the patient and the pa-tient agrees to be treated.”

“Physicians are next cautioned to verify and authenticate the location and identity of the patient in question,” he said. “Then they must validate their own iden-tity and credentials to the remote patient. Finally, they must obtain appropriate con-sents and requests after disclosures from the patient.”

LicensureThe model policy plainly states “a

physician must be licensed by, or under the jurisdiction of, the medical board of the state where the patient is located,” said Sacopulos.

Online Disclosures and Necessary Practice Infrastructure

The model policy spends a good amount of time describing what a practice has to do when involving itself in telemedi-cine, and requires half a dozen disclosures to achieve informed consent in telemedi-cine, ranging from hold harmless clauses for technical failure to disclosure of physi-cians credentials, said Sacopulos.

“The model policy then moves on to mandate the physician to have a continuity of care plan and an emergency service plan in place for patients engaging via telemedi-

Incorporating the New Telemedicine Model PolicyFederation of State Medical Boards releases long-awaited model policy

Mike Sacopulos, JD



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cine,” he said. The model policy calls for written poli-

cies and procedures to be created by the practice to address seven different areas, ranging from privacy to quality and over-sight mechanisms. It also mandates that all physician/patient email and other patient electronic communications be stored in the patient’s medical record.

“Here’s a requirement that seems to directly prohibit texting patients,” he said. “Although texting may be allowed, some-how the text messages must be secure and incorporated into the patient chart under this model rule. Finally, the model rule sets forth 14 types of disclosures that should be made on physicians providing medical services using telemedicine technologies. These disclosures would seem to need to be set forth on a website.”

LinksAn interesting part of the model policy

states that physician advertising and links on websites can be considered an “implied endorsement” of the information, services or products offered from those sites, said Sacopulos.

“Here, the model policy is address-ing revenue generate from sites and non-compensated links that providers place on websites,” he said. “Although not fully ex-plained, there seem to be signifi cant legal implications for ‘implied endorsements’ on physician websites.”

PrescribingThe model policy fi nally turns to pre-

scribing for patients, noted Sacopulos. “Following actions we’ve seen by

boards such as the Oklahoma Board of

Medicine, tight restrictions as to patient identity and pharmacy selection are set forth,” he added. “Physicians would be wise to implement the disclosure and web notices set forth in the model policy even if they consider their practice outside the defi nition of telemedicine. It seems certain that we’ll see state medical boards begin to adopt and use all or at least a large part of the model policy in the near future.”

Incorporating the New, continued from page 3

Mike’s New Telemedicine Checklist for Physicians

Examine the electronic ways your practice and patients communicate. From patient portals to staff testing, you need a complete picture of your electronic communications.

The internet many know no bounds, but your license does. Be careful not to provide medical advice to individuals that live in states where you’re not licensed.

Make sure you have proper disclosures posted on websites, portals, and email. Think of these disclosures as an extension of your “informed consent” obligat ions to patients.

Think twice before posting links on your practice’s website. You may incur liability by endorsing others via linking.

If you’re e-prescribing, have policies in place to verify patient identity and appropriateness of the medication.

EMAIL NOTIFICATIONS

UMMC Senior Leader Announces Transition Plans

JACKSON, Miss. – Dr. James E. Keeton, vice chancellor for health affairs and dean of the School of Medicine, has announced he will step down from his role at the end of the next academic year, June 30, 2015. Keeton has served in the position since July 2009, the fi rst six months on an interim basis.

A national search will be conducted to identify the next leader of the Medical Center. The process will yield two-to-three candidates for fi nal selection by University of Mississippi Chancellor Dan Jones, with the approval of the Mississippi Institutions of Higher Learning Board.

“This is a bittersweet decision for me,” Keeton said. “Every day I’ve worked at the Medical Center since 2002 has been a privilege. To be able to serve my alma mater in this way has been pretty special. I’ve had opportunities to work with people – inside and outside UMMC – that would never have come my way but for this job.”

The vice chancellor, who has a dual role as dean of UMMC’s medical school, essentially acts as the chief executive of a $1.6 billion enterprise engaged in health professions education, research and pa-tient care. The Medical Center encom-passes six health sciences schools with more than 2,900 students and employs more than 9,600 people.

Keeton, 74, is a native of Columbus, Miss. He graduated from the University of Mississippi and earned his medical degree at UMMC. He trained in surgery and pe-diatric urology at UMMC and in London, England. He served two years in the Med-ical Corps of the United States Navy at the rank of lieutenant commander. He was in the private practice of pediatric urology for 27 years.

Keeton has led the Medical Center through some challenging times, including during the recession of 2008 and the roll-out of the national health-care law. De-spite those external factors, his tenure has seen the planning, funding and ground-breaking for a new School of Medicine building, the implementation of a $90 mil-lion electronic health record system, and the recruitment of more than 30 individu-als to senior leadership positions.

Dr. James E. Keeton


Incorporating the New, continued from page 3

By CINDy SANDERS

Remember when P.E. was the ‘easy A’ in school? Evidently that’s no longer true.

The 2014 United States Report Card on Physical Activity for Children & Youth high-lights just how far the country has fallen off the honor roll when it comes to getting our school-aged kids to move and play. “You wouldn’t want to bring this one home,” Russell Pate, PhD, said of the report card.

Chairman of the National Physical Activ-ity Plan (NPAP) Alliance and a member of the report card research advisory com-mittee, Pate noted, “There certainly has been a concern for some time that Ameri-can children are not as active as they used to be and not as active as they should be.”

That concern is not only for the toll inactivity takes on youth during their childhood but also the larger, and longer, impact of contributing to chronic condi-tions. “It’s very clear that low levels of physical activity are associated with dis-advantageous health profiles,” Pate stated.

“Not only are they at risk of becoming overweight as children and adolescents, but they are signing up for health prob-lems that will manifest down the line.”

The alliance, a coalition of national organizations and experts committed to ensuring success of the NPAP, created the report card as a baseline measure to assess evidence-based improvement strategies. “The overall picture here … although not positive … does point the way forward and shows us how we can do better in the future,” continued Pate, a professor in the Department of Exercise Science and director of the Children’s Physical Activ-ity Research Group at the University of South Carolina.

In addition to assessing levels of phys-ical activity and sedentary behaviors, the report card also sought to highlight bar-riers keeping American children from op-timal levels of active living. The goal is to raise awareness among parents, providers, educators, community leaders and policy-makers and bring stakeholders together to improve youth fitness.

“We know we’re in bad shape, but we don’t exactly know what areas need attention. I think from a policy standpoint the report card helps move that forward,” said Scott Crouter, PhD, assistant profes-

sor in the Department of Kinesiology, Recreation & Sport Studies at the University of Tennessee – Knoxville.

Crouter, who also serves on the report card advisory commit-tee, added not every plan plays out as expected. “There are policies in place that sup-port physical activity and require P.E. in school,” he pointed out. “Greater than 90 percent of schools are requiring P.E. to be taught, but only about 50 percent of children are attending P.E. classes once a week,” Crouter added of high school stu-dents.

The highest grade given was a B- in the category of the built environment and community resources. The worst score, an F, was given for active transportation.

Since 1969, the percentage of ele-mentary and middle school students walk-ing or biking to school has fallen 25 points from 47.7 percent in 1969 to 12.7 per-cent by 2009. Not surprisingly, proximity played a key role in active transportation. Although many children face long com-mutes to school that necessitate a car or bus, the low numbers for biking and walk-

ing hold true when looking at children who lived two miles or less from school. “We see that once you get past about half a mile from the school, walking or biking decreases dramatically,” Crouter said.

Even when distance makes ac-tive transportation difficult, however, Crouter noted there are innovative ideas to increase movement. One example, he said, is to position parking lots or drop-off points a half-mile to mile away from the school building to encourage walk-ing. Other deterrents that need to be ad-dressed include safety concerns and a lack of sidewalks. “It’s really about changing the environment and how we do things,” Crouter said.

As for the built environment, Pate noted, “Most American kids do live proxi-mal to a park or green space where they could engage in physical activity. The problem is we’re not taking advantage of that opportunity.”

Girls also tend to be even less active than boys. “In some cases, girls are social-ized in a way that places less emphasis on physical activity and organized sports pro-grams,” Pate said. He added Title IX cer-tainly helped make sports more attainable for girls. However, he continued, “Even

Grade: Needs ImprovementReport card highlights deficits in children’s physical activity

Dr. Russell Pate

Dr. Scott Crouter


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Returning to reimbursement issues, Moore pointed out it was a critical year for Mississippi hospitals from the standpoint of payors.

“There was a pretty signifi cant push the entire session to expand Medicaid to all managed care,” he said. “Hospitals just weren’t ready for that, certainly in the sense that managed care in Mississippi in its current state is more about managing costs than true care. We’re all very insis-tent on the fact that a provider-led care management program is what will be suc-cessful – and decrease costs.”

Moore said hospital lobbyists were successful this legislative session by not al-lowing managed care to expand into the inpatient setting.

“It would’ve created a disruptive chain reaction, including a signifi cant change in the disproportionate-share hospital (DSH) and upper payment limit (UPL) programs,” he said. “When you move to a managed care model, your UPL goes away. That’s a lot of money leaving the state, and we desperately need it. We fought very hard to keep it in place.” (House Bill 59, which would have appropriated funds in 2014 from the WC-SRF [Working Cash-Stabilization Re-serve Fund] to the Medical Care Fund to compensate hospitals for the reduction in federal DSH payments, died in commit-tee. The House counterpart, HB 110, did also.)

Top PriorityMHA is taking a lead role in revamp-

ing the state’s healthcare delivery model, a plan Moore told legislators would be prepared before the next legislative ses-sion.

“We’re working with the managed care companies in Mississippi,” he said. “We’re having discussions on what the new model would look like. We’ve al-ready met with Magnolia, and we’ve got a (late June) meeting scheduled with United Healthcare and Humana. They’re com-ing to the table. Humana picked up 26 scattered counties on the exchange that no one else would cover. They probably got a call from CMS encouraging them to show what they could do in Mississippi. We’re looking forward to talking to them. We think it will result in some good op-portunities.”

In the meantime, MHA is also work-ing with Health Catalyst of Salt Lake City, Utah, a healthcare software group that secured $33 million in new investments early last year to keep pace with the rap-idly expanding national demand for elec-tronic records.

“They’re looking very closely at the data across the state to better pinpoint where costs are out of line,” said Moore. “For example, is a particular doctor or fa-cility spending more to take care of a pa-tient with a chronic disease than is being done across the state? A lot of work re-mains to show where we can change the

model. We can become more proactive caring for patients before they get sick, especially those with chronic or multiple chronic diseases like heart failure and COPD. If you watch those indicators, you can take measures to keep the patient from being readmitted. That’s where the money will fall out of the healthcare sys-tem.”

Early on, Moore met with some un-expected fl ak from an unnamed managed care company: “One fi rm told me, ‘look, you probably need to talk to someone else. You’re too rural for us to help.’”

Moore understands Mississippi’s unique rural presence. “It’s a different scenario than many other states, especially when you go into the northeast, where there’s a high population density,” he said. “Once you get outside Jackson, the Gulf Coast and Tupelo, the population is so scattered. Look at Tupelo, where you have the nation’s largest rural hospital. It’s still a rural area and it’s hard to get people the care they need. We need to take it to them.”

Changes to the statewide model must be provider-led, Moore insisted.

In that regard, Moore was pleased to see state lawmakers appropriate $1.5 mil-lion to the Offi ce of Physician Workforce (OPW), directed by John R. Mitchell, MD, a family physician from Pontotoc and hospitalist for NMMC, with the help of a 21-member advisory committee. The funding helps OPW leaders keep pace with Gov. Bryant’s plan to add 1,000 doc-tors by 2025.

“That’s a great situation,” said Moore. “Certainly anything we can do to bring additional physicians and healthcare providers to underserved areas, we need to do that.”

He also believes the state’s small, rural hospitals could play a key role in popula-tion health management, in a way that in-corporates parts of the Patient-Centered Medical Home (PCMH) model.

“When you think about a rural area, where do those patients with chronic con-ditions go to make sure they stay healthy?

They go to a bigger hospital,” he said. “For example, if you have a care manage-ment center in your community, which in my mind is what small rural hospitals will become, they’ll be proactive to make sure John Smith is checking his fl uid and in-take so that he doesn’t get overloaded with fl uid and have to go to the ER and be ad-mitted for congestive heart failure. There’s a huge opportunity for Mississippi’s rural hospitals.”

Burgeoning TelemedicineTelehealth holds huge potential in

the formation of a better delivery system, Moore said.

“Year before last, state lawmakers passed a law that would require insurance companies to reimburse at a face-to-face visit rate for telehealth medicine,” he said. “That was a huge win. UMMC has been such a leader in this movement. Kristi Henderson and her team there have done a fabulous job moving us forward with telehealth. Yet there’s a lot more to be seen.”

Telehealth is still in an embryonic stage of development, Moore noted.

“As it matures, we’re going to be shocked at the delivery opportunities of healthcare,” he said. “If you can follow up with your surgeon, with a high-defi nition camera at your primary care physician’s offi ce, then wow! What have you just saved?”

Moore also believes kiosks will pop up at some very strange places – Wal-Mart, truck stops, schools, places of employ-ment, for example.

“You swipe your insurance and/or debit card, a provider pops up on the screen, and you can immediately discuss healthcare needs, whether it’s a cold or sore throat or one of those minimal prob-lems that can be treated over a monitor,” he said. “You could have a prescription printed out for antibiotics or whatever is needed and be on your way. The technol-ogy is amazing! We thought Bones on Star Trek was such far-fetched fi ction. Now an iPhone is getting closer to the device he used to scan over people! It’s coming.”

Even though he realizes that state government is limited by the amount of money available for various projects, Moore didn’t let it deter him.

“I got to know many legislative lead-ers, and was pleasantly surprised that they have a willingness to listen and un-derstand how important certain projects are to hospitals,” said Moore. “I got that from all state leadership. It matters when you’re on this side trying to make a dif-ference. I’m very proud and happy to say they worked closely with us, and continue to do so.”

Balancing a Fruitful Plate, continued from page 1

Editor’s note: Look for details on the proposed statewide healthcare delivery model in the December edition of Mississippi Medical News.

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After a very rough start, the federal health exchange managed a healthy re-bound before the March 31 general signup deadline. Similarly, state exchanges have hit some glitches but are also now up and running.

Finishing the first half of the year, are the exchanges panning out to be as good as promised … as awful as predicted … or somewhere in the middle? Although much too early to make a definitive pro-nouncement, two of the nonpartisan experts on staff at The Advisory Board Company shared insights into what the first few months have revealed about the exchanges in terms of access, affordability, and expectations.

Rob Lazerow serves as practice man-ager and David Lumbert as a senior analyst in the Research & Insights division of the global healthcare technology, research and consult-ing firm headquartered in Washington, D.C. Despite the physical lo-cation of The Advisory Board Company, Lazerow noted, “Our work is completely non-political. I stress this because everything with Obamacare is so politically charged.”

With that in mind, he and Lumbert broke down what they’ve seen so far.

Big Picture“We wound up with just over 8 mil-

lion, and that includes the special enroll-ment period which extended to April 19,” Lumbert said of the numbers for the pub-lic exchanges. He added the extra two-week period was only for those who had started the enrollment process before the March 31 deadline. “Originally, the Con-gressional Budget Office had projected 7 million so it did exceed that by just over 1 million,” he continued. Lumbert added nearly half of the enrollees selected a plan in March. “There was definitely a surge at the end due to technical problems being fixed and more education about the pro-cess and deadlines.”

Lazerow said the CBO provided ag-gregate coverage expansion figures that included exchange uptake, Medicaid expansion and potential changes in the employer market for a net/net effect on coverage in the wake of the Affordable Care Act. “From estimates in February 2013 from the Congressional Budget Office, they expected ultimately around 27 million individuals to gain coverage by 2017,” he said. Lazerow added those projections were adjusted downward in February 2014 to project an increase in coverage for nonelderly individuals by about 13 million in 2014, 20 million in 2015, and 25 million in each of the sub-sequent years through 2024. The latest report from Health & Human Services

shows coverage hitting the CBO projec-tion with 8.019 million enrolled through marketplace plans and an uptick in Med-icaid/CHIP enrollment of 4.824 million.

Even with expanded coverage, that still leaves about 31 million nonelderly U.S. residents uninsured. However, about 30 percent of that group, according to the CBO and Joint Committee on Taxation (JCT), are unauthorized immigrants who would not qualify for most Medicaid ben-efits and exchange subsidies. As for the others, the CBO and JCT estimate 20 percent would qualify for Medicaid but choose not to enroll, 5 percent would not be able to get Medicaid coverage because they live in states that didn’t expand the program, and 45 percent would simply opt not to purchase coverage even though they have access to insurance through the exchanges, an employer or directly from an insurer. Still, by 2016, more than 90 percent of legal nonelderly residents are anticipated to have health coverage in the United States.

In assessing the pros and cons of ACA, both analysts noted items in the ‘good’ column might go south down the road just as those tallied as potential nega-tives might not turn out to be a problem over the long term.

So Far, So Good“One of the more baseline elements

is that we now have a reliable, working marketplace where people can go to see a range of plans and the prices for them,” said Lazerow. He added one of the policy objectives was to offer individuals more choice when it came to coverage op-tions. Prior to ACA, most employers and individual carriers offered limited plan options. Lazerow noted that expansion is happening not only in the public mar-ketplaces but also in private exchanges now, as well. “Consumers shopping on exchanges often have a lot more choice in the types of health insurance plans avail-able to them,” he said of the current cli-mate.

Another goal was to create affordable options. “When you factor in all the sub-sidies — and there are subsidies for pre-mium support and cost-sharing subsidies — it appears affordable coverage is now within reach for many,” Lazerow contin-ued.

While most people know front-end subsidies are available to individuals be-tween 100 percent and 400 percent of the federal poverty level (FPL), Lazerow said not as many individuals are aware of the cost-sharing subsidies that also exist. “This is for individuals below 250 percent of the federal poverty level,” he explained, add-ing it helps reduce costs associated with co-payments, deductibles and co-insur-ance. “That’s really important because in-dividuals may not fully understand they’re exposed to those deductibles when they access certain services,” he continued.

“The insurance companies have

reported between 80 and 90 percent of enrollees did pay their first month pre-mium,” Lumbert said. Lazerow added this is on par with what has historically been seen with other individual commercial plans. “The question now,” Lumbert con-tinued, “is whether people will continue to pay the second, third months … especially those who were uninsured before and are unaccustomed to paying a premium every month.”

Another positive for consumers and providers is the new plans include a more generous benefits package. Lumbert noted a 2012 analysis published in Health Af-fairs found 51 percent of pre-ACA poli-cies didn’t offer the minimum standard for ‘essential benefits’ the law requires.

However, when policy termination notices were sent out last year for plans that didn’t meet the litmus test, some fami-lies found the new standards to be a nega-tive, rather than a positive. In the wake of the outcry … and President Obama’s as-sertion people could keep plans they liked … carriers have been allowed to extend coverage deemed out of compliance until 2015.

Red Flags & Open QuestionsThe nightmare rollout got the federal

exchange off to a bumpy beginning. “The

turnaround seems to have done the job, but I don’t think it was the starting place the administration was hoping for,” Laz-erow said tongue-in-cheek. Although en-rollment rebounded, the question remains whether or not the rough start will have a lasting impact on public perception.

Long before the rollout however, the die was cast in what has become a seri-ous issue for long-term hospital survival … particularly in rural areas. In negotiating the terms of ACA, hospitals made conces-sions based on certain coverage assump-tions. Lazerow noted the ‘gets’ outweighed the ‘gives’ in the original scope of the leg-islation. However, he continued, “The Medicaid expansion is a state-by-state issue now. One thing we see for hospitals and health systems is they face all of the downsides of the Affordable Care Act, but they don’t necessarily get all the upside.” Several states without Medicaid expansion have already witnessed the demise of some rural inpatient facilities, which could cre-ate access issues down the road.

Another issue now that the exchanges are active is how patients will operate under the new plans. Lazerow questioned how newly insured individuals would react to costs. “Is there going to be sticker shock … not at the point of coverage … but at

Exchange RateAn early analysis of the federal health exchange

Rob Lazerow



January 10, 2015Jackson, Mississippi

Registration is open!

Mississippi lawmakers approved and Gov. Phil Bryant signed the creation of a Youth Concussion Law (HB 48), which requires public and pri-vate schools with youth activities to adopt and implement a concus-sion management plan and return-to-play pol-icy that includes certain components, including an endorsement by the Mississippi State Depart-ment of Health (MSDH) on a compre-hensive concussion recognition education course, among other safety measures for student athletes.

In response to a nationally debated topic, state lawmakers established the Umbilical Cord Blood Banking Program in the MSDH to provide standards for the highly anticipated program, and provided funding for the bill.

“We had no position on this bill, but we monitored it,” said Tim Moore, presi-dent and CEO of the Mississippi Hospi-tal Association (MHA). “One of our big concerns was that hospitals were going to have mandated expenses with the new law, and hospitals already can’t afford to do what they’re doing.”

The bill mandates the MSDH to pro-vide education materials and create an awareness program on the potential ben-efits of cord blood banking. Also, MSDH must approve brochures and materials

distributed by cord banking companies.Labor unions won’t be happy with

the passage of SB 2653, which prohibits mass picketing of a residence or place of business. Gov. Bryant also signed HB 49, which requires drug testing for certain screened TANF recipients, and HB 547, a health insurance bill that requires insur-ers to honor the assignment of benefits for a year or until the insured revokes the policy.

It withstood 26 actions in both cham-bers and much public debate before Gov. Bryant signed HB 1400, a pro-life bill pro-hibiting abortions to be performed at or after 20 weeks.

In relatively smooth fashion, state lawmakers passed SB 2217, to revise the Anatomical Gift Act to avoid unnecessar-ily delays in organ transplantation.

Concerning schoolchildren, the Mis-sissippi Asthma and Anaphylaxis Child Safety Act (SB 2218) was approved to re-vise provisions requiring school districts to take certain actions relating to children with asthma and anaphylaxis, such as al-lowing the self-administration of asthma medicine at school.

HB 1275, a comprehensive bill that extends the automatic repealer on the statute that provides healthcare services covered under the Medicaid program, de-letes the limitation on covered emergency room visits, and directs the division to update the case-mix payment system for nursing services, among other mandates.

The bill passed after 27 actions and sev-eral amendment revisions.

Mental health changes were made, with the passage of SB 2483, which revises the screening process for mental commit-ment cases. Also, SB 2829 revises autho-rized services provided by regional mental illness and intellectual disability commis-sions to include the creation and operation of primary care health clinics.

Other new laws include: SB 2408 defines “radiation therapy

services” in the state’s certificate-of-need (CON) law; Gov. Bryant signed it March 17.

HB 392 reenacts and extends the re-pealer on the Health Information Tech-nology Act.

HB 542 expands coverage of treat-ment of autism spectrum disorders through the State and School Employees Health Insurance Management Board.

SB 2646 tweaks requirements for health insurance and employee benefit plans in the state concerning telemedicine services coverage. Specifically, it defines “store-and-forward telemedicine services” and “remote patient monitoring services.”

Death by CommitteeA proactive healthcare measure, HB

201, might have seen overweight people sigh collectively in relief when it died in committee. The bill would have mandated the obese to participate in an online pro-gram on obesity.

CON-related legislation introduced during the 2014 session involved the de-nial of a 60-bed nursing home in Jones County (HB 203).

A nursing education bill requiring community colleges to offer online asso-ciate degree program for LPNs (HB 205) also died.

Addressing the rise of disability insur-ance filings, HB 283 would have allowed persons seeking disability benefits to ob-tain medical records at no charge until the final determination of disability. That measure died in committee.

Even though the much-discussed Mis-sissippi Patient Protection Act of 2014 (HB 553) was “a good bill … we supported,” said Moore, it died in committee.

On the Senate side, HB 1349, which would have allowed public and private hospitals to collect certain debts by a set off against a debtor’s tax refund, died in committee.

SB 2120, which would have required hospitals to offer patients flu vaccinations prior to discharge, died in the House.

SB 2389, which would have allowed the Mississippi Development Authority to certify certain areas as a Health Care Industry Zone, died in committee, as did SB 2915, which would have expanded the Health Care Industry Zone Act to include Port Bienville.

After passing both chambers, HB 1289, to create the Commission on the Future of Medicaid and Health Care in Mississippi, died in conference, as did SB 2056, which would have defined adult day care facilities for licensure purposes.

SB 2404, a bill that would have re-

moved the open meetings exemption for public hospitals, died in committee, as did SB 2524, which would have extended the repealer on Medicaid services and in-cluded technical adjustments.

Cash StrappedHB 146, which would have created

the Health Disparities Council, also died in committee, as did HB 275, which would have appropriated additional funds for the Office of Health Disparity Elimina-tion through the MSHD.

Other MSHD-related bills that died included HB 276, to provide funding to federally qualified health centers (FQHCs); HB 280, which would have appropriated a grant to the Southern Health Commission in Washington County; and HB 284, to appropriate funds to establish and operate two STD/HIV specialty clinics.

An appropriation bill (HB 356) to fund care for incarcerated persons with behavioral health issues didn’t pass from committee.

Near MissesAfter a promising start in the session,

SB 2117, which would have established the Mississippi Qualified Health Center Incubator Grant Program in the MSDH, died on the calendar April 2.

“We were disappointed the funds didn’t make it to that particular bill, which would have provided dollars to start new rural health clinics,” said Moore. “We were successful adding those clinics to that bill, which we thought was extremely important, because there are a number of places where the rural health clinic is the only form of healthcare in communities.”

The House passed HB 413 – the es-tablishment of the Mississippi Qualified Health Center and Rural Health Clinic Capacity Building Grant Program – yet it died in the Senate.

“This capacity bill would have helped federally qualified health centers or rural health clinics extend their hours or ser-vices,” said Moore. “We were excited about that, too, but when it came down to it, neither bill made it as a result of non-funding.”

HB 546 was also stopped short in the Senate; the bill would have prohibited health insurers from denying prescription drugs based solely on network distinctions of providers.

HB 550, which would have required health insurance policies to make pay-ments and reimbursements to the Uni-versity of Mississippi Medical Center (UMMC) at a comparable rate, also failed in the Senate.

HB 551, which would have allowed the state insurance commissioner to de-velop uniform hospital claims forms for use for all hospital services reimburse-ment claims, also died in the Senate, as did HB 638, which would have revised health insurance policies to include cover-age for mental illness. However, the Sen-ate version (SB 2331), which clarifies when health insurance policies must include coverage for mental illness, was signed by the governor March 6.

New Laws Taking Effect July 1, continued from page 1

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• Integrated Delivery Systems • Patient Centered Medical Homes • Quality Reporting • ICD-10

the point of service, and how does that im-pact their utilization?”

Lazerow and Lumbert are also tak-ing a wait-and-see stance when it comes to narrowing networks. Lazerow noted a number of health systems and hospitals are increasingly willing to explore the tradeoff between price and volume … ac-cepting lower reimbursement rates in ex-change for creating a deeper relationship with a payer. The same is being seen with private practices.

“It is not just an exchange issue by any means,” Lazerow noted. However, he continued, “It might be more visible on the exchange side.”

Lumbert said it would be interesting to see how patients respond to not having every hospital, every physician included in their plan. Another concern is whether or not there is enough transparency for consumers to fi gure out on the front end exactly who is included in a plan. “For some state-based plans, California comes to mind, there was a feature where you could search for plans based on providers, and there was a glitch where some provid-ers were coming up that weren’t actually in plan,” Lumbert said.

The Bottom Line“We’re fundamentally talking about

the restructuring and changing of the health insurance marketplace,” Lazerow stated.

He said while it is too early to deter-mine whether ACA is the major catalyst for the fundamental changes that are beginning to be seen in the employer-sponsored market … changes that were al-ready underway before the health reform legislation … the law clearly impacted the individual side of the equation. “Certainly it was transformative for those who didn’t have coverage options before and the indi-vidual market as a whole,” Lazerow noted.

With the rise of private exchanges, employers are looking to employees to take more responsibility for their own health and make more decisions about their plans and coverage options … much like in the public exchanges.

“One of the questions we’re asking is if we are on the brink of a new retail healthcare experience,” Lazerow said. “Are we headed into a retail insurance marketplace when the individual patient … the end consumer … is making a lot more decisions especially in three areas — point of coverage, point of service and again at the point of renewal?”

Only time will tell how it all plays out and what it will ultimately mean for pro-vider market share.

Exchange Rate, continued from page 7

with that progress, there’s still a pretty pronounced gender gap.”

When grading sedentary behaviors, the team used the primary indicator of two hours or less of screen time per day, which is in line with the American Academy of Pediatrics recommendation. Although about half the children in America ages 6-11 do adhere to this recommendation, signifi cant ethnic disparities exist, which resulted in the grade of D.

Sedentary behavior included both lei-sure time (watching television or playing a screen-based game) and productive time (reading on a screen or using the com-puter for homework). It should be noted that the negative effects associated with leisure time sedentary behavior have not been observed with productive sedentary behavior. The research team noted future studies should examine the two types of screen time independently to determine health impact.

Pate stressed the research team was sensitive to screen requirements for home-work, but he said that really isn’t the prob-lem. “Kids are spending way too much time in front of screens that really have nothing to do with academic learning,” he asserted. The average time per day Ameri-can youth spent in sedentary pursuits was 7.1 hours.

Despite the poor grades, both Pate and Crouter found a silver lining in the report card. “The good news is now we have a document that pulls everything to-gether and gives us a starting point,” said Crouter. “It helps support where we need to go next, and it gives us the fuel to do that.” He continued, “It’s not about fail-

ing grades and putting blame in any one place. It’s not about blame at this point. It’s where we are so let’s make it better.

Pate concurred, “The report card points out the severity and nature of the problem.” He added the information gathered would be used to review and re-vise the NPAP. “In late 2015, we expect to release the second iteration of the plan,” he said.

In the meantime, Pate concluded, “There absolutely is no substitute for par-ents being attentive to this issue.”

Grade, continued from page 5

The GradesOverall Physical Activity D-

Sedentary Behaviors D

Active Transportation F

Organized Sport Participation C-

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School C-

Community & The Built Environment B-

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An incomplete was given in areas where there is currently insuffi cient information available to establish a grade.

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GrandRounds

Our healthcare specialists have solutions to most every situation you mayencounter in your practice - and more importantly, can help you avoid manypitfalls that often occur in the complex world of today’s medicine.

Every day we partner with hospitals, physicians and other healthcare providerswith issues regarding reimbursement, Stark & Anti-kickback, Licensure, HIPAA,and Certificates of Need - as well as everyday needs such as practice structure,employment guidance and liability defense.

We’re the perfect partner for your healthcare practice. Give us a call to reviewyour challenges - we’ll make a prescription for a trouble-free path.

(601) 856-7200www.cctb.com

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Our healthcare specialists have solutions to most every situation you mayencounter in your practice - and more importantly, can help you avoid manypitfalls that often occur in the complex world of today’s medicine.

Every day we partner with hospitals, physicians and other healthcare providerswith issues regarding reimbursement, Stark & Anti-kickback, Licensure, HIPAA,and Certificates of Need - as well as everyday needs such as practice structure,employment guidance and liability defense.

We’re the perfect partner for your healthcare practice. Give us a call to reviewyour challenges - we’ll make a prescription for a trouble-free path.

(601) 856-7200www.cctb.com

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New Procedure At UMMC Repairs Heart Without Opening Children’s Chests

A significantly less invasive proce-dure a University of Mississippi Medical Center pediatric cardiologist carries out in a catheterization lab is giving kids and parents a new option for a perimembra-nous ventricular septal defect (PVSD).

Ten children have successfully un-dergone Dr. Makram Ebeid’s procedure to plug a PVSD in their heart’s lower half by transporting the plug on a cath-eter that is advanced through the child’s leg. It’s a transformational development borne of clinical trials that could, in time, replace the decades-old standard of surgery requiring at least a three- to five-day stay and post-op care in the pediat-ric cardiac care unit, Ebeid said.

If more parents only knew they could avoid open-heart surgery on their babies or toddlers, many would jump at the chance, said Dr. Jorge Salazar, pro-fessor of pediatric heart surgery and co-director of the UMMC Children’s Heart Center.

A ventricular septal defect is an opening in the septum wall that sepa-rates the heart’s left and right ventricals. That congenital flaw is almost always re-paired during open-heart surgery.

Ebeid, however, has developed a trans-catheter approach. Guided by X-ray imaging, Ebeid threads a wire through a tiny hole in the patient’s leg and into a blood vessel or artery. The wire is guided to the patient’s heart, and the cardiologist passes instruments over the wire that are used to make repairs, such as a plug to seal an opening in the heart, or replacement valves to relieve those that no longer work.

Save “a few scattered cases here and there,” Ebeid said, he’s the only car-diologist placing a plug in a perimem-

branous ventricular septal defect in a catheterization lab. A muscular ventricu-lar septal defect, typically located a little lower in the ventrical, is more commonly repaired in a catheterization lab.

Ebeid was chosen as part of other clinical trials to test the small, nickel-and-platinum plug manufactured by St. Jude Medical.

Few pediatric cardiologists are telling parents of the new treatment option, or perhaps know about it at all, Salazar said.

Parents of Ebeid’s patients get all of the information – and aren’t pressured one way or the other, Ebeid said.

Pass Christian resident Lindsey Stout chose catheterization for her 2-year-old son Wyatt. His pediatric cardiologist first discovered a “massive hole” not long af-ter Wyatt’s birth, and after watching him carefully for a year, referred the family to Ebeid, Stout said.

Stout said Ebeid told her 95 percent of cardiologists would just open him up, but that he felt comfortable closing it with a catheter. It wasn’t a difficult deci-sion for her she said.

Ebeid discovered a total three holes, Stout said. If we had done surgery, they would have had to break his ribs and to stop the almost 2-year-old’s heart she said.

Open-heart surgery requires plac-ing the child on a heart-lung bypass ma-chine. The child is temporarily on a venti-lator in the pediatric ICU, but goes home in five days or less. If Ebeid concludes a patient is a better candidate for surgery, even after he’s begun catheterization, the child often can go to the operating room right then for surgery performed by Salazar.

The change in Wyatt’s health was immediate, his mom said. Before, he was tired all the time and ran out of breath quickly she said.

Ebeid and Salazar know the pro-cedure has worked when an echocar-diogram shows improved function and heart size. And, Ebeid said, there’s an-other sign of success, one that certainly brings joy to the heart of a parent.

Memorial Welcomes Internal Medicine Physician

Memorial Physician Clinics wel-comes Nancy C. Montz, MD, in the prac-tice of Internal Medicine at Memorial Physician Clinic, in Biloxi.

Dr. Montz graduated with her undergraduate degree from the Univer-sity of New Orleans. She earned her medical doc-torate from Louisiana State University Health Sciences Center, School of Medi-cine in New Orleans. Dr. Montz complet-ed her residency in Internal Medicine at LSU Health Sciences Center in New Or-leans.

Dr. Montz is Board Certified in inter-nal medicine.

Dr. Nancy C. Montz

Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.


GrandRoundsMedEvolve EHR Software is Certified for Meaningful Use Stage 2

MedEvolve, a provider of practice management software, electronic health records (EHR), and physician revenue cycle management services, today an-nounced that its EHR solution, MedE-volve EHR 6.0, has been tested and was certified for Meaningful Use Stage 2 on April 13, 2014 by Drummond Group’s Electronic Health Records Office of the National Coordinator Authorized Cer-tification Body (ONC-ACB) program. MedEvolve EHR 6.0 met the require-ments for ONC’s Complete EHR 2014 criteria which were adopted by the Sec-retary of the US Department of Health and Human Services. MedEvolve’s EHR 6.0 supports both Meaningful Use Stage 1 and Stage 2 measures, and is certified for use by eligible providers to qualify for EHR incentives.

Drummond Group’s ONC-ACB cer-tification program certifies that EHRs meet the meaningful use criteria for ei-ther eligible provider or hospital tech-nology. In turn, healthcare providers us-ing the EHR systems of certified vendors are qualified to receive federal stimulus monies upon demonstrating meaningful use of the technology – a key compo-nent of the federal government’s push to improve clinical care delivery through the adoption and effective use of EHRs by U.S. healthcare providers.

This Complete EHR is 2014 Edition compliant and has been certified by an ONC-ACB in accordance with the ap-plicable certification criteria adopted by the Secretary of the U.S. Department of Health and Human Services. This certifi-cation does not represent an endorse-ment by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments.

SVMIC Declares $7.5 M Dividend

State Volunteer Mutual Insurance Company’s Board of Directors has de-clared a dividend of $7.5 million to be returned to all policyholders renewing in the twelve-month period following May 15, 2014.

This is the seventh consecutive year SVMIC has declared dividends for its physician policyholders. Policyholders will receive the dividend in the form of a credit on the renewal premium. Ad-ditionally, rates will remain unchanged for 2014.

Since SVMIC’s inception, a total of $335.5 million has been returned to phy-sician policyholders. For additional infor-mation, call SVMIC at (800) 342-2239 or email [email protected].

Southern Miss Alumnus Langton Appointed to State Board of Health

A prominent University of Southern Mississippi alumnus brings his experi-ence and expertise gained in the world of business as one of the newest mem-

bers of the Mississippi State Board of Health.

Edward J. “Ed” Langton (’70), CEO and Chairman of the Board of Grand Bank in Hattiesburg, was appointed by Gov. Phil Bryant to the State Board of Health and was sworn in at its April meeting. Langton holds a bachelor’s degree in business administration from Southern Miss and has served as past president of The USM Foundation and the University’s Alumni Association.

The State Board of Health’s primary duties include providing policy for the agency; appointing a State Health Officer to operate the agency; approve the State Health Plan; and approving all rules and regulations of the agency. Langton’s term on the board runs through June 2017.

A graduate of Long Beach, Miss. High School, Langton is a military veter-an who served as a first lieutenant in the U.S. Army. He has more than 40 years of experience in banking and finance and is founder, Chairman and CEO of Mort-gage Funding Corporation, a mortgage banking firm specializing in the nation-wide purchase of mortgage loans. His multi-faceted career includes experi-ence in real estate development and in-vestment, magazine publishing and the automotive and construction industries.

For his service to the university, Langton was inducted into its Alumni Hall of Fame in 2001, received its Con-tinuous Service Award in 2006 and the Moran Pope Meritorius Service Award in 2012. In 2010, Langston and his family made a generous gift to Southern Miss to construct its Centennial Gateway at the main entrance of the Hattiesburg campus.

He is also active in his community, having served on numerous boards of local non-profit organizations, including on the advisory board for the DuBard School for Language Disorders at South-ern Miss. Langton is also founder and chairman of IF-I Foundation, a non-profit charitable foundation.

Hattiesburg Clinic Welcomes Hernandez

William J. Hernandez, CNP, recently joined Hattiesburg Clinic’s Downtown Medical Associates as a nurse practitio-ner.

He earned his Bachelor of Science in nursing through the University of Medicine and Dentistry of New Jersey and Ramapo College of New Jersey in Mahwah, N.J. He received his Master of Science in nursing from the University of Alabama in Birmingham, Ala.

Hernandez is a U.S. Navy veteran of the Gulf War in Operations Desert Storm and Desert Shield. He is board certi-fied by the American Academy of Nurse Practitioners. Hernandez is a member of the Delta Epsilon lota Honor Society, Graduate Nursing Association, Missis-sippi Nursing Association, New Jersey Nursing Association and the Oncology Nursing Society. He joins Charles D. Her-nandez, DO.

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Mississippi Medical News July 2014

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