C M S Bulletinhh-law.com Business • Employment • Estates and Trusts • Health Care Litigation • Oil and Gas • Public Finance • Real Estate Care is Your Business, Change

Allegheny County MediCAl SoCiety

BulletindeCeMber 2019

Winter nourishment

New Stark and Anti-Kickback rules

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Business • Employment • Estates and Trusts • Health Care Litigation • Oil and Gas • Public Finance • Real Estate

Care is Your Business, Change is OursThe healthcare environment is changing. Physicians must focus on providing the highest quality care with intense competition for their time. Medical practices face increased challenges tied to changes to regulation, insurance protocols, cost-management and revenue management.

Houston Harbaugh has over 30 years of experience in helping physicians and medical practices manage change through contract negotiations with hospitals and payors; contract management; advocacy and new practice start-up counsel. We have provided critical support in practice mergers and acquisitions. And we have provided sound advocacy on issues ranging from HIPAA compliance to medical staff and peer review matters.

Every challenge a medical practice can face, we have seen. We have helped practices of all size and structure meet these challenges. And we know what is ahead.

BulletindeCeMber 2019 / Vol. 109 No. 12

Allegheny County MediCAl SoCiety

ArticlesOpinion Departments

Materia Medica .....................425Trikafta™ (ivacaftor/tezacaftor/ elexacaftor): A breakthrough therapy for cystic fibrosis patients who carry at least one F508del mutationAdam Patrick, PharmD candidate

Legal Report ........................428Regulatory sprint to coordinated care: New Stark and Anti-Kickback rules Michael A. Cassidy, Esq.

Special Report .....................432Update on the prevalence of blindness at the Western Pennsylvania School for Blind ChildrenHeidi Ondek, EdD Albert Biglan, MD Beth Ramella, MEd

Special Report .....................437Reportable Diseases 2019: Q1-3

Special Report .....................4382019 PAMED House of Delegates report

Editorial ................................406Winter nourishment Deval (Reshma) Paranjpe, MD, FACS

Editorial ................................410Retirement Richard H. Daffner, MD, FACR

Editorial ................................413Then and nowAndrea G. Witlin, DO, PhD

Perspective ..........................415Choosing a Medicare plan Namita Ahuja, MD

Society News .......................418• Greater Pittsburgh Diabetes Club• Pennsylvania Geriatrics Society – Western Division• Pittsburgh Ophthalmology Society• Pennsylvania Medical Society announcements

Activities & Accolades.........421

Membership Benefits...........422

In Memoriam ........................424• Robert Love Baker, MD

Editorial Index......................440

Advertising Index.................442

On the coverLight the NightMalcolm Berger, MD

Dr. Berger specializes in neurology.

ACMS ALLIANCECo-PresidentsPatty Barnett

Barbara WibleRecording Secretary

Justina Purpura Corresponding Secretary

Doris DelseroneTreasurer

Sandra Da CostaAssistant Treasurers

Liz BlumeKate Fitting

2019 Executive Committee

and Board of Directors

PresidentAdele L. TowersPresident-elect

William K. JohnjulioVice President

Patricia L. BononiSecretary

Peter G. EllisTreasurer

Matthew B. StrakaBoard Chair

Robert C. Cicco

DIRECTORS 2019

Thomas P. Campbell Michael B. Gaffney

Keith T. Kanel Jason L. Lamb

Maria J. Sunseri2020

David L. BlinnLawrence R. JohnBruce A. MacLeod

Amelia A. ParéAngela M. Stupi

2021William F. CoppulaDavid J. Deitrick Kevin O. Garrett

Marcy L. Jackovic Raymond E. Pontzer

PEER REVIEW BOARD2019

Robert W. BragdonJohn A. Straka

2020James W. Boyle

Matthew A. Vasil2021

Thomas P. Campbell Keith T. Kanel

PAMED DISTRICT TRUSTEEAmelia A. Paré

COMMITTEESAwards

Keith T. KanelBylaws

Patricia L. BononiFinance

David L. BlinnGala

Patricia L. BononiMembership

William K. JohnjulioNominating

Thomas P. Campbell

COPYRIGHT 2019:ALLEGHENY COUNTY MEDICAL SOCIETYPOSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 713 Ridge Avenue, Pittsburgh, PA 15212.

ADMINISTRATIVE STAFF

Chief Executive OfficerJeremy T. Bonfini

([email protected])

Senior Manager,Society Governance and

Medical Community EngagementDorothy S. Hostovich

([email protected])

Manager, Medical Community Engagement and Society

Governance Michelle Besanceney

([email protected])

Director of Operations, Finance and Compliance

Amanda S. Kemp ([email protected])

Director of PublicationsMeagan K. Sable

([email protected])

Vice President of Physician Engagement and Digital Strategy

James D. Ireland ([email protected])

Director, Medical Community Engagement

Nadine M. Popovich ([email protected])

EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 713 Ridge Avenue, Pittsburgh, PA 15212; (412) 321-5030; fax (412) 321-5323. USPS #072920. PUBLISHER: Allegheny County Medical Society at above address.

The Bulletin of the Allegheny County Medical Society welcomes contributions from readers, physicians, medical students, members of allied professions, spouses, etc. Items may be letters, informal clinical reports, editorials, or articles. Contributions are received with the understanding that they are not under simultaneous consideration by another publication.

Issued the third Saturday of each month. Deadline for submission of copy is the SECOND Monday preceding publication date. Periodical postage paid at Pittsburgh, PA.

Bulletin of the Allegheny County Medical Society reserves the right to edit all reader contributions for brevity, clarity and length as well as to reject any subject material submitted.

The opinions expressed in the Editorials and other opinion pieces are those of the writer and do not necessarily reflect the official policy of the Allegheny County Medical Society, the institution with which the author is affiliated, or the opinion of the Editorial Board. Advertisements do not imply sponsorship by or endorsement of the ACMS, except where noted.Publisher reserves the right to exclude any advertisement which in its opinion does not conform to the standards of the publication. The acceptance of advertising in this publication in no way constitutes approval or endorse-ment of products or services by the Allegheny County Medical Society of any company or its products.

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ISSN: 0098-3772

Improving Healthcare through Education, Service, and Physician Well-Being.

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Bulletin Medical Editor

Deval (Reshma) Paranjpe([email protected])

Associate EditorsRichard Daffner

([email protected])Charles Horton

([email protected])Anthony L. Kovatch

([email protected])Scott Miller

([email protected])Amelia A. Paré

([email protected])Joseph C. Paviglianiti

([email protected])Anna Evans Phillips

([email protected])Andrea G. Witlin

([email protected])

Managing EditorMeagan K. Sable

([email protected])

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Editorial

406 www.acms.org

Winter nourishmentDeval (Reshma) PaRanjPe, mD, FaCs

Happy Holidays! It’s that time of year again – we all could use some

cheer, company and delicious food to warm our hearts and get us through to the new year.

Here are some unique and delight-ful holiday suggestions that might take you off the beaten path for an unex-pectedly fun outing:

Miracle Christmas pop-up bar• Downtown: Miracle on Liberty,

717 Liberty Ave., in The Clark Building• South Side: Miracle on Carson,

2240 East Carson St., formerly the Lava Lounge

• Both locations are open until Tuesday, Dec. 31, from 5 p.m. to 2 a.m.; South Side location opens daily at 4 p.m.

Nationally award-winning hometown mixologist Spencer Warren is bring-ing back the wildly popular Miracle, a Christmas-themed pop-up bar that celebrates all things Christmas with lavish decorations and fabulous liba-tions – 22 unique specialty cocktails in all this year that will at once make you feel hip … and forget about any other joint pains. This year, Pittsburgh is treated to two locations, which promis-es to break up the congestion, and is important to remember should you tell someone to meet you at Miracle. Both Miracle bars will be partnering with 412

Food Rescue as in the past, with a goal of raising $50,000 in donations.

Christmas Story pop-up bar • DoubleTree Hotel Bar, 500 Mans-

field Ave., Green Tree• Thursday, Dec. 19, and Friday,

Dec. 20, 4:30 to 9 p.m.If you’re like me and can’t get

enough of this beloved holiday film, you may want to get a grown-up Christmas Story fix during the two-day run of this new pop-up bar featuring 360 degree film décor (Red Ryder BB gun, bun-ny suit and all) as well as cardboard cutouts of the actors. You’ll be offered cinema-themed cocktails including the “Oh Fudge,” “Major Award” and “Pink Nightmare” as the movie streams con-tinuously in the background. And watch out for that Leg Lamp – remember, it’s “Fra-JEE-Lay. And please don’t shoot your eye out – trust me, I’m an ophthal-mologist.

A Gilded Age Christmas: Holiday Tours of Clayton

• The Frick Mansion, 7227 Reynolds St., Point Breeze

• Open until Sunday, Jan. 5• Tickets: www.thefrickpittsburgh.orgCome see the opulence of a bygone

era and step back in time as you walk through the doors of the Frick Mansion. Beautifully decorated in period style,

Christmas at the Frick is not to be missed: a lovely break from the hustle and bustle of modern times. Round out your visit with a visit to the Katherine Hepburn costume exhibit (through Jan. 12) and lunch at the Café at the Frick (members may make reservations; others, first come first serve) or neigh-boring Point Brugges for mussels and other delights.

City of Pittsburgh Gingerbread House Competition

• City-County Building, Downtown• Until Jan. 3; Mondays-Saturdays,

10 a.m. to 8 p.m.; Sundays, 10 a.m. to 5 p.m.

Come look at hundreds of com-munity-made gingerbread houses on display for inspiration and wonder (look, but don’t eat, please!)

Lumaze Interactive Light Show• Strip District: 31st Street Studios • Until Saturday, Jan. 4• https://www.lumazelights.com/

pittsburgh-christmas/Tired of the cold? Here’s an indoor

light festival with seasonal food and beverages, light gardens, entertain-ment and more than 30 vendors from the I Made It! Market at its vendor market. Season passes available; also look for Groupon specials.

Editorial

407ACMS Bulletin / December 2019

Chanukah Festival at the Waterfront

• Monday, Dec. 23, 8 a.m. to 5 p.m.• https://jewishpgh.org/event/chanu-

kah-festival-at-the-waterfront-2/Celebrate the first night of Chanu-

kah with an all-day event featuring an outdoor concert, menorah lighting, food vendors, and games and children’s activities.

Chinese food and movies on Christmas Eve and Christmas Day

• Row House Cinema, Lawrenceville• Tuesday, Dec. 24, and Wednes-

day, Dec. 25 If Chinese food and a day at the

movies are a tradition for you, come switch it up at Row House Cinema. Choose from a wide selection of mod-ern holiday classics including Die Hard, Krampus, National Lam-poon’s Christmas Vacation and The Muppet Christmas Carol. Order Chi-nese take-out and sushi at the conces-sion stand and have it delivered to your seat mid-movie for a new experience.

New restaurants worth a tryGordo’s Taco Diablo (297 Beverly

Road, Mt. Lebanon)From the people behind Café Io,

behold Mexico City inspired tacos, with a twist. Dinner weekdays; lunch and dinner weekends. Closed Monday.

Threadbare Cider and Mead Tast-ing Room (Ross Park Mall)

Threadbare Cider and Mead has opened a tasting room and bottle shop next to that of its sister brand, Wigle Whiskey, at the Ross Park Mall. If holiday shopping has you in need of some cheer, stop by and sample their

award-winning ciders and mead made from local fruits and honey. (www.threadbarecider.com)

Guapo (Federal Galley, 200 Chil-dren’s Way, North Side)

Discover the Land of Enchantment at Guapo. New Mexico native turned Pittsburgher Frank Adelo is turning out traditional New Mexican cuisine red-olent of fragrant Hatch Chile. Nothing warms up your blood on a cold day like enchiladas slathered in red, green or Christmas (some of each) chile sauce. Tacos and other delights also are on the menu, with fillings that range from carne adovada (Hatch chile braised pork stew), chicken, shrimp or vege-tarian calabacitas (fire roasted squash, onions, corn, mushroom and more Hatch chile with cheese). Libations range from beer to palomas, margari-tas and a lovely cocktail program.

Open for lunch and dinner seven days a week, plus weekend brunch starting at 10 a.m. (https://www.federal-galley.org/restaurants/guapo/)

KIIN Lao and Thai Eatery (5846 Forbes Ave., Pittsburgh Squirrel Hill, formerly Bangkok Balcony)

KIIN Lao & Thai Eatery features Lao and Isan-style cuisine (Isan is a region of Thailand bordering both Laos and Cambodia). Bangkok balcony favor-ites also are included on the menu for those who miss the old restaurant. KIIN means “Eat together” in both regions and is a fitting name for this adventure.

Open Monday through Friday, 11 a.m. to 10 p.m.; weekends 11 a.m. to 11 p.m.

Coming attractionsPittsburgh Restaurant Week

Winter 2020 Edition: Friday, Jan. 10, through Sunday, Jan. 19

The Winter Edition of Pittsburgh Restaurant week is the perfect excuse to come out of post-holiday hibernation, join friends and try out new eateries and revisit old favorites, all while enjoying fabulous deals and prix fixe menus.

You can find the schedule, including restaurants and menus, here: http://pittsburghrestaurantweek.com/restau-rants/winter-2020-restaurants/

Fig & Ash (East Ohio Street, North Side)

Upscale wood-fired grill entrees from a chef who has graced the finest restaurants in Pittsburgh. Opening: winter 2019.

Oakmont Barbecue Company (Allegheny River Boulevard, Verona)

What to expect: The same delicious barbecue that’s been served by the popular Oakmont Barbecue Company food truck – pulled pork, beef brisket, ribs, nachos and mac and cheese – only in a brick-and-mortar setting. Opening: early 2020.

The Woods House (Monongahela Avenue, Hazelwood)

The John Woods House was built in 1792 and may be the oldest dwelling in the City of Pittsburgh. It is being reno-vated into a Scottish pub featuring both Scottish and Pittsburgh (think piero-gies) fare and, naturally, many kinds of beer. Step back into history and enjoy an overlooked but legendary homesite. Opening: 2020.

The Eagle Food and Beer Hall (Penn Avenue, Downtown)

What to expect: More excellent fried chicken in Pittsburgh. Brined, dredged and deep-fried, the Eagle’s chicken will be served with hot honey, southern favorites, craft beer and, best of all, blues music. Opening: 2020.

Continued on Page 408

The Coop Chicken and Waffles (401 East Ohio St., cor-ner of Cedar and East Ohio streets, formerly Rita’s Italian Ice, North Side)

More great fried chicken, this time with a plethora of waffles. The eponymous food truck will now have a brick-and mortar shop which will deliver to Allegheny General Hospital and Downtown. Opening: January 2020.

Wishing you delicious holidays and a warm and wonderful winter!

Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at [email protected].

Editorial

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410 www.acms.org

Editorial

RetirementRiChaRD h. DaFFneR, mD, FaCR

The email from the International Skeletal Society (ISS) invited me to be on the faculty for the Refresher Course

at their annual meeting. I responded that I was flattered to be asked and added that I had been retired (at that time) for five years. The return email insisted that I participate and speak on the imaging of suspected spine trauma. After all, the chairperson reminded me, I was still considered an expert in that area, having written what was considered the definitive textbook on the subject as well as the recommen-dations for imaging on that topic for the American College of Radiology in their Appropriateness Criteria®. And so, as Michael Corleone said in “Godfather III:” “Just when you think you’re out, they pull you back in.”

I have been asked by many colleagues and friends who were nearing retirement age if I had any advice and words of wisdom on the subject. In short, here are six areas for potential retirees to consider: 1). Know when the time is right; 2). Understand that retirement is not just stopping working; 3). Have a plan; 4). Fill your time; 5). Financial considerations; and, perhaps most importantly 6). Be aware of how your retirement will affect your spouse/partner. Let’s consider each of these areas.

Knowing when the time is rightYears before I thought of retiring, older colleagues, whom

I met at professional meetings, often asked me when I was going to retire. My answer was always the same, “Either when I have a serious health issue or if the job stops being fun.” In 2007, I underwent a total hip replacement and was off work for two months. As I sat rehabbing at home, I thought that if retirement was going to be like this, I wasn’t ready for it.

Two years later, I had the other hip replaced. This time, however, I began thinking that this wasn’t so bad. I got up later, had a leisurely breakfast, read the newspapers, did

the New York Times crossword puzzle, and could take a nap whenever I felt like it.

I still wasn’t ready. I enjoyed my work – the daily con-sultations with various clinicians, as well as teaching my residents and the medical students. But things were chang-ing. Our group was one of the last independent practices in the then West Penn-Allegheny system that had recently been taken over by Highmark. Pressure was being put on our chairman to have the group become Highmark employ-ees, like the other physicians in the system. At the time, there were five members of the group who were over age 65, and I felt that subtle pressure was being placed on us to retire. For me, the fun stopped when I learned that my week-end call was being increased by 25%. At the same time, I received a phone call from my tax advisor asking if I had taken my minimum required deduction (MRD) from my IRA, since I had turned 70 and a half. Some quick mathematical calculations of my MRD from not only my IRA, but also from my TIAA/CREF accounts from my days working at Duke, showed that I would be pushed into a higher tax bracket. So, the prospect of working harder and paying more in taxes convinced me that the time was right to retire.

Another, perhaps more common, scenario is the situation where the physician loses his/her ability to continue practicing. This may be the result of illness, including (early) dementia. In some instances, the physician recognizes his/her shortcom-ings and voluntarily retires. In others, his/her partners may notice a drop in clinical acumen, lower productivity, or an in-creased error rate and recommend that their colleague retire. In these situations, the hospital Medical Staff Committee may recommend retirement and loss of privileges.

Understanding what retirement isMany people think retirement is simply stopping work.

And, for many, that is exactly what they do. They stop work-


Editorial

ing, sit at home, watch television, eat snacks, gain weight and often die at an early age. During their working lives, they never developed outside interests or hobbies. For them, their occupations were their lives. For others, however, and I include myself in that group, retirement meant leaving one chapter of their lives, and moving on to one or more new chapters. That may involve an entirely new occupation, par-ticularly for those who have the financial need (see below). Or, pursuing and/or developing other interests. Often, the retiree becomes (more) involved in (additional) volunteer activities or seeks to broaden their knowledge bases by participating in one or more adult education programs, such as Osher at CMU or at the University of Pittsburgh.

When I announced that I was going to retire to my chairman, he asked me if I would consider continuing giving lectures to our residents and students. He pointed out that I gave more didactic conferences to our residents than any other faculty member. Furthermore, he reminded me that many of my topics covered areas that the other staff either had no interest in or that they felt were not in their areas of expertise. As a musculoskeletal (MSK) radiologist, I concen-trated on interpreting (old fashioned) X-ray images as well as CT applications to bone abnormalities. My younger MSK colleagues preferred doing MRI and invasive procedures (arthrograms, biopsies and CT-guided screw placements). And so, I agreed to continue lecturing for two years, but with the stipulation that I now be paid the going rate for visiting professors. The reason I set a time limit was because I felt that without exposure to current clinical cases, my material would become outdated. Fortunately, my former partners were more than generous in providing me with new material whenever I requested it.

Having a planMost new retirees have some sort of plan for what they will

be doing with all their free time: getting up later in the morning; spending more time with their children and/or grandchildren; taking longer vacations, for example. For many, they will now be able to spend more time on hobbies, projects, or in volun-teer activities to which they already belong. In many instanc-es, however, most of those activities already take place in evenings, after the normal working day. I already played in a community concert band and belonged to a flute choir. I joined a second band that played primarily during summer months when most other community bands took time off.

I have been a Boy Scout leader for 43 years, devoting one evening a week to troop meetings and two weeks for summer camp. I immediately signed up to be on the staff of two additional weeks of an Advancement Camp, where I taught several different merit badges. In addition, I signed up to be on the medical staff for Mountainfest, a Council-wide event at Heritage Reservation, our main scout camp. In addition, as a member of the Laurel Highlands Council Enterprise Risk Management Committee, I agreed to be the Council Medical Supervisor, overseeing the medical policies and procedures at our many resident and weekend camps.

Finally, I increased my vacation time. In addition to my two weeks at scout camp, I increased my week at a summer cabin owned by my cousin at lake Luzerne, in the Adiron-dacks. And my wife and I also extended our annual visit to Grand Cayman to an additional week.

Filling your timeFilling your time once you retire is a must. Think about

other interests that you have and make your participation in them a reality. Again, this may involve taking on additional responsibilities in organizations to which you already belong. I have been a Trustee of the Albany College of Pharmacy and Health Sciences (ACPHS), my alma mater, on and off for many years. The year I retired, the president of ACPHS announced his retirement after the current academic year. The chairman of the Board asked me to chair the Search Committee, since he knew “I had the time.” That job required frequent trips to Albany from July through December, when we selected our new president. I didn’t realize how many trips I made until the Southwest Airlines gate agent in Albany started greeting me by name!

I joined other organizations, volunteering at South Hills Interfaith Movement (SHIM), building shelves and storage areas for their food pantries; Rotary Club; Mt. Lebanon Reader’s Theater, where we read one-act plays at retire-ment and nursing homes; and Global Links, where I rebuild wheelchairs that are sent to Central and South America.1

One of my most rewarding activities is the participation in the Osher Lifelong Learning Institute programs. Here one can take a variety of courses covering a list of topics in arts and humanities, business and commerce, science, social sciences, as well as a diverse list of topics called “learning by doing.” We are fortunate here in Pittsburgh, in that we


412 www.acms.org

Editorial

have two Osher programs – one at CMU and the other at the University of Pittsburgh. The CMU program has a fixed number of memberships due to space limitations; the Pitt program is under the auspices of their Graduate Education Department and has open membership. In addition to taking courses, I am also a study leader for both programs. The thing I appreciate most about the Osher program is that all participants, both learners and study leaders, are mature adults, who are motivated to learn. This is in sharp contrast to my experience teaching medical students and residents.

And, of course, I have been able to contribute to the Bul-letin first as an author of Perspective pieces, and now as an assistant editor. Filling my time has led me to often observe that I’m busier now than when I had gainful employment.

Financial considerationsMaintaining your lifestyle and determining what you do

in retirement is, of course, dependent on how financially secure you are. Some people, unfortunately, can’t retire because they have not done the requisite financial planning to assure a comfortable retirement. Sadly, Social Security is not enough to live on. Furthermore, serious or prolonged illness can rapidly deplete one’s retirement “nest egg.” Financial planning for retirement should begin immediately when one joins the workforce after residency or fellowship. Unfortunately, many young physicians don’t think of this as they start practicing. An important but simple tool is to make a table of one’s yearly income and expenses from existing savings and checking accounts. This will change over time, as children enter college, graduate and move on with their lives. The result, under each set of family circum-stances, will give you a monetary number of what you need to maintain your current lifestyle. There may be a need for sacrifices – perhaps one less vacation, or eating out less frequently. Or, if you have planned properly, you can be as-sured by your financial advisor that you have enough money to maintain your lifestyle until age 110.

From Page 411

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board,

the Bulletin, or the Allegheny County Medical Society.

Reference1. Daffner RH. The ‘R’s’ have it. ACMS Bulletin 2017; August,

288-289.

Spousal/partner considerationsDon’t forget your spouse or domestic partner when

considering retirement. In most instances, while we are busy tending to the ills of humanity, they also have developed a lifestyle of their own. Retirement often is a cause of divorce among older couples. Physicians, because of their busy pro-fessional schedules, don’t often spend a lot of time at home. Once they retire, they’re home much more, especially if they don’t fill their time.

It’s often been said that retirement leads couples to either become much closer, or, get on each other’s nerves. Right after I retired, my wife of 48 years explained the “rules of the house” (for example, “Last one up makes the bed”). There are activities we do together as well as those we do individ-ually.

SummaryRetirement represents entering a new stage in one’s

life. The retiree will have opportunities to participate more frequently in activities which they enjoy, or to try new ones. Approaching retirement requires planning, not only to fill your time fruitfully, but also to assure that you will have the financial wherewithal to maintain your current lifestyle.

Dr. Daffner, associate editor of the ACMS Bulletin, is a retired radiologist who practiced at Allegheny General Hospi-tal for more than 30 years. He is emeritus clinical professor of Radiology at Temple University School of Medicine and is the author of nine textbooks. He can be reached at [email protected].

For classified advertising information, including special member rates, email Bulletin Managing Editor Meagan Sable at [email protected],

call (412) 321-5030, ext. 105, or visit www.acms.org.


Editorial

Then and nowanDRea G. Witlin, DO, PhD

The good ole days in medicine were unquestionably different for patients

and doctors alike. Recently, I’ve been a party to numerous discussions lament-ing “the loss” of those “better times.” Personally, I’m not convinced that when I started school in the ’70s (my reference point) was that idyllic. The abuse and harassment were pervasive. Complaining was not an option.

As students and house staff, we both marveled and were appalled at our autonomy. I could write a book of my exploits that would make you shutter with horror and disbelief. That said, our independence afforded us irreplaceable experience. Fortunately, today’s trainees are not subject to that “baptism of fire” that had been pervasive when I trained. Attendings were infrequently “in house” (especially after 5 p.m.) and were seldom sited at a vaginal delivery unless the woman was a VIP or “crowning.” We residents “made the call” regarding Cesarean(s) with attendings arriving with our patient already on the OR table. Undeniably, we had our share of complications and were regularly reprimanded for either calling too early or too late.

Technology in obstetrics/gynecology (OBG) was in its infancy then. We were lucky if we had a bulky Doppler device that could detect the fetal heart rate by 14 weeks. Our first real-time ultrasound

replaced the static B scan unit midway through my second year of residency. This wonderful new technology was the size of a volleyball that required two hands to grasp. Needless to say, the resolution was poor, but at least we could finally view a beating fetal heart. The much-maligned vaginal probes weren’t introduced until years later. We could start “dating” pregnancies, but early scans were far from routine and rarely ordered. Worse, as residents, we were routinely chastised for ordering GYN ultrasounds. The rationale – if you could feel a pelvic mass, why did you need an ultrasound? If you couldn’t feel a mass (even in the obese patient), you weren’t worth your salt as a resident. Quantitative human chorionic gonad-otropins (HCGs) were only available to monitor trophoblastic disease and were not used to determine viability or monitor ectopic pregnancies. The first in-vitro baby was a case report. Assist-ed reproductive technologies were in their infancy. The rare amniocentesis was performed by marking a spot on the patient’s belly that corresponded to a pocket of amniotic fluid as observed on our rudimentary ultrasound in radiol-ogy, followed by transport to the clinic where a needle was inserted blindly (and hopefully without complication). Admittedly a positive – it was more fun to deliver a baby and discern the

gender for the first time and share the excitement with the gleeful parents!

Radiology was light years behind! “Plain films” and floro(s) predominat-ed and had to be reviewed with the radiologist in the hospital department. Nuclear medicine scans were avail-able, albeit with poor resolution. Head CT scans were introduced during my residency but lacked the current res-olution. Abdominal CT scans followed later. High-resolution chest CTs for pulmonary embolisms (PEs) weren’t even in the vocabulary. MRIs didn’t appear until I was in practice but were rarely ordered because of cost and reimbursement issues.

Pharmacology was rudimentary as well. One could actually recognize the classes and function of most medi-cations. Chemo options were limited. Rheumatologic treatments were limited to NSAIDs, prednisone, methotrexate and gold. DMARDs and monoclonal antibody therapies weren’t even a figment of anyone’s imagination. We entertained the drug reps and were anxious for their samples (and gifts). Fortunately, the TV ads were absent.

Patients tended to present “sicker” and/or more advanced in their disease process. Diffuse early complaints were usually ignored or dismissed. Retro-spectively, my personal medical care


414 www.acms.org

Editorial

was a casualty of this practice and my diagnoses were delayed. Conversely, there was a lack of treatment heroics for end-stage disease and its related complications. Advanced heart failure was a death sentence. Liver transplant for end-stage disease secondary to cancer or lung transplant for cystic fi-brosis would have been unfathomable. Death was considered inevitable for many conditions.

Inpatient treatment was the norm. Hospice didn’t exist. Critically ill and dying patients “camped out” in their hospital beds for days to months. The positive was that we witnessed the true extent of human suffering. We inter-acted with family members and under-stood their anguish. Correspondingly, progress notes were sparse and many times illegible. Everyone knew what was going on, so why write about it?

Camaraderie amongst physicians was common. It was not uncommon to see the hospital cafeteria popu-lated with groups of house staff and attendings following morning teaching rounds. Residents commiserated to-gether in the resident’s lounge while on

call and schemed together to deal with our harassment from the nurses. There were no iPhones, iPads, laptops, not even TVs in the patient’s rooms. Just old-fashioned communication.

Malpractice insurance was less expensive, malpractice suits less com-mon and awards smaller. Defensive medicine was rarely discussed though we did focus on adhering to current, quality standards of care. I don’t recall any current or pending lawsuits for any of our attendings. It was almost unheard of for a resident to be sued. We routinely had patients transferred manifesting outrageous complications secondary to egregious “malpractice” and negligent care. Yet, it was almost unheard of that our patients sued their local doc.

Life was definitely less complicated by today’s terms. We still had burnout (although the term wasn’t used), drug and alcohol abuse, and suicides. There were the never-ending complaints about the administrators. Docs made decent incomes, some more than others. Some chased money and some didn’t. There were good docs and bad, caring nurses and not. Docs and

nurses who routinely stayed overtime and those who did the minimum to get by. Those who kept up and those who didn’t.

So, let’s be real … do you really want to return to the good ole days? There are clearly vexing issues (insur-ance authorizations and administrative quagmires) that present seemingly insurmountable stressors for patients and doctors alike. It is likely that my generation and those before didn’t object vehemently enough and that we allowed these problems to fester and multiply. But we dealt with them, nev-ertheless. Life’s a trade-off. I, for one, prefer to tackle the current obstacles and not ruminate about those elusive halcyon times.

Dr. Witlin, associate editor of the ACMS Bulletin, is a retired maternal/fetal medicine physician and research-er. She can be reached at [email protected].

The opinion expressed in this column is that of the writer and does not necessarily reflect

the opinion of the Editorial Board, the Bulletin, or the

Allegheny County Medical Society.

From Page 413

Improving Healthcare through Education, Service,

and Physician Well-Being.


PerspectivePerspectivePerspective

Choosing a Medicare plan

namita ahuja, mD

Before you can choose the Medicare Advantage plan that is best for you, it’s important to understand the basics of

Original Medicare. Medicare is a federal health insurance program. In order

to qualify, you must be a U.S. citizen or lawfully present in the United States. You also must be age 65 or older; or be under age 65 with certain disabilities; or have permanent kidney failure requiring dialysis.

Medicare has four parts: Part A hospital coverage, Part B medical coverage, Part C Medicare Advantage plans and Part D prescription drug plans.

Part A hospital coverageMost people do not pay a monthly premium for Part A. If

you or your spouse worked for 10 years and paid Medicare taxes, you will not have to pay a premium.

Part A helps cover inpatient hospital care; skilled nursing facility care; home health care; and hospice care.

Your costs under Part A include inpatient hospital deduct-ible; inpatient hospital copays; skilled nursing copays; and your monthly plan premium, if applicable.

Part B medical coveragePart B requires you to pay a monthly premium along with

a yearly deductible before coverage begins. You also are responsible for paying part of the costs that Part B does not cover. Services that are NOT covered by Medicare include: routine hearing, dental and vision exams; hearing aids or glasses (except for glasses after cataract surgery); emer-gency assistance while traveling outside the United States; fitness club membership; long-term care (such as a nursing home); and prescription drug coverage.

Part B helps cover doctor and other healthcare provider services; outpatient surgery; lab and X-ray services; ambu-lance services; preventive services; and durable medical

equipment like prosthetics, wheelchairs and hospital beds.What costs are you responsible for under Part B? Part B

includes the following costs: your Medicare Part B monthly premium, if applicable; yearly deductible (paid before Medi-


Mark Your Calendar 28th Annual Clinical Update in

GERIATRICMEDICINEMarch 5-7, 2020

Marriott Pittsburgh City Center, Pittsburgh, PA

Course Directors: Shuja Hassan, MD ■ Neil M. Resnick, MD ■ Lyn Weinberg, MD

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Presented by

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UPMC / University of Pittsburgh Aging Institute

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Center for Continuing Education in the Health Sciences

*Join the Society Now and Save! Call Nadine Popovich at (412) 321-5030.

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The fastest growing segment of the population comprises individuals above the age of 85 years. The purpose of our conference is to provide an evidence-based approach to help clinicians take exceptional care of these often frail individuals.

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This course is the recipient of the American Geriatrics Society State Achievement Award for Innovative Educational Programming.

For more information on conference details, please visit our website:http://www.dom.pitt.edu/UGM or email us: [email protected]

This activity is approved for the following credit: AMA PRA Category 1 Credit™, ANCC, and ACPE. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

416 www.acms.org

care begins paying); and coinsurance (percentage of the cost that Medicare does not pay).

Part C Medicare Advantage plans

Part C is referred to as Medicare Advantage plans. Medicare Advantage plans are Medicare-approved private health plans. Medicare Advantage plans work differently from supplement plans. They allow you to get all of your Part A Hospital, Part B Medical and, sometimes, Part D Prescription Drug coverage combined into one plan. They also can provide you with some additional benefits and services that Original Medicare does not cover. Medicare Advantage plans can have lower out-of-pocket costs than Original Medicare.

When enrolled in a Part C Medicare Advantage plan, you can get coverage for: Medicare Part A (hospital cover-age) and Medicare Part B (medical coverage).

To join a Medicare Advantage plan, you must: be a U.S. citizen or lawfully present in the United States; be enrolled in Medicare Parts A and B; live for six months or more each year in the plan’s service area; and not have permanent kidney failure (some exceptions may apply).

Medicare Advantage plans help cov-er all services that Parts A and B cover, except hospice care (which is covered by Medicare). Additional benefits and services that Medicare does not cover include hearing, dental, vision, travel and fitness.

You will have some costs when enrolled in a Medicare Advantage

plan. You will pay your Part A monthly premium (if applicable) and Part B monthly premium, if applicable. You also will pay your Medicare Advantage plan monthly premium, if applicable. You are responsible for any out-of-pocket costs such as copays, deduct-ibles and coinsurance that come with the Medicare Advantage plan you chose.

Additionally, there are two types of Medicare Advantage plans: Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). HMO plans use a network of participat-ing hospitals and doctors for your care. With an HMO plan, you must receive services from participating hospitals and doctors, except for emergency care, out-of-area urgent care and out-of-area kidney dialysis. Make sure your current doctors are included in the plan’s provider network before joining a plan.

PPO plans offer coverage for services received both in and out of the plan’s provider network. With a PPO plan, you may pay a higher coinsurance, copayment, or deductible for care received outside of the plan’s participating provider network.

Part D prescription drug coverage

Part D coverage is offered through Medicare-approved private insurance companies. You can receive Part D coverage through a prescription drug plan (PDP) or by including it in a Medi-care Advantage prescription drug plan (MAPD).

Part D helps cover brand-name and generic medications. Prescription coverage varies by plan; each plan has a formulary that lists the drugs that are

covered by that plan. Your costs when enrolled in a Part D plan include: your Part D plan monthly premium, if appli-cable, any out-of-pocket costs such as copays, coinsurance and deductibles included with the prescription drug plan that you choose, and a late enrollment penalty (this only applies if you have a period of 63 days without Part D coverage).

Some Medicare Advantage plans cover prescription drugs. If your plan does not cover your prescriptions, or you do not have a Medicare Advantage plan, you may want to consider adding Part D coverage.

You want to make sure you get the most out of your Medicare ben-efits. Keep these helpful thoughts in mind as you weigh your Medicare coverage options.

Look for a plan that helps you save with low cost doctor visits. This cost is a called a copay. This will be very important if you think you will visit the doctor often. Many Medicare Advan-tage plans offer options with savings at the doctor’s office.

Ask yourself, does this plan offer care from respected doctors and hospitals in my area? Many plans offer cost savings by requiring you to get your medical care from doctors and hospitals in a set network of providers that accept the plan. Ask about the network of any plan you are consid-ering. Find out if it offers high quality care from the most trusted doctors and hospitals in your community.

Look for a plan that gives you the coverage you need AND fits your monthly budget. This is why it is important to compare your options. While some options may have lower costs for hospital stays or specialist


From Page 415


visits, they may come with a steep monthly premium. Determine what your actual health needs are and find the plan that is right for you and your budget.

DO NOT assume the plan you have now will remain the same. Check to see what is changing about your cur-rent coverage. The benefits you have now may change. This means you may be able to get more savings and value by switching to a new option. Find out what about your current health plan is going to change. Start learning about your options now so you have time to make a smart decision.

Consider if it is important for you to have doctor, hospital and prescription coverage in one plan. Having pre-scriptions included with your medical coverage may help you from having to take more than one card to the doctor, hospital and pharmacy. A Medicare Ad-vantage plan allows you to get all three types of coverage for one monthly premium with one card to carry.

Make sure you know how the

company you are considering works with Medicare. Medicare Advantage plans are Medicare-approved plans offered by companies with a Medicare contract. Unlike Medicare Supplement plans, Medicare Advantage plans al-low you to get all your Part A hospital, Part B medial, and sometimes, Part D prescription drug coverage combined into one plan. They also can provide you with some extra benefits and services that Original Medicare does not cover.

Find out if the coverage option you are considering would require you to buy extra coverage for other needed services such as preventive dental, routine vision, fitness and world travel. Medicare Advantage offers import-ant extra benefits you don’t get from Original Medicare alone. You pay one premium and get all your coverage under one plan. These extra benefits add more value to your healthcare coverage and can help you stay healthy.

Request information about your op-

tions so you can start to review your choices. Requesting this information ensures that you will be able to review all your options and select a choice you can feel confident in without feeling pressured to make a decision. Always make sure the information you request is FREE, and that there is no obligation to buy anything for respond-ing.

Dr. Ahuja is the current president of the Pennsylvania Geriatric Society – Western Division. She is board certified in Geriatrics and Hospice & Palliative Medicine and is senior medical direc-tor of Medicare at UPMC Health Plan and a clinical assistant professor with the Division of Geriatric Medicine at University of Pittsburgh. She can be reached at [email protected].


The opinion expressed in this column is that of the writer and does not necessarily reflect

the opinion of the Editorial Board, the Bulletin, or the

Allegheny County Medical Society.

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Diabetes Club program attracts record number

The Greater Pittsburgh Diabetes Club (GPDC) met Oct. 29 at the Rivers Casino. Ralph A. DeFronzo, MD, speaker, presented: “Treatment of T2DM: A Sound Approach Based upon its Pathophysiology.”

The program broke a record with the highest attendance to date (107) and the most exhibitor sponsors (14).

The next GPDC educational pro-gram offering CME credits is scheduled for April 30, 2020, and will feature An-drew F. Stewart, MD, who will present: “Beta Cell Regeneration for Diabetes: Moving from Impossible to Possible.”

For more information, call Michelle Besanceney, administrator, at (412) 321-5030, ext. 100, or email [email protected].

Geriatrics Teacher of the Year Award: Call for nominations open

The Penn-sylvania Geri-atrics Society – Western Division (PAGS-WD) is seeking nominations for the Geriatrics Teacher of the Year Award. The award will be presented to two outstanding teachers for their dedication and commit-ment to geriatrics education.

The annual award will recognize and honor both a physician and a professional from another healthcare

discipline, including nursing, advanced practice, physical therapy, pharmacy, occupational therapy, dentistry, audiol-ogy, speech-language, pathology and social work, who have made significant contributions to the education and training of learners in geriatrics and to the progress of geriatrics education across the health professions. Members and non-members of the Pennsylvania Geriatrics Society will be considered.

Eligible nominees will have demon-strated leadership and inspired learn-ers to better the care of older adults and will have contributed to the growth of geriatrics in their professions. Teach-ing expertise and/or education program development are valued in the selec-tion of the recipient for this honor.

Award eligibility and criteria, along with the nomination form, is available on the Society’s website at www.pagswd.org. Nominations must be received on or before Jan. 25, 2020. Questions regarding the awards or nomination process can be directed to Nadine Popovich, administrator, at [email protected] or (412) 321-5030.

Awardees will be recognized at the

28th Annual Clinical Update in Geri-atric Medicine conference, scheduled for March 5-7, 2020, at the Pittsburgh Marriott City Center. The ceremony will take place Thursday, March 5, 2020, where recipients will be honored with a plaque and receive complimentary membership in the society for one year.

POS hosts November meetingThe Pittsburgh

Ophthalmology Society (POS), met Nov. 7 at the Allegh-eny County Medical Society.

The Society wel-comed local faculty and POS members Ian Conner, MD, PhD, assistant professor of Ophthalmology, Glaucoma and Cat-aract Service, chief of Ophthalmology, UPMC Shadyside, diplomate, American Board of Ophthalmology and associate residency program director, University of Pittsburgh School of Medicine; and Deepinder Dhaliwal, MD, L.Ac, pro-fessor of Ophthalmology, University of Pittsburgh School of Medicine, director

418 www.acms.org

PerspectivePerspectiveSociety News

Attendees listen to the presentation at the Greater Pittsburgh Diabetes Club dinner program Oct. 29 at Rivers Casino.

Michelle Besanceney / acMs

Dr. Dhaliwal



of Refractive Surgery and the Cornea Service, UPMC Eye Center and found-er and director, Center for Integrative Eye Care, University of Pittsburgh.

More than 60 members attended to hear Drs. Conner and Dhaliwal present two exceptional lectures, followed by active question-and-answer sessions after each lecture.

Following the first lecture, Jamie Odden, MD, resident at the University of Pittsburgh Eye Center, presented an interesting case for review and dis-cussion by Dr. Conner and attendees.

Thank you to Aerie Pharmaceuticals for sponsoring the meeting.

POS hosts December meeting The Pittsburgh Ophthalmology Soci-

ety (POS), met Dec. 5 at the Allegheny County Medical Society and welcomed Collin M. McClelland, MD, associate professor, Department of Ophthalmol-ogy and Visual Neurosciences, Univer-sity of Minnesota, and the Reinhardt L. and Ruth H. Schmidtke Endowed Chair in Neuro-Ophthalmology. Dr. McClel-land specializes in neuro-ophthalmol-

ogy and adult strabis-mus. Special thanks to Pamela Rath, MD, for inviting Dr. McClelland to speak and to Atlas Ocular and Carl Zeiss Meditec for their sup-port of the program.

Dr. McClelland presented two interesting lectures on Diplopia and Tips in the Evaluation for Giant Cell Arteritis, with a lively ques-tion and answer session following the

nadine PoPovich / acMsAt left, at the Nov. 7 POS meeting, are, from left, Jamie Odden, MD (resident presenter); Ian Conner, MD, PhD (pre-senter and POS Board member); and David Buerger, MD, FACS (POS president). At right, at the Dec. 5 POS meeting are, from left, Collin McClelland, MD (guest faculty); Gabrielle Bonhomme, MD (POS member); and Marshall Stafford, MD, POS president-elect.

Dr. McClelland


420 www.acms.org

presentations. Jared Weed, MD, resident at the University of Pittsburgh Eye Center, presented an interesting case for commentary by Dr. McClelland.

Mark your calendar for upcoming 2020 monthly meetings. The next monthly meet-ing will take place Thursday, Jan. 9, when the POS welcomes Ho Sun Choi, MD, San-ta Clara Ophthalmology, San Jose, Calif.

Dr. Choi specializes in the diagnosis and treatment of cataracts, glaucoma, diabetic retinopathy, age-related macular degen-eration, dry eye syndrome and other eye conditions. He also created the Solo Eye Physicians network, which has more than 130 members throughout the entire country. Dr. Choi currently serves as a committee member on the OMIC board of directors. Thank you to Horizon Therapeutics for support of the program.

Complete meeting details and registration can be found on the POS website at www.pghoph.org.

The final monthly meeting of the educational series will be held Thursday, Feb. 6, 2020, when POS members wel-come Rishi Singh, MD, staff physician, Cole Eye Institute, and medical director, Clinical Systems Office, Cleveland Clinic. In addition, Dr. Singh is associate professor of Oph-thalmology, Case Western Reserve University, Cleveland, Ohio.

Dr. Singh will present: “Influence of systemic control on anti-VEGF treatment outcomes in diabetic macular edema” and “Diagnosis and management of central serous chorio-retinopathy.” Online registration begins January 14 at www.

pghoph.org. Thank you to Thierry Verstraeten, MD, for inviting Dr. Singh and to Dutch Ophthalmic USA for support of the program.

POS members also are reminded to renew their member-ship dues. If you are unsure of membership status, please contact Nadine Popovich, administrator, at (412) 321-5030 or [email protected].

Pennsylvania Medical Society announcements• Nominate a physician member for one of Pennsylvania

Medical Society’s (PAMED’s) annual awards between now and Jan. 13 – www.pamedsoc.org/Awards

• PAMED’s Year-Round Leadership Academy is a great way for physicians to get foundational leadership skills – combination of online learning and live courses; peer-to-peer, professional development, and performance coaching; the opportunity to work on a Capstone project; and a lot of CME are just some of the many benefits. The cost is $2,500 for members. Scholarships are available – apply by Feb. 3 – www.pamedsoc.org/YRA

• Medical marijuana often leaves physicians with more questions than answers. PAMED is hosting a hands-on workshop April 20, 2020, at Mount Nittany Medical Center in State College, Pa. Learn more and register at www.pamed-soc.org/Marijuana2020. The cost is $49 for members.

• NORCAL will be doing a more in-depth presentation on the topic of dealing with difficult patients at PAMED’s spring practice administrator meetings (April 14 - Harrisburg/Live Webcast, April 21 – Doylestown, and April 29 - Cranberry Township).For more information, visit https://www.nor-cal-group.com/library/topic/physician-ratings

• Our next Frontline call will be held at 11:30 a.m. on Thursday, Jan. 9. To sign up, visit https://bit.ly/38AJkry.


From Page 419

Dr. Choi

Dr. Singh

ACMS Members:Professional announcement advertisements

are available to ACMS members at our lowest prices.

Contact Meagan Sable, managing editor, at [email protected].

Congratulatory message?

Retiring? New Partner?

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PerspectivePerspectiveActivities & Accolades

ACMS member recognized for contributions to rheumatology

ACMS mem-ber Susan Manzi, MD, MPH, is the recipient of the American College of Rheumatology’s 2019 Distinguished Clinical Investigator Award. She recently was presented with the award at the American College of Rheumatology/Association of Rheu-matology Professionals (ACR/ARP) Annual Meeting in Atlanta.

The meeting is attended by an esti-mated 16,000 participants from around the world. At this year’s event, Dr. Manzi also had the honor of presenting the “ACR: Year in Review” along with David S. Pisetsky, MD, PhD, Duke University Medical Center.

Chair of the Allegheny Health Network (AHN) Medicine Institute and

ACMS member celebrates new practiceACMS member Nicole Vélez, MD, founder of Pittsburgh Skin, held a grand opening Sept. 26 to celebrate the new practice. The event was facilitated by the North Pittsburgh Chamber of Commerce, who led the festivities. Dr. Vélez is a dermatologist and Mohs surgeon.

Photo Provided

Dr. Manzi

PerspectivePerspectiveIn Memoriam

Robert Love Baker, MD, 93, died after a stroke sustained in July 2019.

Dr. Baker graduated in medicine from Northwestern University and the University of Pittsburgh. He completed his internship at St. Francis Medical Center in 1948-49. His neurological surgery residency was one of the first at the Western Pennsylvania Hospital, where he trained from 1949-52; he also trained at the University of Pittsburgh from 1954-55.

A veteran of the U.S. Air Force, he served as a captain during the Korean War, practicing neurological surgery at

Maxwell Air Force Base in Montgom-ery, Ala.

Board certified in neurological sur-gery in 1958, he practiced at more than 20 hospitals in Western Pennsylvania, serving patients from 1955-2003.

His wife of 65 years, Barbara Jane Kessler Baker, is deceased. Also de-ceased is a daughter, Gwendolyn Ann Baker Thomas.

Surviving are son Robert Love Baker II, DO (Connie); daughter Patricia Diane Baker Dement (Joseph); son-in-law James Henry Thomas Jr.; grandchildren Robert Love Baker III

(Kathleen), Andrew Hoffman Baker (Allison), James Henry Thomas III (Samantha), David Kessler Thomas, Barbara Diane Thomas, Jessica Leigh Dement Connolly (Paul), Timothy Miller Dement (Emily) and Bennett Baker De-ment (Elizabeth); great-grandchildren Penelope Jeanne Baker, Elizabeth Grace Baker and Liam Robert Baker; sister-in-law Vicki Kessler Cole; and numerous nieces and nephews.

A memorial service was held Satur-day, Dec. 7, 2019, at Hebron Church, Pittsburgh.


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Help your patients talk to you about their BMI

Allegheny County Medical Society is offering free posters explaining body mass index (BMI) and showing a colorful, easy-to-read BMI chart. The posters can be used in your office to help you talk about weight loss and management with your patients.

To order a quantity of posters, call the society office at 412-321-5030.You can view or download a smaller version online at www.acms.org.

Allegheny County Medical Society

PerspectivePerspectiveActivities & Accolades

director of its Lupus Center of Excel-lence, Dr. Manzi is among an elite group of honorees including leading researchers, clinicians, mentors and other professionals who exhibit superi-or commitment to the advancement of the field of rheumatology.

Dr. Manzi is internationally known for her research and patient care in lupus, and has published more than 200 research reports on lupus and related diseases. Notably, she and her

colleagues at the Lupus Center of Ex-cellence helped design Avise-SLE™ – a blood test to help clinicians diagnose lupus with greater ease and accuracy. Her research program has been gener-ously supported by organizations such as the National Institutes of Health (NIH), Department of Defense, Lupus Foundation of America and the Arthritis Foundation. Dr. Manzi has served on advisory boards for the FDA and more than 20 pharmaceutical and biotech companies, and has chaired or served on numerous NIH study sections and

data safety monitoring boards.“In addition to being a compassion-

ate physician, insightful leader and devoted patient advocate, Dr. Manzi is a brilliant clinical scientist whose contributions have led to significant advancements in quality, innovation and best practices in the diagnosis and treatment of patients with autoimmune diseases,” said Mary Chester Wasko, MD, MSc, division director, Rheuma-tology, AHN. “As a true asset to the rheumatology community, she could not be more deserving of this award.”

From Page 421


Materia Medica

Cystic fibrosis (CF) is a genetic condition that affects the cystic

fibrosis transmembrane conductance regulator (CFTR) gene. This gene codes for production of the CFTR protein which is incorporated into any organ that produces mucus; these or-gans include but are not limited to the lungs, liver, pancreas, intestines and sweat glands.1 The primary function of mucus is to protect the linings of the airways, digestive tract and other or-gans and tissues by forming a natural slick buffer. In individuals with CF, the mucus is thick and sticky and can build up, leading to blockages, damage, or infections. The lungs are most often involved in the serious complications related to disease progression, but patients also may have difficulty main-taining adequate nutritional status due to impaired nutrient absorption. While there is not yet a cure for CF, patients are leading longer, healthier lives thanks to advancements in the treat-ment and support of the condition.

CF patients are most often pre-scribed a variety of medications including antibiotics, anti-inflammatory medications, bronchodilators, mucus thinners and CFTR modulators.1 CFTR modulators are rapidly becom-ing more popular in their use as a mainstay therapy for the treatment of

mutation-specific CF, as more studies are coming out attesting to the clinical benefits they may provide. Ivacaftor, a CFTR potentiator, has proven to be well-tolerated and produced signifi-cant results in CF patients with certain types of gating mutations.2 Dosing of ivacaftor is dependent on age but is to be taken twice a day with fatty foods to increase absorption. In patients with two copies of F508del, the most common mutation in CF patients, the “corrector” drugs lumacaftor and tezacaftor have been used in combi-nation with ivacaftor to provide clinical benefits in patients with the identified mutations.3,4 In patients older than 12 years, lumacaftor 200mg/ivacaftor 125 mg (Orkambi™) is taken every 12 hours daily with fat-containing foods, while tezacaftor 100 mg/iva-caftor 150mg (Symdeko™) is taken once in the morning with a dose of ivacaftor 150 mg taken 12 hours later in the evening.3,4 Lumacaftor/iva-caftor(Orkambi™) was approved for use in 2015, and tezacaftor/ivacaftor (Symdeko™) was approved for use in 2018.3,4

What it is5

Trikafta™ is a combination of ivacaftor, tezacaftor and elexacaftor approved by the U.S. Food and Drug Administration (FDA) for the treatment CF in patients aged 12 years and older who have at least one F508del muta-tion in the CFTR gene.5

How it works2,3,4,5

Elexacaftor and tezacaftor are “corrector” compounds that bind to different sites on the CFTR protein and work synergistically to facilitate the cellular processing and trafficking of F508del-CFTR and thus increase the amount of CFTR protein delivered to the cell surface.3,4,5 Ivacaftor is a “po-tentiator” that aids in opening the chan-nel gate of the CFTR protein at the cell surface.2,5 The combined effects of elexacaftor, tezacaftor and ivacaftor increase the quantity and function of F508del-CFTR at the cell surface leading to greater CFTR activity and improved chloride transport across the membrane.5

Indication5

Trikafta™ is indicated for the treatment of CF in patients of at least 12 years of age who carry at least one F508del mutation in the CFTR gene.5

Dosage5

Adults and pediatric patients aged 12 years and older:5

• Morning dose: Two elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg tablets by mouth

• Evening dose: One ivacaftor 150 mg tablet by mouth

• Doses should be taken approxi-mately 12 hours apart with fat-contain-ing food.5

Trikafta™ (ivacaftor/tezacaftor/elexacaftor)

aDam PatRiCk, PhaRmD CanDiDate

A breakthrough therapy for cystic fibrosis patients who carry at least one F508del mutation


426 www.acms.org

• Should not be used in patients with severe hepatic impairment (Child-Pugh Class C). Patients with moderate hepatic impairment (Child-Pugh Class B) should be assessed to determine if potential benefit exceeds the risk. If therapy is to be used in these pa-tients, they should only receive the two Trikafta™ tablets in the morning without taking the ivacaftor dose in the evening. Liver function tests should be closely monitored.5

• Reduce dose when co-adminis-tered with drugs that are moderate or strong CYP3A inhibitors.5

How supplied5

Trikafta™ is only supplied as a fixed dose combination containing elex-acaftor 100 mg, tezacaftor 50 mg and ivacaftor 75 mg. It is co-packaged with ivacaftor 150 mg tablets.5

Adverse events5,6,7

The most common adverse drug

reactions to Trikafta™ (occurring in ≥5% of patients and at a frequency higher than placebo by ≥1%) were headache, upper respiratory tract infection, abdominal pain, diarrhea, rash, alanine aminotransferase increased, nasal congestion, blood creatine phosphokinase increased, aspartate aminotransferase increased, rhinorrhea, rhinitis, influenza, sinusitis and blood bilirubin increased.5,6,7 Nota-bly, the incidence of rash events was higher in female Trikafta™-treated patients (16%) than in male Trikaf-ta™-treated patients (5%).5,6,7 Hor-monal contraceptives may play a role in the occurrence of rash.5,6,7

Drug interactions5

Trikafta™ should be appropriately dose reduced when co-administered with strong (e.g., ketoconazole, itracon-azole, posaconazole, voriconazole, telithromycin and clarithromycin) or moderate (e.g., fluconazole, erythro-mycin) CYP3A inhibitors. Foods and

drinks containing grapefruit should be avoided.5

Contraindications5

Trikafta™ should not be used in pa-tients with severe hepatic impairment (Child-Pugh Class C).5

Use in pregnancy5

There is limited human data from clinical trials on the use of Trikafta™ or its individual components, elexacaftor, tezacaftor and ivacaftor, in pregnant women to inform a drug-associated risk.5

Clinical efficacy5,6,7

The efficacy of Trikafta™ in patients with CF aged 12 years and older was evaluated in two Phase 3, double-blind, controlled trials. Patients discontinued any previous CFTR modulator thera-pies, but continued on their other stan-dard-of-care CF therapies. Patients had a ppFEV1 at screening between 40-90%. Patients with a history of

Materia Medica

From Page 425

Table 1.6,7

Primary and Secondary Endpoints

Heterozygous F508del mutation (vs placebo)

Homozygous F508del mutation (vs tezacaftor/

ivacaftor)% improvement in absolute change in lung function at

week 4

13.8 (95% CI: 12.1, 15.4; P<0.0001)

10.0 (95% CI: 7.4, 12.6; P<0.0001)

% improvement in absolute change in lung function at

week 24

14.3 (95% CI: 12.7, 15.8; P<0.0001)

--

Mmol reduction sweat chloride through week 24

41.8 (95% CI: -44.4, -39.3; P<0.0001)

45.1 (95% CI: -50.1, -40.1; P<0.0001)

% reduction in pulmonary exacerbations

63 (RR: 0.37 [95% CI: 0.25, 0.55]; P<0.0001)

--

Point improvement in CFQ-R respiratory domain score

20.2 (95% CI: 17.5, 23.0; P<0.0001)

17.4 (95% CI: 11.8, 23.0; P<0.0001)


colonization with organisms associated with a more rapid decline in pulmonary status, including but not limited to Bur-kholderia cenocepacia, Burkholderia dolosa, or Mycobacterium abscessus, or who had an abnormal liver function test at screening, were excluded from the trials.6,7

The first trial was a 24-week, ran-domized, double-blind, placebo-con-trolled study in patients who had an F508del mutation on one allele and a mutation on the second allele that results in either no CFTR protein or a CFTR protein that is not responsive to ivacaftor and tezacaftor/ivacaftor.6 This trial evaluated 200 Trikafta™ and 203 placebo patients with CF aged 12 years and older with the mean age being 26.2 years. The primary end-point assessed at the time of interim analysis was mean absolute change in ppFEV1 from baseline (mean at baseline: 61.4%) at week four.6 Of the 403 patients included in the interim analysis, there was a 13.8% (95% CI: 12.1, 15.4; P<0.0001) treatment differ-ence between Trikafta™ and placebo for the mean absolute change from baseline in ppFEV1 at week four.6 The treatment difference for the mean absolute change in ppFEV1 from baseline through week 24 was similar to week four at 14.3% (95% CI: 12.7, 15.8; P<0.0001).6 Improvements in ppFEV1 were observed regardless of age, sex, baseline ppFEV1 and geo-graphic region. Secondary endpoints of absolute change in sweat chloride from baseline at week 4 and through week 24, number of pulmonary exac-erbations through week 24, absolute change in BMI from baseline at week 24, and absolute change in CFQ-R Respiratory Domain Score from

baseline at week 4 and through week 24 all reported statistically significant treatment difference indicating the superiority of Trikafta™ over placebo (Table 1, page 426).6

The second trial was a four-week, randomized, double-blind, active-con-trolled study in patients who are homozygous for the F508del muta-tion.7 Patients received tezacaftor 100 mg qd/ivacaftor 150 mg q12hr during a four-week open-label run-in period and were then randomized and dosed to receive Trikafta™ or tezacaftor 100 mg qd/ivacaftor 150 mg q12hr during a four-week double-blind treatment period.7 There were 107 patients with CF aged 12 years and older with a mean age of 28.4 years evaluated in this trial.7 The primary endpoint was mean absolute change in ppFEV1 from baseline at week four of the dou-ble-blind treatment period. Following the four-week open-label run-in period with tezacaftor/ivacaftor, mean base-line ppFEV1 was assessed at 60.9%.7 Treatment with Trikafta™ compared to tezacaftor/ivacaftor resulted in a statistically significant improvement in ppFEV1 of 10.0% (95% CI: 7.4, 12.6; P<0.0001).7 The key secondary efficacy endpoints were absolute change in sweat chloride and CFQ-R Respiratory Domain Score from base-line at week four and both reported back statistically significant treatment difference in patients treated in the Trikafta™ arm vs the tezacaftor/iva-caftor arm (Table 1).7

Cost information8

Trikafta™ will cost $311,503 annual-ly, or $23,896 per 28-day pack, accord-ing to the Securities and Exchange Commission.8

Conclusion1-8

Trikafta™ is a triple combination of elexacaftor, tazocaftor and ivacaftor that is available as an oral tablet and is FDA-approved for CF patients that are 12 years or older and who have at least one F508del mutation of the CFTR gene. Where previously ap-proved therapies required patients to be homozygous for the F508del mutation, Trikafta™ can cover patients even if they are only heterozygous for the mutation. This represents a broad-ening spectrum of coverage that can now affect 90% of CF patients.1 In two clinical trials, one comparing against placebo and the other comparing against tezacaftor/ivacaftor, Trikafta™ was shown to lead to statistically significant improvements in absolute change in lung function and CFQ-R respiratory domain score as well as reductions in pulmonary exacerbations and sweat chloride levels. Its wide applicability across heterozygous and homozygous F508del mutated patients paired with its early and significant clinical response lead many to believe that Trikafta™ is a huge step forward in the treatment of CF but further compar-ative studies are needed to definitively determine its place in therapy.

At the time of this writing, Mr. Patrick was on a clinical rotation in the Center for Pharmaceutical Care at Allegheny General Hospital. For any questions concerning this article, please contact Tucker Freedy, PharmD, at the Allegh-eny Health Network, Allegheny General Hospital, Center for Pharmaceutical Care, Pittsburgh, Pa., (412) 359-3192, or email [email protected].

Materia Medica


428 www.acms.org

Materia Medica

References1. U.S. Department of Health and

Human Services, National Heart, Lung, and Blood Institute. (2019). Cystic Fibrosis. Bethesda, MD: U.S. Government Printing Office.

2. Condren M.E., Bradshaw M.D. Ivacaftor: A novel gene-based therapeutic approach for cystic fibrosis. J Pediatr Phar-macol Ther 2013;18:8–13.

3. Schneider E.K., Reyes-Ortega F., Li J., Velkov T. Can Cystic Fibrosis Pa-tients Finally Catch a Breath With Luma-caftor/Ivacaftor? Clin Pharmacol Ther

2017;101(1):130–141.4. Taylor-Cousar JL, Munck A, McKone

EF, van der Ent CK, Moeller A, Simard C, et al. Tezacaftor–ivacaftor in patients with cystic fibrosis homozygous for Phe508del. N Engl J Med 2017;377:2013-23.

5. TRIKAFTA(TM) oral tablets, elexacaftor, tezacaftor, ivacaftor oral tablets; ivacaftor oral tablets. Vertex Pharmaceuticals Incor-porated (per manufacturer), Boston, MA, 2019.

6. Middleton PG, Mall MA, Dřevínek P, et al. Elexacaftor–Tezacaftor–Ivacaftor for Cys-tic Fibrosis with a Single Phe508del Allele. N Engl J Med 2019; 381(19):1809-1819.

7. Heijerman HGM, McKone EF, Downey DG, et al. Efficacy and safety of the elexacaftor plus tezacaftor plus ivacaftor combination regimen in people with cystic fibrosis homozygous for the F508del mu-tation: a double-blind, randomised, phase 3 trial. Lancet (Published Online October 31, 2019 https://doi.org/10.1016/ S0140-6736(19)32597-8).

8. FDA approves drug to treat cystic fibrosis in patients 12 and older-and it will cost $311,503. Advisory Board. 2019; published online Oct 28. https://www.advi-sory.com/daily-briefing/2019/10/28/cf-drug (accessed Nov 5, 2019).

From Page 427

On Oct. 22, 2019, the Centers for Medicare & Medicaid Services

(CMS) and OIG (Office of Inspector General) released new proposed rules regarding Stark Law Exceptions and Anti-Kickback Safe Harbors in response to what has universally been christened as the “Regulatory Sprint to Coordinated Care,” first announced by the U.S. Department of Health and Human Services (HHS) in June 2018.

As background, please remember that, although the Anti-Kickback Safe Harbors and the Stark Law Exceptions

are confusingly similar with respect to their intended purpose, they serve the following different functions:

1. The Stark Act prohibits physicians from referring only the Stark “desig-nated health services” to healthcare entities with which they have financial relationships.

2. The Anti-Kickback statute pro-hibits anyone from paying, receiving, soliciting, or offering any kind of remu-neration in exchange for the referral of any Medicare or governmental health covered service.

The regulators have provided “Stark Law Exceptions” and “Anti-Kickback Safe Harbors” which are remarkably similar but apply in the different context described above.

In general, the new Safe Harbors and Exceptions cover three major areas:

1. Coordinated Care and Val-ue-Based Enterprises.

2. Extension of the EHR Safe Har-bor sunset.

3. Revising the definition of fair mar-ket value that applies to both the Stark

Legal Report

Regulatory sprint to coordinated care: New Stark and Anti-Kickback rules

miChael a. CassiDy, esq.


Legal Report

Law Exceptions and the Anti-Kickback Safe Harbors (AKS).

This article is intended to cover the “new kid on the block,” i.e., the value-based enterprises (VBE). The new definitions for the Stark Act and the AKS are each attached as Exhibit A and Exhibit B, respectively. A VBE is essentially defined as two or more VBE participants collaborating to achieve at least one value-based purpose as parties to a value-based arrangement, which has an accountable body or person responsible for management and a governing document describing its purpose. That is a rather circular definition, and the specific definitions for both the Anti-Kickback Safe Harbor and the Stark Exceptions can be found

on pages 430 and 431.In order to provide a sense of the

vagueness of the intended scope of these arrangements, I have inserted the two following quotes from the regu-latory announcements:

Evolution of healthcare landscape

“The health care landscape when the physician self-referral law was enacted bears little resemblance to the landscape of today. As some CMS RFI commenters highlighted, the physi-cian self-referral law was enacted at a time when the goals of the various components of the health care system were not merely unaligned but often in conflict, which each component

competing for a bigger share of the health care dollar without regard to the inefficiencies that resulted for the system as a whole – in other words, a volume-based system. According to several commenters, the current physician self-referral regulations –intended to combat overutilization in a volume-based world – are outmoded because, by their nature, integrated care models protect against overutiliza-tion by aligning clinical and economic performance as the benchmarks for value. And, in general, the greater the economic risk that providers assume, the greater the economic disincentive to overutilize services. According to more than one of these commenters, the

Tucker Arensberg lawyers have experience in all major healthcare law issues including:

• Compliance • Reimbursement • Mergers & Acquisitions • Credentialing & Licensing for Individuals & Healthcare

Facilities • Employment Contracts and Restrictive Covenants • Tax & Employment Benefits

tuckerlaw.com

Visit our Med Law Blog for the latest news and information for you and

your medical practice medlawblog.com

Pittsburgh, PA Harrisburg, PA New York, NY

Jerry Russo, Investigations Rebecca Moran, Mergers &Acquisitions

and Physician Contracts

For additional information contact any of the following attorneys at (412) 566-1212:

Mike Cassidy, Compliance Contracts, Peer Review, Stark/AKS Paul Welk, Mergers & Acquisitions Danielle Dietrich, HIPAA, Collections & Litigation


430 www.acms.org

current prohibitions are even antithetical to the stated goals of policy makers both in the Congress and within HHS for health care delivery and payment reform. Although we agree in concept, we continue to operate substantially in a volume-based payment system. Thus, we must proceed with caution, even as we propose the significant changes outlined in this proposed rule.”

The government regulators are late to the game in recognizing the ambigu-ity and the absence of reality regarding the existing regulations. The regulatory philosophy has long been to make ev-erything illegal and then work their way backwards, granting Exceptions and Safe Harbors, precisely because actu-ally “describing” an acceptable arrange-ment is extremely difficult, especially when the violation could be based upon the intent of the individuals. That lack of clarity has always created a great deal of potential risk for participants.

VBE description“We intend the definition of ‘val-

ue-based enterprise’ to include only organized groups of health care provid-ers, suppliers, and other components of the health care system collaborating to achieve the goals of a value-based health care system. An ‘enterprise’ may be distinct legal entity – such as an ACO – with a formal governing body, operating agreement or bylaws, and the ability to receive payment on behalf of its affiliated health care providers. An ‘enterprise’ may also consist only of the two parties to a value-based arrangement with the written docu-mentation recording the arrangement serving as the required governing document that describes the enterprise

and how the parties intend to achieve its value-based purpose(s). Whatever its size and structure, a value-based enterprise is essentially a network of participants (such as clinicians, pro-viders and suppliers) that have agreed to collaborate with regard to a target patient population to put the patient at the center of care through care coor-dination, increase efficiencies in the delivery of care, and improve outcomes for patients. We have proposed our definition of ‘value-based enterprise’ in terms of the functions of the enterprise as it is not our intention to dictate or limit the appropriate legal structure for

qualifying as a value-based enterprise.”Accountable care organizations

(ACOs) were the first attempt to pro-vide exceptions for organized health-care enterprises. ACOs were created by the Accountable Care Act of 2010. A standing joke for legal presenters discussing ACOs was to ask the audi-ence what an ACO was called before it was called an ACO. The answer is: a felony!

These ideas are new, and the general intent is to protect legitimate value-based enterprises from the Anti-Kickback or the self-referral pro-hibitions. However, at this stage, they

From Page 429

Legal Report

New Definitions: Stark Act (Exhibit A) Value-Based Activity:

(1) Means any of the following activities, provided that the activity is reasonably designed to achieve at least one value-based purpose of the value-based enterprise:

(i) The provision of an item or service; (ii) The taking of an action; or (iii) The refraining from taking an action.

(2) The making of a referral is not a value-based activity. Value-Based Arrangement: means an arrangement for the provision of at least one value-based activity for a target patient population between or among—

(1) The value-based enterprise and one or more of its VBE participants; or (2) VBE participants in the same value-based enterprise.

Value-Based Enterprise (VBE): means two or more VBE participants—

(1) Collaborating to achieve at least one value-based purpose; (2) Each of which is a party to a value-based arrangement with the other or at least

one other VBE participant in the value-based enterprise; (3) That have an accountable body or person responsible for financial and

operational oversight of the value-based enterprise; and (4) That have a governing document that describes the value-based enterprise

and how the VBE participants intend to achieve its value-based purpose(s). Value-Based Purpose: means—

(1) Coordinating and managing the care of a target patient population; (2) Improving the quality of care for a target patient population; (3) Appropriately reducing the costs to, or growth in expenditures of, payors

without reducing the quality of care for a target patient population; or (4) Transitioning from health care delivery and payment mechanisms based on the

volume of items and services provided to mechanisms based on the quality of care and control of costs of care for a target patient population. VBE Participant: means an individual or entity that engages in at least one value-based activity as part of a value-based enterprise. Target Patient Population: would mean an identified patient population selected by a value-based enterprise or its VBE participants based on legitimate and verifiable criteria that are set out in writing in advance of the commencement of the value-based arrangement and further the value-based enterprise’s value-based purpose(s).


Legal Report

are obviously quite vague. This calls to mind Justice Potter Stewart’s quote regarding pornography:

“I shall not today attempt further to define the kinds of material I un-derstand to be embraced within that shorthand description, and perhaps I could never succeed in intelligibly doing so. But I know it when I see it …” – Jacobellis v. Ohio (U.S. Supreme Ct. 1964).

Since these proposed regulations are brand new, fairly short in the way

of explanation, fairly broad in the terms of coverage and without any actual ex-amples of what does and doesn’t work, you should be very cautious when you first participate in any VBE design to take advantage of these situations.

Mr. Cassidy is a shareholder at Tucker Arensberg and is chair of the firm’s Healthcare Practice Group; he also serves as legal counsel to ACMS. He can be reached at (412) 594-5515 or [email protected].

Moving?Be sure to let us know ....

We can update our system to better serve

you! When your patients call,

we will know where to send them.

Call (412) 321-5030 to update your

information.

Where-to-Turn cards give important information

and phone numbers for victims of domestic violence. The cards are the size of a

business card and are discreet enough to carry in a

wallet or purse.Call ACMS at

(412) 321-5030 for more information.

Where to turn… Domestic Abuse

Palm Cards Available at ACMS

New Definitions: Anti-Kickback Safe Harbors (Exhibit B) Value-based activity

(A) Means any of the following activities, provided that the activity is reasonably designed to achieve at least one value-based purpose of the value-based enterprise:

(1) The provision of an item or service; (2) The taking of an action; or (3) The refraining from taking an action.

(B) Does not include the making of a referral. Value-based arrangement means an arrangement for the provision of at least one value-based activity for a target patient population between or among:

(A) The value-based enterprise and one or more of its VBE participants; or (B) VBE participants in the same value-based enterprise.

Value-based enterprise or VBE means two or more VBE participants:

(A) Collaborating to achieve at least one value-based purpose; (B) Each of which is a party to a value-based arrangement with the other or at least one

other VBE participant in the value-based enterprise; (C) That have an accountable body or person responsible for financial and operational

oversight of the value-based enterprise; and (D) That have a governing document that describes the value-based enterprise and how

the VBE participants intend to achieve its value-based purpose(s). Value-based enterprise participant or VBE participant means an individual or entity that engages in at least one value-based activity as part of a value-based enterprise. VBE participant does not include a pharmaceutical manufacturer; a manufacturer, distributor, or supplier of durable medical equipment, prosthetics, orthotics, or supplies; or a laboratory. Value-based purpose means:

(A) Coordinating and managing the care of a target patient population; (B) Improving the quality of care for a target patient population; (C) Appropriately reducing the costs to, or growth in expenditures of, payors without

reducing the quality of care for a target patient population; or (D) Transitioning from healthcare delivery and payment mechanisms based on the volume

of items and services provided to mechanisms based on the quality of care and control of costs of care for a target patient population.

Target Patient Population means an identified population selected by the VBE or its VBE participants using legitimate and verifiable criteria that:

(A) Are set out in writing in advance of the commencement of the value-based arrangement; and

(B) Further the value-based enterprise’s value based purpose(s).

432 www.acms.org

Special Report

Update on the prevalence of blindness at the Western Pennsylvania School for Blind Children

heiDi OnDek, eDD

albeRt biGlan, mD

beth Ramella, meD

Background

In 2005, we reported the causes of childhood blindness at our school between years – 1887 through 2000. Over the

past four decades, we have observed an evident change in the causes for blindness in our school population. The most common causes for blindness are no longer related to defects in the eyes, but rather due to changes within the brain and visual pathways: cortical visual impairment (CVI). Today, more than 70% of the children at the Western Pennsylvania School for Blind Children (WPSBC) have a di-agnosis of CVI. The education of this population of children is a challenge and requires many specialized adaptations in the educational process to provide the children with an education and to foster their autonomy. Herein, we provide information on CVI and we relate how to best educate these children.

Progress: Many causes for blindness in children have been reduced or eliminated

In the early part of the 20th Century, blindness was mainly caused by conditions that are now, for the most part, treatable. Corneal opacification due to infection was elimi-nated with the introduction of the Crede’ prophylaxis (1900) and the introduction of penicillin in the 1940s.

Blindness related to retinal detachments in childhood

has been greatly reduced by improved instrumentation and newer surgical techniques. Blindness due to glaucoma and children’s cataracts has been greatly reduced.

The epidemic of blindness caused by retinopathy of prematurity (ROP) has been reduced by early treatment. However, even with improved neonatal care, the premature infant remains at risk for ROP and is highly susceptible to intraventricular hemorrhages (IVH). These hemorrhages can damage the optic radiations and can add a cortical compo-nent to the infant’s blindness.

With effective treatments reducing causes for blindness, cortical defects have arisen as the most common cause of blindness in children attending our school. Table 1 (below, page 433) lists the five most prevalent causes of blindness in children attending our school over the past 18 years.

Table 1. Causes for blindness at the WPSBC: Top 5 vision conditions for each year

Year 2000: 183 students Vision Diagnosis Number of Children

Cortical Visual Impairment (CVI) 84Optic Nerve Disorders 27

Retinopathy of Prematurity (ROP) 11Septo-Optic Dysplasia (SOD) 10

Retinal Disorders 9


Special Report

Year 2005: 185 studentsVision Diagnosis Number of Children


Retinopathy of Prematurity (ROP) 17Septo-Optic Dysplasia (SOD) 8

Retinal Disorders 7



Retinal Disorders 14Retinopathy of Prematurity (ROP) 14

Septo-Optic Dysplasia (SOD) 12



Retinal Disorders 10Retinopathy of Prematurity (ROP) 9

Cataracts 5



Retinal Disorders 12Septo-Optic Dysplasia (SOD) 9

Retinopathy of Prematurity (ROP) 6

What is cortical visual impairment (CVI)? Although vision or sight is primarily associated with

the eyes, the eyes are only a part of the complex system needed for processing visual information. It has been esti-mated that about 40% of the brain is involved with the visual system. Unlike children with defects in the eyes or anterior visual pathways, children with CVI usually have normal appearing eyes but they will have difficulty processing or understanding what their eyes see.

The term cortical visual impairment, sometimes referred to as “cortical blindness,” is blindness that occurs as a result of injury to, or lack of proper development of, the brain. Causes include asphyxia, prematurity with intraventricular hemorrhage extending into the brain causing peri ventricular leukomalacia (PVL), hydrocephalus, stroke, head trauma, “shaken baby” and infections such as meningitis or enceph-alitis.


434 www.acms.org

Symptoms and signs observed in an infant or very young child with CVI include poor eye contact after 3-6 months of age. The child may prefer viewing objects with high contrast or bright colors, use head movement to sustain visual attention, demon-strate visual latency, field preference, non-purposeful gaze, absent blink reflex, variable vision, and objects may be held close to the eyes.

The diagnosis of CVI requires a thorough examination of the visual system. A complete history to include birth and the neonatal period is a great place to start. Questions about infec-tions, strokes, hemorrhages and head trauma should follow.

On examination, the eyes are usually found to be normal but may exhibit some degree of secondary optic nerve atrophy. Additional testing should include assessment of the level of visual acuity using high contrast objects, and assessment of the field of vision. The anterior visual pathways, pupil reflexes, are usually normal. The clinical evaluation should be followed by an MRI scan of the head. Spe-cialized ophthalmic testing may be considered: visually evoked response (VER), pattern, visual evoked potential (VEP) and possibly an electroretino-gram (ERG) to exclude retinal causes for blindness.

CVI may cause only mild reduction of central vision or reduction of the field of vision. CVI may be tempo-rary or permanent. Research shows that children with proper educational interventions and who are neurolog-ically stable make marked progress over time. Recovery of some visual function may be seen in some chil-

dren. The cause, extent and timing of the cortical damage will determine the extent of recovery of vision and function. Following the insult, a child’s brain may slowly recover lost function. With intervention, brain plasticity may reorient pathways to recover some function.

Is this important?The high prevalence of cortical

blindness that we see at the WPS-BC is a problem of most developed countries. With the reduction of the eye-related causes of blindness, the remaining population may have CVI and have complex medical issues. Working to educate these children with physical and intellectual challenges, and to provide them with some degree of autonomy, is a challenge to the child, family, therapists, the educators and to society.

Western Pennsylvania School for Blind Children (WPSBC)

Established in 1887, the Western Pennsylvania School for Blind Children’s (WPSBC) educational program was initially geared toward serving students with the single disability of blindness. With a change in the population served, school programs have evolved and have been restructured to provide services for children with medical complexity and blindness.

The mission of the Western Penn-sylvania School for Blind Children is to nurture the unique abilities of individ-uals with blindness and visual impair-ment through educational excellence and a lifetime of learning. The vision of the Western Pennsylvania School for Blind Children is to be a global leader in education and advocacy for

individuals with blindness and visual impairment.

We at the WPSBC recognize our responsibility to continuously pursue improved methods of identification and educational interventions for children believed to have CVI. For this to hap-pen, medical research in partnership with special educators of the visually impaired is essential.

Programs for CVI at the WPSBC

WPSBC is a leader in CVI instruc-tional strategies. On campus, and with our outreach programs, our school has established a separate CVI program for enrolled and non-enrolled students. This program draws families of children with CVI, or suspected CVI, from all over the United States. The goal of our educational program is to maxi-mize potential in undamaged areas of the brain and to facilitate functioning areas of the brain to develop plasticity and reorganized pathways to provide better visual function. Programs at the school are linked with many of our local universities.

Beginning education and habilitation/rehabilitation

Early contact of the family with available services and intervention are critical to success. Research on critical periods of development prove that op-portunities are lost when interventions are delayed.

We recommend that the family or caregivers visit our school as soon as the diagnosis has been established. Families with children with suspected CVI can be self-referred to our school for evaluation at any age. When they can be scheduled on our campus, our

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assessments are provided at no cost to the family. The child should have a medical evaluation and diagnosis established by a medical professional. Eye care professionals, physicians, school districts, early intervention agencies and Intermediate Units are the source of many of our regional referrals.

Assessment of the child’s capability

The first part of the process is a comprehensive evaluation and functional assessment of the child’s capabilities with a goal of determining the best way to reach and stimulate the child. This assessment includes the child with family members and uses an interview format.

For enrolled students or students participating through an outreach clinic, we partner with parents, medical pro-viders and school districts to conduct appropriate functional vision evalua-tions specific to the child with CVI.

The assessment is a three-part process which includes interviewing the parents, observing the child and direct assessment. The assessment is made over a period of approximately two hours.

During the interview, the history of birth and development and any medical issues are reviewed. The child is ob-served to determine how they play and interact with a variety of visual stimuli. The assessment is used to determine the child’s current level of functional vision, to determine the child’s level of functional vision and to make recom-mendation on building upon the vision they have developed using accessible materials, environments and learning strategies. From the assessment,

instruction recommendations, con-sultation on the current Individualized Education Plan (IEP) and adaptations are given for presenting material, not only in school, but also for daily life activities.

Recommendations and implementation

Immediately following the as-sessment, an informal verbal report is shared with the parents including some basic recommendations. This is followed by a comprehensive narrative report including recommendations. This report is provided to the parents with extra copies which can be dis-tributed to educators, physicians and specialists such as physical therapists, occupational therapists, speech ther-apists and mobility specialists. This report includes a design for instruction and intervention that matches the child’s visual function and medical needs.

Some learning strategies may include modifying materials (i.e., use of a particular color and light; adding Mylar to the surface of a target to “grab” visual attention; presenting material on a black background; high-lighting around print letters in a color; occluding parts of a page for print to decrease complexity) in all forms of learning instruction. These modifi-cations make the learning materials accessible to the educator and student and are individualized based on the results of assessment. These recom-mendations also should be integrated into the student’s daily routine. Vision strategies are written and included in the Specially Designed Instruction section of each student’s Individual-ized Education Plan (IEP). The IEP will

be driven by the child’s vision. These assessments are reviewed and updat-ed annually and modified to respond to progress made and maturation of the child.

Ongoing servicesEducation is a lifelong process.

Our staff remains dedicated to the success of each individual. Our goal is to ensure that each child receive an optimal education and is committed to providing skills which are needed for daily life. To provide this, our school’s professional team of teachers, ther-apists, instructional aides and resi-dential aides receive ongoing training specific to CVI. The needs of each child are continually evaluated and updated to better help the child and family adapt to the daily environments and make learning accessible for students.

Providing a proper education and safe care for our students is labor intensive. At our Oakland location, we have a staff to child ratio of 4:1 and a 24-hour, on-site nursing staff to oversee and respond to the complex medical needs that often accompany children with CVI.

Support for our school comes in part from students’ home school districts, which pay 40% of tuition; the Com-monwealth of Pennsylvania pays 60%. Private donations and grants, and the WPSBC Foundation, fund an array of supports and services that would not otherwise be made available for students.

Graduation and beyondFollowing graduation, it is import-

ant that the school provide continuing

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guidance and support for the grad-uated young adult and the family. Services for continuing support are sporadic. The school advocates for state, federal and private funding for programs that will continue this edu-cation and support process throughout life.

For more information or to schedule a CVI evaluation, contact Beth Ramella at (412) 621-6028.

If you or one of your staff would like a tour of our unique educational facility, you can contact Heidi On-deck, EdD, at https://www.wpsbc.org; Western Pennsylvania School for Blind

Children, 201 North Bellefield Ave., Oakland, Pittsburgh, Pa., 15213-1499; (412) 621-0100; or Albert Biglan, MD, at [email protected] or (412) 794-8581.

Dr. Ondek joined the Western Pennsylvania School for Blind Chil-dren as superintendent and executive director in July 2018. She began her career in public education more than 30 years ago as a special education teacher, later becoming director of pupil services, elementary princi-pal, high school principal, assistant superintendent and superintendent in various school districts in Texas and Pennsylvania.

Dr. Biglan is a retired pediatric ophthalmologist who has served on the Board of the WPSBC since 2000.

Ms. Ramella has been working at the Western Pennsylvania School for Blind Children for more than 20 years. Currently, she is the outreach director and CVI project leader. In her outreach position, she creates and implements programming for blind and visually impaired students across the state of Pennsylvania and evaluates children at both the Outreach Program and CVI Clinic. Ms. Ramella is Perkins-Roman CVI Endorsed and a mentor for Cor-tical Visual Impairment in the state of Pennsylvania.

From Page 435

940M20260-011 Medtronic HCP Product Half Page Ad OUTLINED.indd 1 1/24/19 2:09 PM


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REPORTABLE DISEASES 2019: Q1-Q3

Allegheny County Health Department Selected Reportable Diseases/Conditions

Selected Reportable Disease/Condition* January to September 2017 2018 2019**

AMEBIASIS 1 1 1 CAMPYLOBACTERIOSIS 89 110 95 CREUTZFELDT-JAKOB DISEASE 4 3 1 CRYPTOSPORIDIOSIS 19 22 27 DENGUE FEVER 0 0 1 GIARDIASIS 26 45 67 GUILLAIN-BARRE SYNDROME 4 0 1 HEPATITIS A 5 4 7 HEPATITIS B ACUTE 10 3 3 HEPATITIS B CHRONIC 52 50 58 LEGIONELLOSIS 84 75 74 LISTERIOSIS 3 3 3 MALARIA 4 4 3 MEASLES 0 1 7 MUMPS 1 2 2 NEISSERIA MENINGITIDIS 0 1 1 PERTUSSIS 53 15 29 SALMONELLOSIS 122 102 105 SHIGELLOSIS 11 15 12 SHIGATOXIN-PRODUCING E COLI 5 19 14 STREPTOCOCCUS PNEUMONIAE INVASIVE 45 32 35 TOXOPLASMOSIS 6 1 3 TYPHOID FEVER 1 1 1 VARICELLA 38 18 23 WEST NILE VIRUS 2 1 0 ZIKA VIRUS 1 0 0

* Case classifications reflect definitions utilized by CDC Morbidity and Mortality Weekly Report. ** These counts do not reflect official case counts, as current year numbers are not yet finalized. Inaccuracies in working case counts may be due to reporting/investigation lag. NOTE: Disease reports may be filed electronically via PA-NEDSS. To register for PA-NEDSS, go to https://www.nedss.state.pa.us/NEDSS. To report outbreaks or diseases reportable within 24 hours, please call the Health Department’s 24-hour telephone line at 412-687-2243. For more complete surveillance information, see ACHD’s 10-year summary of reportable diseases: https://www.alleghenycounty.us/Health-Department/Resources/Data-and-Reporting/Infectious-Disease-Epidemiology/Epidemiology-Reports-and-Resources.aspx.

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ALLEGHENY COUNTY MEDICAL SOCIETY 713 RIDGE AVENUE • PITTSBURGH, PA 15212-6098 P: 412-321-5030 • f: 412-321-5323 • www.acms.org

2019 PAMED House of Delegates October 25-27, 2019 - Hershey, PA Report The PAMED House of Delegates met the weekend of October 25-27, 2019 in Hershey, PA. It was a busy weekend of business and activities. The ACMS had a full delegation in attendance. Chairing the delegation was Kevin O. Garrett, MD; and Vice Chair David J. Deitrick, DO.

ACMS DELEGATES / ALTERNATES David L. Blinn, MD Todd M. Hertzberg, MD Patricia L. Bononi, MD Scott Heyl, MD Gil Citro, MD Keith T. Kanel, MD Robert C. Cicco, MD Bruce A. MacLeod, MD Douglas F. Clough, MD Barbara S. Nightingale, MD Patricia L. Dalby, MD Joseph C. Paviglianiti, MD David J. Deitrick, DO Matthew B. Straka, MD Peter G. Ellis, MD Maria J. Sunseri, MD Amber L. Elway, MD Adele L. Towers, MD Trent Emerich, MD Rajiv R. Varma, MD Stephen N. Fisher, MD Matthew A. Vasil, DO H. Jordan Garber, MD David Webster, MD Kevin O. Garrett, MD John P. Williams, MD Mark A. Goodman, MD G. Alan. Yeasted, MD

ACMS was pleased to include the participation and interest of the following Residents and Medical Students:

Residents Medical Students Shea Ford, MD Jordan Hay Michael Hu, MD, MPH, MS Victoria Humphrey Shreyus Kulkarni, MD Deirdre Martinez-Meehan Michael McDowell, MD Samyuktha Melachuri Nallammai Muthiah Arnab Ray Lauren Strelec

It was an exciting House of Delegates for the ACMS delegation. Lawrence R. John, MD became the 170th President of the Pennsylvania Medical Society at his inaugural Saturday evening. Over 400 colleagues joined family and friends in recognition of this event. Trent Emerich, MD and Scott Heyl, MD were recipients of the Top 40 Physicians under 40 Award. The Early Career Physicians Section presented the award at their business meeting.

Special Report

ALLEGHENY COUNTY MEDICAL SOCIETY 713 RIDGE AVENUE • PITTSBURGH, PA 15212-6098 P: 412-321-5030 • f: 412-321-5323 • www.acms.org

2019 PAMED House of Delegates October 25-27, 2019 - Hershey, PA Report The PAMED House of Delegates met the weekend of October 25-27, 2019 in Hershey, PA. It was a busy weekend of business and activities. The ACMS had a full delegation in attendance. Chairing the delegation was Kevin O. Garrett, MD; and Vice Chair David J. Deitrick, DO.

ACMS DELEGATES / ALTERNATES David L. Blinn, MD Todd M. Hertzberg, MD Patricia L. Bononi, MD Scott Heyl, MD Gil Citro, MD Keith T. Kanel, MD Robert C. Cicco, MD Bruce A. MacLeod, MD Douglas F. Clough, MD Barbara S. Nightingale, MD Patricia L. Dalby, MD Joseph C. Paviglianiti, MD David J. Deitrick, DO Matthew B. Straka, MD Peter G. Ellis, MD Maria J. Sunseri, MD Amber L. Elway, MD Adele L. Towers, MD Trent Emerich, MD Rajiv R. Varma, MD Stephen N. Fisher, MD Matthew A. Vasil, DO H. Jordan Garber, MD David Webster, MD Kevin O. Garrett, MD John P. Williams, MD Mark A. Goodman, MD G. Alan. Yeasted, MD

ACMS was pleased to include the participation and interest of the following Residents and Medical Students:

Residents Medical Students Shea Ford, MD Jordan Hay Michael Hu, MD, MPH, MS Victoria Humphrey Shreyus Kulkarni, MD Deirdre Martinez-Meehan Michael McDowell, MD Samyuktha Melachuri Nallammai Muthiah Arnab Ray Lauren Strelec

It was an exciting House of Delegates for the ACMS delegation. Lawrence R. John, MD became the 170th President of the Pennsylvania Medical Society at his inaugural Saturday evening. Over 400 colleagues joined family and friends in recognition of this event. Trent Emerich, MD and Scott Heyl, MD were recipients of the Top 40 Physicians under 40 Award. The Early Career Physicians Section presented the award at their business meeting.

ACMS is pleased to announce the following election results for ACMS delegates:

Todd R. Hertzberg, MD was voted as Vice Speaker of the House. John P. Williams, MD was voted as Hospital-based Trustee to the PAMED Board.

For business at hand, ACMS presented two resolutions to the House. The results were:

Restrictive Covenants in Physician Contracts – Approved to develop a coalition to continue efforts at the federal level.

Review of Disparity between Dues Paying vs. Non-Dues Paying Members To Allocate Seats at the House of Delegates – Referred for study

These will be reviewed by the PAMED Board of Trustees and reported back to the Delegation.

ACMS presented a memorial resolution for George F. Buerger, Jr., M.D. It is with regret that we note for our senior members a memorial resolution for Roger Mecum, who served as executive director for PAMED for many years and passed away October 23, 2019. Also recognized was the tragedy at the Tree of Life on its one-year anniversary. The House of Delegates held a moment of silence for all. ACMS congratulates the Top 40 Physician winners, our elected delegates to PAMED office and special congratulations and best wishes to Dr. John as he begins his term as President, PAMED. A special thanks to all the delegates for their time, interest, lively discussion and participation in the ACMS caucus and the PAMED committees. The goal is better physicians and a better medical community - and we are grateful for your efforts. Additional information on the House of Delegates, election results, Reference Committees and Resolutions can be found at www.pamedsoc.org/Delegation.

Improving Healthcare through Education, Service, and Physician Well-Being.

PerspectivePerspectiveEditorial Index

440 www.acms.org

AACMS Alliance News............259, 305, 333Activities & Accolades ........218, 260, 306, 340, 384, 421BCClassifieds ............................216, 314 Community Notes.........260, 307, 333DEEditorial:Summer nourishment ...................198 Deval (Reshma) Paranjpe, MD, FACSWe believe in the getting physicians back to the art of medicine............. 200Amelia A. Paré, MDMedical malpractice 101: A primer – Part II: The road to the courtroom...204Richard H. Daffner, MD, FACRBeneath the veil of the white coat....207Andrea G. Witlin, DO, PhD If the spirit moves you....................238 Deval (Reshma) Paranjpe, MD, FACSMoving, on.......................................240Charles Horton, MD Medical malpractice 101: A primer – Part III: Elements of a malpractice suit...................................................242Richard H. Daffner, MD, FACR It’s complicated................................246Andrea G. Witlin, DO, PhD I rather like you, and I don’t want you to die.................................................282

Deval (Reshma) Paranjpe, MD, FACS Personalized medicine: Evolution, not revolution.......................................284 Anna Evans Phillips, MD, MS Medical malpractice 101: A primer – Part IV: The expert witness..............286Richard H. Daffner, MD, FACRIs it really self-inflicted?...................292Andrea G. Witlin, DO, PhDPhysician life hacks.........................322Deval (Reshma) Paranjpe, MD, FACSTaking the tide.................................324Richard H. Daffner, MD, FACRThe Jekyll and Hyde of EMRs.........326Andrea G. Witlin, DO, PhD Pocket MBA.....................................362 Deval (Reshma) Paranjpe, MD, FACSA voice of one..................................364 Richard H. Daffner, MD, FACRWhen the music stops.....................366 Andrea G. Witlin, DO, PhD‘Generation A’ comes of age............368 Anthony L. Kovatch, MDWinter nourishment..........................406 Deval (Reshma) Paranjpe, MD, FACSRetirement.......................................410 Richard H. Daffner, MD, FACRThen and now..................................413 Andrea G. Witlin, DO, PhDFFeature:Moving physicians from burnout to wellness a priority for new PAMED president..........................................386

GHIIn Memoriam:George F. Buerger Jr., MD ..............219Eugene W. Delserone, MD..............307Robert Love Baker, MD...................424JKLLegal Report:Feds utilize 1960s-era organized crime law to attack private insurance fraud.................................................223 William M. Maruca, Esq.Physician non-compete restrictions.......................................226 Karen E. Davidson, Esq.Medicare physician fee schedule changes: 2020.................................310 Michael A. Cassidy, Esq.Private equity deals – back to the future?.............................................346 William H. Maruca, Esq.Regulatory sprint to coordinated care: New Stark and Anti-Kickback rules...........................................................................428 Michael A. Cassidy, Esq.Legal Summary: Beth Anne Jackson, Esq........144, 264, 390

Volume 109 No. 7 July 2019 Pages 193-232Volume 109 No. 8 August 2019 Pages 233-276Volume 109 No. 9 September 2019 Pages 277-316Volume 109 No. 10 October 2019 Pages 317-356Volume 109 No. 11 November 2019 Pages 357-400Volume 109 No. 12 December 2019 Pages 401-444

PerspectivePerspectiveEditorial Index


MMateria Medica:Brexanolone: An advancement in the treatment of postpartum depression..................................... 220Erlynn B. Frankson, PharmD Sean W. Clark, PharmDEstradiol vaginal inserts (Imvexxy®) for the treatment of dyspareunia in post-menopausal women............... 262Archana Raghavan, PharmDSara Weinstein, PharmD, BCPSBezlotoxumab (Zinplava™): For the prevention of recurrence of clostridium difficile infection...............................308 Anna Zuschnitt, PharmD candidateSwitching between P2Y12 inhibitors: Considerations in dosing and timing...............................................342 Aubrey Dusch Kylie Horvath Maleia Ruane Suzann Sebastiani Courtney A. Montepara, PharmD Bictegravir/emtricitabine/tenofovir alafenamide (Bitkarvy).....................386 Kevin Wissman, PharmDErica Wilson, PharmD, BCPSTrikafta™ (ivacaftor/tezacaftor/ elexacaftor): A breakthrough therapy for cystic fibrosis patients who carry at least one F508del mutation.........425 Adam Patrick, PharmD candidateMedical Student Musings: A medical education should be a liberal education.........................................254Arthi NarayananMembership Benefits: 296, 336, 378, 422Miller Time:High-dose opiates and benzodiazepines in end-of-life care.............................372 Scott Miller, MD, MA, FAAHPM

NOPPerspective:PCPs can provide valuable care during hospice............................................209Robert H. Potter Jr., MD, CMD, FAAFPI am who I am, and not what I do: Redefining self-identity to combat physician burnout.............................210Wendy Palastro, MD Tired of saying goodbye..................248Jorge Lindenbaum, MDTo be, or not to be...........................249Maria J. Sunseri, MD, FAASMPlatelet-rich plasma: New uses in dermatology.....................................251Jorge Lindenbaum, MDManagement of uveitis: A partnership between rheumatology and ophthalmology.................................294 Jared Knickelbein, MD, PhDThe fine line between functionality and cosmesis.........................................300 Suzan Obagi, MDKnowledge of nutrition is power: What will you do with yours?....................329 Kristen Ann Ehrenberger, MD, PhDHow to advise your patients when they ask about stem cell treatment for osteoarthritis...................................331 Paul S. Lieber, MDAn ode to Planet Nine Pluto: A human hospice physician sharing a pet hospice experience.........................374 Keith R. Lagnese, MD, FAAHPM, HMDCA case for diversity in the Pittsburgh workorce..........................................380 William Simmons, MDChoosing a Medicare plan...............415 Namita Ahuja, MDQ

RReportable Diseases.............274, 437SSociety News .............. 212, 256, 302, 334, 383, 418Special Report:RCM services allow for profitablity and more focus on patient care.......229Jacqueline MeriweatherDirect primary care: A win-win for doctoros and patients......................265Kirsten Lin, MDHighlights of the ADA 2019 revisions to the standards of care in diabetes...........................................267Lori Bednarz, RN, MSN, CDE, CPT NASH: A patient’s perspective.........271Tony VilliottiReview of child deaths in Allegheny County, 2008-2017: Data and insights..........................................392Michael Freedman, MD, MPhilHarm reduction saves lives: The role of naloxone in reducing overdose deaths in Allegheny County.........................396Alice Bell, LCSWUpdate on the prevalence of blindness at the Western Pennsylvania School for Blind Children..................................432Heidi Ondek, EdD Albert Biglan, MD Beth Ramella, MEd2019 PAMED House of Delegates report...............................................438TUVWXYZ

PerspectivePerspectiveAdvertising Index

442 www.acms.org

2019 Bulletin Advertising Index: July-DecemberAccountingKline Keppel & Koryak PC............................. (412) 281-1901

Billing/Claims/CollectionsFenner Consulting ........................................ (412) 788-8007ClinicalAllegheny Health Network ............................ (724) 933-1445 Encompass Health ........................................ (877) 937-7342Hand & UpperEx Center ................................ (724) 933-3850Vujevich Dermatology Associates, PC........... (412) 429-2570

ComplianceHIPAA One.................................................... (801) 770-1199InsuranceNORCAL Mutual.............................................(800) 445-1212Ophthalmic Mutual Insurance Company ....... (800) 562-6642

LegalFox Rothschild LLP.........................................(412) 391-1334Houston Harbaugh PC................................... (412) 281-5060

Tucker Arensberg PC.................................... (412) 566-1212Quatrini Rafferty.......................................................(888) 288-9748Medical SuppliesMedtronic ....................................................... (877) 691-8185MiscellaneousACMS Foundation ......................................... (412) 321-5030AAMRO ......................................................... (800) 489-1839Jewish Healthcare Foundation ...................... (412) 594-2550Pennsylvania Medical Society........................(717) 558-7750Southwest PA Environmental Health Project ... (724) 260-5504Real Estate/DevelopmentBerkshire Hathaway: The Preferred Realty.....(800) 860-SOLDBerkshire Hathaway: Julie Wolff Rost .............(412) 521-5500Beynon & Co. ..................................................(412) 261-3460

Wealth ManagementCharles Schwab ............................................ (412) 347-5959

The Bulletin depends on its advertisers. Be sure to tell them you saw their ad here.

ACMS members: We want to hear your

opinions on important topics affecting healthcare. Email [email protected]

to learn more about submitting a Perspective column to the Bulletin.

ACMS Bulletin 2020 Copy DeadlinesIssue DeadlineFebruary 2020 Monday, Jan. 13March 2020 Monday, Feb. 10April 2020 Monday, March 16May 2020 Monday, April 13June 2020 Monday, May 11July 2020 Monday, June 15August 2020 Monday, July 13September 2020 Monday, Aug. 10October 2020 Monday, Sept. 14November 2020 Monday, Oct. 12December 2020 Monday, Nov. 16January 2021 Monday, Dec. 14

fillerThank you for your membership in the

Allegheny County Medical SocietyThe ACMS Membership

Committee appreciates your support. Your membership

strengthens the society and helps protect our patients.

Please make your medical society stronger by encouraging your colleagues to become members of the ACMS. For information, call the membership department at (412) 321-5030, ext. 109,

or email [email protected].

Happy Holidays from all of us at

ACMS!

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