PRESIDENT’S COMMENTS: Who’s Your Daddy? Folder/magazines... · 2018-11-02 · PRESIDENT’S COMMENTS Who’s Your Daddy? By Wiley T. Robinson, MD, FHM President Tennessee Medicine

VO

L. 1

06

, N

O.

2

| F

EBR

UA

RY 2

01

3

Editorial: Physician Suicide

Primary Care Medicaid Payments

Stroke-Like Symptomsin Severe Hyponatremia

PRESIDENT’S COMMENTS:

Who’s Your Daddy?

TMA Elections 2013

Vote for Your Leaders!

THE RIGHT PRESCRIPTION FOR A BETTER PRACTICE.

Physician Services, Inc.

Visit our website and let us help you, today.

www.tnmed.org/tmaphysicianservices Call toll-free 1-800-659-1862

Today, running a practice often competes with practicing good medicine. TMA’s Physician Services network of vendors has the cure for your business needs – from all your business and personal insurance needs to credit card processing, IT solutions, and better pricing on your consumables.

Scan to visit us online!

To learn more, contact:Michael Hurst

[email protected] 800-659-1862

isit our wV

ou, todayebsite and let us help yisit our w

.ou, today

.tnmed.orwwwCall toll-fr

g/tmaphysicianser.tnmed.oreeCall toll-fr 9-1862 1-800-65

vices g/tmaphysicianser

President’s Comments5 Who’s Your Daddy?—Wiley T. Robinson, MD, FHM

Editorial7 Suffering in Silence: Physician Suicide—David G. Gerkin, MD

Member News11 Alert: HealthSpring Contract Attachment; Report VSHP-Quest

Issues; TMA Renewal Promotion Winners; Insurance Issues Chairman Dr. Leonard; 2013 Medicare Payments; EHR Attestation;PITCH 2013 Registration; Flu Could Get Serious; Reportable Disease List Revised; TMA Photo Gallery; Member Notes; IMPACT Capitol Hill Club

Special Features29 Medicaid Payments for Primary Care Services in 2013-2014

—Becky Morrissey31 Understanding Health Reform Series—Impact of the Federal

Insurance Exchange on the Growing Physician Shortage—Katie Dageforde, JD

33 Private Placement Insurance: Retirement Planning With Taxes in Mind—Chris Stout

The Journal35 Original Contribution—Reversible Stroke-Like Symptoms with

Severe Hyponatremia—Lindsey N. Holloman, MD; Victor O. Kolade,MD, FACP; Daniel R. Zapko, MD; Laura B. Youngblood, MD

39 Original Contribution—Metaplastic Breast Cancer: A Presentationof Two Cases and a Review of the Literature—Millard Ray Lamb,MD, FCP; Elena Gertsen, MD, PhD, PGY3; Eleanor Middlemas

42 Original Contribution—A Novel Medication Error in the Treatmentof Hyperthyroidism—Bhavesh B. Barad, MD; Alan N. Peiris, MD(Lon), PhD, FRCP (Lon)

43 Journal Commentary—Vitamin D Deficiency: Awaiting FinalProof?—Jacob George, MD; Hakam Khazrik, MD; Dima A. Youssef,MD; Alan N. Peiris, MD(Lon), PhD, FRCP(Lon)

For the Record44 TMA Alliance Report—TMAA Members-at-Large Make a

Difference—Emily Shore45 New Members; In Memoriam; Correction46 Advertisers in This Issue; Instructions for Authors

Volume 106, Number 2 + February 2013

WWW.TNMED.ORG

CONTENTS

F

23Cover Story

The Times They Are A-Changin’: Physician PracticesEvolve—Brenda Williams

19Elections

TMA Voter’s Guide 2013

Nomina�ons now beingaccepted for 2013/2014The Tennessee Medical Associa�on’s Physician

Leadership College is an intensive leadership

development program designed to train TMA

members in the core ap�tudes to excel in

leadership posi�ons within organized

medicine, medical prac�ce and business.

For more informa�on, visit

www.tnmed.org/leadershipcollege

PresidentWiley T. Robinson, MD

Chief Executive OfficerRuss Miller, CAE

Office of Publication2301 21st Avenue SouthPO Box 120909Nashville, TN 37212-0909Phone: (615) 385-2100 Fax (615) [email protected]

EditorDavid G. Gerkin, MD

Editor EmeritusJohn B. Thomison, MD

Managing EditorBrenda Williams

Editorial BoardLoren Crown, MDJames Ferguson, MDRobert D. Kirkpatrick, MDKarl Misulis, MDGreg Phelps, MD

Bradley Smith, MDJonathan Sowell, MDJim Talmage, MDAndy Walker, MD

Tennessee MedicineJournal of the Tennessee Medical Association(ISSN 1088-6222)Published monthly under the direction of the Board ofTrustees for members of the Tennessee Medical Association, a nonprofit organization with a definitemembership for scientific and educational purposes,devoted to the interests of the medical profession ofTennessee.

This Association is not responsible for the authen-ticity of opinion or statements made by authors or in

communications submitted to Tennessee Medicinefor publication. The author or communicant shall beheld entirely responsible. Advertisers must conform to the policies and regulations established by theBoard of Trustees of the Tennessee Medical Association.

Subscriptions (nonmembers) $30 per year for US,$36 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association member-ship dues includes the subscription price of Tennessee Medicine.

Copyright 2013, Tennessee Medical Association. Allmaterial subject to this copyright appearing in Tennessee Medicine may be photocopied for noncom-mercial scientific or educational use only.

Periodicals postage paid at Nashville, TN, and atadditional mailing offices.

POSTMASTER: Send address changes to:Tennesssee MedicinePO Box 120909, Nashville, TN 37212-0909

In Canada: Station A, PO Box 54, Windsor, Ontario N9A 6J5

Advertising Representative: Michael Hurst – (615) 385-2100 or [email protected] Graphic Design: Aaron & Michelle Grayum / www.thegrayumbrella.com

My friend Father John Sewell, who is the rector at St. John’sEpiscopal Church in Memphis, has helped me understandthe difference between a job and work. He draws on this

distinction from Reinventing Work by Matthew Fox. The word “job”is derived from the Middle English word “gobbe” and was laterchanged to “jobbe.” The original meaning was “lump” or “piece,”denoting “piece-work” or a discreet task that was often not joyful.The word “work” comes from the word “rolle” in Old French, whichis the roll of parchment an actor reads from. This helps to explainthat one’s work is the “roll” (read “role”) one plays in the whole ofone’s life.

As many of us were growing up, most physicians owned theirmedical practices, worked long hours and treated their patients forthe length of their careers. Patients rarely changed doctors and abond formed between the patient and their doctor. Insurance com-panies, hospitals and the government never interfered with that re-lationship, regardless of where the doctor’s payment came from,which usually was from the patient. Everyone was largely satisfiedwith the care provided. Physicians were treated with great respectand they were quite satisfied with their professional careers they hadsacrificed and worked so hard to achieve. Alas, that time has passedand many factors including healthcare reform, work-life balance is-sues, increased regulatory and administrative paperwork, health in-formation technology implementation, and especially financialreform of the healthcare system are causing an increasing numberof physicians with private practices to seek employment directly withhospitals, universities, health systems and the government.

A recent New England Journal of Medicine study found the num-ber of physicians who are truly independent has been declining at arate of about two percent per year since the year 2000. Estimates thisyear suggest this decline will reach five percent, resulting in less thanone-third of U.S. physicians remaining truly independent.

The expected two-thirds of U.S. physicians who would be em-ployed are finding many options. Direct employment by their localhospitals is one such arrangement, although Tennessee state lawprohibits direct hospital employment of radiologists, pathologists,anesthesiologists and emergency room physicians. Hospitals in Ten-nessee are aggressively employing physicians in an effort to remaincompetitive. Physician-hospital service agreements are another workarrangement. This is the type of arrangement that has been in placefor years with hospital-based practices such as radiology, pathology,

anesthesiology and emergency room physicians. Employment by aregional or national specialty company is also popular. Tennessee-based TeamHealth is one such company that has been successful inemploying physicians. The universities in our state, such as Vander-bilt, East Tennessee State University, Meharry and the University ofTennessee, have long employed physicians with varying degrees ofsuccess. Many physicians in our state are employed by the VA systemand others work for the federal government in underserved areasthrough loan forgiveness programs.

The move toward physician employment potentially provides anumber of benefits. Some of these are reduced administrative re-sponsibilities, better access to leading-edge healthcare IT tools, fa-cilities or equipment, stability in a rapidly changing businessenvironment, and possibly shorter and more predictable work hourswith a more manageable call schedule. However, the largest driver inphysician employment today is finances. Physicians are faced with anunstable reimbursement environment that seems to change monthly.

As safe as employment may seem, there are pitfalls to this rushto employ physicians. One of these is the expense involved. De-pending on one’s specialty, physician practices are worth over a mil-lion dollars a year per doctor to the bottom line of a hospital. Nowonder hospitals spend an estimated $50,000-$75,000 to recruiteach new physician. If you add in training, credentialing and themarketing of a new physician practice, that number can reach$200,000 per year over the first three years as the physicians andhospital adapt to the new arrangement. This can lead to circum-

PRESIDENT’S COMMENTS

Who’s Your Daddy?By Wiley T. Robinson, MD, FHMPresident

5Tennessee Medicine + www.tnmed.org + FEBRUARY 2013

The decision to practice independently, to be employed or to change employment

is a difficult one and can be life-changing. The decision should

be made very carefully.

“

”

(Continued on page 8)

Struggling in Silence: Physician Suicide

COMMENTARY

In July 2009, Roland Gray, medical director of the Physician’sHealth Program (PHP) of the Tennessee Medical Foundation,wrote an article in Tennessee Medicine about physician suicide.

This alert to the problem has plagued me since then, particularlysince the subject has not been fully addressed as needed. The rate ofsuicide among medical students, residents and physicians haschanged little in the last few decades. The title I used for this edito-rial came from a PBS presentation on the subject televised severalyears ago. It is also personal since I have lost classmates and col-leagues to suicide.

Doctors have the highest suicide rate of any profession basedon most studies. The statistic is varied as far as individual studiescomparing the number to the general population but in the profes-sions, male physicians have a 40-percent higher rate and femalephysicians as high as 130 percent. The numbers may seem smallcompared with the general population but if stated differently, arealarming. Of concern to me is that number is over 400 per year andis equal to one to two medical school classes. More alarming is thatsuicide is the most common cause of death in medical students, tiedwith accidents in some studies.

What does it mean when physicians take their own lives? Sadly,though doctors have a lower mortality risk from cancer and car-diovascular disease compared with the general population, they havea significantly higher rate of dying from suicide, the end stage of atreatable disease process. In most populations, suicide is often theresult of untreated depression, and the attempt is more successfulin individuals who “know how” to take their own lives, as is char-acteristic of doctors.

Depression is as common in the medical community as in theoverall population, affecting an estimated 14 percent of males and20 percent of females. Further, because of the stigma often relatedto depression, lack of self-reporting underestimates the pervasive-ness of the illness. Indeed, though physicians seem to follow theirown advice about smoking and common risk factors for prematuredeath, they are unwilling to confront their own depression, a signif-icant cause of mortality that inexplicably affects them.

Another problem is that many doctors are uncomfortable treatingfellow physicians, especially in the field of mental health. Part of theproblem is the so-called “VIP syndrome,” described by Louise Andrewin an online Medscape article on physician suicide. The article statedthe syndrome, “…characterized by well-intentioned, but superficial or

inadequate, treatment based on collegiality and concerns about con-fidentiality, can detract from the effectiveness of therapy.”Mental health experts who have studied physician depression andsuicide stress that immediate treatment and confidential hospital-ization of suicidal physicians can be lifesaving, even more so than inother populations. The specter raised by this approach and the pos-sibility of temporary withdrawal from practice, the lack of confi-dentiality and not reaching out in a time of crisis and seekingeffective treatment is common and devastating.

In addition to depression as a cause of suicide in physicians, Dr.Gray describes the effects of life stressors so common in those dealingwith people's lives and healthcare issues as a significant contributor. Itincreases stress and burnout and affects not only the office environ-ment but an attempt to have a stable home life and marriage. Medicineis a fraternity led by passionate professionals educated to strive for per-fection and despise weakness. It is a high-stress profession.

“It’s embarrassing for a physician who is held up by society as anicon to admit that we may need help,” said Dr. Luis Sanchez, direc-tor of the Physician Health Services in Massachusetts, similar to ourown PHP, which was created to aid doctors with mental health andsubstance abuse problems. “We do not want to admit we might havesome faults or frailties.”

“It’s about changing a culture of shame and blame to adopting aculture of safety, so that when doctors have a problem they feel theycan talk about it,” said Dr. John Fromson, chairman of the AmericanPsychiatric Association's Committee on Physician Health, who com-pared the efforts to initiatives aimed at reducing medical errors. “Weneed to reward people who ask for help rather than punish them.”

“With the economic challenges we face today, the level of pres-sure and competitiveness will continue to escalate. It should be aresponsibility of institutions to help their physicians take care oftheir well-being as they take care of the patients,” says Ellen R. GritzPhD, co-editor of the book and professor and chair of M. D. An-derson's Department of Behavioral Science.

Because of physicians’ strong self-motivation to pursue a suc-

EDITORIAL

By David G. Gerkin, MDEditor


Why are not more people talking aboutphysician suicide?“

”

cessful professional vocation, an essential source of their self-es-teem, the stress of trying to achieve this excellence adds to thedilemma. In physicians, it is especially a problematic since the prac-tice of medicine, even under optimal conditions, is challenging andfraught with disappointments and self-perceived failures. The fre-quent character of a doctor’s self-motivation in the pursuit of thisperfectionism can be devastating in many, and lead to despair andreactions such as “burn out” and in some, suicide. More educationis needed about this illness and its disparate and terrible impact onthe medical profession, starting as early as medical school and con-tinuing throughout their professional lives. There is a need both inthe profession and in public opinion to view mental illness and re-sponse to stress as a part of living and deal openly with it rather thanwith a fear of repercussion or shame. Those so affected, includingphysicians, should be more receptive to this diagnosis and utilizeavailable treatment. Almost all states and even healthcare institutionshave physician health programs, a resource not usually available tothose in the general population. The tragedy is that, even with theavailability of these programs, most do not avail themselves of suchcare. In addition, the chance of a “challenge” to stable mental healthstatus and lifestyle routine affects all doctors at some time, and ris-

ing to the level of suicide or loss of professional activities affects notonly the profession but all parts of society.

Why are not more people talking about physician suicide? In fact,if one does an Internet search using these words, nine out of 10 linkslist only physician-assisted suicide? As common as the problem is, thisstatement makes us look at the complex problem with a different view.Why in newspapers, medical journals and in general discussion do weavoid the use of this word? I think it reflects the image created by thestigma, the theme of failure and, for some reason, an appearance of“shame.” If we cannot be truthful and move forward using the com-plex issues we are dealing with to help those in the profession and ourpatients who are “struggling in silence," we are not serving the livingor honoring the struggles of those who could not survive.

Given the current stress of providing good health care and theincreasing amount of tension engendered in the practice of medi-cine, doctors must strive to take care of themselves and support theircolleagues. Many times, suicidal caprice is a temporary urge can beovercome if we have and provide support to our colleagues. We mustnot lose ourselves or our colleagues in a moment of desperation.+

EDITORIAL

8 Tennessee Medicine + www.tnmed.org + FEBRUARY 2013

WHO’S YOUR DADDY(Continued from page 5)

stances that place volume over value. Under Medicare’s tangled pay-ment system, hospitals receive significantly higher reimbursementsthan individual doctors for specialty services, in some cases, as muchas three times more. Several recent physician practice acquisitionsby hospitals have ended up in court. The state attorney general of Cal-ifornia is looking into whether hospital-physician partnerships aredriving up prices in a way that violate antitrust laws. Clearly in theshort run these arrangements raise costs to payers. When specialtyphysicians become hospital employees, payers such as Medicaremust start paying more for the same services performed by the samedoctors in the same locations.

Other potential pitfalls include dealing with medical suppliers.Medical device firms, healthcare IT companies and pharmaceuticalcompanies will see their target customers shift from physicians tohospitals and health systems. Also, patients may choose non-em-ployed physician services due to financial and service reasons. An ar-ticle in The Wall Street Journal advised patients that choosing ahospital-employed physician could increase their out-of-pocket costsbecause a service might be more expensive than at independentpractices. Certainly there is no free lunch. Employed physicians willhave to generate enough revenue to pay for their salary, benefits andoverhead associated with their practice and generate something be-yond that to pay their employer.

The decision to practice independently, to be employed or tochange employment is a difficult one and can be life-changing. Thedecision should be made very carefully. Fortunately, membership inthe Tennessee Medical Association provides a significant resourcewhen one is considering employment. Your TMA/AMA representa-

tives voted this November on AMA guidelines for physician employ-ment. Your TMA has access to ideal physician contracts from vari-ous sources. The law of supply and demand favors physicians whenmaking these decisions because there are many fewer physiciansthan there are job opportunities. Physicians should always spend atleast as much time considering how to exit a contract as they doviewing the upside of employment.

Finally, when considering who is your boss or “Who’s yourdaddy?,” two questions must be answered: Is your value to your pa-tients equal to or greater than your value to hospitals, payers or youremployer? And is being a physician a job or is it your life’s work?Let’s hope your value is greatest to your patients and your work is notjust a job, but is your role in life.+

Share your thoughts with Dr. Robinson at [email protected].

3

EARLY BIRD DISCOUNT • $99 UNTIL MARCH 1ST!

April 5-7, 2013 + Franklin, Tennessee

For details and hotel registration visit www.tnmed.org/medtenn2013 or scan here:

MedTenn 2013 will be an annual mee�ng like noneother. Get ready to:

ENGAGE by connec�ng with friends, colleagues and other physician

leaders like you from across Tennessee.

EMPOWER yourself with informa-�on and updates from

our experts, including sessions on clinical hot topics likeOpioids and Newborns and Mental Health: Changing theS,gma, plus a primer session on the Controlled SubstanceDatabase.

EVOLVE your prac�ce and your outlook withthe latest informa�on on the

change that’s transforming pa�ent care, including updateson ICD-10, Federal Quality Ini,a,ves, the Direct ProjectExchange and Vital Connect.

Join your fellow physicians inNashville for MedTenn 2013!

++

+

The TMA is proud to announce the winners of its member re-newal promotion contest. Thomas Clayton, MD, of PhysiciansAssociates, LLC, in Crossville, is the winner of an iPad2. DavidJarvis, MD, of The Frist Clinic in Nashville, won a Kindle Fire. Thecontest was held through November 1 among TMA members re-newing early for 2013. Special thanks to members who have re-newed early, and to all our members. +

Dr. Clayton Dr. Jarvis receives his Kindle Fire from TMA Membership Services Associate Director

Chris Tanner.

Member NewsVisit www.tnmed.org for the latest TMA news, information and opportunities!


Physicians: Report Issues With VSHP-QuestTMA members are urged to contact the Association with any pa-tient care issues that have arisen out of an exclusive lab servicesagreement between Volunteer State Health Plan (VSHP) andQuest Diagnostics.

Effective October 1, 2012, VSHP, a TennCare managed careorganization, contracted with Quest to be the exclusive providerof laboratory services except for certain services contained onVSHP’s “Exclusion List.” Before and since this arrangement, theTMA has had productive dialog with VSHP to improve lab serv-ices to VSHP patients. This has included the provision of morepick-up sites but more importantly, adding services to the Exclu-sion List where direct patient care would be negatively affectedotherwise.

VSHP is in the process of finalizing its Exclusion List for theyear. If your practice is experiencing legitimate issues that im-pact patient care as a result of this exclusive arrangement,please let the TMA know about it as soon as possible by contact-ing Phyllis Franklin at [email protected] or Katie Dage-forde at [email protected].

This arrangement might be extended to other BlueCrossBlueShield line of businesses other than TennCare in the future,so the TMA wants to make the process work as well as possiblefor participating physicians.

QUESTIONS?Contact the TMA at 800-659-1862. +

TMA members are being asked to contact the Association if they havereceived a HealthSpring contract with an attachment seeking to limittheir participation in other Medicare Advantage plans.

A member physician with a rural practice alerted the Legal De-partment to the attachment. Like the physician, the TMA has strongconcerns about the exhibit and the consequences of non-compliance.The TMA has contacted HealthSpring and the Centers for Medicareand Medicaid Services (CMS) seeking response to its concerns.

The “Exhibit A” attachment requires the physician agree to oneof three options:

1. Participate only in the HealthSpring plan and no otherMedicare Advantage plan. In exchange, the physician will re-ceive an increase in monthly reimbursement per each mem-ber (an exclusivity payment); or

2. Participate in the HealthSpring plan and one other MedicareAdvantage. Again, the physician will receive an increase inmonthly reimbursement per each member. The amount is lessthan the additional fee offered in 1; or

3. Participate in the HealthSpring plan and the Medicare Advan-

Member Alert: HealthSpring Contract Attachment

(Continued on page 17)

TMA AnnouncesMember RenewalPromotion Winners!

You are valued by your association! Renew now at www.tnmed.org/renew.

Tennessee Medicine + www.tnmed.org + FEBRUARY 201312

Member News

PERSONAL

Professional Title: Solo fam-ily physician for 31 years.Practice Interests/Special-ties: Anti-smoking efforts.Most Important Accom-plishments: Beautifuldaughter and three grand-daughters.Family: Wife of 21 years,daughter, three granddaugh-ters, dad and mom still liv-ing, one sister, seven cats.

Something Not Widely Known About You: I love to garden, lovecomputers and science fiction, sing tenor in my church choir.Currently Reading: The Bible.

COMMITTEE

Years as Chair: One. Why I Agreed to Step Into a Leadership Role: I was rotating offthe board of trustees and wanted to stay involved with the TMA.Goals/ Philosophy as Committee Chair: Our committee servesas a clearinghouse for the TMA president's goals, staff liaison is-sues, and questions from members about insurance, with thepurpose of fulfilling the mission of the committee.Most Important Committee Accomplishments: Ongoing advo-cacy for members with insurance companies often resulting inlarge financial savings.Importance of the TMA/Committee: The intelligent and diversemembers of the committee give valued opinions and practicalsuggestions concerning oftentimes controversial issues pertain-ing to the ever-changing world of insurance. TMA members needthis advice to help them navigate the changes taking place.+

CMS has issued guidance on updates to 2013 Medicare pay-ment amounts, claims processing, and reopening of the partic-ipation enrollment period. The new law averts the 26.5-percentSGR cut for all of 2013 and the two-percent sequester throughthe end of February. It also extends the work GPCI (GeographicPractice Cost Index) floor for a year.

Read the CMS announcement at www.tnmed.org/upload-edFiles/Documents/CMSMedicareUpdate.pdf.

CAHABA GBAThe 2013 Medicare payment schedules are now posted on theCahaba GBA website, www.cahabagba.com. The searchabledata bases are being created and will be available as soon aspossible, by January 23 at the latest. Providers may continue tosubmit claims; Cahaba is holding them and releasing as in-structed by CMS. There was one small glitch with some claimsbeing released and denied because there was no fee schedulein the system yet, however these claims will be identified andcorrected with no provider action required.

For more information contact the TMA at 800-659-1862.+

2013 Medicare PaymentRates Updated

Eligible professionals (EPs) who participated in the MedicareElectronic Health Record (EHR) Incentive Program in 2012must complete attestation for the 2012 program year by Feb-ruary 28, 2013. To be eligible to attest you must have com-pleted your 2012 reporting period by December 31, 2012.

CMS encourages Medicare EPs to register and attest assoon as possible to resolve any potential issues that maydelay their payment.

NEED HELP?CMS has several resources located on the EHR Incentive Pro-grams website to help EPs properly meet meaningful use andattest. Visit www.cms.gov/Regulations-and-Guidance/Legis-lation/EHRIncentivePrograms/index.html?redirect=/EHRIn-centivePrograms or call TMA Practice Solutions at800-659-1862. +

Get Paid for 2012:Medicare EPs Attestby Feb. 28

Interested in serving on a TMA Committee? Visit www.tnmed.org/TMA_committees or contact the TMA at 800-659-1862.

TMA InsuranceCommittee ChairmanDr. Charles Leonard

MEET

Member News


PITCH 2013 is March 6 – Register Now!Registration is now open for PITCH 2013 (Physician Involved in Ten-nessee’s Capitol Hill) on Wednesday, March 6. Visit www.tnmed.org/pitchto sign up and learn details of medicine’s big day in Nashville. At-tendees will attend legislative hearings, plan one-on-one sessionswith their elected representatives, and enjoy a community lunchwith legislators. Bus transportation from upper East Tennessee,Knoxville, Chattanooga, Memphis and Jackson will be made avail-

able if a minimum of 20 people sign up to ride a bus at least twoweeks prior to the PITCH date.

SIGN UPVisit www.tnmed.org/pitch; for more information on making travelarrangements, please contact your Component Medical Society orRenee Arnott at 800-659-1862 or [email protected]. +

Tennessee health providers should continue year-round, weekly re-porting and submission of specimens from all patients whose ill-nesses meet the definition for Influenza-Like Illness (ILI). That fromTennessee Department of Health officials who said influenzaviruses, predominantly seasonal influenza type A (H3N2), are cir-culating in the state, with intense activity in some regions.

The TDH said there is potential for this to be a relatively seriousflu season because, historically, overall mortality has been higherduring seasons when H3N2 strains are dominant. Vaccination is thebest tool to reduce the risk of mortality; the CDC reports a goodmatch between circulating viruses and the vaccine.

See the Surveillance Summary Report for the Tennessee Sen-tinel Provider Network for Influenza-Like Illness (ILI) athttp://health.state.tn.us/TNflu_report_archive.htm.

SURVEILLANCE REQUIREMENTSSurveillance activities, including the reporting of cases and sub-mission of specimens, continue year-round. The 2012-2013 in-fluenza-like illness (ILI) surveillance year began Sept. 30, 2012, andruns through Sept. 28, 2013.

Providers should continue year-round, weekly reporting of and sub-mission of specimens from all patients meeting the ILI case definition:

• Fever >= 100F or 37.8C plus cough and/or sore throat, in theabsence of a known cause (other than influenza).

• ILI classification is based on symptoms only (i.e. it does notrequire any test).

FLU VACCINEThe CDC also released new recommendations for influenza antiviralmedication. These are summarized in the attached and available atwww.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm.

Tennessee has not detected cases of novel influenza A H3N2vinfections currently identified in several states in association with

swine contact at agricultural fairs. Sentinel Providers are urged tosubmit specimens on all patients meeting the ILI case definition andto contact public health for patients with ILI and contact with swine.Surveillance specimens are essential to detection: the TennesseeState Public Health Laboratory can test for this novel strain.

For more information, contact the Tennessee Department ofHealth at 615-741-7247.+

Health Officials: Flu Could Get Serious in Tennessee

The Tennessee Department of Health has revised its list ofReportable Diseases and Events. The latest updates wereeffective on January 1, 2013, and have been updated online.The updates are also linked in the TMA Law Guide atwww.tnmed.org/lawguide, under its topic “CommunicableDiseases” (member login required).

On the TDH site, physicians and other providers can ac-cess a summary of changes, a matrix and list of reportablediseases in Tennessee.

QUESTIONS?Read more at www.tnmed.org/tn-reportable-disease-up-dates-2013. Visit the state’s Reportable Diseases webpage at http://health.state.tn.us/ReportableDiseases/De-fault.aspx, or contact TDH at 615-741-7247. +

Reportable DiseaseList Revised for 2013


Member News

T M A P H O T O G A L L E R Y

U.S. Representative Dr. Phil Roe (above, right) poses with Roane Anderson County Medical Society President Dr. Ed Cap-parelli during the Congressman’s appearance at the society’s monthly meeting on November 8 in Knoxville. Dr. Roe waspresented with a plaque thanking him for his service and dedication to health care; RACMS members Dr. Frank Genella,Oak Ridge, and Dr. Julian Ahler, MD, Harriman, were presented with their 50-year pins.

Blount County Medical Society President Dr. Eric Schrock poses withwife Kathy during the society’s regular meeting on November 9. Themeeting featured TMA General Counsel Yarnell Beatty speaking onhealth reform, and 50-year presentations to BCMS members Drs.Homer Isbill, Henry Callaway, Ted Flickinger and Cecil Howard.

Physicians, legislators, spouses and guests get the lowdown on TMA legislation and the upcoming General Assembly ses-sion at the annual Northeast Tennessee physician/legislator dinner in Johnson City in late November. Legislative guestsincluded Lt. Gov. Ron Ramsey, Senate General Welfare Committee Chair Rusty Crowe and House Budget SubcommitteeChair and House Health Committee member Mike Harrison.

Member News


T M A P H O T O G A L L E R Y

TMA’s AMA delegation took care of business but also enjoyedsome island flavor during the AMA November meeting inHawaii. (L-R): University of Tennessee Health Science Centermedical student representative John Schmidt poses with Dele-gation Chair Dr. Don Franklin and TMA President Dr. WileyRobinson.

The TMA hosted “Hurricane Nights” in November toraise money for flood buckets for victims of HurricaneSandy. (L-R): Janice Cooper with The Memphis MedicalSociety, Dr. Lanetta Anderson-Brooks, and Dr. DanielleHassel of Collierville all chipped in during the Memphisevent at Folk’s Folly Steakhouse.

Students at the University of Tennessee Health Science Center(UTHSC) learn about more than health care at a programdubbed “Utensil University.” Debbie Neal with the School of Pro-tocol gives etiquette lessons to prepare them for job and resi-dency interviews. Photo: Ms. Neal shows med students, includingTMA member Martina Swinger (3rd from left), how to hold aglass and shake hands with others at a reception.

TMA member Dr. Steve Dickerson, a Nashvilleanesthesiologist, is shown with his family shortlyafter being sworn in as one of three physiciansserving in the Tennessee Senate. Dr. Dickersonjoins Dr. Mark Green of Clarksville and Dr. JoeyHensley of Hohenwald, previously a state repre-sentative, in the upper chamber this year.


Member News

M E M B E R N O T E S

Frederick A. Boop, MD, Kevin T. Foley, MD, and Jon H. Robertson,MD, all of Semmes-Murphey Neurologic & Spine Institute in Mem-phis, have been named to U.S. News & World Report’s 2012 TopDoctors list. Dr. Boop is a professor of neurosurgery at the Univer-sity of Tennessee and is chief of pediatric neurosurgery at LeBon-heur Children’s Hospital. Dr. Foley is director of complex spinesurgery at Semmes-Murphey, a professor of neurosurgery at theUniversity of Tennessee Health Science Center, director of the spinefellowship program for the University of Tennessee Department ofNeurosurgery, and medical director for both the Medical Education& Research Institute and the Image-Guided Surgery Research Cen-ter. Dr. Robertson has served as chair of UTHSC’s Department ofNeurosurgery, and is a former president of the American Associa-tion of Neurological Surgeons (AANS), the Society of University ofNeurosurgeons, and the North American Skull Base Society.

R. Wesley Dean, MD, of Powell, has been ap-pointed to the American Academy of FamilyPhysicians Quality and Practice Board; he willserve a four-year term through 2016. The boardoversees healthcare delivery systems, perform-ance measurement, practice redesign/qualityimprovement, privileging, health informationtechnology, practice management, private sec-

tor advocacy and physician payment issues for the AAFP. Board cer-tified in family medicine, Dr. Dean has recognized by the nationalCouncil on Quality Accreditation for diabetes and heart/stroke. Dr.Dean practices with Summit Medical Group in Knoxville. He is a for-mer president of the Tennessee Academy of Family Physicians and amember of the Knoxville Academy of Medicine.

Phillip R. Langsdon, MD, FACS, of German-town, has been elected by his peers as one ofthe “Best Doctors in America” for 2013, his 18th

time among that listing. A facial plastic surgeonwith The Langsdon Clinic in Memphis, he is aprofessor in the University of Tennessee HealthScience Center Division of Otolaryngology/Head-Neck Surgery. He is an alternate delegate

to the TMA from The Memphis Medical Society.

The Memphis Medical Society installed new officers during its an-

nual meeting in late January. Charles N. Larkin, MD, a pediatrician

at Pediatrics East, is president. Robert H. Miller, MD, is immediate

past-president. Additional officers are Gary W. Kimzey, MD, presi-

dent-elect; O. Lee Berkenstock, MD, vice-president; Melanie L.

Woodall, MD, secretary; and Thomas J. O’Donnell, MD, treasurer.

Dr. Boop Dr. Foley Dr. Robertson

Dr. Ver Halen Dr. Watson Dr. Woodall

Dr. O’Donnell Dr. Parker Dr. Shephard

Dr. Kimzey Dr. Miller Dr. Monroe

Dr. Chase Dr. Hassel Dr. Kerlan

Dr. Larkin Dr. Berkenstock Dr. Campbell

Member News


M E M B E R N O T E S

Incoming board members are Danielle H. Hassel, MD; Jeffrey E.

Kerlan, MD; and Jon P. Ver Halen, MD. Returning board members

are Tommy J. Campbell, MD; Nancy A. Chase, MD; Justin Monroe,

MD; Autry J. Parker, MD; Claudette J. Shephard, MD; and Andrew

T. Watson, MD.

Benjamin W. Johnson Jr., MD, of Nashville,

has been named director of regulatory affairs

and practice outcomes for the Center for

Spine, Joint and Neuromuscular Rehabilita-

tion. Dr. Johnson is board certified in anes-

thesiology and pain management and

previously was the center’s medical director.

He has also been listed among Becker’s Ambulatory Service Cen-

ters Review “Top 150 Pain Management Physicians to Know.” The

national recognition is based on a physician’s contributions to the

field including research and development, awards received from

major organizations, and leadership positions held. He is chair of

the TMA Practice Management & Quality Committee, a member of

the Public Health Committee, and former member of the TMA

Board of Trustees. Dr. Johnson is a member of the Nashville Acad-

emy of Medicine.

Wayne J. Riley, MD, MPH, MBA, MACP, of

Nashville, has been elected to the Institute of

Medicine of the National Academies’ Class of

2012 for his contributions to the field of med-

icine, medical sciences and health care. His

leadership roles include the Association of

Academic Health Centers, U.S. Department of

Veterans Affairs National Academic Affiliations Council and the

National Institutes of Health’s Blue Ribbon Advisory Committee;

he is current chair of the NIH National Advisory Council on Minor-

ity Health and Health Disparities. Dr. Riley is president and CEO of

Meharry Medical College. He is a member of the Nashville Acad-

emy of Medicine.

Are you a member of the TMA who has been recognized for an honor,award, election, appointment, or other noteworthy achievement?Send items for consideration to Member Notes, Tennessee Medicine,2301 21st Ave. South, PO Box 120909, Nashville, TN, 37212; fax 615-312-1908; e-mail brenda.williams@ tnmed.org. High resolution (300dpi) digital (.jpg, .tif or .eps) or hard copy photos required.

The IMPACT Board of Trustees recognizes the following IM-

PACT donors who have become Capitol Hill or Platinum Club

members in the past month. We greatly appreciate all IM-

PACT contributors for their help in assuring that candidates

supportive of organized medicine receive generous finan-

cial support from IMPACT. To join IMPACT or the Capitol Hill

Club, please contact Gary Zelizer at 800-659-1862 or e-mail

[email protected], or log on to www.tnimpact.com.

Mark Brzezienski, MD, Chattanooga

Bill Law, Jr., MD, Knoxville

D. Marshall Jemison, MD, Chattanooga

James Kennedy, MD, Chattanooga

Robert Kirkpatrick, MD, Germantown

Douglas Liening, MD, Chattanooga

Jason Rehm, MD, Chattanooga

William Rodney, MD, Memphis

Larry Sargent, MD, Chattanooga

Jimmy Waldrop, Jr., MD, Chattanooga

Charles White, Jr., MD, Lexington

+

Capitol Hill Club

tage plans the provider currently contracts with and theprovider must close the panel of the other plans to newpatients. The physician will receive an increase inmonthly reimbursement per each member. The amountis less than the additional fee offered in 1 or 2.

Additionally, the exhibit states that if Healthspring determinesthe provider is not in compliance with the exhibit, then he or shewill have to refund all exclusivity payments received fromHealthSpring from the date of non-compliance forward.

Although the TMA has no answers yet, we felt it was impor-tant to alert our members to this exhibit and the potential finan-cial consequences. As we receive updates of consequence, theTMA will notify members online and through the TMA Weekly.

CONTACT TMAIf you have any questions or have received this contract, pleasecontact Phyllis Franklin at [email protected] or KatieDageforde at [email protected]. +

MEMBER ALERT: HEALTHSPRING CONTRACTATTACHMENT(Continued from page 11)

RAC Audits . . .are you the next target?Unfortunately, physicians are a soft targetwhen it comes to a RAC audit investigation.

That's why The TMA Insurance Agency offers an insuranceprogram to combat the financial damage that can be caused byRAC audits. Our program pays for the investigation costs andshadow audits, as well as fines and penalties resulting from theprocess. As RAC audits continue to increase, your facility is atgreater risk for a review and potential fines.

Why not be prepared and take a proactive step to protect yourpractice and reputation? Contact us today to learn more aboutthis specialized program!

THE TMA ASSOCIATIONINSURANCE AGENCY, INC.Exclusive Insurance Plan Administratorfor the Tennessee Medical Association

[email protected]

800.347.1109

Polls open Friday, February 1

Polls close at 5:00 p.m. CST, Thursday, February 28

All ballots must be received by the TMA by this deadline to be counted

TMA Election Center - www.tnmed.org/elections

TMA ELECTIONS 2013

Voter’sGUIDE

It’s election time! Candidates for leadership positions for 2013-2014 are up for your vote. Use this Voter’s Guide to study thenominees, find out how to vote and then cast your ballot online.}

1. Starting February 1, all members with valid emails on file will re-ceive an e-mail with a link. Click on the link and sign in towww.tnmed.org. If you’ve never signed in, there are instructionson the sign-in page or if you need additional assistance, contactthe TMA at 800-659-1862.

2. Members may also access the online election center directly byclicking on the TMA Elections icon on the rotating marquis at thetop of our home page.

3. Once you successfully sign in, you will land on the TMA Electionspage containing instructions on how to vote, candidate profiles,and a direct link to your personalized ballot.

4. When you are ready to vote, click on the “Vote Now” button. 5. Complete the process by casting your vote for statewide offices

first and then regional offices. You can revisit the ballot as manytimes as necessary; your vote will not be counted until you push

the “Submit” button. You can change votes up until the time youcomplete and submit your ballot.

6. Once you have submitted your ballot, you will receive a confirma-tion message.

7. All votes will be tabulated at the close of elections on February 28.As soon as the election is certified, results will be posted ontnmed.org and published in Tennessee Medicine.

8. In the event of runoff elections, you will be notified to vote againat the same convenient site with the same password.

All ballots must be cast online by 5:00 p.m. CST on Thursday, Feb-ruary 28, or they will not be counted.

Still have questions? Call the TMA at 800-659-1862 and ask forRenee Arnott or e-mail [email protected].

ELECTIONS


CastYOURVOTE

Ballots for the 2013 TMA Leadership Elections are available to eligible voting members of the TMA. All ballots and candidate profiles, as well as the entire votingprocess, are available online at www.tnmed.org/elections.

MEET THE CANDIDATES

ELECTIONS


PRESIDENT-ELECT:Richard Briggs, MD, KnoxvilleDouglas Springer, MD, Kingsport

BOARD OF TRUSTEES (4 Seats) :Region 1 - Keith Anderson, MD, MemphisRegion 3 - Pete Powell, MD, FranklinRegion 6 - Nita Shumaker, MD, HixsonRegion 8 - Tim Gardner, MD, Johnson City

JUDICIAL COUNCIL (4 Seats) :Region 2 - Susan Lowry, MD, Martin

“ - Kellie Wilding, MD, JacksonRegion 4 - Ron Overfield, MD, NashvilleRegion 6 - Eugene Ryan, MD, ChattanoogaRegion 8 - Fred Mishkin, MD, Kingsport

AMA DELEGATION (10 Seats) :Richard DePersio, MD, Knoxville

Chris Fleming, MD, GermantownDonald Franklin, Jr., MD, ChattanoogaJohn Ingram, III, MD, AlcoaJames King, MD, SelmerRobert Kirkpatrick, MD, MemphisLee Morisy, MD, MemphisWiley Robinson, MD, MemphisBarrett Rosen, MD, NashvilleB W. Ruffner, Jr., MD, Signal Mountain

PRESIDENT-ELECT— Serves on the TMA Board of Trustees forthree years, one year each as President-Elect, President, and Immediate PastPresident. As president, they serve as official spokesperson for the Associa-tion on important medical issues, meet as called upon with state and fed-eral governmental officials regarding medical policy and the position of theTMA, and chair the Executive Committee.

Nominee: Richard M. Briggs, MDCity: KnoxvilleCMS: Knoxville Academy of Medicine

Specialty: Cardiovascular/Thoracic SurgeryMedical School:University of Kentucky College of Medicine

Email: [email protected]

Nominee: Douglas J. Springer, MDCity: KingsportCMS: Sullivan County Medical Society

Specialty: Internal Medicine, GastroenterologyMedical School: University of Calgary Faculty of Medicine


Governance experience, vision, active practice management, legislative in-teraction, medical society leadership role, membership chairman for TMA andadvocacy are qualities I will bring to the office of president-elect. In my roleas trustee of a $750M health system, I have had experience and specifictraining at the Governance Institute and currently serve as chairman of Qual-ity. The TMA must play a central role as the state confronts health insuranceexchanges and Medicaid expansion. As an organization, we need to move for-ward with the TMA strategic plan and associated governance issues. The TMAderives its strength from membership, and therefore continuing/expandingrelations with members, county medical societies, specialty societies, em-ployed physicians and university physicians is essential. As president-electI will work to strengthen these bonds to provide the strategic horsepower theTMA requires to facilitate its mission to the citizens of Tennessee and itsphysicians.

TMA BOARD OF TRUSTEES— Trustees serve on the Board forthree years, helping to determine policy and details of management of the As-sociation between meetings of the House of Delegates. The Board makes de-cisions regarding TMA expenditures and fulfills the responsibilities anddirectives given by the House of Delegates.

REGION 1Nominee: Keith G. Anderson, MD

City: GermantownCMS: The Memphis Medical Society

Specialty: Cardiovascular Disease/Internal MedicineMedical School:University of Tennessee Health Science

CenterEmail: [email protected]

REGION 4Nominee: James E. “Pete” Powell, MD

City: FranklinCMS: Williamson County Medical Society

Specialty: Internal Medicine/PediatricsMedical School: University of Alabama School of Medicine


Actively participating in the TMA is the best way to be involved in healthcarereform and quality care discussions. I requested the nomination of TMATrustee to represent and serve the physicians and patients in the state ofTennessee to the best of my ability. It is very important for physicians to de-fend quality medical care and the integrity of our profession. Being a trusteewill allow me to work with members of the TMA to accomplish these goals. Iam qualified to serve as a trustee based on 17 years of clinical experiencein Tennessee as a primary care and urgent care physician in community andacademic settings, graduating from the inaugural TMA Physician Leader-ship College and actively serving on three TMA committees. I completed mymasters in Management of Healthcare and serve as assistant chief medicalofficer for Vanderbilt University Medical Center managing a multi-specialtypractice.

2013 TMA ELECTION NOMINEES

ELECTIONS


REGION 6Nominee: Nita W. Shumaker, MD

City: HixsonCMS: Chattanooga-Hamilton County Medical

SocietySpecialty: Pediatrics

Medical School: East Carolina University School of MedicineEmail: [email protected]

With the dramatic change in health care today, I believe that caring for pa-tients also requires us to be involved in organized medicine. Our first re-sponsibility is to our patients, and organized medicine represents our besthope to preserve and protect the doctor-patient relationship in the midst ofchange. I am a board-certified pediatrician with Galen Medical Group. Mypassion is motivating parents to raise healthier children by maintaining ahealthy weight and getting adequate physical activity. I am an attendingphysician at Erlanger and Children’s Hospitals and was in medical staffleadership from 2000-2010, including two years as chief of staff. I am onthe board of the Southside/Dodson Avenue Community Health Centers andthe Erlanger Board of Trustees. I am on the UT College of Medicine in Chat-tanooga Clinical Faculty. In 2010, I was president of the Chattanooga-Hamilton County Medical Society and I am a member of TMA and theAmerican Academy of Pediatrics.

REGION 8Nominee: Timothy L. Gardner, MD

City: Johnson CityCMS: Washington-Unicoi-Johnson County

Medical SocietySpecialty: Dermatology/Dermatopathology

Medical School: University of Virginia School of MedicineEmail: [email protected]

As an upcoming graduate of the TMA Physician's Leadership College 2012-2013 with past experience in local medical society leadership, I am lookingforward to having the opportunity to participate at the state level as atrustee of the Board. I can promise you enthusiasm and true professional-ism if given the opportunity.

JUDICIAL COUNCIL— A member from each region will serve twoyears on TMA Judicial Council, which has the power to censure, expel, suspend,or take other action against members or component medical societies via formaldisciplinary action. Councilors investigate each matter of alleged improper con-duct and help component medical societies maintain their viability in the region.

REGION 2Nominee: Susan Lowry, MD

City: MartinCMS: Northwest Tennessee Academy of Medicine

Specialty: Family MedicineMedical School: Quillen College of Medicine


I have been nominated for the office of councilor. I would like to represent North-west Academy in this position. I have gained much experience as chief of staff atthe local hospital. I was involved with many physician liaison activities betweenthe hospital and physicians. We had many physicians with competency problemsand personal issues and I was able to help direct the group for a compromisingsolution for all parties. I feel I am able to find acceptable solutions for many legal,personal and professional problems. I can work with foundations, hospital leader-ship and other businesses to solve the complex problems that face typical physi-cians in today’s busy world. I am an active listener and am open to other’s ideas. Iwork well with all levels of medical personnel. Thank you for considering me.

Nominee: Kellie W. Wilding, MDCity: JacksonCMS: None

Specialty: Family MedicineMedical School: University of Tennessee Health Science Center


REGION 4Nominee: Ronald E. Overfield, MD

City: NashvilleCMS: Nashville Academy of Medicine

Specialty: Radiology/Nuclear MedicineMedical School: Vanderbilt University School of Medicine


REGION 6Nominee: Eugene H. Ryan, MD `

City: ChattanoogaCMS: Chattanooga-Hamilton County Medical Society

Specialty: Internal Medicine/Pediatric UrologyMedical School: Medical College of Georgia


REGION 8Nominee: Fredric R. Mishkin, MD

City: KingsportCMS: Sullivan County Medical Society

Specialty: Gastroenterology/Internal MedicineMedical School: Indiana University School of Medicine


ELECTIONS


AMA DELEGATION— These individuals represent the TMA at the AMAHouse of Delegates Annual and Interim meetings each year. The Annual Meet-ing is held in Chicago in June and lasts 4-5 days. The Interim meeting, usu-ally held in December, is shorter and rotates throughout the nation. TMAreimburses attendees’ travel and reasonable expenses. Preparation for themeetings includes review of the relevant resolutions and a conference call withTMA staff a week before the meeting to review the TMA’s positions on resolu-tions. The delegation is comprised of six delegates and six alternate delegates.The delegation itself delineates which members are delegates and which arealternate delegates.

Nominee: Richard J. DePersio, MDCity: KnoxvilleCMS: Knoxville Academy of Medicine

Specialty: OtolaryngologyMedical School: University of Tennessee Health Science

CenterE-mail: [email protected]

Nominee: J. Chris Fleming, MDCity: MemphisCMS: Memphis Medical Society

Specialty: Ophthalmology, Ophthalmic Plastic/Reconstructive Surgery

Medical School: University of Tennessee Health ScienceCenter

E-mail: [email protected]

Nominee: Donald B. Franklin, MDCity: ChattanoogaCMS: Chattanooga-Hamilton County Medical

SocietySpecialty: Nephrology

Medical School: Medical College of GeorgiaEmail: [email protected]

Nominee: John J. Ingram, III, MDCity: AlcoaCMS: Blount County Medical Society

Specialty: Internal MedicineMedical School: University of Tennessee Health Science

CenterEmail: [email protected]

Nominee: James D. King, MDCity: SelmerCMS: Consolidated Medical Assembly of West

TennesseeSpecialty: Family Medicine/Geriatrics

Medical School: University of Tennessee Health ScienceCenter


Nominee: Robert D. Kirkpatrick, MDCity: MemphisCMS: The Memphis Medical Society

Specialty: Family MedicineMedical School: University of Tennessee Health Science

CenterE-mail: [email protected]

Nominee: Lee R. Morisy, MDCity: MemphisCMS: The Memphis Medical Society

Specialty: General/Trauma SurgeryMedical School: Chicago Medical School


Nominee: Wiley T. Robinson, MDCity: MemphisCMS: The Memphis Medical Society

Specialty: Internal MedicineMedical School: St. George’s University School of Medicine


The positions of the AMA often do not coincide with those of us who practicemedicine in the state of Tennessee. We need representatives from the TMAwho will stand up for what is right for the patients and physicians of ourstate. I will do all that I can to ensure the AMA takes positions that improvethe care of Tennessee citizens and that help Tennessee physicians practicequality medicine with the least amount of interference.

Nominee: Barrett F. Rosen, MDCity: NashvilleCMS: Nashville Academy of Medicine

Specialty: Orthopedic SurgeryMedical School:Medical College of Georgia


Nominee: B. Winfred Ruffner, Jr., MDCity: ChattanoogaCMS: Chattanooga-Hamilton County Medical

SocietySpecialty: Oncology

Medical School:Duke University School of MedicineE-mail: [email protected]

Having graduated from medical school in 1964, I have seen many changes inhow health care is delivered. Most of my professional life has been spent inthe private practice of medicine and I will use whatever influence I have withthe AMA trying to hold on to the best parts of the professional life I enjoyed. Ihave been chosen twice to sit on the reference committee that reviews resolu-tions regarding "Medical Service" – largely insurance-related, including pay-ment issues. This group also addresses Medicare, Medicaid and the care ofthe uninsured. In addition, I represent the TMA on AMA's Physicians Consor-tium for Performance Improvement, which is an effort to come up with meas-ures that are physician-friendly, practical and improve patients' outcomes.You have an outstanding delegation and I will be honored to continue to serve.

www.tnmed.org/elections

PRACTICING MEDICINE

23

by Brenda Williams

The baby boomers amongus remember the title ofBob Dylan’s iconic album.

Almost 50 years later, it’s still a time-less phrase that describes life, of coursehealth care, and in this context, theever-evolving world of physician prac-tice. From Medicare to Medicaid tomanaged care to health system re-form, physicians are finding their op-tions are always changing, andthese days seemingly at a morerapid pace.

“I always say we need to em-brace the imperfection of thepractice of medicine, because itis changing,” said Ann Brown,MD, medical director atMethodist Healthcare PrimaryCare Group, a division ofMethodist Le Bonheur Health-care in Memphis. “We have toadapt to that roller coaster –you’ve got to keep moving.”


PRACTICING MEDICINE

24

EMBRACE CHANGE

Dr. Brown, board-certified in internal medicine withtraining in pediatrics, has enjoyed a high-profile ca-reer spanning nearly every scenario, from managed

care employee to the VA system to large multi-specialty groupsto smaller private practice (her four-female-physician practicewas acquired by Methodist in December 2010) to now physi-cian executive, where she oversees aligned physicians in thePrimary Care Group. She still sees patients two days a week, inpart because she wants to maintain her role as a physician ad-vocate among the administration.

Dr. Brown is among a select group of doctors recentlychosen to participate in TMA focus groups aimed at deter-mining the changing needs and desires of what could be oneof the largest emerging practice models: the employed physi-cian. The American Medical Association (AMA) cites data fromphysician recruiting firm Merritt Hawkins showing nearly one-third of final-year residents list hospital employment as theirfirst choice of practice setting.

That model encompasses a host of options, from doctorsemployed by hospitals, academic institutions or large multi-specialty practices to “hospital-aligned” physicians and med-ical staff members. But they all have common denominators:someone else pays the overhead, worries about malpracticeand regulation, provides security, technology, equipment and

supplies, recruits other physi-cians and brings in patients.

Physicians also have the op-tion of moving into executive po-sitions, as Dr. Brown has done.Medical director, chief medicalofficer, medical informatics offi-cer, vice president, presidentand chief executive officer posi-tions are just a few of the grow-ing posts available to physicianswho emerge as leaders.

Non-employed doctors face changes as well – privatepractice is becoming more challenging with the regulatory re-quirements of the ACA. New payment and practice modelsfocus on quality and efficiency, including accountable care or-ganizations, patient-centered medical homes, and pay for per-formance. Smaller groups overwhelmed by the host of newrules, the cost of electronic health record systems and upkeepand declining reimbursement are increasingly opting to mergewith similar or larger practices, larger healthcare systems andhospitals. Meanwhile, the concierge practice model remainsa small percentage but according to its champions, continuesa slow but steady growth as more physicians abandon thehassles and red tape of traditional practice.


Dr. Brown

THE DRIVING FORCE

Our experts say changeitself may be thebiggest driver of

these new options. “The environment has changed

recently because of financialpressures, because the cost ofhealth care is going up and upand up, even though physicianservices themselves are a smallpercentage,” said Joseph Annis,MD, a Texas anesthesiologistserving on the AMA Board of

Trustees. He cites uncertainty for new physicians who want astable paycheck, the ability to pay down their medical schooldebt and a sense of security for the future. He cites the in-

creasing hassle factor in medicine, which has nothing to dowith taking care of patients. And he cites the current genera-tion of physicians who have a different perspective on workand lifestyle. “A generation ago, being a physician was theirlife. Now they want a private life, too – a more balanced andmore stable family life. And that’s not a negative thing,” Dr.Annis said.

That is a lesson older physicians could learn, according toDr. Brown, who said it is time to let go of an idealized andsomewhat outdated view of the “best way to practice medi-cine.”

“Too many physicians in my age range – and maybe a littleyounger – are still holding on to something that’s disappear-ing,” she said. While Dr. Brown said she hopes to see contin-ued diversity in the medical field, including solo and smallpractices, running from change or ignoring it is not the an-swer. “Change is good,” she said.

Dr. Annis

PRACTICING MEDICINE

Tennessee Medicine + www.tnmed.org + FEBRUARY 2013 25

MEETING NEW NEEDS

Organized medicine is following the trends of prac-tice and adjusting its focus accordingly, particularlywith employed physicians. That from Chris Tanner,

associate director of Membership Services at the TMA.“All indications are this is a growing segment of the physi-

cian population in Tennessee, and we want to make sure theTMA is in line with their wants and needs,” he explained. TheAssociation’s focus group project began in Memphis and willcontinue working its way east through the state’s metropoli-tan areas where this type of model is concentrated.

“We’re bringing in a cross-section of physicians, all agesand demographics; the one thing they have in common is theyare all employed -- some by hospitals, some by academic en-tities, some by physician groups,” Tanner said. The object isto get non-biased feedback by an objective third party, in thiscase, Edge Healthcare, and use it to evaluate and revamp TMAservices to accommodate their new model. He said physiciansin the first focus group actually learned about helpful servicesthe TMA is already offering, including contract review, educa-tion and identity theft protection. “So we’ve already discov-ered we need to do a better job of promoting those toemployed physicians,” he added.

The AMA is also aligning serv-ices for these new types of prac-tice models, including anewly-approved set of principlesto guide physicians who havechosen the employment route.Dr. Annis, who helped lead theeffort, said the principles ad-dress six potentially problematicaspects of the employer-em-ployee relationship, including:conflicts of interest, advocacy,contracting, hospital-medical

staff relations, peer review and performance evaluations, andpayment agreement.

“If there’s an underlying theme, it’s the protection of thepatient, and the protection of the relationship between thepatient and the physician, because sometimes the hospital’sbottom line may be adversely affected by what the physicianwants to do for the patient,” he said. “We want to make surethe patient interest is paramount.”

Meanwhile, there is an increasing number of physicianswho are choosing jobs that don’t involve direct patient care ...or any clinical work, for that matter.

Mr. Tanner

NON-CLINICAL OPTIONS

H ow about an MDdoing sports? It’s notunheard of, accord-

ing to Steve Babitsky, Esq., pres-ident of SEAK (Skills, Education,Achievement, Knowledge), Inc.SEAK trains physicians for new orside careers in legal, workers’compensation and occupationalmedicine fields, and claims to bethe leading provider of non-clin-ical career training for physi-cians.

Doctors turn to non-clinical careers for a lot of reasons: unhappy with reimburse-ment or the hassles of practice, low career satisfaction,wanting to diversify, needing something to fall back on as they

get older, or looking for something less stressful. Babitsky saidthe great thing is they are suited for almost anything, andmost of them don’t realize it.

“I’ve worked with physicians for more than 30 years, I’vemet tens of thousands of them and they’re all hard-working,intelligent and responsible people. There’s no restriction onwhat they can do.” A physician’s clinical skills and training arehigh in demand in the business world, he said, adding theyare great candidates for consulting, entrepreneurship, pharmawork, medical devices, biotech, informatics, government ad-ministration, medical-legal work, not to mention doctors whowork as media figures, political pundits, novelists, financialadvisors and yes, even sportscasters.

Babitsky said SEAK aims to open their eyes to all the pos-sibilities and help them in the transition process.

“They can take their medical knowledge and skills fromclinical medicine into any field,” he said. “Health care is one-sixth of the economy, but there are still five-sixths left.”

Mr. Babitsky

PRACTICING MEDICINE


RIDE THE WAVE

For those who choose to remain in clinical work, it iscertainly a challenging time. Dr. Ann Brown said thephysician community should embrace change, but

maintain its multiformity.“We can’t sit still when life is moving around us. I believe

it’s better to ride the waves of change -- you go up and downwith the wave but you won’t be taken under,” she said,adding, “I don’t think people who prefer to remain inde-pendent should come into the fold; if we had everybody em-ployed then we would have no change. I like having thediversity in the medical community as much as possible -- theybring things to the table that are different than we bring. Med-ical staff, employeds, PSAs, every single group can give inputon how to make the whole system work better.”

And as doctors adapt to thechange, the TMA is here to help,said Chief Executive Officer RussMiller.

“Medical practice mergers, ac-quisitions and full employment isthe direction health care seemsheaded in the near term,” hesaid. “As with all the changes wehave seen in health care, all op-tions have many sides. The rightfit for one doctor or group is not

a good fit for the next. The TMA is constantly challenging andaligning its resources and we can assure physicians we will behere for all our members, be they employed, on their own, intraining or in transition.” +

Mr. Miller

TMA Benefits & Serviceswww.tnmed.org/benefits/

TMA Contract Review Servicewww.tnmed.org/contract-review/

AMA Principles for Employed Physicianswww.ama-assn.org/resources/doc/hod/ama-principles-for-physician-employment.pdf

SEAK, Inc. Non-Clinical Careerswww.nonclinicalcareers.com/pages/homepage1a.html

LEARNMORE

www.tnmed.org/renew

Our Members Get It.

Make Sure You Don’t Lose It! Renew Now.

SAVINGS• eHealth/Health Informa#on Technologies• Worker’s Comp Insurance• Document Management Solu#ons• Financial Services• Insurance Recovery Program

ADVOCACY• Prac#ce Management Resources• Expert Consul#ng & Prac#ce Services• Legisla#ve & Regulatory Affairs• Contract Review

EDUCATION• Discounted Online CME• Workshops & Seminars• Leadership Training• Pa#ent Sa#sfac#on Survey

Renew your membership onlineor call the TMA at 800-659-1862

From reforming tort laws to recouping insurance claims, your TMA provides countless benefits – worth more than the cost of membership!

M

One partner.One price.One unbeatable IT solution.

Full service managed IT for practices of all sizes, for an all-inclusive monthly price and no hidden charges.

Flat Fee ITStrategic IT Planning

Network Monitoring

Network Security

Desktop & User Support

Hardware & Software Upgrades

Disaster Recovery

Cloud Solutions

1410 Donelson Pike, Suite B-5 · Nashville , TN 37217

WWW.GUIDANTPARTNERS.COM

615-277-1526

I n f o r m a t i o n T e c h n o l o g y A d v i s o r s

UNDERSTANDING HEALTH REFORM SERIES

INTRODUCTION1

Medicaid payments are changing under thePatient Protection and Affordable Care Act(ACA) enacted in 2010. The law requiresthat reimbursement for services provided toMedicaid patients, including TennCare, byprimary care physicians (PCPs) in 2013 and2014 be reimbursed at the higher of either:1. The Medicare rate in 2013 or 2014; or2. The payment amount calculated usingthe conversion factor from the 2009Medicare fee schedule.

The administration fee of the Vaccines forChildren (VFC) program will also be up-dated for the first time since the program’sinception in 1994.

The federal government will match theincrease in reimbursement at 100 percentand there will be no additional costs for anystate. The overall goal is to increase PCP par-ticipation in Medicaid, which increases ac-cess to health services for a population thatis more prone to chronic conditions. Addi-tionally, provision of preventive care willhelp improve the overall health of these pa-tients and decrease healthcare costs. CMSpublished the final rule in the Federal Reg-ister on November 6, 2012.2

PRIMARY CARE SPECIALTIESThe Centers for Medicare and MedicaidServices (CMS) designated the following asprimary care specialties:1. Family Medicine2. General Internal Medicine 3. Pediatrics

Subspecialties of the three specialties listed

above, recognized by the American Board ofMedical Specialties (ABMS), AmericanBoard of Physician Specialties (ABPS) or theAmerican Osteopathic Association (AOA),are also eligible for the increased reim-bursement. These rates apply to those reim-bursed on a fee-for-service basis as well asthose who receive capitation payments frommanaged care plans. An email from the As-sistant Director of Certification at ABPSstated the organization only offers certifica-tion in family practice and internal medicineand does not offer certification in any sub-specialties.

ACTION REQUIREDPhysicians eligible for increased reimburse-ment will have to attest to their specialty (1-3 in previous section) and to one of thefollowing:1. That the physician is board-certified inthe specialty to which he or she attests;or

2. If not certified (includes those who areboard-eligible) that at least 60 percentof the codes billed by the physician forcalendar year 2012 were the E&M codesor vaccine codes specified in the finalrule by CMS.

NONPHYSICIAN PRACTITIONERSThe final rule clarifies that eligible servicesprovided by a nonphysician practitioner (i.e.nurse practitioner, physician assistant, nursemidwife, etc.) under the supervision of aphysician who is eligible and enrolled maybe paid at the higher rate. The service maybe billed under the physician’s provider num-ber or the nonphysician’s provider number.

E&M CODES Codes eligible for the increased reimburse-ment are:1. 99201 through 99499; 2. Vaccine administration codes - 90460,90461, 90471, 90472, 90473 and90474 or their successors;

3. New Patient/Initial Comprehensive Pre-ventive Medicine—codes 99381through 99387;

4. Established Patient/Periodic Compre-hensive Preventive Medicine— codes99391 through 99397;

5. Counseling Risk Factor Reduction andBehavior Change Intervention— codes99401 through 99404, 99408, 99409,99411, 99412, 99420 and 99429; and

6. E&M/Non Face-to-Face physician Serv-ice—codes 99441 through 99444.

The list above includes codes that are notcurrently reimbursed by CMS, which said it

SPECIAL FEATURE

Medicaid Payments for PrimaryCare Services in 2013-2014By Becky Morrissey


The overall goal is toincrease PCP

participation in Medicaid which

increases access tohealth services for apopulation that is more prone to

chronic conditions.

“

”

intends to develop rates for these codes. Thefinal rule does not require reimbursementof codes that are not currently reimbursedunder TennCare or Medicaid. The increasedpayments may be paid quarterly or added tothe claim payment.

WHEN WILL THE MONEY REALLY BEPAID?While the effective date of this law was Janu-ary 1, 2013, do not expect to see a largercheck immediately. Tennessee has untilMarch 31, 2013, to submit a State PlanAmendment (SPA) that incorporates the

higher reimbursement to CMS. CMS will have90 days to review and comment back to thestate on the SPA. Once the SPA is approved itwill be effective retroactively back to January1, 2013, and physicians will receive the in-creased reimbursement for services providedsince January 1. CMS states in the final rulethat the additional payment must be remittedto PCPs “without any effort from theprovider.”3 It is not yet clear what the processwill be to pay the increase to physicians inTennessee. Once the TMA is aware of theprocess, it will notify members. +

References:

1. All information in this document is taken from the final

rule implementing this program that was published by

CMS. 77 Fed. Reg 215, 66687 (Nov. 6, 2012) (to be

codified at 42 CFR pts 438, 441 and 447). Available at

http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/

2012-26507.pdf.

2. Federal Register, Vol. 77, No. 215. Pub. Nov 6, 2012.

Available at http://www.gpo.gov/fdsys/pkg/FR-2012-

11-06/pdf/2012-26507.pdf.

3. Medicaid Program: Payments, 77 Fed. Reg 215, 66687

(Nov. 6, 2012) (to be codified at 42 CFR pts 438, 441

and 447). Available at http://www.gpo.gov/fdsys/

pkg/FR-2012-11-06/pdf/2012-26507.pdf.

Ms. Morrissey is a paralegal in the TMA De-partment of Legal and Government Af-fairs. Contact her at 800-659-1862 [email protected].

SPECIAL FEATURE


While the effective date ofthis law was January 1,

2013, do not expect to see alarger check immediately.

“

”

Get info. Find answers. Share ideas. Your connection begins at USA.gov – the official source for federal, state and local government information.

Equals total government connecting.

PLUSPART INFO GETTING

PART IDEASHARING

Many of the advertisers in this Journal

are long standing patrons of our monthly

publication. Their products and services

are of the highest quality available. Don't

take them for granted. Read their adver-

tisements, and when you patronize them,

be sure to tell them you saw their ad in

Tennessee Medicine.

your advertisers.


Governor Haslam announced on Mon-day, December 10, that Tennesseewill not create its own insurance ex-

change in line with the Affordable Care Act(ACA). However, the governor’s announce-ment does not mean Tennesseans will notparticipate in an exchange. Instead, the fed-eral government, through the Department ofHealth and Human Services (HHS), will cre-ate its own exchange for states that opted notto create their own. Insurance exchangesunder the ACA are online marketplaces opento individuals without employer-sponsoredhealth care and employers with fewer than100 employees, to shop for and comparehealth insurance plans. The exchanges willalso provide subsidies for individuals withincomes between 100 and 400 percent ofthe poverty level. While this will likely resultin more insurance coverage for individuals,it also means more patients in a healthcaresystem already hurting for physicians.

The main goal of the Affordable Care Act(ACA) is ultimately to provide insurance cov-erage for every American in one way or an-other, which is the purpose of the individualmandate, potential Medicaid expansions, aswell as the insurance exchanges. This meansthat in about a year from now, a massive in-flux of newly insured patients will enter thehealthcare market. The CongressionalBudget Office (CBO) estimates that 12 mil-lion individuals will purchase insurancethrough the exchanges, and that total ex-change enrollment is set to reach over 29million by 2021.1 About 75 percent of theenrollees in 2014 will be newly insured peo-ple, unfamiliar with the insurance systemand likely not previously involved with a pri-mary care physician (PCP).2

With the ACA and all of its coordinatedcare efforts, PCPs will be at the forefront of

the healthcare delivery system. Unfortunately,as everyone in health care is well aware, wehave a physician shortage in this country thatis ever growing, especially within primarycare. A recent study by the Mayo Clinic foundthat fewer than 22 percent of general in-ternist medical students plan to becomePCPs.3 The majority, 64 percent, stated theywould be entering a specialty instead. An-other study found we will need over 50,000more PCPs by 2025 due to the ACA provi-sions, normal population growth, and theaging baby boomer generation.4 The babyboomer generation not only affects the in-crease in the over-65 patient population butalso the decrease of working physicians, asmany will reach retirement age and leave theprimary care practice that fewer new physi-cians are entering.

Studies and surveys have been con-ducted to determine the reasons fewer physi-cians are choosing to stay with primary care.One such study found that lagging salarygrowth over the past decade may be thecause.5 Since the 1980s, physicians’ salarieshave grown much slower than other health-care professionals, including pharmacists,dentists, and nurses. While some specialtiesundoubtedly earn more than others, thestudy revealed that PCPs were the lowestearners. The researchers also suggested thismay be because more women and minori-ties are becoming physicians, who tend toget paid less than white, male physicians.6

Whatever the reason, salary is certainly notenticing more medical students to becomePCPs.

OFFERING INCENTIVESSo how do we get physicians to join and stayin primary care?

Probably the most obvious answer to

that question is to offer physicians and med-ical students the two things most people inany profession want: more money and an en-joyable working environment. The federalgovernment already has a loan repaymentprogram through the National Health Serv-ice Corps to incentivize PCPs to practice inunderserved areas but those programs arerelatively small.7 Since raising taxes or in-creasing fees to fund this program may bedifficult to justify in this economy, some ex-perts have suggested increasing PCPs’ rev-enue stream by taxing their income at alower level than it is right now.8 This couldincentivize medical students to pursue pri-mary care with the promise of future earn-ings.

There are some encouraging signs thatthe federal government is already starting totreat the PCP shortage as a priority. In No-vember, CMS released final rules requiringsome states to reimburse Medicaid generalinternists, family care physicians and pedi-atric physicians at rates at least equal toMedicare reimbursement for certain serv-ices, which will result in a 73-percent in-crease in reimbursement for these services.9

The increase will be fully federally funded in2013 and 2014. While the rule requiresstates to start the new reimbursement rateon January 1, 2013, CMS has not yet ap-proved any state’s plan, which means the re-imbursements will not take place at the firstof the year as expected. However, this rule isan unprecedented federal step in the rightdirection for encouraging growth in the pri-mary care field.

Some states have joined the push for pri-mary care by starting primary care initiativesto better train PCPs and address the issuessurrounding the practice. California andConnecticut have started primary care insti-

SPECIAL FEATURE

Impact of the Federal InsuranceExchange on the Growing Physician ShortageBy Katie Dageforde, JD


tutes with collaboration from the varioushealthcare sectors to create incentives forpursuing a primary care career and re-taining physicians that are already practic-ing.10,11 Connecticut’s program evenincludes a simulation studio for physiciansto learn about their office’s work flow andefficiency that includes state-of-the-arttechnology. Both initiatives are geared to-ward addressing the PCP shortage at a statelevel and creating better primary care en-vironments.

In the private sector, concierge medi-cine is a tool hospitals and healthcare or-ganizations are using to entice physiciansto stay in primary care. Physicians whopractice concierge medicine can use it asan extra source of income on a cash-onlybasis while still giving their insurance-based patients the option for traditional of-fice visits.12 It is also a desirable workingenvironment for most PCPs because it givesthem fewer patients per hour, which meansmore time to fully evaluate each patient’shealthcare needs. Burnout in the medicalprofession is most prevalent among pri-mary care and internal medicine physi-cians. One of the chief complaints, afterdealing with billing and insurance proce-dures, is too much patient volume and toolittle time to fully address patients’ health-care needs.13 Utilizing concierge servicesand other innovative practice solutions mayhelp address these issues.

PREPARING FOR THE INEVITABLE Clearly people are starting to formulatelong-term plans for solving the physicianshortage crisis but with the insurance ex-changes set to begin in a year, physiciansneed short-term solutions as well. What arewe to do with the nearly 30 million newly-insured patients starting in 2014?

The good news is the influx of new pa-tients is not likely to overload the systemright away or all at once. Most of these pa-tients, around 88 percent, will be relativelyhealthy—ranging in age from 18 to 64years—which of course leaves out the veryyoung and very old who typically requiremore care. Further, these newly-insuredpatients will not be accustomed to regularcheck-ups with a PCP and therefore willlikely not seek one out right away. They will

wait until they are either sick or injuredwhich, as we previously stated, will not beimmediate since they are a relativelyhealthy patient population.

Eventually, however, these new patientswill seek primary care services and, ac-cording to the studies described above,they will exacerbate the PCP shortage prob-lem. Because the influx will not be imme-diate, it gives the healthcare community asmall amount of time to prepare for andcombat the problem.

Many are already taking action, suchas hospitals that are increasing residencyprograms and stepping up physician re-cruiting. Hospital Corporation of America(HCA), headquartered in Nashville, isadding 400 to 600 residency spots to itshospitals in western Florida, and a largeportion will be devoted to internal medi-cine training.14 HCA executives hope that bytraining physicians at their hospitals, theywill be more likely to retain those physi-cians after residency, thereby decreasingthe physician shortage in that area. Studieshave shown that physicians tend to stay inthe state in which they either studied orcompleted their residency.

Physicians can take matters into theirown hands by hiring more mid-levelproviders, such as nurse practitioners andphysician assistants, to prepare for the 30million newly-insured patients. Althoughthese professionals cannot replace a physi-cian in terms of training, with sufficient su-pervision they can be invaluable tools toaddress the primary care needs of thesenew patients. They allow PCPs to increasetheir patient volume without having tophysically see each patient, thereby treat-ing more individuals despite the physicianshortage.

While all of the long-term and short-term plans discussed here may help allevi-ate the problem, the fact is we need morephysicians to care for the many patients theinsurance exchange will bring in 2014.Tennessee physicians need to be preparedfor this change and adapt their practicesaccordingly. +

References:

1. CBO: Estimates for Insurance Coverage Provisions of

the Affordable Care Act Updated for the Recent

Supreme Court Decision. Jul 2012.

2. PWC Health Research Institute: Health Insurance Ex-

changes: Long on Options, Short on Time. Oct 2012:4.

3. Colin P. West CP, et al.: General Medicine vs. Subspe-

cialty Career Plans Among Internal Medicine Resi-

dents. JAMA 308(21):2241-2247, 2012.

4. Stephen M. Petterson, et al.: Projecting US Primary

Care Physician Workforce Needs: 2010-2025. Ann

Fam Med 10:503-509, 2012.

5. Seth E. Seabury, et al.: Trends in the Earnings of Health

Care Professionals in the United States, 1987-2010.

JAMA 308(20):2083-2085, 2012.

6. Genevra Pittman: Salary growth lagging for primary

care doctors, Reuters, Nov 27, 2012.

7. National Health Service Corps: Loan Repayment. Avail-

able at http://nhsc.hrsa.gov/loanrepayment/.

8. Uwe E. Reinhardt: If Primary-Care Doctors Were Taxed

Like Hedge-Fund Managers. Economix blog, NYT, Oct

26, 2012.

9. 42 CFR 438, 441, 447.

10. California Advanced Primary Care Institute. Available at

http://www.capci.org/index.html.

11. Connecticut Institute for Primary Care Innovation.

Available at http://www.stfranciscare.org/cipci-

home.aspx.

12.Heather Punke: Using Hybrid Concierge Medicine to

Attract, Incentivize Primary Care Physicians, Becker’s

Hosp Rev, Nov 15, 2012.

13. Tait D. Shanafelt, et al.: Burnout and Satisfaction with

Work-Life Balance Among US Physicians Relative to

the General US Population. Arch Intern Med,

172(18):1377-1385, 2012.

14. Karen Caffarini: Hospital chain’s new physician re-

cruiting tool: adding residents. AMed News, Dec 10,

2012.

Ms. Dageforde is assistant general coun-sel for the TMA. Contact her at 800-659-1862 or [email protected]. Formore information on health system re-form, visit the TMA’s web resource pageat www.tnmed.org/health-system-reform.

SPECIAL FEATURE



Private placement insurance productsoccupy a unique place in the spectrumof financial products. While having the

same tax benefits, these products offer policystructures and investment alternatives notfound in traditional retail variable universal life(VUL) and variable annuity (VA) products. Be-cause they can only be offered to qualified pur-chasers and accredited investors, privateplacement variable universal life (PPVUL) andvariable annuities (PPVA) offer access to bothinvestment alternatives and customized prod-uct designs that are difficult or impossible toobtain in traditional retail or registered prod-ucts. They are optimal in their use as a tool toaddress a multitude of financial, income, andestate tax planning objectives.

Because of its preferential treatment froman income tax perspective, insurance must beproperly structured to assure it maintains its taxbenefits. Clients should work with brokers ex-perienced in structuring policies just for themand in working with multiple insurers to obtainthe most favorable underwriting outcome.

PRIVATE PLACEMENT VARIABLE UNI-VERSAL LIFE (PPVUL)Life insurance can enjoy favorable tax treat-ment as an asset that can be owned through-out its lifespan without incurring income taxes.The policy’s account value accumulates free ofrecognition of income for tax purposes in thesame way as an annuity. In addition, when thepolicy results in a death benefit, the benefici-ary receives it without its inclusion as ordinaryincome Registered VUL products share a num-ber of characteristics with PPVULs.

PPVULs are much more flexible than VULsin both policy charges and structure. Sinceeach policy is a private offering to a specificindividual the policy can be customized to theclient’s needs. This can mean that factors af-

fecting the insurer’s expenses can be reflectedin the pricing of the policy. Identical to PPVAs,policy assets are held in separate accounts notaccessible by the insurer’s creditors and canbe reallocated between available investmentchoices without penalties or tax consequences.However, there may be lockout periods wherereallocations are not allowed.

PRIVATE PLACEMENT VARIABLE AN-NUITIES (PPVA)Unlike registered VAs, PPVAs are designed pri-marily for buyers interested in accumulatingassets without recognizing income for tax pur-poses. Due to the qualification threshold forprivate placement investments, PPVA holdersgenerally are not looking for the guaranteedreturn benefits found in registered VAs. As aresult, PPVAs are usually much less expensivethan registered VAs. In addition, becausegrowth in the value of an annuity is tax-de-ferred, PPVAs are especially attractive vehiclesfor investors interested in accumulating assetsin investment funds that are tax-inefficient, orannually generate a high degree of ordinaryincome in their investment returns.

PPVAs are structured with no upfrontcharges on premium investments and no back-end charges on withdrawal or surrender. Pol-icy assets are held in separate accounts that arenot accessible by creditors of the insurancecompany. Policy account values can be reallo-cated between available investment choiceswithout penalties or tax consequences. In ad-dition, policy owners invested in exempt in-vestment funds do not receive K-1 statements.

WHY USE PRIVATE PLACEMENT IN-SURANCE?Customization of Policy Charges -PPVULs and PPVAs can be structured to bemore attractive to their typically affluent buyer.

Policies usually have low premium loads (orin some cases no premium loads) and sur-render charges are almost non-existent. Dueto the large size of the average PPVUL or PPVAcase, policies can be designed with lower ad-ministrative charges (or other charges) thanare usually found in traditional products.Enhanced Choice of Investment Op-tions - PPVULs and PPVAs can offer invest-ment alternatives that are not registered, suchas hedge funds and other non-registered in-vestment funds. These funds often employstrategies that require limitations on when in-vestors can redeem shares in order to achievetheir investment objectives, which includeseeking to obtain returns not correlated to eq-uity markets while also maintaining lowervolatility on a periodic basis.

Accredited investors interested in accessingthese types of investment strategies, whileminimizing the effects of current period in-come taxes, may naturally find themselvesconsidering private placement products.+

Mr. Stout is a wealth strategist at Ever-green Consulting, Inc., an M FinancialGroup Member Firm; 615-309-0832;[email protected].

Variable life insurance and variable annuity products are long –terminvestments and may not be suitable for all investors. An investmentin variable life insurance is subject to fluctuating values of the un-derlying investment options and it entails risk, including the possibleloss of principle. Variable universal life insurance combines protectionand tax advantages of life insurance with the investment potential ofa comprehensive selection of variable investment options. The insur-ance component gives you the flexibility to potentially increase thepolicy’s cash value.

When considering alternative investments, including hedgefunds, you should consider various risks including the fact the somealternative investment products: often engage in leveraging and otherspeculative investment practices that may increase the risk of invest-ment loss, can be illiquid, are not required to provide periodic pric-ing or valuation information to investors, may involve complex taxstructures and delays in distributing important tax information, arenot subject to the same regulatory requirements as other registeredproducts, often charge high fees, and in many cases the underlyinginvestments are not transparent and are known only to the invest-ment manager.

This material is intended for educational purposes about aninvestment product and is not an offer to purchase or solicitation ofan offer to purchase an investment product.

SPECIAL FEATURE

Private Placement Insurance:Retirement Planning WithTaxes in MindBy Chris Stout


ARE INSURANCE HASSLESDRAINING YOUR PROFITS?

Insurance Recovery Program

Visit our website and let us help you, today.

www.tnmed.org/insurance-recovery-programCall toll-free 1-800-659-1862

“We collected close to $200,000 on old claims that would have otherwise been lost.” — Mitch Falk, The Patriot Group

•Slow Pay/No Pay•Credentialing• Contracting and Compliance Consulting•Recoupments• Insurance Hassles•Timely Filing• Denials After Obtaining Prior

Authorization or Verifying Eligibility• Not Being Paid According to

Your Contract•And More

Let us work for you. With our extensive knowledge of insurance and collections, you can take our staff’s expertise to the bank.

Introducing TMA’s new Insurance Recovery Program, a program designed for you, to assist you in recovering “lost” dollars from third party payers and government insurance programs.

EAR

URSN IE

ECANUR

SS HAE

SLES

EARDRA

URSN IEAINING

ECANURYOUR

SS HAEFIR PRO

SLESSTFI ?

w Ies n’AA’Mr, a pmargsso a, tuo yrs fallo” dtsorevod gn a

.samrg

ecnarusnw Imargor

nu iot ysisdrihm torrs f r

tnemn

ayo Png

g and Comp nts

Hassles g er Obtaining P

erifying EligibilityVor on

g

acting and Compliance Consulting

rior Denials After Obtaining Perifying Eligibility

ding to aid Accor Pact

ith our extensivWou. yance and collections, y nsur

tise to the bank.s exper’ aff

ding to

e ith our extensivou ance and collections, y

tise to the bank.

e c l e ot

e colle “W“We th avha

ed c ecte close to erwise he been

e collected close to $200,000 on old claims that would e otherwise been lost.” alk, — Mitch F

e collected close to $200,000 on old claims that would oupatriot GrThe Palk,

e collected close to $200,000 on old claims that would

ebsite and let us help yisit our wV

.tnmed.orwwweeCall toll-fr 1-800-65

.ou, today y.ebsite and let us help y

y-prervecoovance-rg/insur.tnmed.or9-1862 1-800-65

amogry-pr

er R vecoance RIInsur

g amgry P ory P

Reversible Stroke-LikeSymptoms with SevereHyponatremiaBy Lindsey N. Holloman, MD; Victor O. Kolade, MD, FACP; Daniel R. Zapko, MD; and Laura B. Youngblood, MD


ORIGINAL CONTRIBUTION

THE JOURNAL

ABSTRACTA 65-year-old Caucasian female was brought tothe Emergency Department by her husband forincreasing generalized weakness, slurredspeech and new-onset facial droop. A non-con-trast computerized tomography scan of herbrain was negative; however, she was found tohave a sodium level of 99 mmol/L. Her dailymedications included hydrochlorothiazide,omeprazole and irbesartan. On physical exam-ination, she was found to have slight confusion,lethargy, slowed speech, generalized weaknessand left-sided facial droop but no other focaldeficits. Over the course of her hospital stay, thepatient’s sodium levels were corrected slowly.On the fifth day of admission, the majority ofthe patient’s neurologic symptoms had re-solved, suggesting her stroke-like symptomswere correctable with sodium repletion.

CASE REPORTA 65-year-old Caucasian female was broughtinto the Emergency Department for evaluationof generalized weakness and stroke-like symp-toms. She had reported weakness for the pre-ceding two days; on the morning of admission,the patient was unable to get out of bed andwas noted to have a left-sided facial droop andslurred speech. She was taken to a nearbycommunity hospital where she was evaluatedfor a possible acute stroke. A non-contrastcomputerized tomography (CT) scan of thehead was performed, which showed no acuteabnormalities. When her electrolyte levelswere checked, however, the patient was re-ported to have a sodium level of 99 mmol/L;

she was then transferred to our facility. On at-tempting to get a history from the patient, itwas noted she had very slowed, slurred speechand struggled to remember details from thatmorning. Her husband noted that she had re-cently increased her fluid intake to includethree or four 32-ounce bottles of water per dayin addition to tea; she had admitted to an in-creased thirst for three months. The patientstated that on the night before admission, shedrank three 32-ounce bottles of water beforegoing to bed; she repeatedly asked for waterduring examination. The patient had not hadany seizure-like activity but reported dizzinesson the morning of admission.

Her medical history was notable for hy-pertension, hyperlipidemia, hypothyroidismand chronic obstructive pulmonary disease;she denied having had hyponatremia previ-ously. She had been admitted to the commu-nity hospital for pneumonia the month beforepresentation; her sodium level at dischargethen was 138 mmol/L. Her husband and herfriend, however, recalled being told she hadlow sodium and potassium early in that hos-pitalization.

She lives with her husband and is retiredfrom working at an electronic plant. She de-nied alcohol use but had accumulated 28pack-years of smoking before quitting twomonths prior to admission. Family history wasonly significant for heart disease in hermother. Her medications included levothy-roxine 88 micrograms daily, metoprolol 50mg twice daily, irbesartan 300 mg daily, ator-vastatin 10 mg daily, diazepam 5 mg q8h asneeded, hydrochlorothiazide 25 mg daily (for

many years), omeprazole 20 mg daily, VivelleDot patch 0.025mg twice weekly, and aceta-minophen as needed. She had been onomeprazole for at least two years before thisevent; no medications were identified as new.

On physical examination, the patient wasfound to be lying in bed awake but lethargic,and confused. She weighed 134 pounds andwas 4 feet 10 inches tall – equating to a bodymass index of 28. She was hypertensive(171/81) and tachypneic (22/minute). Heroxygen saturation was 96% with oxygen aug-mentation at 2 liters per minute. Her skin wasdry and had decreased turgor; mucous mem-branes were pink but dry (all signs of dehy-dration). Orthostatic vital signs could not beobtained because she was unable to cooperatedue to confusion. The patient manifested con-tact sensation to light touch but had noticeableleft-sided facial droop and slurred speech, aswell as 3-4/5 strength in all extremities withoutpronator drift.

Initial laboratory values included sodium<100 mmol/L (from two samples), potassium3.3 mmol/L, chloride 64 mmol/L, blood ureanitrogen 7 mmol/ L, creatinine 0.50 mg/dL,glucose 108 mg/dL, total calcium 8.2 mg/dL,magnesium 1.4 mg/dL, albumin 3.2 g/dL; thy-roid stimulating hormone 0.288 µIU/mL, T48.40 µg/dL, creatine phosphokinase 114 U/L,random cortisol 27.70 µg/dL. Serum osmolal-ity was 212 mOsm/kg (270-300), urine osmo-lality 314 mOsm/kg (500-800) (see Figure 1),and urine sodium 25 mmol/L. A chest x-rayshowed no evidence of active pulmonaryprocess, pneumothorax or pleural effusion,and CT angiography of the head with contrast

A o Y

U

E

S

S

S

e

a

d

e

e

a

THE JOURNAL


showed no branch occlusions or focal largevessel stenosis. Magnetic resonance imaging ofthe brain was consistent with chronic ischemicchanges without acute infarct. Cardiac enzymesand an echocardiogram were normal. Urinal-ysis showed trace albumin and blood, small ke-tones, and four red blood cells per highpowered field.

Based on her clinical picture on admis-sion, the focus of therapy was on her severe,potentially life-threatening hyponatremia,which was attributed to thiazide use and in-creased water intake. She was initially placedon hypertonic saline (3 percent) at 20 mL perhour in order to raise her sodium levels at arate no greater than 0.33 mmol/L/hr; sodiumlevels were checked every three hours. Overthe course of her stay, half normal saline and 5-percent dextrose water were used to moderatethe rise in serum sodium (Figure 2). Desmo-pressin was given twice to pre-empt overcor-rection of sodium levels in the setting ofpolyuria (Figure 3). On day five (sodium 122mmol/L), the patient’s facial droop had re-solved, she was able to sit up in bed on herown, and her generalized weakness had im-proved. At discharge on day nine of admission,the patient was fully oriented and had a sodiumlevel of 133 mmol/L. Hydrochlorothiazide wasdiscontinued and the patient was counseled notto take any thiazide medication subsequently.

DISCUSSIONHyponatremia is defined as being a sodiumlevel of less than 135 mmol/L, and severe hy-ponatremia is described as a sodium concen-tration below 1201 or 1252 mmol/L. Symptomsrange from headache, lethargy and obtunda-tion to seizures, coma and respiratory arrest.Severe hyponatremia is most commonly due tomultiple causes, including increased fluid in-take, low sodium diet, thiazide use, congestiveheart failure, sodium loss, syndrome of inap-propriate antidiuretic hormone secretion(SIADH), whether idiopathic, due to malig-nancy, or associated with drugs like narcotics,carbamazepine or selective serotonin reuptakeinhibitors;2 this remains true when thiazide useis identified as a cause.2-4 It is only rarely causedby hypovolemia (3.5 percent of cases).2 How-ever, if the patient has chronic hyponatremia,symptoms are relatively non-specific and in-clude fatigue, forgetfulness, confusion, lethargyand muscle cramps.1 Hyponatremic en-

cephalopathy that mayoccur can be reversible orpermanent. Our patienthad not reported symp-toms like the ones de-scribed here previously;her generalized weaknesshad developed gradually,many days before the facialdroop and slurred speechoccurred. Although shenoted dizziness, she didnot have any seizure activ-ity, which might be ex-pected at such a lowsodium level if it had de-veloped acutely.

Although our patientpresented with both hy-ponatremia and hy-pokalemia, hyponatremiais a more common com-plication of thiazide usethan hypokalemia.5 Thi-azides work by blockingthe Na+Cl- transporter inthe distal convolutedtubules. Elderly patientswith a history of thiazide-induced hyponatremiamay have similar baselinerenal parameters tohealthy elderly subjects butfail to dilute urine maxi-mally and displaymarkedly impaired freewater clearance after awater load.6 The result isan increased loss ofsodium and water in theurine leading to sodium-rich urine, as seen inour patient.

The average time to development of thi-azide-induced hyponatremia in one series was105 days.7 Our patient, however, had used hy-drochlorothiazide for 35 years and was un-aware of abnormal sodium levels until themonth before presentation. Risk factors forthiazide-induced hyponatremia may includeolder age, hypokalemia and low body mass.7 Itis recommended that thiazide diuretics not bestarted in patients who have psychogenic poly-dipsia; however, this patient only recentlybegan increasing her fluid intake. No cause for

polydipsia was found in her history; her friendsaid she had an “addictive personality,” im-plying a tendency to do things in excess.

Angiotensin II receptor blockers (ARB),such as irbesartan, cause natriuresis and maytheoretically cause hyponatremia.8 Indeed, hy-ponatremia is the most common adverse ef-fect attributed to each of fourARB-hydrochlorothiazide combinations inJapan (irbesartan not included).9

Severe hyponatremia has also been attrib-uted to omeprazole, potentially due to in-creased urinary sodium loss or inappropriateantidiuretic hormone secretion.10 This effect

FIGURE 1. Urine osmolarity during hospitalization.

FIGURE 2 . Sodium levels during hospitalization. Arrows indicatetiming of desmopressin administration.

FIGURE 3. Daily urine output. Arrows indicate timing of desmo-pressin administration.

has been reported after administration ofomeprazole for four-to-150 days; typically,successful sodium repletion required with-drawal of the drug.10 Omeprazole use may nothave contributed to hyponatremia in this case,as treatment was successful without cessationof the drug.

The association between hypokalemiaand thiazide-induced hyponatremia has beenattributed to transcellular ion exchange;7

potassium efflux from cells in the face of hy-pokalemia is coupled with sodium influx thatmay contribute to hyponatremia. It has beenproposed that maintenance of normal serumpotassium via supplementation and/or co-treatment with a potassium-sparing drug willprevent thiazide-induced hypokalemia;7 how-ever, our patient was concomitantly treatedwith an ARB and presented with hypokalemia.

Weakness is a common symptom in hos-pitalized patients with thiazide-induced hy-ponatremia.11 Neurologic manifestations ofhyponatremia appear to be associated withhigher serum glucose levels and lower serumalbumin levels.2 Neither of two series assess-ing patients with severe hyponatremia re-ported any cases of slurred speech or facialweakness.1,12 Facial droop and hemiparesishave been described once before in associ-ation with what may have been thiazide-in-duced hyponatremia; focal deficits improvedwith sodium repletion.13 Hypoglycemia andhyperglycemia have been known to presentas stroke that resolved with correction of themetabolic derangement;13 hypoxia is anotherof several neurologic and non-neurologicdisorders that may cause stroke-like symp-toms.13,14

Treatment of severe hyponatremia maybe complicated by neurologic sequelae if cor-rection occurs too rapidly. Concern for os-motic demyelination syndrome develops ifserum sodium is raised at a rate greater than12 mmol/L/day; lesions may occur in the pon-tine region,12 periventricular white matter,basal ganglia and thalamus. Overcorrectionhas been reported in patients treated with hy-pertonic saline, including one like ours whohad hypovolemic hyponatremia associatedwith thiazide use, associated with water di-uresis;15 desmopressin acetate has been suc-cessfully used to prevent overcorrection ofhyponatremia and possible neurologic se-quelae.4 Post-treatment neurologic sequelae

have been reported when sodium correctionexceeded 12 mmol/L in 24 hours or 18mmol/L in 48 hours.12

CONCLUSIONFocal neurologic findings such as facialdroop are rare in severe hyponatremia. Fur-ther, the improvement of such symptomsdays after beginning treatment can only beexplained by cautious sodium replacement.It appears that stroke-like symptoms asso-ciated with hyponatremia are amenable togradual sodium repletion. +

References:

1. Ellis SJ: Severe hyponatraemia: complications and

treatment. QJM 88:905-909, 1995.

2. Shapiro DS, Sonnenblick M, Galperin I, et al.: Severe

hyponatraemia in elderly hospitalized patients: preva-

lence, aetiology and outcome. Intern Med J 40:574-

580, 2010.

3. Clayton JA, Le Jeune IR, Hall IP: Severe hyponatraemia

in medical in-patients: aetiology, assessment and out-

come. QJM 99:505-511, 2006.

4. Perianayagam A, Sterns RH, Silver SM, et al.: DDAVP is

effective in preventing and reversing inadvertent over-

correction of hyponatremia. Clin J Am Soc Nephrol

3:331-336, 2008.

5. Clayton JA, Rodgers S, Blakey J, et al.: Thiazide diuretic

prescription and electrolyte abnormalities in primary

care. Br J Clin Pharmacol 61:87-95, 2006.

6. Clark BA, Shannon RP, Rosa RM, et al.: Increased sus-

ceptibility to thiazide-induced hyponatremia in the eld-

erly. J Am Soc Nephrol 5:1106-1111, 1994.

7. Chow KM, Szeto CC, Wong TY, et al.: Risk factors for

thiazide-induced hyponatraemia. QJM 96:911-917,

2003.

8. Burnier M, Rutschmann B, Nussberger J, et al.: Salt-

dependent renal effects of an angiotensin II antago-

nist in healthy subjects. Hypertens 22:339-347, 1993.

9. Kinoshita H, Kobayashi K, Yaguramaki T, et al.: Losar-

tan potassium/hydrochlorothiazide (Preminent®) and

hyponatremia: case series of 40 patients. Hum Exp

Toxicol 30:1409-1414, 2011.

10. Shiba S, Sugiura K, Ebata A, et al.: Hyponatremia with

consciousness disturbance caused by omeprazole ad-

ministration. A case report and literature review. Dig

Dis Sci 41:1615-1617, 1996.

11. Sharabi Y, Illan R, Kamari Y, et al.: Diuretic induced hy-

ponatraemia in elderly hypertensive women. J Hum

Hypertens 16:631-635, 2002.

12. Sterns RH, Cappuccio JD, Silver SM, et al.: Neurologic

sequelae after treatment of severe hyponatremia: a

multicenter perspective. J Am Soc Nephrol 4:1522-

1530, 1994.

13. Berkovic SF, Bladin PF, Darby DG: Metabolic disorders

presenting as stroke. Med J Aust 140:421-424, 1984.

14.Nair JR, Chatterjee K: Methyl iodide poisoning pre-

senting as a mimic of acute stroke: a case report. J

Med Case Reports 4:177, 2010.

15.Mohmand HK, Issa D, Ahmad Z, et al.: Hypertonic

saline for hyponatremia: risk of inadvertent overcor-

rection. Clin J Am Soc Nephrol 2:1110-1117, 2007.

Dr. Holloman is a recent graduate of theUniversity of Tennessee Health SciencesCenter, Memphis; Drs. Kolade and Zapkoare with the Department of Medicine,University of Tennessee College of Medi-cine, Chattanooga; Dr. Youngblood iswith Memorial Health Care System, Chat-tanooga.

For reprints, contact Dr. Kolade at theDepartment of Medicine, University ofTennessee College of Medicine-Chat-tanooga, 975 East 3rd Street, Box 94,Chattanooga, TN 37403; phone: 423-778-4448; fax: 423-778-2611; email: [email protected].

THE JOURNAL


ABSTRACTMetaplastic breast cancer has been difficult todiagnose and classify for a number of reasons.Its rarity prevents any important conclusions tobe made, such as factors determining progno-sis, immunohistochemistry patterns and suc-cessful treatment regimens. Here a number ofstudies of metaplastic breast cancer are dis-cussed, along with the presentation of two cases.

INTRODUCTIONMetaplastic breast cancer (MBC) has beenfound to occur in around five percent ofrecorded cases of breast cancer.1 Accordingto regional cancer data services in JohnsonCity, TN, there have been a mere four casesreported since 1995, two of which will bediscussed in this report. Typically, MBC isdifficult to identify solely with a mammogramand it has been reported in a number of ar-ticles that it is triple-negative.1-3

It has been classified in a variety of ways,one of which was divided into five categoriesby Wargotz and Norris: matrix-producingcarcinoma, spindle-cell carcinoma, carci-nosarcoma, squamous cell carcinoma ofductal origin, and metaplastic carcinomawith osteoclastic giant cells.4-8 This classifi-cation is mentioned widely among the liter-ature but is not considered universal.Because of its rarity, it has been difficult todetermine what factors affect the outcome ofthe patient. Studies’ conclusions among theliterature often conflict one another.

CASE 1An 87-year-old woman presented with an ab-normal ultrasound and mammogram reveal-

ing a 4-cm irregular solid mass in the upperouter quadrant of her left breast. An ultra-sound-guided biopsy showed metaplasticcarcinoma as a combination of sarcoma andcarcinoma. A mastectomy with a sentinelnode biopsy and possibly an axillary dissec-tion was agreed to be the most appropriatecourse of treatment. During surgery, a hem-orrhagic area just inferior to the breast wasnoted but was not located within the lymphnodes. Surgical pathology concluded it wasmetaplastic carcinoma with 90-percent car-cinosarcomatous elements. AE1/3 and pan-kimmunostains highlighted the carcinomatouscomponent, while vimentin immunostain waspositive for malignant mesenchymal compo-nents which featured chondromyxoid and os-seous differentiation. The tumor was also ER,PR and HER-2 negative, or “triple negative,”meaning hormonal receptors did not re-spond. This patient did not seem willing toundergo post-surgery radiation but the op-tion remained available to her.

A little more than seven months later, aphysical exam revealed a 1.5-cm, firm, hardand fairly discrete nodule just superior to theprevious excision. The patient agreed to un-dergo an excisional biopsy to completely re-move the nodule, considering there was achance it was not benign and should be ofconcern. Unfortunately, the nodule turnedout to be recurrent carcinosarcoma involv-ing fibrovascular adipose tissue and skeletalmuscle; also, it responded negatively to ER,PR, and HER-2 once again. A CT scan re-vealed interval development of multiple pul-monary nodules consistent with metastaticpulmonary disease, as well as nonspecific tis-

sue thickening in the left axilla at the site ofthe previous lymph node dissection. The pul-monary nodules were 11 mm and 17 mm insize.

It was discussed with this patient’s familythat at her age, more than one chemotherapyagent might be hard to tolerate. This patientdecided on the option of hospice with a sin-gle therapeutic agent, Abraxane. Presently,this patient is doing well in hospice and de-nies any problems such as pain, edema, orchanges in weight.

CASE 2A 56-year-old female presented with a lumpin her left breast at the three-o’clock positionfrom what was thought to be a bruise; amammogram unfortunately showed a very ir-regular dominant mass. The referral doctorquestioned whether this mass originated inthe lung or in the breast. The pathology re-port concluded the tumor did not show im-munoperoxidase staining for small-cellcancer of the lung and was also negative forfeatures of neuroendocrine tumors. It readthat because squamous areas were stronglypositive for cytokeratin, it was unlikely to bea lung primary (Figure 1). Many areas showthe morphology of a small-cell undifferenti-ated carcinoma, while other areas showlarger cells with squamous components. Thetwo appearances often transitioned from oneto the other; morphology was not typical of aductal or lobular carcinoma of the breast(Figures 2-3). The report also mentionedthat HER-2 was non-amplified, and ER andPR were so low they were essentially nega-tive; therefore, it could be considered triple-

Metaplastic Breast Cancer: APresentation of Two Cases anda Review of the LiteratureBy Millard Ray Lamb, MD, FCP; Elena Gertsen, MD, PhD, PGY3; and Eleanor Middlemas



THE JOURNAL

negative. This description is consistent withmetaplastic breast cancer.

A PET scan revealed mammary lymphnode involvement. A referral doctor recom-mended having neoadjuvant therapy beforeconsidering surgery on this patient. A combi-nation of Adriamycin at 20 mg/m2 for the firstthree days, Ifex at 1.5 grams/m2 for the firstfour days, and Mesna at 225 mg/m2 beforeand after each Ifex was decided on. This ag-gressive treatment was chosen because of theaggressive variant of breast cancer. After amonth and two rounds of chemotherapy, thepatient was recorded to be responding excel-lently with minor symptoms (nausea, vomit-ing) and alopecia. The tumor shrunk fromroughly a softball size to a walnut size.

She underwent surgery two months afterbeginning chemotherapy. The entire 4.5-cmtumor was removed and it was noted that twolymph nodes were involved. Once removed,the tumor was described as a well-defined,lobulated, tan, fibrous mass. The pathology re-port after chemotherapy differed from theoriginal, claiming it was a poorly-differentiatedinvasive carcinoma with no specific type,rather than describing an unusual tumor closeto metaplastic carcinoma. The patient receivedtwo rounds of chemotherapy after surgery anddecided to start radiation therapy instead.

After a month and five radiation treat-ments, the patient appeared to have somemuscle pain in her back. It did not appear tobe bone pain because it was not centralized.Another month later, the patient had such badchest pain and upper back pain that she couldnot hold her position during radiation ther-apy. Testing revealed complete collapse of theT3 vertebral body with deformity of the ventralcord. This concluded there were small metas-tases within the T2 and the T9 vertebra. Cur-rently, the patient is in the process of decidingon her course of action.

DISCUSSIONMetaplastic breast cancer (MBC) is a rela-tively rare type of cancer found in less thanfive percent of breast cancer populations.1

What sets it apart from other cancers is aprocess called metaplasia, where the epithe-lial section of the tumor goes through a trans-formation process into a non-glandularmesenchymal tissue. The actual volume ofMBC may be difficult to locate as it could be

a small section of the over-all breast tumor. There areadditional reasons for dif-ficulty in diagnosis, con-sidering variation ofpathology, lack of charac-teristic imaging patternson mammograms and therelatively small number ofcases.

In reviewing the num-ber of cases, the variabil-ity in terminologycombined with the rarityof this form of cancercompromises the ability tocompare a clinical seriesin terms of prognosis andtreatment of the lesions.Oberman suggests classi-fying all mixed carcino-mas of the breast asmetaplastic cancer. He ad-ditionally classified theminto spindle cell carci-noma, invasive ductal car-cinoma with extensivesquamous metaplasia, andinvasive carcinoma withpseudosarcomatous meta-plasia.9 Yamaguchi classi-fied metaplastic breastcancer as squamous ep-ithelial, spindle cell, os-teocartilaginous, andmatrix elements.1 Wargotzstated the carcinosarcomawas defined as 50-percentmalignant spindle cellsand 50-percent pleomor-phic bipolar cells/poly-morphic cellularcomponents less reactiveto cytokeratin with highdegrees of cellularity, nu-clear pleomorphism andmitotic activity. The spin-dle-cell carcinoma wascharacterized by predom-inance of spindle cells andbland bipolar cells grow-ing as feathered fascicles.The matrix-producing car-cinoma was defined as ei-

THE JOURNAL


FIGURE 1. The staining pattern shows that the tumor cells do nothave definitive neuroendocrine differentiation.

FIGURE 2. Small focus of invasive ductal carcinoma with perdomi-nance of small cell and squamous features.

FIGURE 3. Small cell and squamous features often transitionedinto each other. This is the same tumor at a higher magnification.

ther of the lesions mentioned earlier associ-ated with an osseous or cartilaginous matrix;additionally, two other classifications identi-fied as squamous cell carcinoma with ductalorigin and metaplastic carcinoma with osteo-clastic giant cells.4-8

There are a number of common findingsthroughout these cases. The tumor is relativelyrare, occurring in less than five percent ofbreast cancers, and some studies say it occursin less than one percent.1-3 Mean age is gen-erally in the 50s, although in a number ofstudies, the age can range from the 20s up tothe 80s.3-9 Some studies indicate the prog-nostic features in MBC are shifted with higherincidence of a number of poorly prognosticfeatures such as tumor size, poor high nucleargrading and triple negativity in terms of es-trogen receptor/progesterone receptor andHER-2-neu.2-5,10 Most studies show estrogenreceptor positivity much less than 10 percent.One study from Sweden used a cohort-basedcomparison and commented that actual sur-vival was not much different when matched tomore traditional breast cancers in a stage-by-stage basis, with recommendations for ag-gressive treatment and survival being similarto other breast cancers in a similar stage andnuclear grading.3 The studies which lookedat histopathological make-up of the tumorsnote that Vimentin is generally positive for themesenchymal cells, cytokeratin for the ep-ithelial cells, and S100 protein for the my-oepithelial cells.3-9

With the exception of the cohort studyfrom Sweden, most authors feel this form ofbreast cancer tends to have a poorer prog-nosis than other breast cancers, although weare unable to say if this is a statistical errorassociated with a selection bias since mostof these tumors do present with high-riskfeatures. A number of studies correlatetumor size with prognosis, although that isnot uniformly found.4-6,9 There are some au-thors who feel the presence of high-gradespindle cells as well as the presence of squa-mous elements were important factors oftenassociated with a poor prognosis.1 Accord-ing to the same authors, patients with sarco-matous change in squamous cells had ahigher recurrence.1 Wargotz, et al., claimthat osteoclastic giant cell type, matrix-pro-ducing carcinoma type, spindle cell carci-noma type or squamous cell carcinoma of

ductal origin type have a better survival ratethan carcinosarcoma type.6-8 Another groupof authors suggests the type of cancer has noeffect on the outcome of the patient.10

Due to the nature of a small number ofpatients in each series, there are no specificrecommendations available for treatment formetaplastic breast cancer. It is not clearwhether chemotherapy, given either neoad-juvantly or adjuvantly, has done anything toimprove survival. A variety of treatments withvarious chemotherapeutic agents have beentried but there is no consensus on which isbest.

In our case reports we have two types ofpatients, the first a young patient presentingwith masses in her breast and, at the time,thought to be a candidate for adjuvant ther-apy treated with neoadjuvant chemotherapy,surgery and radiation. Unfortunately, she de-veloped spinal column metastases while onradiation treatment. It should be noted thatduring the neoadjuvant part of her treat-ment, the breast tumor itself had a markedreduction in tumor size and the oncologistwho treated her felt the tumor waschemotherapy-sensitive. However, the devel-opment of metastatic disease while on radi-ation immediately after chemotherapyshowed that some elements of the tumorwere chemotherapy-resistant to the combi-nation being administered. Whereas, thesecond patient presented with an advancedtumor at an elderly age, elected no treat-ment, and went with hospice.CONCLUSIONThese two case reports demonstrate what canbe seen in a clinical oncology office, wherewill rarely see a typical tumor such as MBC. Itwill usually present with poor prognostic fea-tures at an age where tolerance to treatmentmay be compromised secondary to co-mor-bid illnesses or advanced age. While one pa-tient accepted treatment, the other patient alsotook a reasonable approach of palliative carewith hospice. For future MBC patients to re-ceive the best treatment possible, each caseshould be determined individually, looking atparameters of the tumor staging, prognosticfeatures, patient’s health and co-morbid fea-tures. Until research finds a more definitiveproven option of treatment, allowing the pa-tient to choose between aggressive and pal-

liative care, the best route of treatment re-mains undetermined. +

References:

1. Yamaguchi R, Horii R, Maeda I, et al.: Clinicopathologic

study of 53 metaplastic breast carcinomas: their ele-

ments and prognostic implications. Human Pathol

41:679-685, 2010.

2. Rayson D, Adjei AA, Suman VJ, et al.: Metaplastic breast

cancer: Prognosis and response to systemic therapy. Ann

Oncol 10:413-419, 1999.

3. Beatty JD, Atwood M, CTR, et al.: Metaplastic breast can-

cer: clinical significance. Am J Surg 191:657-664, 2006.

4. Wargotz ES, Norris HJ: Metaplastic Carcinomas of the

Breast. I. Matrix-Producing Carcinoma. Human Pathol

20:628-635, 1989.

5. Wargotz ES, Deos PH, Norris HJ: Metaplastic Carcinomas

of the Breast. II. Spindle Cell Carcinoma. Human Pathol

20:732-740, 1989.


Breast. III. Carcinosarcoma. Cancer 64:1490-1499,

1989.


Breast. IV. Squamous Cell Carcinoma of Ductal Origin.

Cancer 65: 272-276, 1990.


Breast. V. Metaplastic Carcinoma with Osteoclastic Giant

Cells. Human Pathol 21: 1142-1150, 1990.

9. Oberman HA: Metaplastic Carcinoma of the Breast: A

Clinicopathologic Study of 29 Patients. Am J Surg Pathol

11:918-929, 1987.

10.Okada N, Hasebe T, Iwasaki M, et al.: Metaplastic carci-

noma of the breast. Human Pathol 41:960-970, 2010.

Ms. Middlemas is a premed student at Geor-gia Tech University, Atlanta, GA; Dr. Gert-sen is with the Department of Pathology atEast Tennessee State University’s QuillenCollege of Medicine and Johnson City Med-ical Center; Dr. Lamb is partner at McLeodCancer and Blood Center, a clinical profes-sor of medicine at Quillen College of Med-icine, and staff physician at Johnson CityMedical Center, Johnson City, TN.

For reprints, contact Dr. Lamb at theMcLeod Cancer and Blood Center, 310 State ofFranklin Road, Johnson City, TN 37604; phone:423-926-3611; email: [email protected].

THE JOURNAL


A Novel Medication Error in theTreatment of HyperthyroidismBy Bhavesh B. Barad, MD, and Alan N. Peiris, MD (Lon), PhD, FRCP (Lon)



THE JOURNAL

INTRODUCTIONSafe prescription practice depends on the vigi-lance of multiple health professionals. Accordingto the Institute of Medicine,1 nearly 80 percent ofadults in the United States use medications on aweekly basis. Medication errors may harm anestimated 1.5 million people in the United Statesannually, with a resultant increase of $3.5 billionin extra medical costs. In this report, we describea novel medication error involving a substitutionof methazolamide for methimazole during thetreatment of hyperthyroidism.

CASEThe patient was a 52-year-old white female re-ferred for endocrine evaluation. She indicatedthyroid issues for the last eight years and alsohad hair loss. Her past medical history was sig-nificant for deep vein thrombosis, pulmonaryembolism, back surgery and tubal ligation. Asister had unspecified thyroid issues. The pa-tient’s medications were warfarin, famotidine,furosemide, gabapentin, diazepam and OTCanalgesics. Blood pressure was 110/70, pulse104, regular, and the patient had a small mo-bile multi-nodular goiter with brisk deep ten-don reflexes. Laboratory results: TSH < 0.004uIU/ml (0.4-4), free T4 1.29 ng/dL (0.89-1.76),and free T3 7.3 pg/mL (1.5-4.1). Thyroid ul-trasound confirmed a multinodular goiter andI-123 thyroid scan revealed increased iodineuptake. The patient was commenced on pro-pranolol 10 mg po qid. She was counseled onthe diagnosis (multi-nodular goiter with T3 tox-icosis) and management of her hyperthy-roidism; she elected to try methimazole and wasstarted on 10 mg po bid and Atenolol 50 mgdaily substituted for propranolol.

When seen for follow-up six weeks later,her medications had been refilled. However, itwas noted she was on methazolamide at this

time and was no longer taking methimazole.Further investigation revealed her methimazolewas refilled with methazolamide based on theprescription written by her primary careprovider. The patient was informed of this byher primary care provider and methazolamidewas discontinued at the follow-up endocrinol-ogy visit. There was no evidence that the patientwas adversely affected by methazolamide overthe three-to-four weeks of use. She was plan-ning to have radioactive iodine ablation as de-finitive therapy.

In the U.S. there are more than 33,000trademarked and 8,000 nonproprietary med-ication names.2 Many drug names sound andlook alike. To minimize confusion, the Food andDrug Administration (FDA) screens nearly 300drugs every year with similar names and rejectsnearly one-third of the names proposed by thedrug companies.3 In our patient, methazo-lamide was used instead of methimazole due toa prescription error that also went undetectedby the pharmacy. Methazolamide, a carbonicanhydrase inhibitor, is a rarely used drug and, assuch, perhaps its use should have been moreclosely examined. It has been used for glau-coma, ankylosing spondylitis and in patients in-tolerant to acetazolamide with acute mountainsickness or pseudotumor cerebri.4 Fortunatelyour patient was not observed to have any ad-verse drug effects; however, methazolamide hasbeen reported to have several serious adversereactions including delirium, seizures, leukope-nia or thrombocytopenia, with occasional hy-persensitivity reactions like Stevens-Johnsonsyndrome.5-7

Prescription error can be reduced if vigi-lance is maintained at every step during themedication ordering and refill process. Patientshould be advised to bring their medications forall healthcare visits.

Patients to be more educated about their pre-vailing ailments and prescribed medications. Weare hopeful that implementation of electronichealth record systems to standardize the pre-scription ordering/renewal system will decreasemedication errors. Pharmacies should be vigi-lant and have a low threshold for contactingphysicians, especially in the setting of high-riskmedications and/or medications that are usedrarely, to ensure accurate usage. +

References:

1. Aspden P, Wolcott JA, Bootman JL, Cronenwett, LR, eds.:

Preventing Medication Errors. Committee on Identify-

ing and Preventing Medication Errors, Board on Health

Care Services, Institute of Medicine of the National Acad-

emies, Washington, DC, Natl Acad Press, 2006.

2. Mansur JM: Enhanced Medication Safety, Joint Com-

mission International. Available at http://www.joint-

commissioninternational.org/Medication-Safety-Art

icles/. Accessed Feb 28, 2012.

3. Food and Drug Administration: Strategies to Reduce

Medication Errors: Working to Improve Medication

Safety. Available at http://www.fda.gov/Drugs/Re-

sourcesForYou/Consumers/ucm143553.htm. Ac-

cessed Feb 28, 2013.

4. Chang X, Yang X, Zhang Y: Treat ankylosing spondylitis

with methazolamide. Int J Med Sci 8(5):413-419, 2011.

5. Cotter JB: Methazolamide-induced Stevens-Johnson syn-

drome: A warning! Arch Ophthal 116(1):117, 1998.

6. Cyr M, Laizure SC, Dacunha CM: Methazolamide-in-

duced delirium. Pharmacother 17(2):387-389, 1997.

7. Cohen AM, Prialnik M, Ben-Nissan DS, et al.: Methazo-

lamide-associated temporary leukopenia and throm-

bocytopenia. Dal Inst Chem Phys 23(1):58-67, 1989.

From the Department of Internal Medicine,James H. Quillen College of Medicine, EastTennessee State University, Johnson City, TN.

For reprints, contact Dr. Barad [email protected].

Vitamin D Deficiency: Awaiting Final Proof?By Jacob George, MD; Hakam Khazrik, MD; Dima A. Youssef, MD; and Alan N. Peiris, MD (Lon), PhD, FRCP (Lon)


JOURNAL COMMENTARY

THE JOURNAL

Vitamin D deficiency is a common disease,associated with multiple adverse outcomes.The endocrine effects of vitamin D are wellrecognized; the autocrine and paracrine ef-fects of this steroid hormone are less wellappreciated. These functions include an-timicrobial and immune-modulation effects,as well as benefits on cardiovascular health,autoimmune disease, cancer and metabo-lism. Vitamin D deficiency increases mortal-ity and even a modest amount of vitamin Dmay enhance longevity.1

Vitamin D deficiency is particularly trou-bling in ethnic minorities and obese and in-stitutionalized individuals. While the numberof publications on vitamin D deficiency hasincreased exponentially in the last few years,the findings have apparently been polarizedinto two beliefs. First, espoused by the Insti-tute of Medicine, is the belief that vitamin Ddeficiency is overhyped and very modest re-placement with 600 units per day is ade-quate to meet nutritional needs.2 The secondis the belief that vitamin D deficiency is pres-ent to a significant extent in the United Statesand the global population, and that it needsreplacement with doses higher than previ-ously used.3 The recently updated EndocrineSociety recommendations about vitamin Dintake encouraged the use of 1000 to 2000international units (IU) as an initial dailydose. There is evidence that vitamin D3doses under 10000 units daily are safe.

Many healthcare providers are waitingfor the final proof, which is customarily in-terpreted as randomized double-blindplacebo-controlled long-term trials. Somepending studies may address these issues butthe results will not be known for four to fiveyears. Moreover, the ongoing VITAL studyuses only 2000 IU of vitamin D3, which is

likely insufficient in obese and minority pa-tients. An alternate viewpoint using the Brad-ford Hill criteria for causality espoused byW.B. Grant4 weighs the evidence on the basisof temporal relationship, strength of associ-ation, dose response relationship, consis-tency, plausibility and consideration ofalternate explanation coherence. Since vita-min D meets many of these criteria as an eti-ologic factor in many chronic diseases, itappears prudent to provide at least a re-placement of 1000-2000 units per day pend-ing the “final proof” of long-termrandomized studies. Grant, et al., have pro-posed that such an approach may reducemortality.5 It is likely that this initial dose willneed modification based on follow-up test-ing, since the vitamin D dose response curveshows a wide distribution. Since individualcustomization of vitamin D dosage will likelybe needed, ongoing studies using a fixeddose regimen may result in vitamin D ade-quacy in some, but not in all, study subjects.

In Tennessee, many counties such asHawkins County have extremely poor healthoutcome parameters. Rural citizens are morelikely vitamin D deficient and that may con-tribute to adverse health outcomes.6 Waitingfour to five years before adequately treatingprevalent vitamin D deficiency is not a viableoption. As such, we believe that when therisk-benefit ratio of available data is consid-ered, all individuals should be considered forreplacement with 1000-2000 units of vitaminD3 daily with appropriate monitoring to en-sure desired vitamin D status. +

References:

1. Autier P, Gandini S: Vitamin D supplementation and total

mortality: a meta-analysis of randomized controlled tri-

als. Arch Intern Med 167:1730-1737, 2007.

2. Ross AC, Manson JE, Abrams SA, et al.: The 2011 report

on dietary reference intakes for calcium and vitamin D

from the Institute of Medicine: what clinicians need to

know. J Clin Endocrinol Metab 96:53-58, 2011.

3. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al.: Eval-

uation, treatment, and prevention of vitamin D defi-

ciency: an Endocrine Society clinical practice guideline.

J Clin Endocrinol Metab 96:1911-30, 2011.

4. Grant WB: How strong is the evidence that solar ultravi-

olet B and vitamin D reduce the risk of cancer?: An ex-

amination using Hill’s criteria for causality.

Dermatoendocrinol 1:17-24, 2009.

5. Grant WB, Boucher WB: Requirements for Vitamin D

across the life span. Biol Res Nurs 13:120-133, 2011.

6. Bailey BA, Manning T, Peiris AN: Vitamin D and medical

costs in veterans: The impact of living in rural and urban

areas. J Rural Hlth, 28(4):356-63, 2012.

From the Department of Internal MediDr.Peiris is chief of endocrinology at Moun-tain Home VAMC, Mountain Home, TN,and professor of medicine at East Ten-nessee State University (ETSU), JohnsonCity, TN. Dr. Youssef is assistant professorof medicine in the ETSU Division of Infec-tious Diseases. Drs. George and Khazrikare with the Departments of Internal Med-icine at Mountain Home VAMC and ETSU.

This material is the result of workssupported with resources and the use offacilities at the Mountain Home VAMC. Thecontents of this report do not reflect theposition of the U.S. Government or the De-partment of Veterans Affairs.

For reprints, contact Dr. Peiris at Med-icine Service 111, Mountain Home VAMC,Mountain Home, TN 37684; phone: 423-439-6368; fax: 423-439-6387; email:[email protected].

FOR THE RECORD


TMA ALLIANCE REPORT

For membership information, contact Emily Shore at 731-587-2257 or [email protected]; orTMAA Executive Assistant Judy Ginsberg at 615-460-1651, 800-659-1862 (toll free) or [email protected].

The mission statement of the TMAAis to partner with physicians topromote the good health of Ten-

nessee and support the family of medicine.The members-at-large (MALs) have thesame benefits as other members; they justdon’t have an alliance in their area to af-filiate with.One benefit offered to MAL is the privi-

lege of applying for health grant. Manyprojects qualify for grants to assist in ex-penses for activities for better health.TMAA membership has declined, as has

the TMA in Tennessee, as well as otherstates. It is up to us as members-at-largeto work with our organization to promotebetter health and happiness for thosearound our state. Members-at-large alsocan create a base to establish a new al-liance. I have enjoyed the TMAA from bothperspectives. Over the past 40 years the Tennessee

Medical Association and the TennesseeMedical Association Alliance have workedtogether, keeping abreast of legislative ac-tivities, both state and national. Several

laws in our state have passed in recentyears due to the hard work of physiciansand their spouses. Members-at-large willjoin with regular members to attend PITCH(Physicians Involved at Tennessee CapitolHill) with their spouses. All regions of Ten-nessee will come together for one strong,coordinated visit to the General Assemblyon March 6. Wear a white coat along withyour spouse to let legislators know of yourinterest and dedication to the medical pro-fession. Come along and join TODAY! +

TMAA Members-at-LargeMake a DifferenceBy Emily Shore, Membership Vice President

Alliancesupporting the family of medicine

READ US

ONLINEwww.tnmed.org/tmm

NEW MEMBERS

BRADLEY COUNTY MEDICAL SOCIETY Jack P. Martz, DO, Ooltewah

CHATTANOOGA-HAMILTON COUNTY MEDICAL SOCIETY Christina M. Aguirre, MD, Chattanooga Jacob O. Avila, III, MD, Chattanooga Charles A. Bevan, III, MD, Chattanooga Whitney K. Black, MD, Chattanooga Peter E. Boehm, Jr., MD, Chattanooga David Castrilli, MD, Chattanooga Clint A. Christensen, MD, Chattanooga Ana Cornea, MD, Chattanooga Steven J. Cowart, MD, Hixson Kristen E. Dunbar, MD, Chattanooga Alia Durrani, MD, Chattanooga Jason C. Eck, DO, Chattanooga Alexandra Feliciano, MD, Chattanooga Katherine M. Fyall, MD, Chattanooga Bobby A. Garcia, MD, Chattanooga Vincent W. Gardner, MD, Chattanooga Shelly L. Gibbs, MD, Chattanooga Andrew D. Goins, DO, Chattanooga Laura C. Gowder, MD, Chattanooga William B. Harris, DO, Chattanooga Rehan A. Kahloon, MD, Chattanooga Sandra D. Kaplan, MD, Chattanooga

Tarah J. Kuschel, MD, Chattanooga Lesley V. Landis, MD, Chattanooga Mary L. McKenzie, DO, Hixson Charles J. Meyer, MD, Ooltewah Jonathan Mikail, MD, Chattanooga Eric C. Nelson, MD, Chattanooga Andrew G. Patton, MD, Chattanooga Richard W. Pigg, MD, Chattanooga Jarrod R. Smith, MD, Hixson Mindy W. Smith, MD, Chattanooga Rondell A. Smith, MD, Chattanooga Brent L. Soder, MD, Chattanooga Richa Tevatia, MD, Chattanooga Jessica M. Thomas, MD, Chattanooga Shavonda Thomas, MD, Chattanooga Vanessa Vasconcelos, MD, Chattanooga Sheila L. Venkatesh, MD, Chattanooga Betsy J. Washburn, MD, Chattanooga James E. White, MD, FACS, Chattanooga Talla M. Widelock, MD, Chattanooga Gavin R. Wilks, MD, Chattanooga Joshua M. Willis, MD, Chattanooga

KNOXVILLE ACADEMY OF MEDICINE Michael Godbold, MD, Knoxville Dawn W. Nichols, MD, Knoxville

THE MEMPHIS MEDICAL SOCIETY Christian S. Fahey, MD, Memphis Kenneth A. Grinspun, MD, Memphis Christopher P. Ingelmo, MD, Germantown

SULLIVAN COUNTY MEDICAL SOCIETY Kimberly M. Helms, MD, Kingsport Jennifer C. Peters, MD, Kingsport

TMA DIRECT Verna Bain, MD, Hendersonville Jason K. Roth, MD, Gallatin Larry N. Smith, MD, Gainesville

WARREN COUNTY MEDICAL SOCIETY Jeffrey S. Peterson, DO, McMinnville

WASHINGTON-UNICOI-JOHNSON COUNTYMEDICAL ASSOCIATION Jay B. Mehta, MD, Johnson City

WILLIAMSON COUNTY MEDICAL SOCIETY Ronald C. Cate, MD, Nashville


IN MEMORIAM

RICHARD C. BRAUN, MD, age 82. Died December 2, 2012. Graduate ofWashington University School of Medicine. Member of Cumberland CountyMedical Society.

WILLIAM O. CAMPBELL, MD, age 84. Died December 10, 2012. Grad-uate of University of Tennessee Health Science Center. Member of Chat-tanooga-Hamilton County Medical Society.

CAROLINE ARMISTEAD RIELY, MD, age 68. Died December 13, 2012.Graduate of Columbia University College of Physicians and Surgeons. Mem-ber of The Memphis Medical Society.

DOUGLAS H. CROCKETT, MD, age 89. Died December 31, 2012. Grad-uate of University of Tennessee Health Science Center. Member of Wash-ington-Unicoi-Johnson County Medical Society.

BENJAMIN FRANKLIN SCOTT, III, MD, age 93. Died January 13, 2013.Graduate of University of Arkansas College of Medicine. Member of TheMemphis Medical Society.

DAN SUMNER SANDERS, JR., MD, age 95. Died January 14, 2013. Grad-uate of Vanderbilt University School of Medicine. Member of NashvilleAcademy of Medicine.

CORRECTION

IN ASSOCIATION BETWEEN CESAREANDELIVERY RATE AND BODY MASS INDEX,By Jodi A. Berendzen, MD, and Bobby C.Howard, MD (Tennessee Medicine, Vol. 106,No. 1, p. 37), the wrong data was entered forTable 2. Below is the corrected Table. Ten-nessee Medicine regrets the error.

TABLE 2. Cesarean delivery rate by body mass index for nulliparous and multiparous women.

BMI GroupUnderweight (BMI <18.5)Normal weight (BMI 18.5-24.9)Overweight (BMI 25.0-29.9)Obese (BMI 30.0-39.9)Morbidly Obese (BMI >40.0)Total

N (%)39 (26.0)311 (31.4)197 (39.1)188 (40.8)73 (56.6)808 (36.2)

Nulliparas10 (17.2)122 (26.2)75 (37.7)80 (45.2)31 (64.6)318 (33.5)

Multiparas29 (31.5)189 (36.0)122 (40.0)108 (38.0)42 (51.9)490 (38.1)

Are You HIPAA Compliant?The TMA Can Help. Take our new online course:Employee HIPAA Training: Maintaining Privacy and SecurityAn efficient, cost-effec$ve program designed for healthcare employees and businessassociates who need HIPAA training in order to be compliant under federal law.

Top Reasons You (& Your Employees) Should Take This Course• Meets Federal HIPAA Training Requirements• Protect your pa$ents & your prac$ce• Avoid fines, breaches and legal ac$on• Easy online access

Course Intended for: Physicians • Nurses • Office staff • Billing personnelCFO’s & CEO’s • Administrators • Prac$ce managers • Contractors

www.tnmed.org/hipaaLearn more:

H


BlueCross/BlueShield of Tennessee............................6

Guidant Partners ......................................................28

HIPAA Employee Training ..........................................46

MedTenn 2013............................................................10

State Volunteer Mutual Insurance Company ............48

St. Jude Children’s Research Hospital ......................30

Tennessee Medical Foundation ................................38

The TMA Association Insurance Agency, Inc. ......18, 47

TMA Insurance Recovery Program............................34

TMA Member Renewal................................................27

TMA Physician Leadership College..............................4

TMA Physician Services, Inc. ......................................2

USA.Gov......................................................................30

XMC, Inc. ......................................................................9

LIST OF ADVERTISERSINSTRUCTIONS FOR AUTHORSManuscript Preparation – Manuscripts should be submitted to the Editor, David G.Gerkin, MD, 2301 21st Avenue South, Nashville, TN 37212. A cover letter should identifyone author as correspondent and should include his complete address, phone, and e-mail.Manuscripts, as well as legends, tables, and references, must be typewritten, double-spacedon 8-1/2 x 11 in. white paper. Pages should be numbered. Along with the typed manu-scripts, submit an IBM-compatible 3-1/2 high-density diskette containing the manuscript.The transmittal letter should identify the format used. Another option is you may send themanuscript via e-mail to [email protected]. If there are photos, e-mail themin TIF or PDF format along with the article.Responsibility – The author is responsible for all statements made in his work. Acceptedmanuscripts become the permanent property of Tennessee Medicine.Copyright – Authors submitting manuscripts or other material for publication, as a con-dition of acceptance, shall execute a conveyance transferring copyright ownership of suchmaterial to Tennessee Medicine. No contribution will be published unless such a con-veyance is made.References – References should be limited to 10 for all papers. All references must becited in the text in numerically consecutive order, not alphabetically. Personal communi-cations and unpublished data should be included only within the text. The following datashould be typed on a separate sheet at the end of the paper: names of first three authorsfollowed by et al, complete title of article cited, name of journal abbreviated according toIndex Medicus, volume number, first and last pages, and year of publication. Example:Olsen JH, Boice JE, Seersholm N, et al: Cancer in parents of children with cancer. N EnglJ Med 333:1594-1599, 1995.Illustrated Material – Illustrations should accompany the e-mailed article in a TIF orPDF format. If you are mailing the article and diskette, the illustrations should be 5 x 7 in.glossy photos, identified on the back with the authors name, the figure number, and theword top, and must be accompanied by descriptive legends typed at the end of the paper.Tables should be typed on separate sheets, be numbered, and have adequately descriptivetitles. Each illustration and table must be cited in numerically consecutive order in the text.Materials taken from other sources must be accompanied by a written statement from boththe author and publisher giving Tennessee Medicine permission to reproduce them. Pho-tos of identifiable patients should be accompanied by a signed release.Reprints – Order forms with a table covering costs will be sent to the correspondent au-thor before publication.

SERVICE . . . QUALITY . . . COMMITMENTSERVICE always comes first . . . you deserve it . . . and we will provide it.

QUALITY is important to us. We represent many excellent insurance carriers, all with anemphasis on financial strength, longevity, credibility and value.

Our COMMITMENT to TMA members remains undeniable. If there’s a better way — wewant to tell you about it.

As the exclusive insurance plan administrator for the Tennessee Medical Association since1985, we have a proven track record of our ability to serve, the quality of our products andour commitment to TMA members. We know things are tough out there and we’re here tohelp. Give us a chance to show you our commitment — give us a call today.

Chattanooga 800.347.1109 l Nashville 866.625.0630 l Jackson 888.981.6888 l Memphis [email protected] l TMAinsurance.com

INDIVIDUAL PLANS l EMPLOYEE BENEFITS l PROPERTY & CASUALTY

THE TMA ASSOCIATIONINSURANCE AGENCY, INC.

Exclusive Insurance Plan Administrator for the Tennessee Medical Association

I don’t justhave insurance.

I own the company.

Medical Professional Liability Insurance

Mutual Interests. Mutually Insured.

“Like me, you’ve probably noticed some professional liability insurance carriers recently offering physicians what seem to belower rates. But when I took a closer look at what they had to offer, I realized they simply couldn’t match SVMIC in terms ofvalue and service. And SVMIC gives me the peace of mind that comes when you’re covered by a company with a stellar recordof over thirty years of service and the financial stability of an “A” rating or better since 1984. At SVMIC, I know it’s not justone person I rely on… there are 165 professionals who work for me. And, since SVMIC is owned by you, me, and over 14,000other physicians across the Southeast, we know our best interests will always come first.”

Michael A. McAdoo, M.D.Milan Medical Center

Milan, TNFamily Practice

Contact David Willman, Amy Brown or Deborah Hudson at [email protected] or 1-800-342-2239. www.svmic.comSVMIC is exclusively endorsed by the Tennessee Medical Association and its component societies.

Follow us on Twitter @svmic