S T L O U I S M E D I C A L N E W S . C O M OCTOBER 2013 > 1

David Weinstein, MD

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When leaders at the Florida State University College of Medicine (FSU COM) began crunching numbers, they were pleasantly surprised to learn that roughly two of three medical graduates are practicing medicine in-state, even if they completed residencies elsewhere ... 8

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BY LYNNE JETER

St. Louis hospitals are making signifi cant progress on safety and quality issues as the Centers for Medicare and Medicaid Services (CMS) challenges healthcare providers to become more effi cient in the new pay-for-value era.

“While the transition to a value-driven healthcare system continues to be more of an evolution than a revolution, change appears to be happen-ing,” said Karen Roth, RN, MBA, director of research for the St. Louis Area Business Health Coalition (BHC), and author of the 2013 St. Louis Health Care Industry Overview, a fi rst volume in-depth look at local hospital quality and fi nancial trends based on fi scal year 2011 data, and limited data for FY 2012. “Thanks to pressure by CMS and the hard work of healthcare providers, data suggests that quality at hospitals nationwide and in St. Louis is improving.”

Among the highlights:• St. Louis hospitals scored slightly above the national average in

the CMS Value-Based Purchasing (VBP) Program.• Readmission rates for 2008-11 declined for 15 area hos-

pitals, while the average readmission rate for St. Louis area hos-pitals also declined slightly, compared to the prior three-year period.

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The Advent of Pay-for-ValueSt. Louis area BHC reveals local trends in 2013 Health Care Industry Overview

BY CINDY SANDERS

If you’ve recently enjoyed a golf outing with your friendly pharmaceutical rep or a nice dinner

with a device manufacturer, that information will soon be available for all to see.

The Physician Payments Sunshine Act went into effect Aug. 1 of this year and requires applicable manufacturers to

report certain interactions with physicians and teaching hospitals that are deemed to

have value. ‘Applicable manufacturers’ are defi ned as pharmaceutical, device, biologic and medical sup-ply manufacturers whose products either require a prescription to be dispensed or for which payment under federal healthcare programs is available.

“The Sunshine Act generally applies when phy-sicians or teaching hospitals receive transfers of value from applicable manufacturers, and the applicable manufacturers receive actual or potential value in return,” explained Tom Baker, a shareholder in the

(CONTINUED ON PAGE 10)

Shining a Light on Physician, Industry RelationshipsPhysician Payments Sunshine Act Now in Effect

(CONTINUED ON PAGE 6)

, MD

PHYSICIANS BUSINESS CONFERENCE

POSTPONEDThe October Physicians Business Conference has been postponed. Please see the November Issue of St. Louis Medical News for further details.

2 > OCTOBER 2013 s t l o u i s m e d i c a l n e w s . c o m

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s t l o u i s m e d i c a l n e w s . c o m OCTOBER 2013 > 3

By LUCy SCHULTZE

St. Louis OB/GYN David Weinstein, MD, opts not to bemoan the frustrations physicians often face in their practices. Rather, he works to fix them.

“My focus has been on clinical care and on finding ways to improve the qual-ity of care for patients – and to make it easier for physicians to do what they do best, which is to practice medicine,” he said.

Weinstein is acting upon those convictions both in his practice as part of Consultants in Women’s Healthcare Inc. and as chief of OB/GYN at Mis-souri Baptist Medical Center.

In the latter role, Weinstein has led the hospital’s OB/GYN program since January 2011.

“At a time when other hospitals work only with the physicians they em-ploy, it’s a pleasure to work with a hospital administration that’s committed to part-nering with physicians to try to improve the quality of care in the community that we serve,” he said.

Weinstein’s titles also include chair of the OB/GYN quality improvement com-mittee, chair of the department’s ethics committee and member of the hospital’s medical executive committee. He addi-tionally oversees the obstetrics hospitalist program.

During his tenure as department chair, a key focus for Weinstein has been finding ways to make it more convenient and easy for OB/GYNs to work at Mis-souri Baptist. He worked with adminis-trators to establish a women’s outpatient center within the hospital.

“It was created in response to physi-cian requests for a facility where women can have outpatient procedures in a warm and comfortable setting, with the efficien-cies usually only seen in free-standing surgery centers,” Weinstein said. “It has a high level of patient and physician satis-faction and continues to grow.”

Meanwhile, the hospital has pushed ahead in the area of minimally invasive gynecologic surgery, offering physicians a proctoring program as they learn the new techniques.

In 2012, Missouri Baptist received designation as a Center of Excellence in Minimally Invasive Gynecology – a first in the region. The center offers minimally in-vasive surgical options for hysterectomies, uterine fibroids, endometriosis, ovarian cysts, prolapse and other gynecologic con-ditions.

In obstetrics, Weinstein has worked with hospital administrators to better ac-commodate both patients and physicians. All labor-and-delivery rooms are now equipped with state-of-the-art fetal telem-etry that allows women to move about the room during labor while maintaining mo-bile monitoring of the baby’s heartbeat. The hospital also added new 6 a.m. and

8 p.m. timeslots for scheduled labor-and-delivery procedures.

“We have been responsive to physi-cians’ needs and have tried to make it a physician-friendly service line at the hos-pital,” Weinstein said.

While pursuing such a range of im-provements over a short time frame has added to his schedule, Weinstein doesn’t mind.

“I am busier – but I’d say I’m a high-energy person,” he said. “I always have time and energy for things I believe are positive and meaningful.

“One of the most meaningful things in my private practice has been providing care that makes a difference in people’s lives.

“In my role as chief, that’s just been amplified as I’ve been able to partner with both physician colleagues and hospital administrators to make the OB/GYN program at Missouri Baptist the most pa-tient-focused and physician-friendly pro-gram in town.”

Weinstein has also had the opportu-nity to represent physicians on the board of directors for medical malpractice in-surer Missouri Professionals Mutual, to which he was appointed in April.

A native of Roslyn, N.Y., Weinstein has been part of the St. Louis medical com-munity since the mid-1980s. He received his undergraduate degree in biology from the University of Michgan in Ann Arbor, then came to St. Louis University School of Medicine to earn his medical degree.

Initially, he was interested in family practice.

“I liked the continuity of care,” he said. “But I also loved the surgical sub-specialties, and OB/GYN was the perfect combination of both.”

Weinstein completed his internship and residency in OB/GYN at Wash-ington University School of Medicine/Barnes Hospital, where he served a year as administrative chief resident. He has re-mained connected to the medical school and serves today as an associate professor of clinical obstetrics and gynecology.

In his private practice, Weinstein’s priorities include giving each patient the time that they need and ensuring that every employee in the office embraces a

go-the-extra-mile approach.Consultants in Women’s Healthcare

includes four physicians and two nurse practitioners in addition to support staff.

“The motto in our office is: Take care of patients the way you would want someone to take care of you or your family members,” Weinstein said. “Everybody in our office – from the receptionist to the nurse involved in patient care – makes a difference. This is the culture we strive to encourage in our office.”

Weinstein’s primary areas of interest include obstetrics and laparoscopic surger-ies. Over the years, he has also developed a special interest in osteoporosis, and has served as principal investigator in a num-ber of related studies as well as authored publications. He received certification in clinical densitometry in 2001.

Despite the range of his interests and involvement, Weinstein continues to find everyday rewards in the most basic joys of his field.

“I’ve been in practice 24 years, but I still love obstetrics,” he said. “It’s still a thrill every time I deliver a baby. And it’s special when, years later, you have the chance to take care of the children that you delivered.”

Outside of work, Weinstein enjoys being outdoors – playing tennis, cycling, hiking, skiing – and spending time with family and friends.

He and his wife, Elizabeth, have three daughters: Jennifer, Allison and Kather-ine.

David Weinstein, MDPhysicianSpotlight

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By LyNNE JETER

TALLAHASSEE— Ken Brummel-Smith, MD, almost bypassed specializing in geriatrics because of the lack of edu-cational opportunities at medical schools during the early 1970s, when he attended, and the lack of geriatric resi-dency slots nationwide. Instead, it was a chance encounter that sculpted his career path and en-abled him to establish the nation’s first Department of Geriatrics for an allo-pathic school.

“My first job after fellowship was teaching a family medicine residency, and my director told me about the Society of Teachers of Family Medicine having a conference on teaching geriatrics in the family medicine residency program, and said it was going to be a big deal someday. When asked if I’d go and see what I could find out about it, my first thought was, wow! A free trip to Boston! I really didn’t have much knowledge about geriatrics then,” said Brummel-Smith, past presi-dent of the American Geriatrics Society, and founding chair of the Department of Geriatrics at the Florida State University College of Medicine (FSU-COM). “After getting enthused at the conference and involved in developing educational pro-grams, I switched from family medicine to geriatric medicine.”

Since then, the field of geriatrics has exploded. As baby boomers have aged, the need for geriatricians grows. Cur-rently, 38,000 geriatricians are projected to meet the country’s needs.

“We’re at 7,000 now,” said Brummel-Smith. “The main problem is we don’t have enough applicants. When I started in 1980, hardly anyone believed it was worth talking about. Now, there’s interest from the general public, but not enough inter-est from medical students. Lack of money and prestige are two reasons why.”

To address the shortage, Brummel-Smith routinely encourages high school groups pursuing medical paths to strongly consider geriatrics.

“I always give them data that says: if you look at the top income to the lowest income, geriatricians are at the bottom of the scale,” he said. “We actually make less money with a specialty in geriatrics than we would in our primary specialty of fam-ily medicine or internal medicine. But in-terestingly, you can line up the reverse in job satisfaction. Geriatrics has the highest; neurosurgeons, among the highest paid, have the lowest. We tell them to think about paying your bills and your loans,

but don’t think you need to sacrifice your life to do it. Choose a specialty you love rather than one that pays well. And you’ll be happy the rest of your life.”

Brummel-Smith also ensures that all FSU-COM medical students have rota-tions in geriatric medicine in the school’s community-based curriculum model.

“Otherwise, if you took 1,000 people in a community, 700 would have a rea-son for thinking about their health during that month,” he explained, referencing the well-known study, “The Ecology of Care,” which first appeared in the New England Journal of Medicine in 1961, and was recently revisited with similar results. “About 300 would have contact with the healthcare system in some way. About 100 would be admitted to a hospital, and one would go to an academic teaching medical center. So the population of patients who are taken care of, and the doctors taking care of them in an academic medical set-ting, is almost completely unreal realty. Then medical graduates after residency go into practice where the real situation is. For family medicine physicians, 30 percent will be geriatric patients. For internists, it’s 40 to 50 percent. And they’re just not pre-pared for it. So during medical school and residency, students get a negative view of geriatrics because you’re not seeing that many older patients in academic medi-cal centers, and they hardly ever see geri-atricians as role models. Combined with the negative financial incentives, and the negative emotional incentives that a lot of academic doctors put on geriatrics, it doesn’t surprise me that few people choose geriatrics.”

The tide is slowly turning in favor of geriatric medicine. CMS has elevated geriatrics to primary care status, paying $38,500 per resident annually, a 10 per-cent payment bonus from $35,000. The shift from production- to value-based medicine will also make a difference. South Carolina has adopted a student loan repayment program as an incentive for geriatricians, a move Brummel-Smith hopes other states will emulate.

“In general, there’ll never be enough geriatricians to take care of all people over the age of 65,” he said.

Even though baby steps are helpful, it remains problematic for geriatricians, who don’t fit the standard productivity model of many medical groups.

“Geriatric patients don’t fit into the 15-minute visit model,” he explained. “Older patients have more medical needs and take longer for each appointment. Also, the way our healthcare system is working right now and the way of reimbursement, you’re not being paid to make a patient

Making Geriatrics a PrimaryNational expert discusses decade of change in high demand specialty

Dr. Ken Brummel-

Smith

(CONTINUED ON PAGE 11)

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By CINDy SANDERS

If the workforce ain’t happy … ain’t nobody happy.

This spring the Lucian Leape Insti-tute at the National Patient Safety Foun-dation (NPSF) released a report, Through the Eyes of the Workforce: Creating Joy, Meaning and Safer Health Care, that underscored the fundamental importance the workplace environment plays on patient safety. The result of two roundtables on the topic, the report contends patient safety is inextri-cably linked to healthcare workers’ own sense of safety and well being since provid-ers who feel disrespected or threatened are more likely to make errors and less likely to follow institutional protocols.

Julianne Morath, RN, MS, president and CEO of the Hospital Quality Institute based in Sacramento, Calif., co-led the roundtables with former U.S. Treasury Secretary Paul O’Neill, now CEO of Alcoa. A founding member of the Lucian Leape Institute, Morath was the inaugural recipient of the John M. Eisen-berg Award for Lifetime Achievement in Patient Safety from NPSF and is a noted author and speaker on the topic of safety and workforce improvement.

Going into the roundtables, Morath said the working hypothesis was, “A workforce, no matter how committed and skilled, cannot create a culture of safety unless they themselves are free from harm and disrespect.”

This hypothesis was borne out during the discussions that included the experi-ences and opinions of frontline practitio-ners, leaders of healthcare organizations, scholars, and representatives of govern-ment agencies and healthcare professional societies. Morath said, “It became very evident through the course of the round-tables that we have a long way to go in healthcare workforce safety.”

When workers live in a constant state of risk, they become blind to that risk and resigned to their situation, Morath said. “It’s a dangerous place to be if you think this is as good as it’s going to get no matter what you do,” she noted.

When a workforce reaches this state, Morath continued, the workers won’t speak up or speak out. Yet, the evidence clearly shows having a culture that allows for effective assertion … or a ‘stop-the-line conversation’ … is a prerequisite for pa-tient safety.

Morath, who served as chief quality and patient safety officer at Vanderbilt University Medical Center at the time of the roundtables, said her co-leader

O’Neill has often made the statement that every person in a workforce should be able to answer affirmatively to three essential questions:

1. Am I treated with respect and dig-nity by everyone?

2. Do I have the support and training tools to do my job?

3. Am I recognized and thanked for my contributions?

Unfortunately, ‘no’ is too often the answer to those questions. “It was jarring to find not only was there a lack of respect … but even worse, there was a culture of disrespect in many of our healthcare or-ganizations that was tolerated,” she said of the group’s findings. “We have a some-what historic and toxic culture where the hierarchy has to do with positional titles and the number of degrees,” Morath added.

Vulnerabilities in the system include accepting emotional abuse, bullying and learning by humiliation as ‘normal,’ per-forming demanding tasks under severe time constraints due to the production and cost pressures that dominate today’s healthcare landscape, and having a higher rate of physical harm than such high-risk industries as mining, manufacturing and construction. This culture of fear and in-timidation takes away the joy and meaning from work that most healthcare employees chose for the very purpose of helping oth-ers and making a difference.

“While this report is concerning, it’s also hopeful,” said Morath, noting there were also examples of healthcare work-

places that are getting it right … at least most of the time. New healthcare models that rely heavily on teamwork are also helping make cooperation part of the landscape. “It really requires an apprecia-tion and respect for everyone’s contribu-tion in a team to deliver high quality, safe care in this complex environment in which we work today,” she noted.

The report asserts joy and meaning are created when the workforce feels val-ued, safe from harm and part of the so-lutions for change. The Mayo Clinic and Virginia Mason Medical Center are two examples that Morath said stood out for their culture of respect. She also said Hos-pital Corporation of America (HCA) has an exemplary employee safety and secu-rity initiative.

To create safe, supportive work en-vironments, healthcare facilities must be-come high-reliability organizations with a fundamental precondition that employees are their most valuable assets and that the health and well being of those employees is a non-negotiable priority. The report out-lined seven strategies to move the needle toward becoming this type of an effective organization.

1. Develop and embody shared core values of mutual respect and civility; transparency and truth telling; safety of all workers and patients; and alignment and accountability from the boardroom through the front lines.

2. Adopt the explicit aim to eliminate harm to the workforce and to patients.

3. Commit to creating a high-reli-

ability organization and demonstrate the discipline to achieve highly reliable per-formance.

4. Create a learning and improve-ment system.

5. Establish data capture, database and performance metrics for accountabil-ity and improvement.

6. Recognize and celebrate the work and accomplishments of the workforce regularly and with high visibility.

7. Support industry-wide research to design and conduct studies that will ex-plore issues and conditions in healthcare that are harming the workforce and pa-tients.

“It sounds deceptively simple, but it’s about and individual and collective commitment to continual learning, con-tinual improvement, and continual en-gagement,” said Morath. “When you start, you’re never finished. This is a com-mitment … a long term commitment.”

Happy, Safe Workforce Prerequisite for Patient SafetyReport Emphasizes Impact of Workplace Culture on Patient Outcomes

Through the Eyes of the Workforce

To download the full report and related materials, go online to www.npsf.org. Click on “About Us” and select the Lucian Leape Institute at NPSF. From there, choose the LLI Reports and Statements link under “Related Pages.”

Julianne Morath

6 > OCTOBER 2013 s t l o u i s m e d i c a l n e w s . c o m

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• SSM DePaul Health Center and Christian Hospital reported zero surgi-cal site infections for patients undergoing coronary artery bypass graft in 2011, the most recent year reported.

• A dozen hospitals received an “A” from The Leapfrog Group, a national patient safety organization, as part of its Hospital Safety Score program.

“It’s too early to de-clare the quality prob-lem ‘fi xed,’” said Roth. “One in fi ve Americans still must return to the hospital within 30 days of a heart attack, too often because of a com-plication from care re-ceived.”

Existing pay-for-performance pro-grams including CMS’ VBP are reward-ing providers with bonuses for care that’s far from exceptional, Roth noted.

“For example, St. Louis area hospi-tals with patient satisfaction scores as low as 23 out of 100 received an incentive payment,” she said.

In the region, Medicare losses – a proxy measure of ineffi ciency – decreased nearly 30 percent as a slice of operating revenue, making it the largest one-year decline since BHC began reporting on this metric.

The Medicare Payment Advisory Commission (MedPAC) and other in-dustry leaders challenged the belief that Medicare payments are inadequate to cover the cost of care, noted Roth, point-ing to a 2009 report, in which MedPAC found hospitals in competitive markets were effi cient enough to earn a profi t on Medicare because fi nancial pressure from the private sector forced them to constrain costs.

“MedPAC provided further evidence in its most recent report that competitive market pressure results in lower hospital costs,” she said. “In the future, as CMS maintains pressure on revenue to contain

cost and bases payment on value, hospi-tals must focus on continuous quality and effi ciency improvements to prosper.”

In 2011, St. Louis hospitals boosted charity care, with many hospitals report-ing the highest levels in report history. SSM Health Care and Mercy reported charity care at more than 3 percent of op-erating revenue, a fi rst for both hospital systems.

Strikingly, Missouri Baptist Hospi-tal-Sullivan provided charity care at 8.6 percent of operating revenue, the high-est in the region, and one of fi ve hospitals that provided charity care at 6 percent or greater of operating revenue.

The comprehensive report also notes that St. Louis hospital profi t margins decreased, yet remained strong at 4.2 percent in 2011, compared to 7 percent nationwide. Losses on investments, such as acquisitions of physician practices, were partly the reason.

“It’s clear the journey to better value has just begun,” said Roth. “CMS’ VBP program has only put 1 percent of hos-pitals’ payments at risk and most com-mercial payment reform efforts remain segregated to only a slice of care, such as bundled payment for a specifi c proce-dure.”

The Advent of Pay-for-Value, continued from page 1 St. Louis Hospitals’ Quality and Patient Safety Report Medicare VBP Program Total Blended Performance Score (and Bonus/Penalty Percentage)

Missouri Baptist Sullivan, 90.1 percent (.66 percent)

St. Joseph Hospital Breese, 80.1 percent (.47 percent)

St. Joseph Hospital-West, 79 percent (.45 percent)

Saint Anthony’s Health Center, 77.7 percent (.43 percent)

DePaul Health Center, 73.3 percent (.35 percent)

St. Louis University Hospital, 70.55 percent (.30 percent)

St. Elizabeth Hospital, 68.1 percent (.25 percent)

St. Clare Health Center, 66.7 percent (.23 percent)

Alton Memorial, 65.4 percent (.20 percent)

St. Mary’s Health Center, 63.1 percent (.16 percent)

Barnes-Jewish St. Peters, 63 percent (.16 percent)

St. Joseph Health Center, 62.1 percent (.14 percent)

Progress West HealthCare, 61.78 percent (.14 percent)

Christian Hospital, 61.7 percent (.13 percent)

Missouri Baptist Medical Center, 60.35 percent (.11 percent)

Mercy Hospital St. Louis, 58.9 percent (.08 percent)

Barnes Jewish West County, 54.3 percent (.0 percent)

St. Luke’s Hospital, 54 percent (-.01 percent)

St. Anthony’s Medical Center, 53.2 percent (-.02 percent)

Memorial Hospital, 52.8 percent (-.03 percent)

Mercy Hospital Washington, 52.3 percent (-.04 percent)

Gateway Regional Medical Center, 50.1 percent (-.08 percent)

Touchette Regional Medical Center, 50 percent (-.08 percent)

Mercy Hospital Jefferson, 46.1 percent (-.15 percent)

Barnes Jewish Hospital, 40.55 percent (-.25 percent)

Des Peres Hospital, 40.45 percent (-.26 percent)

Anderson Hospital, 31.7 percent (-.42 percent)

St. Alexius Hospital, 18.3 percent (-.66 percent)

Lincoln County Medical Center, n/a

Note: Information is based on data gathered between July 2011 and March 2012.

SOURCE: CMS Hospital Compare.

To Err is Human, But … Nearly 15 years ago, the Institute of Medicine released the groundbreaking

report, To Err is Human. It brought to public light the serious safety and quality issues occurring in American healthcare and ignited a movement for transformation.

In 2004, CMS launched Hospital Compare to publicly report hospital quality. Four years later, CMS announced it would no longer pay for complications related to certain healthcare-acquired conditions. Earlier this year, CMS’s Value-Based Purchasing program (VBP) began making incentive payments to hospitals based on quality metrics.

SOURCE: St. Louis Area Business Health Coalition, Volume 1: Hospital Quality and Financial

Overview, 2013.

Karen Roth

(CONTINUED ON PAGE 11)

s t l o u i s m e d i c a l n e w s . c o m OCTOBER 2013 > 7

By DAVID A. WILLIAMS

Within the numerous parts of the Af-fordable Care Act, there are still many areas of implementation and enforcement that are unclear. In the confusion, hos-pitals may have missed or are in danger of missing important deadlines like the Community Health Needs Assessment (CHNA). Nonprofit and dual status hospi-tals must submit a CHNA before the end of the fiscal 2012 year. Here’s an overview of what you need to know, along with tips on how to begin structuring your CHNA assessment to become a strategic tool you can use to better serve parts of your com-munity that fall through the cracks, as well as to set budgeting priorities for the next few years.

1. If you are a dual status hospital (a governmental organization that is by stat-ute not required to file a 990) and do not file a 990, you must still complete a Com-munity Health Needs Assessment before the end of the fiscal year. The penalties for not submitting are uncertain, but it seems logical to assume that revocation of a hos-pital’s tax exempt status could be at stake as well as a $50,000 penalty.

2. The fact that the IRS has not yet revealed its mechanism for dual status

hospitals to submit the assessment does not exempt nonprofit and dual status hos-pitals from completing the CHNA.

3. The CHNA process takes several weeks from conceptualizing to staffing, information gathering to analysis, and re-port preparation. The report needs to in-clude an action plan for addressing areas in your community that are underserved and have disproportionately high health issues

4. Think strategically about the CHNA. Under the Affordable Care Act, a Community Health Needs Assessment is required to be completed every three years. Taking the time to put a good pro-cess in place gives you a solid template for conducting CHNAs going forward.

But the CHNA can actually be a very helpful strategic tool to take the tempera-ture of the community; find out where you are having successes like a decrease in dia-betes, which lets you know your program is working. Or you could find out infant mortality rate has risen, so a different ap-proach is needed to help the community in that area. By treating the CHNA as more than a compliance requirement, there is an opportunity to move more swiftly from a reactive status to a proactive status that can get ahead of serious health trends.

Addressing population health man-agement is a vital concern for hospitals. The reimbursement system for Medicare is shifting from a fee-for-service envi-ronment to an outcomes based delivery model. Other payors may adopt this ap-proach moving forward, therefore, status quo is not a strategy for hospitals. The CHNA is a great tool to aid in the culture shift required to move away from the re-imbursement platform that exists today.

Here are key process suggestions to get the CHNA process started at your hospital:

• Develop your supervisory team. Often the hospital administration, under direction from its board, is tasked with taking point on the CHNA. The first priority is to develop a needs listing that identifies both signs of wellness and areas of concern in the community you serve. Review existing programs with an eye for refocusing resources to meet the most critical needs.

• Develop your CHNA imple-mentation team. Include a broad rep-resentation of residents, agencies, and medical personnel that are knowledgeable about your community and will dedicate the time and effort to make the CHNA a success.

• Design the infrastructure nec-essary to manage the process, and to collect and analyze data. An evidence-based approach is necessary to meet com-pliance.

• Establish a plan for gathering primary and secondary data. Primary data on your community provides an op-portunity to identify health trends that need to be addressed. Methods used to collect primary data include postal surveys and web-based surveys, videography, ob-servation, focus groups, and face-to-face interviews. Secondary data is information used to prepare quantifiable benchmarks. Examples of secondary data include de-mographic data about the growth rate of the community population, family income trends, area employers, vital statistics about incidence rates, prevalence rates, mortality, morbidity, and outcomes. Good sources for secondary data include Cen-ters for Disease Control, State Depart-ment of Health, and U.S. Census Bureau.

• Set up a process to analyze the data. Prepare charts that include benchmarks that show how your community stacks up against state and national benchmarks in key areas of wellness and disease.

• Prepare a report that includes the

What You Need to Know NOW about the CHNA Deadline

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• Does your current carrier utilize claim adjusters?The answer you are looking for is NO. Galen does not employ a single claims adjuster. Claims are reviewed within 24 hours of being made by an in house Galen Trial Attorney in combination with Galen’s in house Chief Medical Offi cer. The end result for the insured: a more aggressive and cohesive legal defense producing a 50+% dismissal rate, all of which generates lower premiums offered by Galen.

• What type of requirements does your current carrier meet? Do they meet the Missouri Department of Insurance requirements?Not all medical malpractice insurance companies are required to meet certain Missouri Department of Insurance requirements. Galen is a regulated admitted carrier in MO and IL. Galen meets all regulatory capital requirements.

• Who is your insurance carrier?Galen was founded by physicians in order to protect physicians. We are reinsured with all “A” rated reinsurance carriers, possess over 40 years of experience in underwriting, and more than 26 years in legal and trial practice.

THE QUESTIONS YOU SHOULD BE ASKING OF YOUR CURRENT MEDICAL MALPRACTICE INSURANCE CARRIER AND THE ANSWERS YOU DESERVE AS A PROFESSIONAL

I n s u r a n c e C o m p a n y

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Providing the

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Medicine

(CONTINUED ON PAGE 8)

8 > OCTOBER 2013 s t l o u i s m e d i c a l n e w s . c o m

By LyNNE JETER When leaders at the Florida State

University College of Medicine (FSU COM) began crunching numbers, they were pleasantly surprised to learn that roughly two of three medical graduates are practicing medicine in-state, even if they completed residencies elsewhere.

“We were concerned it was a fluke and hoped the trend kept up,” said Mi-chael Muszynski, MD, dean of the FSU COM Orlando regional cam-pus, and associate dean of clinical research. “Five years later, it’s holding steady between 60 and 64 percent.”

State lawmakers ap-proved the opening of the FSU COM in 2000, after the Board of Regents denied requests in the late 1990s, stating more doctors weren’t needed. The charter class graduated in 2005.

As of May, 82 of 135 FSU COM graduates who have completed residencies are practicing medicine in Florida (61 per-cent). Of those, 70 percent (57) are in-state primary care providers (PCPs) and 16 per-cent (13) are practicing in rural, medically underserved areas of the state.

“The reasons why our statistics are much better than the standard 30/60 per-cent split – that is, 30 percent of graduates from traditional-based medical schools typically return to the state after complet-

ing residency and 60 percent stay where they did their residency – is because of the foundation we laid with our mission state-ment, which was created by us from the very start,” said Muszynski. “We wanted the foundation firmly established so that whoever inherited the program from the pioneers who started the school wouldn’t be able to vary from the mission.”

First, FSU COM stacks the deck on the front end through a holistic applica-tion approach, focusing on applicants who want to live and practice medicine in Florida. Second, the college follows a community-based medical school model during students’ clinical years, where they connect one-on-one with physicians in the community.

And third, medical school faculty makes it fun and interesting to be a com-munity-based doctor with a mentoring system that maintains contact with stu-dents during school and afterward.

“We put a great deal of thought into how our approach might work,” said Muszynski. “We knew we had to make an impression on medical students when they were making choices about their ca-reers. And it’s working. The only thing that surprised us was how well it’s worked. We would’ve been happy with a 40 to 50 percent return, but 60 to 65 percent is as-tounding.”

Deck Stacking Rather than reviewing only grades

and scholastic ability, the FSU COM ap-plication review board selects students with attributes that mirror the school’s mission.

“We quickly discovered that students who stated upfront their agreement with our mission had experience supporting that mission alignment,” said Muszynski. “For example, we noted that many appli-

cants from smaller towns and smaller high schools were involved in a meaningful way with their community and seemed more likely to maintain that mission. We made no apologies for those identifying descrip-tors.”

For several years, FSU COM only ac-cepted in-state applicants. Now, approxi-mately 5 percent of approved applicants cross state lines to attend. Still, the board remains very selective.

All factors considered equal between two applicants – one from a rural area and an urban applicant – the rural applicant may be get a slot above the urban appli-cant, said Muszynski.

“A student from a rural area is more likely to align with our mission just be-cause of their setting,” he explained. “But the rural applicant who didn’t do much extracurricular-wise, where the urban ap-plicant worked with the underserved, then it’s different.”

Middle GroundTo keep the in-state return mindset

strong, the FSU COM uses a community-based curriculum to place third and fourth year medical students in the field.

“Community-based curriculums have been talked down by some schools,” said Muszynski. “We contend its equal worthi-ness. We focus on producing physicians who can care for patients in community settings, and a community-based curricu-lum is central to the process.”

For example, FSU COM has a unique apprenticeship model. Students aren’t assigned to hospitals, wards or resi-dency teams. Instead, they’re assigned to a physician practicing in the community who has been trained to be an educator. That physician typically receives $2,000 a month on a contract basis. As a result of this model, the FSU COM has no full-

time faculty for years 3 and 4, with the ex-ception of the campus dean.

The approach also includes a ge-riatric rotation component to spark interest in caring for older patients. FSU COM has also established a strong student advisor network. Each student is assigned to a community advisor on an 8-to-1 ratio. Students are counseled not only about their careers, but also life in general, volunteerism, and the delicate yet very important work/life balance that perplexes many physicians. Advisors are overseen by a dean or associate dean, depending on the campus, on a 20-to-1 (students-to-dean) ratio.

“That low of a ratio in the U.S. rarely exists,” emphasized Muszynski.

Stage 3To further strengthen community ties

and the job placement network, Florida Hospital recently provided a $2 million gift to establish the Florida Hospital En-dowed Fund for Medical Education to help the FSU COM support its educa-tional mission.

“Our mission aligns strongly with Florida Hospital’s except that we’re not a faith-based school; we’re public,” said Muszynski. “These students are highly sought after, and relationships end up being life-long. We have 16 graduates al-ready practicing in Central Florida. You might think: only 16? But it’s impressive when you consider the number of gradu-ates during our ramp-up years between 2005 and 2010, and those who are just finishing 5-year residencies. We’ve now created a number of scholarships to en-courage students to return.”

Stacking the Deck Part 1One COM’s winning approach to retaining medical graduates

Dr. Michael Muszynski

What You Need to Know NOW about, continued from page 7

David A. Williams, CPA, MPH, FHFMA leads healthcare reimbursement and advisory services at HORNE LLP. For more than 25 years David has focused on the healthcare industry serving hospitals, outpatient centers, home healthcare agencies, skilled nursing facilities, assisted living centers, rural health clinics and mental rehabilitation centers. From offices across the Southeast, HORNE serves healthcare clients across the nation. Visit www.horne-llp.com for more information.

REPRINTS: Want a reprint of a Medical News article to frame? A PDF to enhance your marketing materials? Email subscribe@medicalnewsinc.com for information.

Welcome To The Inaugural Physicians Business Conference!

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health priorities identified by the CHNA. Share it with the community and prepare an action plan to address any healthcare gaps.

If you treat the CHNA as a check-the-box requirement, then you’ll have a nice statistics report you can file. But when done correctly and strategically, the CHNA truly does provide an oppor-tunity for hospitals to proactively budget resources for a multi-year plan that meets the specific health needs of the community of residents it serves.

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Dr. Patrick Sullivan

By CINDy SANDERS

An insidious condition, schizophrenia is estimated to occur in about 1 percent of the population worldwide. Character-ized by a breakdown in thought processes, the mental illness has been described for centuries through accounts of individuals suffering from delusions, paranoia and hal-lucinations.

The chronic, debilitating disorder takes a heavy toll not only on affected in-dividuals but also on their families and society as a whole. An early onset disorder, many patients are fi rst diagnosed dur-ing the late teens or early adult years and struggle throughout their lifetime to manage symptoms.

“It’s a horrible disor-der,” stated Patrick Sullivan, MD, director of the Center for Psychiatric Genomics at the University of North Carolina School of Medicine. “It’s a huge, huge public health problem, and it’s one where the scientifi c discussion has been dominated on partial information.” He added, “People have done the best they can with what informa-tion they have. We’ve been debating the cause of schizophrenia for the better part of a century now.”

On Aug. 25, Sullivan and colleagues helped move that conversation forward with the online publication of a new ge-nome-wide association study (GWAS) in the journal Nature Genetics. “This is the largest published study we’ve done in the fi eld,” noted the lead author who also serves as a professor in the departments of Genetics and Psychiatry and UNC. Col-laborators in the study include co-authors from the Karolinska Institutet in Sweden, the Stanley Center for Psychiatric Re-search at the Broad Institute of MIT and Harvard, and the Mount Sinai School of Medicine in New York.

“We discovered there were 22 places in the genome, 13 of which to our knowl-edge had never been described before, and each is a clue about the cause of schizo-phrenia,” Sullivan said of identifying nearly two dozen locations in the human genome that are involved in the disorder, including one that has previously been implicated in bipolar disorder.

“If fi nding the causes of schizophrenia is like solving a jigsaw puzzle, then these new results give us the corners and some of the pieces on the edges,” he stated, adding the number of genetic variants probably numbers in the thousands. “These 22 are the tip of the iceberg.”

The study was based on a multi-stage analysis that began with a Swedish national sample of 5,000 schizophrenia cases and 6,200 controls followed by a meta analysis of previous GWAS studies and then a rep-

lication of single nucleotide polymorphisms (SNPs) in 168 genomic regions in inde-pendent samples for a total of more than 59,000 people included in the research. The results underscored two takeaways for Sullivan. The fi rst, “We need to do more studies urgently. We’re actually quite en-couraged and believe larger studies of this type will lead to more knowledge,” he said. The second, “The early results we have here certainly indicate two different bio-logical processes are involved.”

The research un-covered two distinct pathways that might

be associated with the dis-order — a calcium channel and micro-RNA 137. Calling the cal-cium channel, which includes the genes CACNA1C and CACNB2,

the ‘queen of the channels,’ Sullivan explained there are a number of FDA-approved calcium channel blockers on the market today that are used for a variety of conditions ranging from hypertension and angina to migraines.

Stressing that it was much too early to draw conclusions, Sullivan said the fi ndings at least indicate the calcium channel might be an area that deserves further attention from those studying schizophrenia. Hypo-thetically, he continued, calcium channel blockers might be found to have unex-pected effi cacy in schizophrenics. “That’s something that needs to be evaluated in a careful, rigorous way,” he said, again cau-tioning against jumping too far ahead.

The second pathway includes its name-sake gene MIR137, which is a known regula-tor of neuronal development. Sullivan noted more than a dozen other genes are also known to be regulated by MIR137, as well.

Schizophrenia has long been known to have a strong genetic component. While it occurs in about 1 percent of the general population, the disorder is found in about

10 percent of people with a fi rst-degree relative diagnosed with schizophrenia. The National Institute of Mental Health notes the highest risk for developing the illness — 40 to 65 percent — occurs in an identical twin of an individual with schizophrenia. Yet, most scientists believe genetics is only one component in developing the disorder, which probably has environmental trig-gers, as well.

While Sullivan said each different approach to solving the enigma of schizo-phrenia is important, he noted the genetic approach offers a strong foundation for discovery. “We can measure the DNA part of people particularly well these days,” he said. “Our study is a step forward in under-standing the genetic basis of the disorder. This is really, truly nice progress.”

He added the new fi ndings provide “a couple of good strides forward” even though an endpoint isn’t yet in sight. “But for researchers and scientists, it shows us a bunch of things we’ve never seen before … and that’s pretty cool.”

And Sullivan expects more information to be forthcoming. “What’s really exciting about this is that now we can use standard, off-the-shelf genomic technologies to help us fi ll in the missing pieces,” he said. “We now have a clear and obvious path to get a fairly complete understanding of the genetic part of schizophrenia. That wouldn’t have been possible fi ve years ago.”

Research Uncovers New Clues to the Causes of SchizophreniaGenome-wide study discovers new variants, pathways

10 > OCTOBER 2013 s t l o u i s m e d i c a l n e w s . c o m

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Baker Donelson Health Law group.Baker, who practices in the fi rm’s At-

lanta offi ce, pointed out the manufacturer doesn’t actually have to receive fi nan-cial benefi t in exchange for the ‘value transfer,’ which can take a wide variety of forms, includ-ing donated items, pay-ment to a physician for consulting services or ex-penditures for entertain-ment. “It’s enough that it might infl uence a physician,” he noted.

“The Sunshine Act is about transpar-ency in two different fundamental ways,” he continued. “First, there is the potential interference in medical judgment in clini-cal trials required for FDA approval of drugs or medical devices. Second, there is potential interference in medical judg-ment in terms of ordering an item or ser-vice for which federal reimbursement is available.”

Baker said the policy is to shine a light on interactions that could be construed to unduly infl uence a physician or teaching hospital and to ferret out confl icts of inter-est. “It’s not saying that transfers of value are, per se, illegal but that the public has a right to know when medical judgment might be infl uenced by the value trans-fer,” he continued. Relationships between physicians and industry will now be on display for patients, auditors, personal injury lawyers and others to see when the Centers for Medicare and Medicaid Services (CMS) begins publishing the re-ported data next fall.

The Back StoryChampioned by Sen. Chuck Grassley

(R-Iowa) and Sen. Herb Kohl (D-Wis.), the impetus behind the Sunshine Act came from mounting concern over poten-tial confl icts of interest within the industry. These confl icts were highlighted by sev-eral egregious incidents involving clinical trials and devices up for FDA approval where physicians received large payments from the manufacturers of the drugs or devices being studied.

Grassley publicly described a number of academic physicians taking money from the National Institutes of Health when

those physician-scientists had direct fi nan-cial interests in their own research. Among the worst offenders, the former chairman of the Psychiatry Department at Stan-ford University received an NIH grant to study a drug when he owned $6 million in stock in the company seeking FDA ap-proval. Similarly, the former chair of the Psychiatry Department at Emory failed to report hundreds of thousands of dollars from GlaxoSmithKline while researching the company’s drugs. Harvard also had to

discipline three researchers who received almost $1 million each in outside income while heading up several NIH grants.

Outside of these fl agrant examples, the concern persists that much smaller gifts might also infl uence medical deci-sions. Earlier this year, Pew Charitable Trust published Persuading the Prescrib-ers: Pharmaceutical Industry Market-ing and its Infl uence on Physicians and Patients, which stated the drug industry spent nearly $29 billion marketing their products in 2011 (Source: Cegedim Stra-tegic Data). Of that amount, $25 billion was spent directly marketing to physicians.

After unsuccessfully introducing the legislation in 2007, the Sunshine Act was incorporated into the Affordable Care Act. A couple of missed rulemaking dead-lines by CMS pushed the law’s effective date to Aug. 1, 2013 for the balance of this calendar year and requires annual report-ing going forward.

What is a Transfer of Value?

With 12 major exceptions (see box), any direct payment or transfer of value of $10 or more (or an aggregate of $100 or more in a calendar year) to a physician or teaching hospital must be reported. Addi-tionally, indirect transfers through an in-

termediary or third party are also subject to reporting.

There are 14 main reporting cat-egories. These include consulting fees, compensation for services other than con-sulting, gifts, entertainment, food, travel, charitable contributions, education, grants, research, royalty or licensing fees, current or prospective ownership or in-vestment interest, direct compensation for serving as faculty or a speaker for a medi-cal education program, honoraria.

Under the new rules, Baker said a physician could accept a ballpoint pen or pad of sticky notes from a manufacturer without it being included in the annual re-port, but most meals, tickets, or gifts prob-ably will fall under one of the reporting categories considering the $10 threshold.

“The days of the pharmaceutical company taking a group of physicians to the Super Bowl are over … or at least it will be disclosed and expose you to the risk of Anti-Kickback statute prosecution,” Baker said. “It’s the entertainment part of it that physicians would probably like to have exposed the least,” he added.

The law also requires applicable man-ufacturers and GPOs (group purchasing organizations) to report ownership inter-ests by physicians or their immediate fam-ily members. It should be noted, however, that purchased industry stocks and mu-tual funds that are generally available to the public are not reportable. If Dr. Smith buys 50 shares of ABC Pharmaceutical stock, which is publicly traded, it doesn’t have to be reported. If a representative of ABC Pharmaceutical gives Dr. Smith stock, then it does.

Ultimately, a patient whose doctor recommends a specifi c device or drug will be able to search the CMS database to see if there is a connection between the physician and the manufacturer. “You’re going to know when your physician has a personal fi nancial interest in your health-care beyond the physician’s professional services,” Baker pointed out.

Disputing a ReportSo what happens if your name ap-

pears on a report, and you disagree with the data? Baker said CMS is going to notify physicians of all their reported re-lationships. Once access is granted to the online portal housing the consolidated re-port, a physician should have at least 45 days to challenge the data and try to re-solve the dispute with the reporting entity.

Those who cannot agree will be given an additional 15 days to come to a resolu-tion before the information is made pub-lic. If no agreement can be reached, the data will be published but fl agged as dis-puted. Physicians cumulatively have up to two years to dispute reports even after the data is published.

“While physicians aren’t required to track transfers of value, they are encour-aged to do so,” said Baker. “How in the world are you going to be able to refute a report if you don’t have evidence to the contrary.”

Shining a Light on Physician, Industry Relationships, continued from page 1

12 Key Exemptions to the Reporting Rule

Certifi ed and accredited CME.

Buffet meals, snacks, coffee breaks that are provided by a manufacturer at a large-scale conference or event when the items are generally available to all attendees.

Product samples that are not intended for sale and are for patient use.

Educational materials that directly benefi t patients or are intended for patient use.

The loan of a medical device for evaluation during a short-term trial period (not to exceed 90 days).

Items or services provided under a contractual warranty in the purchase or lease agreement for a device.

The transfer of any item of value to a physician when that physician is a patient and not acting in his or her professional capacity.

Discounts including rebates.

In kind items for use in providing charity care.

A dividend or other profi t distribution from, or ownership or investment in, a publicly traded stock or mutual fund.

Transfer of value to a physician if the transfer is payment solely for the services of the physician with respect to a civil or criminal action or an administrative proceeding.

A transfer of anything with a value of less than $10 unless the aggregate amount transferred to, requested by, or designated on behalf of the physician exceeds $100 in the calendar year.

Tom Baker

(CONTINUED ON PAGE 13)

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Beyond Expectations

By LyNNE JETER

For many organizations, single sign-on (SSO) technology is simply a tool to increase effi ciency. But in the healthcare setting, it’s a difference-maker. Expedited access to pa-tients’ health records al-lows caregivers to make quicker decisions about treatment options and medications.

As disparate systems continue to be pervasive, with records in multiple environments, an SSO tool easily allows users access to all systems by using just one login credential. SSO simplifi es user interaction, and when done properly, may act as a catalyst to improve workfl ow and documentation.

“Virtually everything is digital and stored electronically,” said Dean Wiech, a national leader in IAM (identity and ac-cess management) healthcare technology. “The real issue becomes making sure the appropriate people have access appro-priate to their position or department in

hospitals. For example, role-based access control – when a user is granted position into the network and applications – allows staff to have the ability to see information appropriate to them. You don’t want a nurse in the maternity ward to have the ability to see what’s going on the respira-tory fl oor.”

Single sign-on security has been a grave concern of CIOs, noted Wiech.

“An employee could walk away from a monitor and leave a session open that anyone else could walk up and see,” he explained. “There are some great tools on the market to fi x the issue; single sign-on is just a part of it.”

Wiech, also managing director of Tools4ever, a supplier of software and integrated consultancy services involving IAM, pointed to one solution: an enter-prise-level SSO that uses badge readers and Follow Me, a tool particularly helpful for physicians making their rounds. “They log into a terminal server and the session goes up so they can go from machine to machine without waiting for any applica-tion to open,” he said. “It remains open through the terminal service environ-

ment.”Time options for inactive screens to

automatically close a session range from 30 seconds to 1 minute, confi gurable to the hospital’s requirements.

“Since information began convert-ing to electronic, the ability to view it has become more widespread,” he said. “You may have 10 to 15 nurses on a fl oor, and you run the risk of a digital fi le being ex-posed.”

In Orlando, for example, a low-level hospital clerk misused his newly discov-ered access to emergency room medical charts by routinely scanning them for au-tomobile accidents and pocketing money for every lead he gave a local attorney.

“For that reason, role-based access control is another tool that ties into single sign-on,” said Wiech. “If proper controls had been put in place during that employ-ee’s hire, he never would’ve had access to the system. You really need an application that takes a look at different types of data elements needed, and confi gure and main-tain that person’s access to the network, data and applications appropriately.”

Simplifying SystemsSecuring SSOs

Dean Wiech

well. You’re paid to provide certain ser-vices. And many things that need to be done aren’t strictly medical. There’s coordination with long term services and supports and so-cial issues and all sorts of things.”

For example, on a recent clinic day, Brummel-Smith spent an hour with the wife and daughter of a geriatric patient who was too demented to understand his condition.

“We wanted time to have an in-depth discussion about care planning,” he said. “I couldn’t bill for that because under Medi-care rules, you can only bill for the patient’s care if the patient is there. But we were doing deep patient care planning that was very emotionally diffi cult, and it’s going to lead not only to a very good outcome as he nears the end of his life, but also it’ll help save CMS a lot of money for unnecessary care he wouldn’t want in the fi rst place. There’s no way I could bill for that.”

The PACE Elderplace Program in Oregon, which Brummel-Smith led before relocating to Florida, used a global-capi-tated model he calls “the ultimate model for reimbursement.”

“If the capitation is fair – and that doesn’t mean exorbitant or skimpy – then you can appropriately care for the pa-tients, and let the geriatric team and the patient decide the right treatment rather than having insurance companies make the decisions,” he said. “We were free from all billing constraints, and we knew we had a certain amount of money to care for all our participants. We had quality measures to meet – some were patient-generated – so we were doing things they wanted, not just what we thought was good for them. It really was the perfect way to practice

medicine.”Overall, there’s an upside to the gap

of supply and demand of geriatricians. Even though geriatrics is labeled for pa-tients over the age of 65, most seniors up to age 74 are relatively healthy and don’t need a geriatrician, Brummel-Smith said.

“The perfect patients for a geriatri-cian are those above age 75, and especially those with multiple chronic conditions and long-term care needs, such as dementia, and the kinds of problems that are very dif-

fi cult for internists and family physicians to take care of in a standard 15-minute visit,” he said, pointing out the American Geri-atric Society considers the specialty both a primary care and consultation model.

“We manage primary care for that population of complex and frail elders, and consultations to other physicians for the ‘younger’ old people,” he explained, “and for older people who are generally receiving good care from their primary care provider.”

Making Geriatrics a Primary, continued from page 4

Even though projections of future spending appear fl at for Medicare, they refl ect a steep increase in private sec-tor healthcare costs that would lead to consumers and employers facing direct healthcare costs equal to 12 percent of the nation’s domestic product by 2020.

“So far, the private sector has been unwilling or unable to implement the same payment reforms as the government,” said Roth. “If this doesn’t change, it will likely lead to the private sector bearing an in-creasingly heavy cost burden.”

Finding creative ways to pool their purchasing power and differentiating those providers striving to reengineer care from those comfortable with status quo will remain the greatest challenge for em-ployers, health plans and other providers of private sector health coverage.

“Healthcare purchasers have long asked providers to improve value,” said Roth. “Now that those calls are beginning to be heard, purchasers must be ready with a response.”

The Advent of Pay-for-Value, continued from page 6

To receive a Medicare bonus payment from the Hospital Value-Based Performance (VBP) program, hospitals only needed to post a total minimum score of 54.7, slightly below the national average.

In St. Louis, the average total performance score for hospitals was 58.79 (.8 percent bonus), slightly above the national average. As a result, 16 local hospitals will receive a payment increase this year under VBP. Likewise, 11 local hospitals will see their payments reduced.

12 > AUGUST 2013

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By CINDy SANDERS

The American Academy of Orthopaedic Surgeons (AAOS) recently released a re-vised clinical practice guideline for treatment of osteoarthritis of the knee with key changes to recommendations regarding the dosage of acetaminophen and use of intra-articular hyal-uronic acid (HA).

David S. Jevsevar, MD, MBA, chair of the AAOS Evi-dence Based Quality & Value Committee and chair of the workgroup for OA of the knee, said the 2013 edition of the clinical practice guide-line (CPG) contains 15 recommendations and replaces the first edition of the CPG, which had elicited some concern over the methodology employed in garnering some of the evidence … specifically that attached to the use of HA.

Jevsevar, a board-certified orthopedic surgeon at Intermountain Zion Ortho-pedics & Sports Medicine in St. George, Utah, said it is the policy of the AAOS to do all CPG data analysis in-house. How-ever, the earlier guideline utilized synthe-sized data from three outside sources — the

Agency for Healthcare Research and Qual-ity, Osteoarthritis Research Society, and Cochrane Database of Systematic Reviews.

Both those who sell and manufacture HA, as well as a number of AAOS mem-bers, were specifically concerned about the issue of viscosupplementation, which gar-nered an ‘inconclusive’ recommendation in the first issue. Jevsevar said the committee was clear that a more vigorous internal re-view of the use of intra-articular hyaluronic acid could result in the same outcome, a stronger recommendation backing the use of HA … or a reversal recommending phy-sicians not use the treatment option. “When

we actually did the analysis, that’s what happened,” he said of the reversal, which resulted in a ‘can-not recommend’ designation for the use of HA for patients with symptomatic OA of the knee.

“When you use clinical sig-nificance as your bar for recom-mendation — and we took the 14 best studies out there — it really doesn’t support the use of visco-supplementation, or HA,” he said. “Although a few individual stud-ies found statistically significant treatment effects, when combined together in a meta-analysis, the

evidence did not meet the minimum clini-cally important improvement thresholds.”

Jevsevar went on to explain there is a difference in statistical significance and clinical significance. He noted that on the clinical pain analysis where 0 is no pain and 10 is the worst pain, having patients move from a 9 to an 8.8 after treatment could be considered statistically significant but wouldn’t feel much different to the person with OA. “We use the higher bar of clinical significance,” he continued. ”We feel that’s the one most important to patients.”

Perhaps not surprisingly, the strong recommendation against the use of HA has created some pushback from physicians. “They feel like we have very few treatments for osteoarthritis that work so they are always concerned when we take one away,” he said. However, Jevsevar continued, “Doing something that is expensive and hasn’t been proven isn’t the right thing either.”

He said it’s hard to gauge the true effectiveness of various treatments in the clinical setting for a couple of reasons. “Ar-thritis research is hard because osteoarthri-tis patients don’t have the same level of pain everyday,” he explained. “Many of those patients want to do anything but surgery, which is understandable,” Jevsevar contin-ued. “They want the treatment to work, but that creates a placebo effect or bias for whatever is being used.” More research, he added, is certainly needed.

One concern for physicians using HA is that insurance companies will quit reim-bursing for the treatment. “We synthesize the evidence, but we don’t make recom-mendations for insurance,” Jevsevar said. However, he admitted insurance compa-nies could misapply the guidelines for finan-cial purposes. Still, he noted, discontinuing reimbursement for viscosupplementation might not be to a payer’s benefit since it could drive more OA patients to opt for the much more expensive knee implant.

Furthermore, Jevsevar said treatment decisions should replicate the foundation of a three-legged stool — 1) the evidence, 2) physi-cian expertise and experience, and 3) patient preferences and values. “You have to take all three into account when treating a patient. One doesn’t trump the other,” he said.

In addition to the controversial HA ‘no’ recommendation, the work group also

reduced the recommended dosage of acet-aminophen from 4,000 mg to 3,000 mg a day, which mirrors an overall change made by the Food and Drug Administration for individuals using acetaminophen for any purpose. In patients with symptomatic OA of the knee, Jevsevar said, “Actually, there’s not a lot of evidence to support the use of acetaminophen.”

Other important recommendations that remained the same in the revised guidelines included:

• Patients who only display symptoms of OA and no other problems, such as loose bodies or meniscus tears, should not be treated with arthroscopic lavage.

• Patients with a body mass index (BMI) greater than 25 should lose a mini-mum of five percent of their body weight.

Jevsevar noted telling patients to lose weight and get active are “tough discus-sions” to have but important ones. Low im-pact exercises including swimming, walking and using an elliptical machine have been proven effective to slow the progression of OA of the knee.

The work group strongly recom-mended against the use of glucosamine and/or chondroitin sulfate or hydrochlo-ride and against the use of acupuncture. A “strong” strength of recommendation means the quality of the supporting evi-dence was high with an implication that practitioners should follow strong recom-mendations unless a clear and compelling rationale for an alternative approach exists. Jevsevar added the ‘no’ recommendations were based on a lack of efficacy rather than a potential for harm. The group also had a moderate recommendation against custom lateral wedge insoles. A moderate recom-mendation also is compelling, but the qual-ity or applicability of the existing evidence is not as strong.

Due to a lack of research, the CPG was unable to recommend for or against the use of physical agents including electrothera-peutic modalities, manual therapy, bracing, growth factor injections and/or platelet rich plasma.

In the second edition, all included stud-ies had to have a sample size of at least 30 participants and a follow-up period of at least four weeks. More than 10,000 separate pieces of literature were reviewed during the evidence analysis phase. When com-pleted, Jevsevar said the updated OA knee CPG was subjected to the most extensive peer review to date for any AAOS CPG. Ultimately, 16 peer reviewers representing multiple specialty societies submitted for-mal reviews. “Each meticulously dissected the final recommendations of the document and, based on their well-informed and in-sightful comments, important changes were made to the final document,” Jevsevar said in an AAOS editorial.

For more information on the second edition OA knee CPG, go online to: www.aaos.org/research/guidelines/GuidelineOAKnee.asp

AAOS Updates Clinical Practice Guidelines for Osteoarthritis of the Knee

GrandRoundsMercy Helps Companies Rein in Health Care Costs

When sore throats, ear infections, al-lergies and other health issues linger, it can cause wreak havoc on work sched-ules and productivity problems with peo-ple who can’t concentrate or take time off work to see a doctor.

Now a convenient option is available for Maritz employees and their families at the company’s St. Louis headquarters. On Aug. 1, Mercy opened Mercy Clinic at Work, a full-functioning, physician-staffed health care clinic on the Maritz campus with access to electronic medical records at any Mercy location.

The Maritz location is open part-time with two physicians, Dr. Shane Ste-phenson of Mercy Clinic Family Medicine at Clayton-Clarkson and Dr. Christian Sutter of Mercy Clinic Family Medicine at Ronnie’s Plaza. They can assess patients, prescribe medication and provide all other services available in a Mercy Clinic primary care office.

Mercy can tailor the program to fit employers’ specific needs. Clinical posi-tions can be covered by registered nurs-es, nurse practitioners in a collaborative agreement with nearby physicians or on-site physicians – depending on the size and needs of the employer.

In late September, Missouri Baptist University opened a Mercy Clinic at Work site to provide a convenient healthcare resource for its 1,200 student population, with 345 who live on campus and 700 stu-dent athletes. In addition, a registered nurse is also onsite to answer questions and provide screenings for front-office employees with the St. Louis Cardinals and St. Louis Rams organizations.

Christian Hospital stroke care earns prestigious Gold Plus Award!

Christian Hospital has again this year received the American Heart Associa-tion/American Stroke Association’s Get With The Guidelines®–Stroke Gold Plus Achievement Award! The award recog-nizes Christian Hospital’s commitment and success in implementing a higher standard of stroke care by ensuring that stroke patients receive treatment accord-ing to nationally accepted standards and recommendations. Christian Hospital was recognized at the silver level in 2011 and at the bronze level in 2010. Chris-tian Hospital achieved a two-year Joint Commission re-certification as a Primary Stroke Center in August 2012.

To receive this recognition, Chris-tian Hospital has achieved 85 percent or higher adherence to all Get With The Guidelines–Stroke indicators for consec-utive 12-month intervals and 75 percent or higher compliance with four of nine quality measures to improve the quality of patient care and outcomes. These in-clude aggressive use of medications like tPA, antithrombotics, anticoagulation therapy, DVT prophylaxis, cholesterol-reducing drugs and smoking cessation. The 90-day evaluation period is the first

By CINDy SANDERS

How will this breast cancer drug react in patients that are HER2 positive? Will this new lung cancer therapy work in a patient with multiple genetic variations?

Finding answers to those questions just got a bit easier with the rollout of a vast data set of cancer-specific genetic variations by scientists at the National Cancer Institute (NCI). Yves Pommier, MD, PhD, chief of the Lab-oratory of Molecular Pharmacology at the NCI, was one of three lead researchers on the study, published July 15 in Cancer Research, that pinpointed more than six billion connections between cell lines with mutations in specific genes and the drugs that target those genetic defects. Paul Meltzer, MD, PhD, chief of the Genetics Branch at the Center for Cancer Research and James Doroshow, MD, director of the Division of Cancer Treatment and Diag-nosis, were the other principal investiga-tors.

Pommier explained the new data-base builds upon the NCI-60 cancer cell line collection, which is comprised of nine different tissues of origin – breast, ovary, prostate, colon, lung, kidney, brain, leu-kemia and melanoma. In their Cancer Research article, the authors note the NIC-60 panel is the most frequently studied human tumor cell line in cancer research and has generated the most ex-tensive cancer pharmacology database worldwide.

“Most of the cell lines are from can-cer tissues that are hard to treat and are usually resistant to therapy,” he said. “The genomic database is unmatched and enables researchers to mine all the gene expression in relationship to a drug.”

Pommier continued, “Each drug has a dif-ferent profile in the cell line because they act on different targets.”

In this most recent study, the investi-gators sequenced the whole exome of the full NCI-60 cell lines to define novel can-cer variants and deviant patterns of gene expression in tumor cells. “The whole ge-nome for the cell line has never been done before,” he said. “Many, many genes had never been sequenced.”

The researchers cataloged the genetic coding variations, developing a list of pos-sible cancer-specific gene aberrations. The group then used the Super Learner algo-rithm to predict the sensitivity of cells with variants to more than 200 anti-cancer drugs … those approved by the FDA and those still under investigation. By study-ing the correlation between the gene vari-ants – such as TP53, BRAF, ERBBs, and ATAD5 – and anti-cancer agents includ-ing vemurafenib, nutlin and bleomycin, the researchers were able to predict out-comes, showing one of the many ways the data could be used to validate and gener-ate novel hypotheses for future investiga-tion.

Access to the data is freely available through multiple sources including the CellMiner and Ingenuity websites. By opening up the scalable data on the whole genome sequencing and drug connectivity,

Pommier and his colleagues hope to help other researchers connect cancer-specific gene variants with drug response to move the science forward. “It’s an evolving system,” he said, adding that profiles on drugs in clinical trials will be added to the database as information becomes avail-able to keep the data set current.

In explaining how the system works, Pommier said a researcher interested in a specific agent could plug that drug into the database. “You’ll get the profile activity of the drug, and then you can ask if there is any match to any specific gene muta-tions,” he said. From there, Pommier con-tinued, the researcher could query, “Are these cells more resistant or receptive to the drug?”

Getting those answers rapidly should help researchers move major lines of on-cology drug development toward per-sonalized medicine to achieve optimal outcomes in a safer, more efficient and effective manner. With the added knowl-edge provided by the data bank, Pommier said researchers might separate patients into groups based on their genetic profile and therefore be able to use specific drugs in a more rational manner.

“Between a targeted drug and a clini-cal application, you need a verification in the middle,” he stated. That’s just what this new database offers.

New Lines of ResearchNCI Data Set Opens Access to Cancer-Related Genetic Variations

Dr. Yves Pommier

Baker pointed out you might not think you received an influential ‘gift’ from a de-vice manufacturer by grabbing a bite of lunch, but even a sandwich, tea, tip and tax is often over the $10 threshold. Short of asking to see the bill, it would be difficult to gauge the cost per person at the table; and without a copy of the receipt, it would be difficult to dispute the reported item.

“As a practical rule, doctors probably aren’t going to be good at refuting the evi-dence,” Baker said.

However, he added, CMS has cre-ated a smartphone app with a version for industry and another for physicians to make it easier to keep track of reportable transfers. “Open Payments Mobile” is available at no charge through the Apple Store and Google Play Store.

TimelineData accumulation for 2013 has al-

ready begun. Below is a timeline of up-coming key dates in the process. • Jan. 1, 2014: Anticipated launch date for CMS physician portal where doc-tors can register to receive notice when their individual consolidated report is ready for review. This portal also provides a means for physicians to contact manu-facturers and GPOs about disputes in ac-curacy. • March 31, 2014: Partial year data

(August-December 2013) must be turned into CMS. • June 2014: Anticipated access to in-dividual consolidated reports from 2013. Physicians have a minimum of 45 days by law to seek corrections or modifications to the information by contacting manufac-turers/GPOs through the portal.September 2014: Searchable reports are published and open to the public.

Be Prepared“The act itself is vexing,” said Baker.

Adding to the frustrations, he continued, is that CMS is interpreting the Sunshine Act very broadly.

“The applicable manufacturers are not going to take any chances,” Baker continued. He noted, those who acciden-tally fail to disclose required data will face penalties of not less than $1,000 and not greater than $10,000 per incident up to a cap of $150,000 annually. Those who knowingly withhold reportable informa-tion face penalties between $10,000 and $100,000 for each value transfer with an annual cap of $1 million.

“Physicians need to know other peo-ple are going to be talking about them,” concluded Baker. “One would hope everything reported is within the legal boundaries … but if you are testing those boundaries, you better stop.”

Shining a Light on Physician,

continued from page 10

LUNG CANCER IS THE DEADLIEST CANCER IN THE

WORLD.

WE CAN CHANGE THAT.

The American Lung Association is leading the fight against the deadliest cancer there is—lung cancer.

Join the fight by giving a gift to the American Lung Association today.

314-645-5505 x1009 | 1-800-LUNG-USA www.breathehealthy.org

1118 Hampton Ave., St. Louis, MO 63139

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GrandRoundsSSM Medical Group adds adult primary care physician in Webster Groves

Ellen Loeffler, MD, board certified family medicine, recently joined Drs. Mi-chael Bartell, Kyra Cass, Edwin “Scott” Schmidt, and Paul Schneider at 8670 Big Bend Boulevard in Webster Groves.

Dr. Loeffler has been in private practice since 2008. She graduated summa cum laude from the University of Missouri – Columbia with her bach-elor of science degree. She earned her medical degree and completed her residency at Saint Louis University School of Medicine.

Dr. Loeffler provides health care to adolescents and adults, ages 13 and up. Her health care services includes, but are not limited to: women’s health, in-cluding well-women exams; preventive care and check-ups, including physicals; identification and management of acute problems and chronic diseases.

Like all SSM Medical Group physi-cians, Dr. Loeffler offers MyChart® to her patients. MyChart is available online or as an app on mobile devices and pro-vides convenient, secure, access to one’s personal health record 24/7.

Washington University Orthopedics launches walk-in injury clinic

Because the injuries of joggers, cy-clists, high school athletes and weekend warriors often occur outside of business hours, Washington University Orthope-dics is opening a walk-in clinic for those with injuries that might require an X-ray, cast or splint.

The clinic will be run by physicians and other health-care practitioners with expertise in orthopedics. Casting, splint-ing and radiology services will be avail-

able onsite.The new Orthopedic Injury Clinic

opened Sept. 3 and is located at the Washington University and Barnes-Jew-ish Orthopedic Center in Chesterfield.

Cardiac electrophysiologist joins SSM Heart Institute

Ayo M. Bamimore, MD, a cardiac electrophysiologist, has joined SSM Heart Institute. He spe-cializes in the diagnosis and treatment of abnor-mal heart rhythms. He performs both catheter-based interventional and device-based surgical procedures to treat cardi-ac arrhythmia, including ablation of atrial fibrillation and other complex cardiac arrhythmias, cardiac resynchronization therapy and implantation of pacemakers and defibrillators.

Dr. Bamimore attended medical school at Obafemi Awolowo University Ile-Ife in Osun State, Nigeria. He com-pleted a residency in internal medicine as well as cardiac and electrophysiology fellowship training at The State Universi-ty of New York Downstate Medical Cen-ter in Brooklyn. He continued his training with a fellowship in clinical cardiac elec-trophysiology at the University of North Carolina in Chapel Hill.

Dr. Bamimore is able to follow many of his patients with implantable devices remotely. Information from the devices is downloaded from the patient’s home to Dr. Bamimore’s office for evaluation. In many cases, this may result in adjust-ments to treatment prior to the next scheduled office visit, possibly reducing unnecessary hospital admissions.

Dr. Bamimore is board certified in cardiovascular diseases, nuclear cardi-ology, adult echocardiography and in-ternal medicine. He is a member of the American College of Cardiology and the

Heart Rhythm Society.He has joined the staffs of SSM St.

Joseph Health Center in St. Charles, SSM DePaul Health Center in Bridgeton and SSM St. Joseph Hospital West in Lake Saint Louis.

Program at Saint Louis University Hospital, SLU Provides Sports Medicine Care for St. Louis Catholic Schools

Saint Louis University and Saint Lou-is University Hospital have engaged in a three-year pilot program with the Archdi-ocese of St. Louis, St. Mary’s High School and Bishop DuBourg High School to provide on-site sports medicine care for their student athletes, offering athletic training services at games and practices. The pilot program is provided to the schools as a community service at no cost to them.

Such partnerships are rare in area high school athletics. Should the col-laboration succeed in improving the care of injured student athletes, the goal is to expand the pilot program to other areas in the St. Louis region.

To launch the program, Bridget Quirk, MAT, was hired by Saint Louis University Hospital to provide on-site training and education at the two schools. A recent graduate of Doisy College’s athletic train-ing program at SLU, she will be work-ing with student athletes in all the high schools’ sports ranging from boys’ football and soccer to girls’ softball and volleyball.

For more severe injuries, SLUCare orthopaedic surgeons and sports medi-cine physicians Scott Kaar, MD, and Ad-nan Cutuk, MD, will be available through the partnership to offer their expertise with accelerated access to care in their orthopaedic sports medicine clinics. Drs. Kaar and Cutuk will also be on the sidelines for Bishop DuBourg and St. Mary’s home football games.

Dr. Ellen Loeffler

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