C M S Bulletin2019/07/17 · write a book, find an agent and publish it; or courses that help your career as a medical writer, expert witness, or other medical expert. 2. The Coursera

Allegheny County MediCAl SoCiety

BulletinJAnuAry 2017

Opinion: E-cigarettes are dangerous, too

2017 ACMS presidentand officers

Act 146 limits retroactive denials

hh-law.com

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

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

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

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

BulletinJAnuAry 2017 / Vol. 107 No. 1


ArticlesOpinion Departments

Feature .................................. 242017 ACMS president and officers

Materia Medica ...................... 28A new roadmap for chronic pain – implications for practiceAaron W. Stewart Karen M. Fancher, PharmD, BCOP

Legal Report ......................... 32‘Clawbacks’ declawed: Act 146 limits retroactive denialsWilliam H. Maruca, Esq.

Materia Medica ...................... 34Anoro (umeclidinium/vilanterol)Sydney Springer, PharmD Gregory Trietley, PharmD, BCPS

Special Report ...................... 36JHF’s Jonas Salk Fellows redesign the health systemJewish Healthcare Foundation

Special Report ...................... 38Survival of physicians in a value-based worldDennis Olmstead, MPA

Editorial ................................... 6New Year’s resolutionsDeval (Reshma) Paranjpe, MD, FACS

Editorial ................................... 8‘Mr. Tambourine Man’Robert H. Howland, MD

Perspective ........................... 10The medical record of the future: Part IIBruce L. Wilder, MD, MPH, JD

Perspective ........................... 14E-cigarettes are dangerous, too:The surgeon general’s latest report should spur state and local actionKaren Hacker, MD, MPHLawrence R. John, MD

Society News ........................ 16• Pittsburgh Ophthalmology Society• Pennsylvania Geriatrics Society – Western Division• ACMS Foundation awards medical student scholarship

In Memoriam ......................... 20• Robert Link Wittig, MD• James G. Pitcavage, MD, FAAP • John F. Delaney, MD, PhD, MPH

ACMS Alliance News ........... 22

Classifieds ............................ 39

On the coverMt. EverestAndrew G. Vayonis, MD

Dr. Vayonis specializes in allergy and immunology and was the first-place winner of the 2016 ACMS Bulletin Photo Contest.

hh-law.com

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

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

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

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

ACMS ALLIANCEPresident

Kathleen ReshmiFirst Vice President

Patty BarnettSecond Vice President

Joyce Orr Recording Secretary

Justina Purpura Corresponding Secretary

Doris DelseroneTreasurer

Josephine MartinezAssistant Treasurer

Sandra Da Costa

2017 Executive Committee

and Board of Directors

PresidentDavid J. DeitrickPresident-electRobert C. CiccoVice President

Adele L. TowersSecretary

William K. JohnjulioTreasurer

Patricia L. BononiBoard Chair

Lawrence R. John

DIRECTORS 2017

Peter G. EllisTodd M. HertzbergBarbara A. KevishDavid A. LoganJan W. Madison

Matthew B. StrakaAngela M. Stupi

2018David L. Blinn

William F. Coppula Kevin O. Garrett

Raymond E. Pontzer John P. Williams

2019Thomas P. Campbell Michael B. Gaffney

Keith T. Kanel Jason L. Lamb

Maria J. Sunseri

PEER REVIEW BOARD2017

Donald B. MiddletonRalph Schmeltz

2018 Sharon L. Goldstein Bruce A. MacLeod

2019Robert W. Bragdon

John A. Straka

PAMED DISTRICT TRUSTEEAmelia A. Paré

COMMITTEESAwards

Donald B. MiddletonBylaws

Robert C. CiccoFinance

David J. DeitrickGala

Patricia L. BononiAdele L. Towers

Nominating Matthew B. Straka

Primary CareLawrence R. John

COPYRIGHT 2017:ALLEGHENY COUNTY MEDICAL SOCIETYPOSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 713 Ridge Avenue, Pittsburgh, PA 15212.

ADMINISTRATIVE STAFFExecutive Director

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([email protected])Bookkeeper

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Director of PublicationsMeagan K. Sable

([email protected])Assistant Executive Director, Director of Member Relations

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Membership Relations ManagerNadine M. Popovich

([email protected])

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

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

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

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

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

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ISSN: 0098-3772Leadership and Advocacy for Patients and Physicians

Affiliated with Pennsylvania Medical Society and American Medical Association

www.acms.org

Bulletin Medical Editor

Deval (Reshma) Paranjpe([email protected])

Associate EditorsCharles Horton

([email protected])Robert H. Howland

([email protected]) John Kokales

[email protected] Miller

([email protected])Amelia A. Paré

([email protected])Gregory B. Patrick

([email protected])Joseph C. Paviglianiti

([email protected])Brahma N. Sharma

([email protected])

Managing EditorMeagan K. Sable

([email protected])

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New Year’s resolutionsDeval (Reshma) PaRanjPe, mD, FaCsMedical editor

Editorial

In January, the energy of the world is fresh and renewed; January feels like

a strange new beginning after the cra-ziness of the previous year’s holidays. You slow down despite yourself, and appreciate the sudden and curious qui-et in the world: the quiet of the snow, of the cold, of the barely perceptible lengthening of the days. What is there to do but think and take stock and plan? This is the perfect time.

Here are some resolutions to inspire you to craft resolutions of your own, as well as some practical suggestions to help you succeed.

Physician, heal thyself. We tell our patients to lose weight and exercise, yet when we return home tired from the workday, we often fail to heed our own advice. Resolve to change that, and become a role model for your patients. If I can do it, so can you. Better yet, let the overachiever patients in your practice become role models for you. If they can do it, so can I.

Things that can help:1. A Fitbit or other activity tracker.

Even a simple pedometer is useful. Turn your fitness goals into a game – we’re all kids inside. A little reward can go a long way.

2. Precision Nutrition. You can find this online – you can register twice a year for this year-long journey into de-

veloping nutrition and exercise habits in incremental baby steps. This comes with a lot of support – online support groups via Facebook, group meet-ings via Skype and a personal coach who will check in on you via email, phone, text and platform, as well as a suggested at-home exercise program tailored to your individual situation and needs. A gentle, easy and sustainable approach to changing habits, and only about $190/month.

3. There’s an app for that. Nutrition tracking apps like MyNetDiary will help you see what you are actually consum-ing; once you realize what you are put-ting into your body, the goals become easier to reach. General fitness apps like MyFitnessPal and LoseIt also help you keep track of nutrition and exercise by setting, reaching and maintaining goals.

Learn something new. We all went to medical school because we had intellectual curiosity; too often, that spark is deadened by the mundane and continuous requirements of work. Put some fun and joy back into your life by learning for fun. Also, if you can’t justify it any other way, realize that diversifying your talents makes you more valuable and less likely to be held hostage by your career, and more able to walk away from it all if you ever have

to. Even if you never make that deci-sion, having the psychological benefit from knowing that you could can be a tremendous gift to yourself.

Things that can help:1. Alternate career courses for

physicians. Courses that can help you write a book, find an agent and publish it; or courses that help your career as a medical writer, expert witness, or other medical expert.

2. The Coursera app, or Khan Academy online. Features practical and valuable college courses taught by college professors from reputable uni-versities in all subjects, free of charge. Never took Economics? Wish you had? Here’s your chance.

3. Great Courses. Video college-lev-el courses on practically every subject from Ancient History to Economics to Wine Appreciation to Public Speaking and Self-Improvement, all taught by experts in the fields. There is a sub-scription fee, but those who take these courses swear by them.

4. Duolingo. A language learning app that you can download on your phone and use to learn and practice a number of new languages. The cool-er, hipper Rosetta Stone for the new millennium.

5. Pocket. An app that lets you save newspaper articles that you see online

but would like to save and read in depth later.Be mindful, be present and be grateful. As many

challenges as we face in this profession, remember we are among the luckiest people on earth. Perhaps not materially as in years past, and perhaps we are put upon more than we have ever been. However, we have the honor to help others in a meaningful way as part of our daily work, even when it seems like we’re only robots typing into the EHR. Others often have to make special efforts to do “good works” – our profession is among those which do good works all the time – and the extra good works we may do outside of work are a bonus. Our ethics are black and white. We’ve been through highs and lows in our training, and we’ve seen things and experi-enced emotional changes and truths that others we meet have not, and will never know. As a consequence, should we choose to realize it, we are privy to a sort of peace that most others will never have.

Medicine internship taught me this: The only things that really matter in life are who stands by you through illness and suffering, who holds your hand and mops your brow as you lie dying, and whether you can look back in those final hours and know that you have been truly loved. If you have any of these at the end, you have won at life. Nothing else matters. The rest – mon-ey, fame, power, possessions, beauty, social status, claiming intellectual or moral superiority, everything – is all useless window dressing. How fortunate we are to know, albeit through hard-won experience, truths like these during our lifetime rather than at the end of it. And how fortunate we are to be able to use this knowledge to focus on love and building our relationships with our loved ones!

Wishing you and your families a happy, healthy, love-filled New Year.

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

7ACMS Bulletin / January 2017

Editorial AlleghenyMedcare

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Michael L. Gomber, MBAMore than 30 years meeting physicians’ needs 412.580.7900 Fax: 724.223.0959E-mail: [email protected]

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Michael L. Gomber, MBAMore than 30 years meeting physicians’ needs 412.580.7900 Fax: 724.223.0959E-mail: [email protected]

Allegheny MedcareHenry Schein, a Fortune 500 Company

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ALLEGHENYCOUNTYMEDICALSOCIETY

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Allegheny Medicare is endorsedby the Allegheny County MedicalSociety—the only medical supplycompany that is!

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

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8 www.acms.org

‘Mr. Tambourine Man’RobeRt h. howlanD, mDassociate editor

Drug overdose is the leading cause of injury death in the United States.

According to United States data from the Centers for Disease Control and Prevention (CDC), overdose deaths involving benzodiazepine drugs rose from 0.58 per 100,000 adults in 1999 to 3.07 in 2013. These data do not specify the extent to which these fatalities may have been associated with the con-current use of alcohol or other drugs. Alcohol use is common and does not require a prescription. Prescription Be-havior Surveillance System data from eight states in 2013 found that benzo-diazepine drugs are prescribed only about half as often as opioid drugs.

Since 1999, opioid drug prescrip-tions have increased markedly and opi-oid overdose deaths have quadrupled. During 2015, drug overdoses account-ed for 52,404 U.S. deaths, including 33,091 (63.1 percent) that involved an opioid drug. Rates of deaths involv-ing heroin and synthetic opioid drugs other than methadone have increased overall. Three studies of fatal opioid overdose deaths have found evidence of concurrent benzodiazepine drug use in 31 to 61 percent of these deaths.

Based on these data, the FDA now requires boxed warnings and patient-focused Medication Guides for prescription opioid analgesic drugs,

opioid-containing cough products and benzodiazepine drugs, describing the serious risks associated with using these medications concurrently.

Beyond opioid and benzodiazepine drugs, the concurrent use of multiple medications from all drug classes is associated with an increased risk of various bodily and central nervous system adverse effects, drug-drug interactions, morbidity and mortality. Falls are the leading cause of fatal and nonfatal injuries among older adults in the United States, and medications are commonly implicated. Medication use therefore is a potentially modifiable risk factor for falls and other serious adverse consequences. If so, what can be done to help our patients and yet minimize or even avoid the use of medication?

Francois Henri LaLanne, better known as “Jack,” was known as the Godfather of Fitness. In 1936, he opened Jack LaLanne’s Physical Culture Studio in Oakland, Calif., which was the nation’s first health and fitness club. At the time of his death at age 96, his 2011 obituary in the New York Times quoted LaLanne as having said, “People thought I was a charlatan and a nut. The doctors were against me – they said that working out with weights would give people heart attacks and

they would lose their sex drive.” The Godfather of Fitness built two gyms and a pool at his home in California, and he apparently began each day with two hours of workouts: weight lifting fol-lowed by swimming. LaLanne followed this routine into his 90s.

Exercise has such profound phar-macological and physiological effects throughout the body that it should be considered a drug therapy. Various forms of exercise have documented benefits for preventing or treating many medical conditions or their sequelae, in-cluding cardiovascular and cerebrovas-cular disease, the metabolic syndrome and diabetes, Parkinson’s disease and other neurological conditions, chronic fatigue syndrome and cancer. Studies also have found that exercise can decrease pain and improve function in patients with osteoarthritis, neck and back pain, fibromyalgia and migraine headache. In psychiatry, exercise benefits have been demonstrated for the treatment of addictions, attention deficit disorder, depression and anxiety

Editorial

Within reasonable limits and precautions, the exercise drug should be prescribed for all patients.


disorders. Exercise is associated with improvements in psychological well-be-ing, sleep quality, energy and sexual function. Exercise enhances memory and cognitive function, decreases the risk of dementia, and slows the rate of cognitive decline associated with normal aging or dementia. Based on its known physiological effects, exer-cise has a potential role in addressing adverse effects that are associated with many drug therapies, including insomnia, sedation, sexual dysfunction, cognitive impairment, weight gain and metabolic effects.

Exercise has been described as a miracle drug, but unfortunately this is not the case. An inherent limitation is that exercise takes time and effort and does not come in a pill. The predispo-sition to engage in voluntary exercise is complex, involving personal, envi-ronmental and even genetic factors. The benefits that have been ascribed

to exercise also are not absolute. Not all individuals will benefit from exercise to the same extent. Individual physical limitations may preclude some patients from engaging in certain forms of ex-ercise, but the broad array of aerobic, resistance, or stretching exercises that are potentially available may permit some type of physical activity for nearly everyone.

The song “Mr. Tambourine Man,” written by the Nobel Laureate Bob Dylan and recorded by him for com-mercial release in 1965, has been interpreted by many people as allud-ing to the effect of drugs and that Mr. Tambourine Man is a coded reference to a drug dealer, although Dylan has denied these interpretations. Physi-cians who are well-intentioned, care-less, negligent, or frankly unsavory have been blamed for the opioid drug crisis. Many people liken doctors to pill pushers or drug dealers. If exercise

were a drug and were evaluated by the FDA, it might very well be approved for many therapeutic indications. Using the public health concepts of primary, sec-ondary and tertiary disease prevention, exercise could be appropriately pre-scribed for virtually anyone to prevent or manage many mental and physical disorders. Within reasonable limits and precautions, the exercise drug should be prescribed for all patients. Physi-cians should strive to identify exercises that are amenable for each patient they treat.

Dr. Howland is a psychiatrist and associate editor of the ACMS Bulletin. He can be reached at [email protected].

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

necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

Editorial

A W A R D S G A L A

Celebration ofE X C E L L E N C E

Join us for a

MARCH 4, 2017HEINZ FIELD EAST CLUB6:00 PM

by February 22Rsvpwww.acmsgala.org

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10 www.acms.org

The medical record of the future: Part II

bRuCe l. wilDeR, mD, mPh, jD

PerspectivePerspectivePerspective

In 1995, when the electronic health record (EHR1) was a relatively novel

concept,2 and a tool not widely adopted in medical practices and health care institutions, I wrote an article entitled, “The Medical Record of the Future.”3

At the time, I was mostly con-cerned about how we could maintain the privacy for patients and protect physician-patient communications. In other words, the discussion was mostly about preventing unauthorized access to the EHR as related to issues pecu-liar to electronically stored information (ESI), in addition to the concerns we already had about paper records. The Health Insurance Portability and Accountability Act (HIPAA) followed in 1996. I also expressed concerns about the tendency toward acquiring massive amounts of information and verbiage without paying enough attention to how necessary information could be retrieved in an efficient way.

It is important to point out now that we were still wedded to the paradigm of the EHR being essentially a souped-up version of the paper chart.

Since 1995, and especially since Executive Order 13335 in 2004, that aimed to have universal use of the EHR by 2014, the need for a new paradigm has become obvious. Just as the cellphone since that time has

become a computer that happens to be able to make phone calls, the EHR has evolved into a system that is becoming integral and indispensable to meet-ing acceptable standards of delivery of medical care, and, unfortunately, contains an embedded tool for admin-istration of payment for health care services.

When “meaningful use” was includ-ed in legislation4 designed to juice the widespread implementation of the EHR as a requirement to obtain funding for implementation, and later to avoid penalties for no implementation, it sounded innocent enough. But the reg-ulatory process then seemed to take on a life of its own, and we all know the rest of the story. The “meaningful use” regimen has essentially shifted to providers the burden of structuring data for the benefit of payers, without regard for the cost in terms of physician labor that takes away from the application of clinical skills directed at patient care. A recent study has attempted to quantitate this cost and its contribution to physician burnout.5 A more sensible approach, and one I believe we will eventually reach, given the appropriate innovative environment, is that data entries into the EHR will be driven only by patient care needs, structuring of data for administrative purposes will be

automated and the burden of structur-ing data to fit a particular format will be placed upon those who desire it. As recently put, “How about returning the record to the exclusive role of being a virtual clinical document that assists the health care team with the care of the patient?”6

While issues of how “meaningful use” requirements impede the efficien-cy and possibly the safety of medical care because of the distractions they may present, there are several other concerns facing physicians in the future, as outlined in a recent commu-nication from the Pennsylvania Medical Society (PAMED).7 In addition, we continue to struggle with issues related to medical professional negligence, maintenance of certification (MOC) and patient safety. Not in any way meaning to ignore the importance of those issues, I present here a broader view of the future of medicine and the challenges physicians face in the coming years. In other words, much of the future of medical practice is bound up with the future of the EHR as it has evolved and will continue to evolve, not just as a “record,” but as a tool that is integral to the delivery of health care, the formulation of health policy, the ongoing evaluation of physician competence8 and the administration of


public health measures.The security of health information

technology (HIT) continues to be prob-lematic, and an adequate solution will require radical changes to the funda-mental architecture of the EHR. We continue to struggle with maintaining the security of personal health informa-tion (PHI), and particularly electronic PHI (ePHI), as well as other personal information collected and stored in connection with delivery of health care. Breaches occur with regularity, and the increasing sophistication of hack-ing technology signals that concerns about protecting individual privacy will continue. The need for interoperability is closely intertwined, in that, under our current paradigm of EHR architecture, more interoperability means increased risk of security vulnerabilities. Another growing concern is that of ransomware, and there have been a number of instances of this in the news. Basically, a hacker can inject malicious code that can prevent the legitimate user from accessing the EHR and all the infor-mation contained therein, until ransom is paid, often using Bitcoin, a so-called cryptocurrency. Ironically, one approach to preventing seizure of information for ransom may lie in application of block-chain technology (the same technology that gave rise to Bitcoin) to HIT.9

“A blockchain is a kind of inde-pendent, transparent, and permanent database coexisting in multiple loca-tions and shared by a community. This is why it’s sometimes referred to as a mutual distributed ledger (MDL).”10

“The block validation system en-sures that nobody can tamper with the records. Rather, old transactions are preserved forever and new transac-tions are added to the ledger irrevers-

ibly. Anyone on the network can check the ledger and see the same transac-tion history as everyone else.”11

Of course, restricting access to the network by hackers remains an issue that has to be dealt with separately, as discussed above.

It is way past the time to consider the EHR, not only as a repository of data, but as a tool to use that data for artificial intelligence and machine learning. To do so requires the creation of an environment that fosters innova-tion. Our present paradigm of protec-tion of intellectual property in traditional ways, i.e., patent and copyright protec-tion, in developing the EHR is deficient. What we need is an ecosystem of end-users who (with assistance from the technology community) collaborate by contributing to the development of an EHR, with the primary motivation of making the integral tool of medical care better for them and their patients – without the profit motive. Such a model is akin to how surgical pedagogy has developed over centuries. That means open source EHR that is licensed appropriately. The EHR can and should be tooled to enable artificial intelligence (AI) and machine learning.

That we need artificial intelligence in the EHR can be illustrated by two phenomena: First, the general medical knowledge base is expanding geomet-rically, and we have probably reached a point where no human being can fully process all the data that is available to her, and bring it all to the bedside; second, the amount of data accumu-lated on an individual patient is, again, too much for any human being to fully absorb and process. As an example of the latter, imagine the flood of data accumulated on an ICU patient, and

how frustrating it is for the physician who must not only access all the data (a daunting task in itself), but process it so that the most appropriate medical decisions are made in a timely fashion. In both of these instances, the need for AI and machine learning is clear, or certainly will be in just a few short years. Not only can algorithms process massive amounts of data, but they also can be designed to analyze it and come up with suggestions for diagnosis and treatment, which would serve as a starting point for the physician to devel-op a plan of care. As the EHR “learns,” from experience, such systems be-come more and more useful.

Moreover, links between the point of care and public health entities need to be facilitated, so that AI can process the mass of data that is accumulated at millions of points of care – an essential if we are to maximize the benefits of “big data,” to detect disease outbreaks, develop health policy, and prioritize research. Underlying these goals is the need for protection of ePHI, which will likely require major modifications in EHR architecture.

As alluded to above, the best way, at least in my view, to achieve the integration of the EHR into medical practice, is to provide for a universal EHR that is inexpensive, available to all and contributed to by all – with proper governance, of course. Ideal-ly, the governance entity would be a consortium of health care providers, payers, government and information technology and AI experts.

In any discussion about the future of health care, there is always an elephant in the room, i.e., the paradox of scientific advances to preserve life,

Continued on Page 12


12 www.acms.org

and in turn resulting in more care and cost. It is a cycle of more treatments for disease resulting in more living time, in turn resulting in more treatment, and more incentives to develop more treat-ments: a kind of positive feedback loop that will result in a geometric increase in costs for the few, and quite possibly with less left over, even for basic public health and preventive services, for the unlucky many. Whatever method we settle on for payment for health care, this paradox will not go away, and we need to address it now, full on – and not continue to ignore it.

I do not believe the problem of increasing health care costs will lie solely in tinkering with payment reform, even though we need such reform. One approach to the problem of increasing

health care costs employs the notion that candid and (if necessary) lengthy discussions between physician and patient (or patient surrogate) in dealing with end-of-life decisions are a sine qua non. Toward this end, the concepts of predictive analytics and predictive modeling12 will help. If patients or their surrogates can rely on predictions about their outcomes, and balance that information with the potential suffering that may occur as a result of treatment, they will better be able to make deci-sions about care, particularly when the patient is elderly, or high-risk due to co-morbidities.

ConclusionThe current path of progress of the

EHR, with its concentration on “mean-ingful use,” and an intellectual property regime that does not fully exploit the

capacity for innovation by end-users is approaching an evolutionary dead-end. It is time to treat the EHR as what it should be: an integral part of medical care that has limitless potential for maximizing the use of information acquired in the provision of health care, and not an impediment to optimal care and a bugaboo for the physician.

Dr. Wilder practiced neurological surgery in the Pittsburgh area. He currently is of counsel in the law firm of Wilder, Mahood, McKinsley and Oglesby. He can be reached at [email protected].

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

necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

From Page 11

References1. Some have chosen to make a

distinction between the EHR and the EMR (electronic medical record), in that the EHR refers to an individual’s health record across all institutions and the EMR as being the record of care during an episode of care, akin to the hospital chart during a hospi-talization. For purposes of this paper, the terms EHR and EMR may be considered interchangeable.

2. The electronic health record, along with its medical-legal implications, actually goes back much further. See, for example, Springer, E, Automated Medical Records and the Law, Health Law Center, Pittsburgh, PA, 1971.

3. The Medical Record of the Future, BULLETIN 1995;84:511-13 (9/9/95). Scanned version available at https://dl.drop-boxusercontent.com/u/26828547/Medi-cal%20Record%20of%20the%20Future.pdf (Access 12/11/16).

4. Health Information Technology for Economic and Clinical Health Act (HITECH),

2009. “To promote the adoption and mean-ingful use of health information technology.” https://www.hhs.gov/hipaa/for-professionals/special-topics/HITECH-act-enforcement-in-terim-final-rule/ (access 12/18/16).

5. Sinsky, C, et al, Allocation of Physi-cian Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties, Ann Int Med, September 6, 2016, Abstract available at http://annals.org/aim/article/2546704/allocation-physician-time-ambulatory-prac-tice-time-motion-study-4-specialties (access 12/18/16).

6. McCanne, D, Physicians spend two hours on EHRs and desk work for every hour of direct patient care, http://pnhp.org/blog/2016/09/07/physicians-spend-two-hours-on-ehrs-and-desk-work-for-every-hour-of-direct-patient-care/ (access 12/18/16), a comment on Note 5, above.

7. For instance, Top Ten Health Care Issues From Pennsylvania’s 2015-2016 Legislative Session, https://www.pamedsoc.org/advocate/topics/general/Legislation2016? utm_source=MagnetMail&utm_medi-

um=email&utm_term=Wilder&utm_cam-paign=Dose%20-%2012%2F8%2F16 (Access 12/18/16).

8. I suggest here that tools can be de-veloped to assess physician competence in nearly real time, quite possibly obviating, or significantly reducing the time and expense requirements of, or the need of, independent testing for licensure renewal and mainte-nance of certification (MOC).

9. A Case Study for Blockchain in Health-care: “MedRec” prototype for electronic health records and medical research data [a white paper], Ekblaw A, et al, August 2016, https://www.healthit.gov/sites/default/files/5-56-onc_blockchainchallenge_mitwhitepaper.pdf (access 11/8/16).

10. What is a blockchain, and why is it growing in popularity, http://arstechnica.com/information-technology/2016/11/what-is-blockchain/ (access 12-11/16).

11. Id.12. What is Predictive Modeling?, http://

www.predictiveanalyticstoday.com/predic-tive-modeling/ (access 12/18/16).


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*This article originally appeared in the Pittsburgh Post-Gazette Dec. 16, 2016.

Last week, the surgeon general issued a report on the hazards of

electronic cigarettes, the first of its kind. Of particular note is that e-ciga-rette use has increased 900 percent among youth nationwide over the last five years.

In Allegheny County, according to a Pennsylvania survey, 25 per-cent of 10th-graders and 28 percent of 12th-graders smoke e-cigarettes compared to a range statewide of 20 percent to 27 percent. In addition to exposing youth to nicotine, e-cigarette use is highly correlated with the use of other tobacco products, and recent re-search suggests that e-cigarettes can act as a gateway to cigarette use.

E-cigarette smoking, which includes vaping, involves inhaling an aerosol. This aerosol is not harmless, contrary to claims of the e-cigarette industry. It often contains nicotine, a tobacco prod-uct that is highly addictive and harmful to the developing adolescent brain and to pregnant women and fetuses. E-cig-arette aerosols can contain a variety of other chemicals, including carbonyl compounds and volatile organic com-

pounds, that are harmful to health and not approved for inhalation.

The e-cigarette industry has heavily marketed to young people using many of the same techniques employed to attract young people to cigarettes years ago. Flavors such as bubble gum and cotton candy and glamorous advertising are tactics specifically targeting youth.

Yes, e-cigarettes may be used by smokers as a less harmful alternative to smoking, but they are not risk-free. Especially worrying is nicotine, an addictive substance that can set the stage for lifetime addiction and future cigarette use.

The surgeon general’s report urges states and local governments to take action, such as including e-cigarettes in existing smoke-free policies. More than 500 localities and states already have done so.

The Allegheny County Health Department now has acted to join other jurisdictions. In October, the Board of Health passed a regulation to prohibit e-cigarettes from smoke-free indoor spaces, but it will not go into effect until it is approved by county council as an ordinance.

E-cigarettes are not covered by Pennsylvania’s Clean Indoor Air Law.

We support a more comprehensive law that encompasses e-cigarettes, but, given the vacuum at the state level, county regulations are a com-mon-sense step in the right direction.

We applaud cigarette smokers’ efforts to quit, and e-cigarettes might someday be approved by the Food and Drug Administration as a cessation strategy. Still, we are greatly concerned about the impact of e-cigarettes on youth and children. Over 75 percent of our County residents including chil-dren don’t smoke tobacco or use e-cig-arettes. They should not have to in-hale emissions from someone else’s e-cigarette in venues that are already smoke-free, nor should they experi-ence the re-normalization of smoking.

We urge Allegheny County resi-dents to support local efforts to limit the use of e-cigarettes in indoor public places where smoking lit tobacco prod-ucts already is prohibited.

Dr. Hacker is director of the Alleghe-

ny County Health Department. Dr. John is chair of Board of Directors of the Allegheny County Medical Society.

E-cigarettes are dangerous, too

KaRen haCKeR, mD, mPh

lawRenCe R. john, mD

The surgeon general’s latest report should spur state and local action

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

of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.


q


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PerspectivePerspectiveSociety News

Pittsburgh Ophthalmology Society meeting set

On Feb. 2, the Pittsburgh Ophthal-mology Society (POS) will welcome guest speaker Dean Eliott, MD, associate director of the Massachusetts Eye and Ear Retina Service, Boston.

Dr. Eliott enjoys a national reputa-tion as a gifted vitreoretinal surgeon and is sought by colleagues for difficult surgical cases. He is especially inter-ested in treating retinal detachment, di-abetic retinopathy, non-diabetic retinal vascular disease, trauma and complex surgical problems.

Dr. Eliott co-directs the Diabetic Eye Disease Center of Excellence at Harvard Medical School – a multidisci-plinary collaboration among clinicians and scientists who are pooling their knowledge and resources with the goal of advancing breakthroughs in treatment for patients with diabetic eye disease. Additionally, he plays an important role training ophthalmology residents and fellows in the clinic and in the operating room as director of the Retina Fellowship and co-director of Massachusetts Eye and Ear’s Vitrec-tomy Course. He also is a sought after regional, national and international speaker.

As a clinical innovator and clini-cian scientist, Dr. Eliott is particu-larly interested in implantable and sustained-release steroid devices, vision-restoring electrical devices and stem cell therapy. He continually receives research funding from the government and industry, and he has

received several honors, including an American Academy of Ophthalmology Achievement Award, the Crystal Apple Teaching Award from the Young Phy-sicians group of the American Society of Retina Specialists, and the Vitreous Society Honor Award.

Members are reminded that regis-tration begins at 4 p.m. with the first lecture beginning at 4:30 p.m. Lance Bodily, MD, will present a resident case at 5:35 p.m. The POS business meeting begins at 5:50 p.m., followed by a reception. Dinner and the second lecture will commence at 7:05 p.m. The Society would like to thank Alimera Sciences and Optovue for co-sponsor-ing the program.

To register for the meeting, please visit www.pghoph.org. The deadline to register for the meeting is Jan. 30.

Annual Meeting slated for March 17

The 2017 Annual Meeting will be held Friday, March 17, at the Pittsburgh Marri-ott City Center, with the Duquesne Club hosting the Annual Banquet.

The Society welcomes Warren E. Hill, MD, medical director, East Valley Ophthalmology, Mesa, Ariz., as the 53rd Thorpe Lectur-er. Dr. Hill has devoted the majority of his professional activities to performing challenging anterior segment surgery for other ophthalmologists and the mathematics of intraocular lens power calculations in unusual clinical situa-tions. He has published many scientific articles, served as visiting professor for numerous grand rounds, and has

delivered more than 550 presentations to ophthalmic societies both in the United States and internation-ally.

Gaurav K. Shah, MD, professor of Clin-ical Ophthalmology and Visual Sciences, The Retina Institute, Washington University School of Medicine, St. Louis, Mo., and Ar-sham Sheybani, MD, assistant professor of Ophthalmology and Visual Sciences, Washington Universi-ty School of Medicine, St. Louis, Mo., complete the list of exceptional guest faculty for this year’s conference.

Dr. Shah has published more than 100 articles in ophthalmologic peer-reviewed journals, along with five book chapters. He has presented at the annual meeting of the American Academy of Ophthalmology, the Amer-ican Society of Retina Specialists, the Retina Society, the Canadian Ophthal-mology Society and the Association for Research in Vision and Ophthalmology. He also has lectured on various topics at several meetings both inside and outside the United States. He has received numerous awards, includ-ing the Heed Foundation Award, the Vitreous Society Honor Award, the American Academy of Ophthalmology Achievement Award and the American Society of Retina Specialists Senior Honor Award. He has been or is cur-rently an investigator in 30 clinical trials dealing with macular degeneration, diabetic retinopathy, uveitis and AIDS. He serves as a reviewer for Archives

Dr. Eliot

Dr. Hill

Dr. Shah

Dr. Sheybani


of Ophthalmology, British Journal of Ophthalmology, Ophthalmic Surgery and Lasers, Retina, Graefe’s Archive for Clinical and Experimental Ophthal-mology, American Journal of Ophthal-mology, and Ophthalmology, and also is an examiner for the American Board of Ophthalmology.

Dr. Sheybani has presented re-search internationally and is currently involved in device design aiming to make glaucoma surgery safer amongst many other endeavors. His areas of specialty include glaucoma and surgical management of the anterior chamber (front of the eye). Dr. Shey-bani completed his medical degree at Washington University School of Medi-cine in St. Louis, followed by residency at Washington University in St. Louis, where he was selected to remain on faculty as chief resident. During that year, Dr. Sheybani was responsible for ophthalmologic trauma and emer-gencies as well as all adult inpatient ophthalmology consultations at Barnes Jewish Hospital. He then completed his fellowship with Dr. Ike Ahmed in Glau-coma and Advanced Anterior Segment Surgery in Toronto, Canada.

Registration and conference details can be found on the society website at www.pghoph.org or by contacting Na-dine Popovich, administrator, at [email protected] or (412) 321-5030.

Annual Meeting for Ophthalmic Personnel set

Running concurrently with the POS Annual Meeting is the 38th Annual Meeting for Ophthalmic Personnel. More than 200 ophthalmic technicians, assistants, coders, photographers and front office staff are expected to attend this year’s meeting at the Pittsburgh

Marriott City Center.This well-respected annual program

is designed for ophthalmic technicians and administrative personnel to provide clinical updates as well as relevant and key technical sessions as it relates to ophthalmology. Planned by co-chairs Pamela Rath, MD, and Laurie Roba, MD, this year’s program is broken into four segments to allow attendees to select the program they are most interested in and for which they may obtain credits. Credits are only granted following approval by the JCAHPO with the formal application for the 2017 conference under consideration.

Highlights for the 2017 program include clinical sessions on: Pediatrics, Cornea (infectious diseases), Glauco-ma, Neuro-Ophthalmology, Oculoplas-tics and Uveitis. Risk management session offerings include: chart audit,

coding, cross training staff and work-up protocol. The program will once again feature the popular workshop sessions.

Registration and course information can be found by visiting www.pghoph.org.

For questions, please contact Na-dine Popovich, administrator, at [email protected] or (412) 321-5030.

POS meets at ACMSThierry Verstraeten, MD, POS pres-

ident, welcomed guest speaker Nathan Radcliffe, MD, director, Glaucoma Ser-vice & Clinical Assistant Professor, NYU Langone Ophthalmology Associates; Cataract and Glaucoma Surgeon, New York Eye Surgery Center, Dec. 8. Dr. Radcliffe, invited by POS member Ian Conner, MD, PhD, is a board-certified ophthalmologist who is an experienced

NadiNe PoPovich / acMSPictured at the Dec. 8 Pittsburgh Ophthalmology Society meeting are, from left, Sharon Taylor, MD, president-elect; Nathan Radcliffe, MD, presenter; and Thierry Verstraeten, MD, president.



18 www.acms.org

glaucoma and cataract surgeon. He has published more than 40 peer-reviewed publications in glaucoma research and has given hundreds of lectures on glaucoma and cataract to thousands of ophthalmologists in 40 states and over a dozen countries. The Ophthalmology magazine named Dr. Radcliffe one of the world’s top ophthalmologists under the age of 40 in May 2015.

During the business meeting, the society welcomed two new members: Matthew Pihlblad, MD, and Alison Zam-belli, MD. Robert Bergren, MD, nom-inating committee chair, announced David Buerger, MD, FACS, as candi-date for the position of president-elect.

POS MACRA program attracts large audience

Members of the Pittsburgh Ophthal-mology Society and their staff mem-bers attended “The Future of Physician Reimbursements: MACRA and APM’s” Dec. 10. The popular two-hour ophthal-mology-specific MACRA presentation included an overview of MACRA and the Quality Payment Program (QPP). Jennifer Swinnich, director, Practice Support, Pennsylvania Medical Society, provided expertise and led the informa-tive discussion. Ms. Swinnich present-ed specialty-specific measures and resources, as well as outlined timelines and steps one can take now to prepare for 2017. Vertical Solutions provided support for the program.

2017 Clinical Update in Geriatric Medicine set

Planning is underway for the 25th annual Clinical Update in Geriatric Medicine conference, jointly provided

by the Pennsylvania Geriatrics Soci-ety – Western Division (PAGS-WD), UPMC/University of Pittsburgh Insti-tute on Aging, University of Pittsburgh School of Nursing, and University of Pittsburgh School of Medicine Center for Continuing Education in the Health Sciences. The conference will be held April 6-8 at the Pittsburgh Marriott City Center.

The fastest-growing segment of the population comprises individu-als above the age of 85 years. The purpose of the conference is to provide

an evidence-based approach to help clinicians take exceptional care of these often-frail individuals. Designed by course directors Shuja Hassan, MD; Judith Black, MD; and Neil Resnick, MD, along with the PAGS-WD planning committee, this award-winning course is designed for family practitioners, internists, geriatricians and other health care professionals who provide care to older adults.

Speakers are selected by a multi-disciplinary committee of academic and practicing clinicians; selection is based

From Page 17

NadiNe PoPovich / acMSPictured at the POS MACRA program Dec. 10 at the ACMS building are, from left, Thierry Verstraeten, POS president; Jennifer Swinnich, director, Practice Support, PAMED, presenter; and Justin Krentz of Vertical Solutions, program sponsor.



on two criteria: (1) expertise – national-ly recognized and often responsible for advances relative to practice, and (2) ability – to share it in a practical, suc-cinct and entertaining way to facilitate its easy incorporation into a practice.

Conference highlights include:• Evidence-based evaluation and

treatment of multiple common clinical problems seen in the office, hospital and long-term care

• Symposium on neurodegenerative diseases including Parkinson’s disease and Alzheimer’s

• Symposium covering the latest updates for common cardiovascular conditions, including hypertension and acute MI in the elderly

• Ask the Expert sessions, allowing participants to get answers to their most vexing questions. This year’s sessions focus on Infectious Disease, Cardiology and Psychiatry.

• Multiple breakout sessions includ-ing: Prognostication in Chronic Dis-ease; Decision Making Capacity; Billing Code Primer; Using Antipsychotics in Long Term Care; and Foot Problems

The dinner symposium, “The Future of Geriatric Medicine,” will be presented by William Applegate, MD, MPH, MACP, former president of the American College of Physicians, dean and head of the health system at Wake Forest, editor of the Journal of the AGS (JAGS), and primary investigator for the seminal SHEP study of systolic hyper-tension and the landmark SPRING trial.

Conference credits include a max-imum of 20.75 AMA PRA Category 1 credits™; with AAFP, Nursing, Risk and ACPE credits available. An application for CME credit for AAFP has been filed with the American Academy of Family Physicians (determination of credit

is pending); social work credits are offered (20.75 hours of social work); and nursing credits are a maximum of 18.3 contact hours. ACPE credits are available with 20.75 contact hours (the maximum amount of continuing educa-tion credit granted).

Registration is now being accepted at http://ccehs.upmc.com/liveformal-courses.jsf. For additional information, call (412) 647-8232 or email [email protected].

Members of the PAGS-WD receive a discount when registering for the conference! To inquire about becoming a member or current membership sta-tus, contact Nadine Popovich at 412-321-5035, ext. 110, or [email protected]. Apply for membership on the Society website at www.pagswd.org.

ACMS Foundation awards medical student scholarship

Allegheny County Medical Society Foundation (ACMSF) awarded a $4,000 scholarship to Gretchen Evans, daughter of James and Carolyn Evans, of Pittsburgh. She attends Drexel University College of Medicine, Philadelphia.

Evans, regional dele-gate for the Pennsylvania Med-ical Society and the Ameri-can Medical Association, intends to specialize in internal medicine. She said, “Organized medicine keeps me inspired as a nascent physician. Look-ing to the future, I plan to remain engaged in organized medicine and the processes that translate re-search to implementations and poli-

cies to improve public health.” Evans believes that strides

that physicians make toward im-proving health policy on a na-tional scale will result in improve-ments in the lives of countless indi-viduals. “For now, I enjoy leadership positions that engage my enthusi-asm for patient-oriented care, evi-dence-based medicine, and teaching. I look forward to contributing my en-ergy to the coordination of care for in-dividual and public health as a physician engaged in my communi-ty and organized medicine,” she said.

In 2004, ACMS Foundation estab-lished this annual scholarship with $10,000 in seed money, which has grown to maturity thanks to generous contributions from the ACMS Founda-tion and local physicians. Eligibility in-cludes status as a third- or fourth-year Pennsylvania medical student from Allegheny County; U.S. citizenship; and full-time enrollment in a Pennsyl-vania medical school.

The Foundation of the Pennsylvania Medical Society is pleased to admin-ister the fund for ACMS Foundation. ACMS’s mission is to provide leader-ship and advocacy for patients and physicians.

The Foundation, a nonprofit affiliate of the Pennsylvania Medical Society, sustains the future of medicine in Penn-sylvania by providing programs that support medical education, physician health, and excellence in practice. It has been helping to finance medical education for more than 60 years.

For information about this schol-arship, call the Foundation’s Student Financial Services office at (717) 558-7854, or visit www.foundationpa-medsoc.org.

Ms. Evans


20 www.acms.org

Robert Link Wittig, MD, 80, of Indi-ana Township, died Sunday, November 27, 2016.

Dr. Wittig graduated in medicine from St. Louis University Medical School; served his internship at Jack-son Memorial Hospital in Miami, Fla.; and served his residency at Western Psychiatric Institute and Clinic.

He practiced medicine for 50 years and greatly enjoyed caring for his patients.

Deceased is his wife of 52 years, Neva Belle Powderly Wittig.

Surviving are children Lori Wittig, MD, Sheri (Billy) Rice and Audrey Wit-tig; grandchildren Luke and Mike Rice; siblings Urban, Barbara and Mike Wit-tig; and nieces and nephews Stephen (Jen) and Liam, Anne (Brad) Sedushak and Catie, Oliver and Emmy.

Services were held Friday, Decem-ber 2, 2016, in St. Joseph Church, O’Hara Township.

***

James G. Pitcavage, MD, FAAP, of Edgeworth, died Monday, December 26, 2016.

Dr. Pitcavage graduated in medi-cine from the University of Pittsburgh and served pediatric residencies at St. Joseph’s Hospital, Syracuse, N.Y., and Children’s Hospital of Pittsburgh.

He was a captain in the U.S. Air Force, serving as a flight surgeon and assigned to the Thunderbirds Flight Demonstration Team.

Dr. Pitcavage was a fellow of the American Academy of Pediatrics and a member of the Pittsburgh Pediatric Society. He served as a distinguished member and director of the Allegheny County Medical Society and was vice chairman of several committees at the Pennsylvania Medical Society. During more than 51 years at Sewickley Valley Hospital, he served as chairman of the Pediatric Department and past chief of the Medical Staff, among other positions. He founded Sewickley Valley

Pediatrics in September 1965, which later became Sewickley Valley Pediat-ric and Adolescent Medicine. Through his practice, Dr. Pitcavage selflessly served the families of Beaver and Allegheny counties for more than 51 years.

Surviving are his wife of 59 years, Julia Ann Pitcavage; children Jo Ann (Joseph) Heuler, Judith (William) Rebholz, James (Ann) Pitcavage, Jon (Nancy) Pitcavage and Joel Pitcavage; grandchildren Genevieve (Casey) Turner, Nicholas Rebholz, Michael Rebholz, James (Sarah) Heuler, Julie Heuler (Benjamin, fiancé), Jessica Heuler, Emily Pitcavage, Gregory Pitcavage and Sophia Pitcavage; a great-granddaughter, Grace Tuner; sister Norine (James) Fanning; and numerous nieces and nephews.

Services were held Tuesday, January 3, 2017, in St. James Church, Sewickley.

PerspectivePerspectiveIn Memoriam

john G. KRah

It is with deep regret that we note the passing of John F. Delaney Jr., MD, PhD, MPH. John served as president of the Allegheny County Medical Society in 2010, after having been actively involved in leadership on the Board of Directors and in other offices for the preceding decade. Most recently, and immediately prior to his death, he served as the District 13 (Allegheny County) Trustee on the Pennsylvania Medical Society Board of Trustees.

John was always actively involved in both the geriatric and psychiatric specialty societies. In addition to his medical degree, John held multiple masters’ degrees and a doctor of pharmacy degree. Along with his active clinical care of patients, with his wife, Rose, also a doctor of phar-macy, he conducted drug research with a particular interest in behavioral health care.

John was an astute leader, and always sought to represent the interest and concerns of physicians in caring for patients. He understood the importance of helping people and

building relationships. He continually sought to bring people together to seek solutions to challenging prob-lems. He knew how to “disagree without being disagreeable.”

John was invariably pleasant, un-selfish and diplomatic while grasping the implications of policy changes on patient care. It was truly a pleasure to have known John and work with him. He will be deeply missed by his colleagues and many friends.

Mr. Krah is executive director of the Allegheny County Medical Society.

In memory of John F. Delaney Jr., MD, PhD, MPH


GeRalD PiFeR, mD

John Delaney Jr., MD, PhD, MPH, passed away on Sunday, November 27, 2016. Although he is no longer with us physically, his spirit will live on through the many lives he has touched through his military and medical career.

John’s first involvement with the military was when he was in the Army ROTC program during his under-graduate pre-medical studies at the University of Pittsburgh. We became friends while serving together with the U.S. Army Reserves 339th 1000-Bed Hospital Unit in East Liberty. John served two years on active duty during the Vietnam conflict and was awarded the cross of active duty. He remained a medical reserve officer until his retire-ment from the military in 1991 with a rank of full colonel.

Meeting John as a young resident, I was impressed by his quiet demean-or, sense of humor and intelligence. Although he did not take himself very seriously, he was very committed to his profession as a neurologist/psychiatrist and to his military career.

My respect for John grew over the next several decades, especially through the military, observing his med-ical practice, and his involvement with organized medicine. He had a storied medical career being board certified both in neurology and psychiatry, and later additionally achieving board certi-fication in geriatric psychiatry.

John was unique in being able to balance a very busy medical and mili-tary career with many other endeavors. His curriculum vitae is 98 pages, but to highlight only some of his accom-plishments: his appointment as medical director of Milestone, Inc., a nonprofit operating center for people of all ages with developmental and behavior health challenges. He also served as chief of staff at the Pittsburgh Veterans Administration Health Facilities, presi-dent of the medical staff at West Penn Hospital, and in 2010, he served as the president of the Allegheny County Medical Society. John most recently represented the 13th District (Allegheny County) as a Trustee of the Pennsylva-nia Medical Society Board.

His patients and colleagues loved him, and many of his patients, even

those with special needs, sent him cards wishing him well during his two-year illness. Some of those patients recalled how John took the time to help them with crafts and games. When his patients thanked him for helping them, he would always respond, “That’s what I’m supposed to do.”

His interests outside of medicine and the military included astronomy (with three telescopes), collecting wrist watches and pens (especially the fountain type) and a love for fine automobiles (he owned 26 “Caddies” over the years).

John absolutely loved medicine. He grew up in Wilkinsburg, and even as a young boy, he dreamed of becoming a physician. After concluding his pre-med studies, he received his MD from the University of Pittsburgh Medical School. He never really retired from the practice of medicine and continued to work until mid-October of 2016, despite his illness.

John will be missed by his wife, Rose, and his family, friends and colleagues. John also will be missed by the greater tri-state area for the input he had to help meet the needs of the neurological, psychiatric, developmen-tally disabled and behavioral challeng-es of the community.

To paraphrase from a statement in the newspaper obituary, the world really is a better place because of Dr. John Delaney Jr.

Dr. Pifer is a retired orthopedic sur-geon and past president of the ACMS.

Tribute to: John F. Delaney Jr., MD, PhD, MPH

John F. Delaney Jr., MD, PhD, MPH

PerspectivePerspectiveIn Memoriam

22 www.acms.org

PerspectivePerspectiveAlliance News

ALLIANCE MEMBERSHIP AREAS OF OPPORTUNITY

Please check to indicate your area of interest. We’ll be in touch to welcome you with enthusiasm. We will mentor you into activities you’ve selected.

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and ACMS Foundation

2016-2017MEMBERSHIP APPLICATION

ALLEGHENY COUNTY MEDICAL SOCIETY ALLIANCE

Level Member ResidentCounty $ 35.00 $ 20.00State $ 55.00 $55.00

National $ 50.00 $ 10.00Total $ 140.00 $ 85.00

Last Name ______________________________________ First Name ______________________________________ M.I. _____ Address: ________________________________________ City ____________________ State _____ Zip __________ Phone: (Area Code) _______________________________ Fax: (Area Code) _________________________________ Email: __________________________________________

Please Indicate:__ New Member __ Reinstated __ Resident Spouse __ Other

Make Checks Payable to: Allegheny County Medical Society Alliance713 Ridge Avenue, Pittsburgh, PA 15212-6098

ACMSA Calendar 2017Tue., Feb. 7 or 14 Committee Catch-Up/Status Reports (Committee/Project Leader/Members)

Sat., March 4 ACMS Foundation Gala (Heinz Field East Club Lounge) Doctor’s Day Recognition Gala Program Ad from ACMSA = Donation to ACMS Foundation (Amy Stromberg, ACMS)

Tue., March 14 Governing Board Meeting – Nominations and Year-End Gifting (ACMS)

Fri./Sat. March 31 Carnegie Science Center PRSEF (Heinz – April 1 Field) (ACMSA – Dr. and Mrs. Da Costa)

Tue., April 11 Governing Board Meeting (ACMS)

Fri./Sat., April TBD PAMED Alliance Spring Confluence (Venue and Details TBD) (ACMSA Reps and Gifting TBD; Regional Rep S. Da Costa)

TBD April Past Presidents’ Luncheon (Leadership and Venue TBD)

Tue., May 9 Combined Board Meeting (ACMS)

Tue., May 23 General Meeting III, Annual Meeting and Luncheon; Confirm ACMSA Leadership Appointments; ACMSA New Members and Recognition, PAMED Alliance President Visit (Chair, P. Barnett/Schenley Park Golf Club)

Tue., June 20 Wrap-Up Kick Off Meeting (ACMS)Content and text by Kathleen Jennings Reshmi

Allegheny County Medical Society Alliance 1925 ~ 2017

XCIINinety-two years of continuous volunteer community ser-

vice in partnership with Allegheny County Medical Society. Join us in membership, on committees and in leadership.

The Alliance will direct proceeds from some ACMSA fund-raising events to embrace a new mission of the ACMS Foun-dation, in support of home and community environments which nurture and develop healthy children and families for a healthy Allegheny County!

Call Alliance at 412-321-5030 for membership and event details and RSVP information.

This document may not be reproduced in whole or in part without the express written permission of the Pennsylvania Medical Society.

©2016 PENNSYLVANIA MEDICAL SOCIETY

Physicians generally may charge for providing copies of patient medical records. However, the Pennsylvania Judicial Code and federal law limit the allowable charge and in some cases prohibit any charge. The lesser of the Judicial Code and federal limits applies when both are applicable. Health care providers are not required to charge for providing copies. Physicians often waive any charge that otherwise would be allowed, especially when providing a copy to the patient or another physician or health care provider for treatment purposes.

The following charts show the maximum charges allowed by the Judicial Code for 2017. The Judicial Code limits do not apply to X-ray film or any other portion of a medical record that cannot be reproduced photostatically. Unless otherwise noted in the chart, for paper copies provided to a patient or the patient’s personal representative HIPAA only permits a reasonable cost-based fee for copying and postage. For electronic protected health information (PHI), upon request of a patient, federal law requires health care providers to provide an electronic copy to the patient and to transmit an electronic copy to a third party. The fee may not exceed the labor cost to copy and transmit the record.

* The chart does not address patient confidentiality considerations, including whether a HIPAA patient authorization is required.

General Rules

Source of request Copying (per page) Retrieval Postage, shipping, and delivery

Patient Paper

Pages 1-20

Pages 21-60

Pages 61+

Microfilm

$1.48

$1.10

$0.37

$2.19

Prohibited by HIPAA privacy rule Actual cost

Personal representative, such as parent of minor Same as limits for patients Prohibited by HIPAA privacy rule Actual cost

Designee of patient, such as attorney with authorization Same as limits for patients $22.04 Actual cost

Special Purpose Requests

To support Copying Retrieval Postage, shipping, and delivery

Social Security claim or appeal $27.92 flat fee No additional charge permitted Actual cost

Federal or state needs-based benefit program $27.92 flat fee No additional charge permitted Actual cost

The physician may require the requester to provide documentation of the purpose of the request, such as an appointment of representative form (SSA-1696-U4) when the patient’s attorney makes the request for a Social Security claim or appeal.

Third party requests

Source of request Copying Retrieval Postage, shipping, and delivery

Subpoena (except as below) Same as limits for patients $22.04 Actual cost

Subpoena from district attorney $22.04 No additional charge permitted Actual cost

Commonwealth agency (executive or independent), such as licensing board

Not permitted as general ruleAllowed only if required by law or authorized by agency guidelines, statements of policy, or notice in Pennsylvania Bulletin

Restrictions on Medical Records Copying Charges for 2017

24 www.acms.org

Feature

2017 ACMS president and officers

David J. Deitrick, DO 2017 ACMS president

Dr. Deitrick graduated from the Kansas City University of Medicine and Biosciences in Kansas City, Mo., in 1993. He completed an internship at St. Francis Hospital in Pittsburgh and his residency at Bridgeport Hospital in Bridgeport, Conn. Dr. Deitrick has been practicing medicine since 1997 and is a Fellow of the American College of Obstetricians and Gynecologists.

Board certified in obstetrics and gynecology, Dr. Deitrick is a member of Jefferson Womens’ Health and is on the staff of Jefferson Hospital of Allegh-eny Health Network.

A member of ACMS since 1990, Dr. Deitrick served on the Board of Directors from 2004 to 2006 and was the Board of Directors Presidential Appointee from 2007 to 2011. He was ACMS treasurer in 2013, secretary in 2014, vice president in 2015 and

president-elect in 2016, serving on the Executive Committee during that time. Dr. Deitrick participated on the Com-munications Committee from 1999 to 2004 and the Nominating Committee from 2001 to 2002. He chaired the Legislative Committee from 2002 to 2006. Dr. Deitrick also has served on the Finance Committee from 2011 to present, currently serving as chair, as well as the Membership Committee from 2007 to 2012, serving as chair in 2007.

At the state level, Dr. Deitrick was an alternate delegate to the Pennsyl-vania Medical Society (PAMED) House of Delegates from 1999 to 2001 and again in 2008. He served as delegate from 2002 to 2007 and again from 2009 to present. Dr. Deitrick was also a member of the Pennsylvania Medical Society Political Action Committee (PAMPAC) Board of Directors from 2001 to 2005.

Dr. Deitrick served as the division director for University of Pittsburgh Physicians Womens’ Health in the Department of Obstetrics, Gynecology and Reproductive Sciences at UPMC Mercy Hospital, serving as chairman of the department of OB/GYN, and was a member of the Medical Executive Committee at UPMC Mercy.

Dr. Deitrick and his wife, Gretchen, reside in McMurray with their sons, Adam, Nathaniel and Benjamin.

Robert C. Cicco, MD 2017 ACMS president-elect

Dr. Cicco is board certified in pedi-atrics and neonatal-perinatal medicine.

He most recently served as associ-ate director of the Neonatal Inten-sive Care Unit at West Penn Hospital and is clinical assis-tant professor, pediatrics, at Temple University School of Medicine.

A member of ACMS since 1980, Dr. Cicco has served on the Board of Directors and Executive Commit-tee since 2014. He was the ACMS treasurer in 2014, secretary in 2015, and vice president in 2016. At the state level, Dr. Cicco served as a delegate to the Pennsylvania Medical Society in 2013. He was a member of the PAMED Task Force on State of Medicine from 2010 to 2013. In addition, he has been the recipient of several prestigious awards, including the ACMS Physician Volunteer Award and the PAMED Physician Volunteer Award. In 2012, The Pennsylvania Chapter of the American Academy of Pediatrics named Dr. Cicco Pediatri-cian of the Year.

Dr. Cicco is a past president of Parent Care, a national association of parents and professionals that advo-cates for family-centered NICU care. Dr. Cicco is a past president of the Pennsylvania Chapter of the American Academy of Pediatrics and also serves as the co-chairman of the Committee of the Fetus and Newborn for the state chapter. In addition, he is a member of the Committee to Establish Recom-


mended Standards for Newborn ICU Design and has served on numerous health department Advisory Com-mittees over the years and currently serves on the Advisory Committee for the Pennsylvania metabolic screening program and the Allegheny County Health Department’s child death review team.

Dr. Cicco graduated from Case Western Reserve University School of Medicine in 1976. He completed his residency at Children’s Hospital of Pittsburgh of UPMC and a fellowship at Magee Women’s Hospital of UPMC.

Dr. Cicco and his wife, Anita, reside in Scott Township. They have four sons, Brian, Michael, Steven and Patrick.

Adele Towers, MD, MPH 2017 ACMS vice president

Dr. Towers, board certified in Internal Medicine and Geriatric Medicine, is affiliated with UPMC Presby-terian Shadyside Hospital, and sees patients at the Benedum Geriatric Center at Montefiore Hospital.

A member of ACMS since 1988, Dr. Towers has served on the Board of Directors since 2011 and was ACMS treasurer in 2015 and secretary in 2016. She has been a member of the Executive Committee and ACMS Foundation Board during that time as well. In addition, Dr. Towers has been a member of the Awards Committee since 2011 and the Foundation Gala Committee, serving as co-chair since 2014.

Dr. Towers has been an associate professor of Medicine and Psychiatry at the University of Pittsburgh School of Medicine since 1992. She was the medical director of UPMC Health Information Management from 2007 to 2013 and served as medical director of UPMC Home Health from 2008 to 2016. Dr. Towers is currently senior clinical advisor of the UPMC Technolo-gy Development Center.

Dr. Towers also is a member of several professional societies including the American College of Physicians, American Geriatrics Society, American Medical Association, and Pennsylvania Geriatric Society – Western Division.

Dr. Towers graduated from the University of Connecticut School of Medicine in 1986. She completed an internship and residency in Internal Medicine at the University of Pitts-burgh School of Medicine in 1989. She also fulfilled a fellowship in Geriatric Medicine from the University of Pitts-burgh School of Medicine in 1991, and received her Master’s in Public Health the same year from the Department of Epidemiology, Graduate School of Public Health at the University of Pittsburgh.

Dr. Towers resides in Wilkinsburg, Pa.

William K. Johnjulio, MD 2017 ACMS secretary

Dr. Johnjulio is certified by the American Board of Family Medicine. He is chair of the Department of Family Medicine at Allegheny Health Network (AHN) and is responsible for oversee-ing all clinical, administrative and aca-demic components of the department. Dr. Johnjulio was formerly the program director of Forbes Family Medicine

Residency at AHN.

A member of ACMS since 2004, Dr. John-julio has served on the Board of Directors since 2013 and was the ACMS treasurer in 2016. He was a member of the Awards Committee in 2013 and the Membership Committee in 2015. He currently serves on the Executive Committee and ACMS Foun-dation Board.

Dr. Johnjulio has held academic appointments in the Departments of Family Medicine at Forbes Regional Hospital, Temple University and Lake Erie College of Medicine, as well as at the University of Pittsburgh College of Pharmacy.

Dr. Johnjulio graduated from the University of Iowa College of Medicine and completed postgraduate training with a family medicine internship at the University of Rochester/Highland Hos-pital and a residency in family medicine at the University of Iowa Hospitals and Clinics. He also completed a Faculty Development program at Duke Uni-versity and a Physicians Leadership Academy Fellowship at UPMC Mercy Hospital.

Dr. Johnjulio is a member of the American Academy of Family Physi-cians and the Society of Teachers of Family Medicine. He also is a member of the Medical Staff Executive Commit-tee at AHN.

Dr. Johnjulio and his wife, Margot, reside in Fox Chapel and have two children, Will and Grace.


Feature

26 www.acms.org

Patricia L. Bononi, MD 2017 ACMS treasurer

Dr. Bononi received her bachelor of science degree from Georgetown University. She received her medical degree from the University of Pitts-burgh in 1985 and completed a med-ical internship and residency at the University Health Center Hospitals of Pittsburgh. Dr. Bononi also completed fellowship training at UPMC in Endocri-nology and Metabolism under Division Chief, Alan G. Robinson, MD.

Board certified by the American Board of Internal Medicine and the American Board of Endocrinology,

Metabolism and Diabetes Mellitus, Dr. Bononi current-ly serves as clinical instructor of medicine at the University of Pittsburgh School of Medicine and Temple Uni-versity School of Medicine. She also has served as medical director of the Allegheny Health Network Center for Diabetes since 2013.

A member of ACMS since 1992, Dr. Bononi has served on the Board of Di-rectors since 2012 and has co-chaired the Foundation Gala Committee since

2014. She currently serves on the Executive Committee.

Dr. Bononi is a Fellow of the American College of Physicians and is a member of several other profession-al societies including the Endocrine Society, American Diabetes Associ-ation, and American Association of Clinical Endocrinology. She served on the Community Leadership Board of the American Diabetes Association of Western Pennsylvania from 2013 to 2015 and currently serves on the Board of Directors of the JDRF of Western Pennsylvania.

Dr. Bononi resides in Wexford. She has two children, Christopher and Maura.

From Page 25

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28 www.acms.org

Materia Medica

aaRon w. stewaRt KaRen m. FanCheR, PhaRmD, bCoP

Chronic pain is defined as pain that typically lasts more than three

months or past the time of normal tissue healing.1 It is estimated that up to 15 percent of adults in the United States have current localized or wide-spread pain that has been present for at least three months, and the overall prevalence of common musculoskel-etal pain conditions such as arthritis, headaches or back pain has been esti-mated at 43 percent of adults.2 Chronic pain can have clinical, psychological and social consequences, including limitations in activities, loss of work time or productivity, social stigma and reduced quality of life.3

Prescription medications are an inte-gral part of improving function and qual-ity of life for patients with chronic pain. Opioid agents are frequently prescribed for both acute and chronic pain; up to 20 percent of patients presenting to physician offices with non-cancer pain or pain-related complaints receive a prescription for an opioid.4 Randomized controlled trials suggest that opioids provide short-term relief of nociceptive and neuropathic pain in non-cancer patients, but these trials have generally lasted 12 weeks or less. Very few stud-ies have been conducted to address the long-term (greater than one year)

efficacy of opioids for chronic pain.3,5

Despite a clear lack of evidence, opioid prescription volume increased 7.3 percent between 2007 and 2012, with rates increasing most frequently in family practice, general medicine and internal medicine compared to other specialties.3, 6 Rates of increase do not match the underlying health status of the population, revealing the lack of consensus on the appropriate use of these agents.

Opioid use can be associated with serious risks, including potentially serious lifelong opioid use disorder and fatal respiratory depression. Further, the risk of such harms is dose-dependent.5,

7 In the past 15 years, the national death rate associated with opioid medi-cations has quadrupled; this problem is even more severe in western Pennsyl-vania.5 In a recent study conducted by the University of Pittsburgh, fatal drug overdoses across the country increased 14-fold between 1979 and 2014, with Pennsylvania among 20 states whose rates of overdose were statistically higher than the national average. Fur-ther, southwestern Pennsylvania was one of three top locations within the state itself to suffer from this trend.8

New guidance availableThe Center for Disease Control

(CDC) released guidelines for prescrib-ing opioids for chronic pain (available at https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf) March 15, 2016.

The purpose of the guidelines is to improve communication between clini-cians and patients about the risks and benefits of opioid therapy for chronic non-cancer pain, improve safety and ef-ficacy of pain treatment, and reduce the risks associated with long-term therapy including opioid use disorder.3 The doc-ument provides recommendations for the prescribing of opioid medication for chronic pain by primary care clinicians in outpatient settings. The guidelines state that the recommendations also may be relevant for acute settings such as emergency medicine and dentistry, but these areas were not their main focus. The guidelines do not include recommendations for opioid use in pe-diatric patients, active cancer treatment, palliative care, or end-of-life care.3

The CDC’s recommendations were made after a systematic review of the best available evidence, along with input from hundreds of experts, review by a federally charted advisory commit-tee and more than 4,000 public com-ments.3,5 The recommendations made within the guidelines are voluntary, as opposed to prescriptive standards. Fur-ther, the guidelines state that clinical decision-making should be based on an established relationship between the clinician and patient, with both parties having a clear understanding of the patient’s clinical situation, functional status and life context.3

The full guidelines contain 12 recommendations that are grouped into

A new roadmap for chronic pain – implications for practice


three areas for consideration:1. Determining when to initiate or

continue opioids for chronic pain2. Opioid selection, dosage, dura-

tion, follow-up and discontinuation 3. Assessing risk and addressing

harms of opioid useDetermining when to initiate or continue opioids for chronic pain

The guidelines recommend that the preferred strategies for chronic pain are non-pharmacologic and non-opioid therapies. Many non-pharmacologic therapies, including physical therapy, psychological therapy, exercise therapy, weight loss and certain interventional procedures may decrease or eliminate chronic pain. Non-opioid pharmacolog-ic agents, including acetaminophen, non-steroidal inflammatory drugs (NSAIDs) and neuropathic agents such as antidepressants and anticonvulsants also may be appropriate and effective for chronic pain. Opioids should only be used if the clinician believes the ben-efits on both pain and function outweigh the risks. Clinicians should evaluate treatment goals and discuss these goals with the patient when an opioid prescription is considered.3

Opioid selection, dosage, duration, follow-up and discontinuation

If opioid therapy is deemed appropri-ate, the guidelines recommend starting with immediate-release products rather than extended-release or long-acting formulations. The lowest effective dose should be used, with frequent reas-sessments of the risks and benefits. Additional caution should be used when initiating opioids in elderly patients or in patients with renal or hepatic insuf-ficiency due to the risks of decreased drug clearance and potential accu-mulation. Reassessment should be conducted when daily doses of more than 50 morphine milligram equivalents (MME) per day are considered, and dai-ly doses of greater than 90 MME should be avoided or carefully justified.3

More information about alternative opioid agents and their approximate MME can be found in Table 1.

The duration of therapy for acute pain should be short: Three days or less is typically sufficient, and more than seven days should rarely be needed. When used for chronic pain, the risks and benefits of opioid thera-

py should be evaluated every one to four weeks of starting therapy or dose escalation. Early and frequent reas-sessment of pain and function provides an opportunity to discontinue opioids in patients not experiencing a clear benefit. An evidence review has shown that patients who do not experience pain relief within one month of initiating opioids are unlikely to experience pain relief from opioids at six months. In pa-tients who are benefitting from contin-ued therapy, assessment of the opioid risks and benefits should be performed at least every three months.3

Patients who are not benefitting from opioid therapy should have their doses tapered to discontinuation. No high-quality comparisons of the effec-tiveness of various tapering strategies have been performed, but the guide-lines suggest that a taper of 10 percent of the original dose per week is rea-sonable. The tapering plan should be individualized based on patient goals and symptoms.3 Assessing risk and addressing harms of opioid use

Before starting and periodically

Table 1. Oral morphine equivalents among various opioids. Conversions to 50 MME and 90 MME daily have been provided.9

Oral Morphine Equivalent (30 mg) 50 MME * 90 MME *

Codeine 200 mg 333 mg 600 mgHydrocodone 30 mg 50 mg 90 mgHydromorphone 7.5 mg 12.5 mg 22.5 mgOxycodone 20 mg 33 mg 60 mgOxymorphone 10 mg 17 mg 30 mgTramadol 120 mg 200 mg 360 mg

* Doses listed are total daily doses. MME = morphine milligram equivalents.


Materia Medica

30 www.acms.org

during opioid therapy, clinicians should evaluate risk factors for opioid-related harms and incorporate strategies to mitigate these risks. One such strategy is to offer naloxone, an opioid antag-onist that can quickly reverse severe respiratory depression associated with an overdose. Risk factors for over-dose include high opioid dosages (≥ 50 MME per day), previous history of overdose or substance abuse disorder, or concurrent benzodiazepine use. Evidence supports the effectiveness of naloxone in preventing opioid-related overdose deaths in the community setting. Naloxone is relatively easy to use in the event of an overdose and has extremely minimal adverse effects, allowing for multiple administrations if necessary. Clinicians also should avoid prescribing benzodiazepines and opi-oid medications concurrently whenever possible to further minimize risk.3

Clinicians should use their state-provided Prescription Drug Mon-itoring Program (PDMP) prior to initia-tion of opioid therapy and periodically throughout therapy. These databases track all controlled substances dis-pensed by pharmacies for a particular patient throughout the entire state and can detect if the patient is at higher risk for abuse or overdose.10

Before prescribing opioids for chronic pain, clinicians should employ urine drug testing. Further urine testing should be considered at least annually to assess for prescribed opioids as well as other controlled prescription prod-ucts and illicit substances.3

Patients who are identified as having an opioid use disorder should receive evidence-based treatment, with the clinician offering or arranging such

therapy when possible. Such interven-tions typically include a medication–as-sisted treatment program in combina-tion with behavioral therapies.3 Limitations of the guidelines

Multimodal therapies require coor-dination of many different health care providers and may not be readily avail-able to patients in rural areas. These therapies also may be time-consuming, slow to take effect and costly if not reimbursed by a patient’s insurance.11 Non-opioid pharmacologic therapies such as NSAIDs are associated with their own risks, including cardiovascu-lar, renal, gastrointestinal and hepatic toxicities.

A second criticism of the guidelines is that they are expert-based and not necessarily evidence-based.11 Previ-ously published guidelines, such as the National Institute of Health 2014 guidelines, were based on literature re-view only and make somewhat different recommendations.12

It also should be noted that the guidelines specifically state that they are intended to apply to patients 18 years of age or older with chronic pain. The appropriate management of chron-ic pain in children and adolescents is even less defined, and prescribers are cautioned that these recommendations should not be extrapolated to pediatric populations.13

Implications for practitionersThe CDC guidelines were devel-

oped using a rational approach to evidence review, and call for thoughtful and safe use of opioid therapy.14 The guidelines are clear in their recommen-dations that opioids should not be con-sidered first-line or routine therapy for chronic pain outside of active cancer,

palliative care, or end-of-life situations. However, this does not imply that pa-tients are required to sequentially “fail” non-pharmacologic and non-opioid therapies before proceeding to opioid therapy.

Although the CDC states that these guidelines are voluntary, they represent the most sweeping and up-to-date effort to address the opioid abuse crisis.15 As such, regulatory authorities and payers may increasingly cite them in an effort to limit unnecessary opioid therapy.14

The state of West Virginia has subsequently released its own expert guidelines, known as Safe and Ef-fective Management of Pain (SEMP) Guidelines, which further expand on the CDC’s recommendations. The SEMP Guidelines have already been endorsed by multiple health organiza-tions within West Virginia, and other states are considering their own guide-lines based on this model.7 In fact, as of Dec. 15, 2016, Pennsylvania’s PDMP website states the following:

“The Pennsylvania Prescription Drug Monitoring Program Office is reviewing the new opioid-related legislation signed by Governor Wolf. The PDMP office will soon publish guidelines about the new legislation on the department’s website and distribute them to the appropriate health care providers and organizations. Please visit our website again soon to look for additional updates on the PDMP-relat-ed legislation.”10

Finally, the management of chronic pain should always be individualized to the specific patient, with a clear understanding between the patient and clinician regarding the risks, benefits and goals of therapy.

From Page 29

Materia MedicaMateria Medica


Mr. Stewart is a doctor of pharmacy candidate at Duquesne University Mylan School of Pharmacy. Dr. Fancher is an assistant professor of pharmacy practice at Duquesne University Mylan School of Pharmacy. She also serves as a clinical pharmacy specialist in oncology at the University of Pittsburgh Medical Center at Passavant Hospital. She can be reached at [email protected] or (412) 396-5485.

References1. Classification of chronic pain. Descriptions of chronic pain

syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, subcommittee on taxonomy. Pain Suppl. 1986; 3: S1-226.

2. Hardt J, Jacobsen C, Goldberg J et al. Prevalence of chronic pain in a representative sample in the United States. Pain Med. 2008; 9(7): 803-12.

3. Dowell D, Haegerich TM and Chou R. CDC guideline for prescrib-ing opioids for chronic pain – United States, 2016. MMWR Recomm Rep. 2016; 65(1): 1-49.

4. Daubresse M, Chang HY, Yu Y et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Med Care. 2013; 51(10): 870-8.

5. Frieden TR and Houry D. Reducing the risks of relief--the CDC opioid-prescribing guideline. N Engl J Med. 2016; 374(16): 1501-4.

6. Levy B, Paulozzi L, Mack KA et al. Trends in opioid analgesic-pre-scribing rates by specialty, U.S., 2007-2012. Am J Prev Med. 2015; 49(3): 409-13.

7. SEMPTM Guidelines. Available at http://sempguidelines.org/. Accessed December 15, 2016.

8. Balmert LC, Buchanich JM, Pringle JL et al. Patterns and trends in accidental poisoning deaths: Pennsylvania’s experience 1979-2014. PLoS One. 2016; 11(3): e0151655.

9. McPherson ML. Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. Bethesda, MD: American Society of Health-System Pharmacists; 2010.

10. Prescription Drug Monitoring Program. Pennsylvania Depart-ment of Health. Available at http://www.Health.Pa.Gov/your-department-of-health/offices%20and%20bureaus/paprescriptiondrugmonitoringpro-gram/pages/home.aspx#.Wfnmhywce2w. Accessed December 15, 2016.

11. The issues with the CDC guidelines on opioids for chronic pain, according to AAPM’s director. Clinical Pain Advisor. Available at http://www.clinicalpainadvisor.com/opioid-addiction/the-issues-with-the-cdc-guidelines-on-opioids-for-chronic-pain/article/524976/. Accessed December 15, 2016.

12. Reuben DB, Alvanzo AA, Ashikaga T et al. National Institutes of Health pathways to prevention workshop: the role of opioids in the treatment of chronic pain. Ann Intern Med. 2015; 162(4): 295-300.

13. Schechter NL and Walco GA. The potential impact on children of the CDC guideline for prescribing opioids for chronic pain: above all, do no harm. JAMA Pediatr. 2016; 170(5): 425-6.

14. New CDC opioid guideline: The good, the bad, the ugly. Medscape. Available at http://www.medscape.com/viewarticle/863183 . Accessed December 15, 2016.

15. CDC issues sweeping new guidelines to restrict opioid prescrib-ing. STAT. Available at https://www.statnews.com/pharmalot/2016/03/15/opioids-painkillers-cdc/. Accessed December 15, 2016.

Election Report for Officers and Delegates

December 14, 2016 The following physicians have been elected to office in 2017, as identified by the audit company of Epstein, Tabor & Schorr. President David J. Deitrick, DO President-elect Robert C. Cicco, MD Vice President Adele L. Towers, MD Secretary William K. Johnjulio, MD Treasurer Patricia L. Bononi, MD Directors Term Expires 2019 Thomas P. Campbell, MD, FACS Michael B. Gaffney, MD Keith T. Kanel, MD Jason L. Lamb, MD Maria J. Sunseri, MD

Other Directors currently serving:

Term Expires in 2017 Term Expires 2018 Lawrence R. John, MD, Chair 2017 Peter G. Ellis, MD David L. Blinn, MD (for Bononi) David A. Logan, MD William F. Coppula, MD Jan W. Madison, MD Kevin O. Garrett, MD Matthew B. Straka, MD Amelia A. Paré, MD Angela M. Stupi, MD Raymond E. Pontzer, MD

Peer Review Board Term Expires 2019 John A. Straka, MD Vacancy due to the passing of John F. Delaney, Jr., MD

Other members currently serving: Term Expires in 2017 Term Expires in 2018 Donald B. Middleton, MD Sharon L. Goldstein, MD Ralph Schmeltz, MD Bruce A. MacLeod, MD

Delegates (Term: 2017-2018) Ragunath Appasamy, MD James A. Betler, MD Douglas F. Clough, MD H. Jordan Garber, MD Todd M. Hertzberg, MD Lawrence R. John, MD Brahma Sharma, MD Carl A. Sirio, MD Maria J. Sunseri, MD Rajiv R. Varma, MD Bruce L. Wilder, MD

Other members currently serving: William F. Coppula, MD Phillip R. Levine, MD William Simmons, MD Patricia L. Dalby, MD Gerald W. Pifer, MD Matthew B. Straka, MD Kevin O. Garrett, MD Ralph Schmeltz, MD John P. Williams, MD Sharon L. Goldstein, MD

Alternate Delegates M. Sabina Daroski, MD (Term Expires 2017) David J. Deitrick, DO Amber R. Elway, DO Mark A. Goodman, MD Brian D. Horvath, MD Jan W. Madison, MD Deval M. Paranjpe, MD Melissa N. Rau, MD Adele L. Towers, MD Matthew A. Vasil, DO

Materia Medica

DO

ACMSelection results

32 www.acms.org

Pennsylvania’s General Assembly has provided some welcome news

for physicians reeling from uncertain-ties about the survival of the Affordable Care Act (ACA), insurers fleeing the ACA exchanges and increasingly fre-quent payer audits. Act 146 was signed into law by Gov. Tom Wolf on Nov. 3, 2016. It adds a new chapter entitled “Retroactive Denial of Reimburse-ments” to title 40 of the Pennsylvania Consolidated Statutes, which regulates insurance. Act 146 bans retroactive denials of paid claims as a result of an overpayment determination more than two years after the date the insurer initially paid the health care provider, with certain exceptions.

The bill was introduced by Rep. Kar-en Bobak of the 117th District in north-eastern Pennsylvania, and was passed unanimously by both the state House and Senate. The bill was championed by many professional organizations in-cluding the Pennsylvania Orthopaedic Society, the Pennsylvania Optometric Association, the Pennsylvania Medi-cal Society (PAMED), the Hospital & Health System Association of Pennsyl-vania and the Pennsylvania Chiroprac-tic Society. The Insurance Federation of Pennsylvania opposed the legislative effort, primarily citing issues with claims from non-physician practitioners. Upon the enactment of Act 146, the Penn-

sylvania Orthopedic Society noted, “The General Assembly’s actions end a 10-year odyssey that pitted the medical community against the health care insurance industry.”

PAMED initially had urged adoption of a 180-day limitation and then worked with lawmakers toward a targeted 12-month limit excepting cases of fraud or improper coding. Although the final legislation as passed adopted a 24-month window, it narrowed the ex-ceptions and no longer allows payers to look back further based on improper coding determinations.

Under Act 146, an insurer may not attempt to retroactively “claw back” pay-ments of claims beyond 24 months after such claims were approved for payment, with the following four exceptions:

• The information submitted to the insurer constitutes fraud, waste or abuse.

• The claim submitted to the insurer was a duplicate claim.

• Denial was required by a Federal or State government plan.

• Services subject to coordination of benefits with another insurer, the medical assistance program or the Medicare program.

As usual with legislation and regu-lations, definitions are critical. Act 146 includes the following definitions:

• “Abuse.” Incidents or practices

of providers, physicians or suppliers of services and equipment which are inconsistent with accepted sound medi-cal, business or fiscal practices.

• “Fraud.” Any activity defined as an offense under 18 Pa.C.S. § 4117 (relating to insurance fraud)

• “Waste.” The overutilization of professional medical services or the misuse of resources by a health care provider.

Equally important is this com-mon-sense rule which requires denials within the 24-month window to be based on policies that the provider could have known about when submit-ting the disputed claim. It is not uncom-mon for an insurer to attempt to deny payments based on policies that were never formally adopted or that were adopted after the fact. This section of the law holds insurers to a higher due process standard:

“An insurer that retroactively denies reimbursement to a health care provid-er under this chapter shall do so based upon coding guidelines and policies in effect at the time the service subject to the retroactive denial was rendered.”

Another common issue is a dispute among insurers over which carrier is pri-mary based on each policy’s coordina-tion of benefit rules. Act 146 requires the responsible payer to allow resubmission of a denied claim based on coordination

‘Clawbacks’ declawed: Act 146 limits retroactive denials

william h. maRuCa, esq.

Legal Report


of benefits for a minimum of 12 months after the date of the denial. Consider a patient who is covered by two policies, A and B. If a claim is paid by Insurer A on Jan. 31, 2017, and is retroactively denied by Insurer A on Dec. 31, 2019, due to a determination that Insurer B is liable, Insurer B must allow the provider to resubmit the claim for at least 12 more months, longer if the entity re-sponsible for payment permits a longer time period. This is particularly helpful since the 24-month limit does not apply to coordination of benefit denials, which may otherwise be delayed beyond the second carrier’s submission deadlines.

Finally, an insurer may request medical or billing records in writing from a health care provider and the provider

must supply those records within 60 days of the request. The period of time in which the health care provider is gathering the requested documentation extends the insurer’s 24-month look-back window, so where such records are requested toward the end of such period, it can stretch to 26 months.

In the past, it took protracted litiga-tion to protect physicians from over-reaching by payers. You may recall the 2008 class action settlement in the case known as Rick Love M.D v. Blue Cross Blue Shield Association, et al., under which Highmark agreed to an 18-month lookback limit in addition to a number of other voluntary reforms. That settlement has now expired and insurers have generally been free to look back as far

as four years under Pennsylvania’s general contractual statute of limitations. Going forward, insurers in Pennsylvania generally cannot look back more than 24 months and must make all retroac-tive denial decisions based on policies and guidelines in place at the time of the patient’s treatment. Act 146 represents a significant victory for Pennsylvania physicians.

Mr. Maruca is a health care partner with the Pittsburgh office of the national law firm Fox Rothschild LLP. He can be reached at (412) 394-5575 or [email protected]. He is the editor of the firm’s HIPAA, HITECH and HIT blog https://hipaahealthlaw.foxroth-schild.com/.

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syDney sPRinGeR, PhaRmD GReGoRy tRietley, PhaRmD, bCPs

Umeclidinium/vilanterol inhalation (Anoro Ellipta) is FDA-approved

for the treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema. It is a once-daily maintenance medica-tion containing a long-acting anticholin-ergic, umeclidinium and a long-acting beta2-adrenergic agonist (LABA), vilanterol.1

SafetyAs with other LABAs, vilanterol

may cause tachycardia, elevation in systolic or diastolic blood pressure, and electrocardiographic changes including T-wave flattening, QTc prolongation and ST segment depression.1 In a 24-week, randomized, double-blind placebo-controlled trial comparing umeclidinium/vilanterol, umeclidinium alone and vilanterol alone groups, there were no clinically significant EKG abnormalities in the treatment groups compared to placebo (18 to 22 percent v. 22 percent, respectively). Other cardiovascular adverse effects related to LABAs were not significantly increased in umeclidinium/vilanterol or vilanterol alone versus placebo.1,2 This also was confirmed in a 28-day safety and tolerability study, which showed no difference in rate of increased blood pressure, pulse rate or QTc changes on electrocardiogram for umeclidinium/

vilanterol vs. placebo.3

Anticholinergic effects – including dry mouth, constipation, blurred vision, tachycardia and urinary retention – can occur with all long-acting anticholiner-gics. However, in trials with umeclidin-ium/vilanterol and umeclidinium alone, there was no difference seen versus placebo in the rate of anticholinergic adverse effects.2 Nonetheless, ume-clidinium/vilanterol should be used in caution with patients with urinary reten-tion or narrow-angle glaucoma.1 Higher rates of anticholinergic adverse effects, including dry mouth and cough, were seen at doses of 250 mcg or higher with umeclidinium, which may be indicative of a dose-related effect.2 This dose far exceeds that used for thera-peutic effect and is not used clinically.

Adverse events that occurred in greater than 1 percent of study popu-lations included pharyngitis, sinusitis, lower respiratory tract infection, con-stipation, diarrhea, pain in extremities, muscle spasms, neck pain and chest pain.1,2

Patients with hypersensitivity to milk protein should not use umeclidinium/vilanterol. This agent also should be avoided in acute treatment of COPD exacerbation and in patients who are rapidly deteriorating or having a life-threatening COPD exacerbation, as it is not a rescue inhaler.1

TolerabilityTolerability of umeclidinium/vilan-

terol has been studied for up to six months. Generally, the tolerability of umeclidinium/vilanterol is similar to that

of placebo, each component separate-ly, tiotropium monotherapy, or flutica-sone/salmeterol in terms of adverse event rate and nature of the event.

In clinical trials, adverse events that resulted in patient discontinuation occurred about 6 percent of the time (compared to 8 percent with umeclidin-ium alone, and 6 percent with vilanterol alone). Withdrawal from studies due to COPD exacerbation occurred in 2 percent of patients (versus 1 percent in the placebo group). 2

In comparison to other long-acting anticholinergics and LABAs, umecli-dinium/vilanterol has a relatively low rate of anticholinergic and beta-agonist class-effect adverse events, though rationale for this is unclear, given umeclidinium has similar in-vitro affinity for muscarinic receptors 1-5.4 Rates of major cardiovascular adverse events (cardiovascular death, myocardial infarction, non-fatal stroke, non-fatal cardiac ischemia) were ≤1 percent.4

In a 28-day safety and tolerability trial of 51 adults randomized to either umeclidinium/vilanterol combination or placebo, there was no difference in rate of tolerability between groups in patients with moderate-to-severe COPD.

EfficacyUmeclidinium/vilanterol has been

compared to fluticasone/salmeterol (Symbicort) in two randomized con-trolled trials of 706 and 697 subjects; those who received umeclidinium/vilanterol had similar rates of improve-ment in lung function.5 Both studies

Anoro (umeclidinium/vilanterol)Materia Medica


showed statistically significant improvement in lung function measured by 0-24 h weighted-mean FEV1, reduction in Transition Dyspnea Index (TDI) and St. George’s Respirato-ry Questionnaire (SGRQ) scoring and similar adverse event rate (26 and 30 percent with umeclidinium/vilanterol versus 27 and 31 percent with fluticasone/salmeterol).5

In a 2015 meta-analysis of 26 trials of patients at least 40 years old with at least a 10 pack-year history, umeclidin-ium/vilanterol was deemed non-inferior to alternative dual long-acting anticholinergic/LABA inhalers in both objective lung function outcomes and subjective improvement in quality of life and COPD symptom management.6 When compared to vilanterol alone or umeclidinium alone, the combination of umeclidinium/vilanterol had greater reported improvement in TDI. Time to first COPD exacerbation was significantly reduced in the umeclidinium/vilanterol group versus vilanterol alone and versus placebo.2

A majority of studies involving umeclidinium/vilanterol have been performed in those at least 40 years of age, and umeclidinium/vilanterol has not been studied in a pediatric population.4

PriceThe cash price of one 30-dose Anoro Ellipta inhaler

(62.5 mcg umeclidinium/25 mcg vilanterol per inhalation) is approximately $200, a cash price similar to that of other combination inhaled medications indicated for COPD.7

SimplicityUmeclidinium/vilanterol inhalation (Anoro Ellipta) is a

once-daily agent for the maintenance of COPD. One inha-

lation provides a full daily dose when administered at the same time each day. The medication administration process is the same as for other Ellipta-brand inhalers, such as Breo Ellipta (fluticasone/vilanterol inhalation).

Inhalers that include shorter-acting LABA agents, includ-ing formoterol and salmeterol, require twice daily dosing, while umeclidinium/vilanterol allows for once-daily therapy.

There are no dose adjustments required for hepatic impairment, renal impairment, or geriatric patients.

Bottom lineA long-acting anticholinergic/LABA combination inhaler

is a first-line agent for adults with severe (GOLD class C) and very severe (GOLD class D) COPD, as defined by a post-bronchodilator FEV1 < 50 percent of predicted. As once-daily umeclidinium/vilanterol inhalation has been found non-inferior to twice-daily anticholinergic/LABA combination inhalers, use of a once-daily agent may improve patient compliance in real-world scenarios, although this has not yet been studied. The medication will likely compete against another once-daily anticholinergic/LABA combination, olo-daterol/tiotropium (Stiolto Respimat), for this market.

Dr. Springer is a PGY1 pharmacy practice resident at UPMC St. Margaret and can be reached at [email protected]. Dr. Trietley is a PGY2 ambulatory care pharmacy resident at UPMC St. Margaret. Heather Sakely, PharmD, BCPS, served as editor, and is the director of Geriatric Phar-macotherapy and the director of the PGY2 Geriatric Phar-macy Residency Program. She can be reached at [email protected].

References1. Anoro Ellipta [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2014.2. Donohue JF, Maleki-Yazdi MR, Kilbride S, Mehta R, Kalberg C, Church A. Efficacy and safety of once-daily umeclidinium/vilanterol

62.5/25mcg in COPD. Respiratory Medicine. 2013; 107: 1538-46.3. Feldman G, Walker RR, Brooks J, Mehta R, Crater G. 28-day safety and tolerability of umeclidinium in combination with vilanterol in

COPD: a randomized placebo-controlled trial. Pulm Pharmacol Ther. 2012 Dec; 25(6): 465-71.4. Blair HA, Deeks ED. Umeclidinium/vlianterol: a review of its use as maintenance therapy in adults with chronic obstructive pulmonary

disease. Drugs. 2015; 75: 61-74.5. Huisman EL, Cockle SM, Ismaila AS, Karabis A, Punekar YS. Comparative efficacy of combination bronchodilator therapies in COPD: a

network meta-analysis. International Journal of COPD. 2015; 10: 1863-81.6. Donohue JF, Worsley S, Zhu CQ, Hardaker L, Church A. Improvements in lung function with umeclidinium/vilanterol versus fluticasone

propionate/salmeterol in patients with moderate-to-severe COPD and infrequent exacerbations. Respir Med. 2015 July; 109(7): 870-81.7. “Anoro Ellipta.” GoodRx. GoodRx, 2015. Web. 13 December 2015.

Materia Medica

36 www.acms.org

Special Report

jewish healthCaRe FounDation

If the U.S. healthcare system were triaged, it would be in critical condition. The country’s massive investment in health care – about 18 percent of the overall gross domestic product, more than twice as much as any other affluent nation – has bought population health outcomes that rank among the worst in the industrialized world.

The time for tinkering at the mar-gins is over. It’s time to dramatically redesign the whole health system so that it’s high-performing, cost-efficient, prevention-focused and accessible to all.

During the fall of 2016, the chal-lenge of creating such a system was taken on by the 36 multidisciplinary graduate students who participated in the Jewish Healthcare Foundation’s (JHF) Jonas Salk Fellowship. The Salk Fellows – hailing from eight schools and a dozen different disciplines – wiped the slate clean and developed master designs of a health system structured to achieve the best health outcomes at the most reasonable cost.

The Salk Fellows worked in teams to re-design health systems focused on a particular age group (adolescents, adults, or seniors). With guidance from JHF staff as well as local and national experts in the field, the Fellows ad-dressed the service delivery, workforce, payment, improvement and safety, and

policy components necessary to reboot the U.S. health system.

Jonas Salk Fellow Guruprasad Raghavan, a biomedical engineering student at Carnegie Mellon University, was part of a team that focused on seniors. His team developed the Senior Wellness & Aging Network (SWAN), a new and more holistic model of care.

With SWAN, seniors have a “well-ness partner” – a trusted community member, embedded within the primary care team who conducts a needs as-sessment, provides on-site education and helps patients navigate an online portal. That portal features resources ranging from in-home services to trans-portation, to medical and nutritional information, to social and recreational opportunities.

“We want to change the myth of what ‘health care’ means,” Ragha-van said. “Health is not just disease management – it’s being physically and mentally well, and socially engaged.”

Salk Fellow Brian McWilliams, a health care administration student at the University of Alabama, was part of a team that crafted an adult-focused system that blends technology, big data and personal touch. His team’s system features a centralized electron-ic health record, used by all providers, that would be used to improve care continuity, support clinical decision making and proactively address patient issues at the individual and population health level. Guided by a health coach,

patients would connect with a team including medical professionals, a be-havioral specialist, a pharmacist and a social worker – either through telemed-icine visits or at centralized regional health centers.

“We want to fill gaps in the system without creating duplicative services,” McWilliams said. “We want to put patients at the center. We want to dismantle siloes and create one-stop shops for accessing care.”

Janell Johnson, studying health care administration at Chatham University, helped to devise an ado-lescent-focused system. Her team’s ideas include health education via games, more teen-friendly incentives for healthy behaviors (think Chipotle discounts for wellness visits rather than just deductible credits) and a peer support program overseen by health and social service providers.

“Having someone who is in an older grade and is a little more experienced, but is still an adolescent, can help kids understand the important role that they can play in their own health,” Johnson said. “They have someone to look up to and learn from.”

JHF will share the Fellows’ blue-prints for a higher-performing health system with its local and national partners, including the Pennsylvania Health Funders Collaborative (a net-work of 45 foundations from across the Commonwealth that advances health philanthropy and policy) and the Net-

JHF’s Jonas Salk Fellows redesign the health system


work for Regional Health Improvement (an alliance of 35 regional health improvement collaboratives from around the United States).

The Salk Fellowship is just one of JHF’s efforts to provide students and young professionals with the skills, experiences and mentorship to reimagine health care. In addition to a summer internship program, JHF also runs annual fellowships related to enhancing patient safety and to helping health professionals provide patient and family-centered end-of-life care. Next year, JHF will re-establish its Quality Improvement meets Innovation Technology (QI2T) Fellowship. The QI2T Fellows will help the Foundation create a new Museum to the Future of Health Care – an online, evolving space for health care experts, technologists, futurists, policymakers, community leaders, students and other stakeholders to learn about cutting-edge health care innovations, spread best practic-es and collaborate on new breakthroughs.

Creativity and concerted action also are the hallmarks of JHF’s new Healthcare Reform Network, which fea-tures two components: the Health Activist Network and the Women’s Health Activist Movement Global (WHAM Global). The Health Activist Network is an online network for physicians and other health professionals who are passionate about health reform, patient safety and quality improvement. WHAM Global will empower women to lead efforts to advance health care systems that are trans-parent, respectful, accountable and equitable. Both the Health Activist Network and WHAM Global will interface with Tomorrow’s HealthCareTM – the Foundation’s virtual platform to facilitate learning, communication, collaboration and engagement – and will include in-person events and Champions programs.

“We challenge our Fellows, interns and reform network participants to cast aside tradition and to look at health care through a new lens,” said JHF President and CEO Karen Wolk Feinstein, PhD. “What if our system of care was designed by Uber or Google, instead of being steeped in century-old conventions? In order to create the health system in which you want to work and receive care, you first have to have a vision.”

Special Report

www.acms.org Ruby Marcocelli

38 www.acms.org

Dennis olmsteaD, mPa

We’re past the tipping point as we proceed headlong into new mar-ket-driven accountability for quality, cost and value. As employers and payers demand proven, value-based health care, and the market shifts from rewarding volume to rewarding value, physicians must be able to demon-strate the highest standard of care to effectively remain competitive for the foreseeable future. It’s not something we should do – it’s something we must do.

Information from the Centers for Medicare and Medicaid Services (CMS), the Commonwealth of Pennsyl-vania and commercial payers indicates this value shift will account for a signif-icant portion of physician reimburse-ment within just a few short years.

As payment models quickly change, employers and payers are demanding greater accountability. Physicians are in a unique position to work together to co-create meaningful solutions that result in the highest quality of patient care available and the appropriate rewards for its delivery.

As a result, many physicians are joining together to seek opportunities for higher levels of success amid these changes. By participating in an aggre-gated, larger network while maintaining practice autonomy, physicians are given every opportunity to succeed in

the new value-based world.To lead this effort and help Penn-

sylvania physicians survive and thrive in this new health care landscape, the Pennsylvania Medical Society’s 2016 House of Delegates (HOD) passed a landmark initiative on Oct. 23, 2016. This historic initiative – called the Practice Options Initiative – will create clinically integrated networks (CINs) as well as a Management Services Organization (MSO) to help Pennsylva-nia physicians succeed in value-based care, while maintaining leadership roles and clinical autonomy.

The MSO will initially provide services within the general categories of revenue cycle, practice operations, and finance and business operations. It will include services such as front-end management as well as back-end management of the practice, staff pay-roll, reimbursement, charge capture, appeals, coding, practice management, etc., as well as Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) readiness and Merit-Based Incentive Payment System (MIPS) reporting. These services will be available to any physician practicing in Pennsylvania or elsewhere.

One way physicians can succeed in value-based care is through CINs. A CIN is a group of separate practic-es – each with a unique Tax Identifi-cation Number (TIN) – collaborating to demonstrate value, meet quality

metrics and improve patient outcomes. This is a direct response to the evolv-ing health care delivery system, which is moving rapidly toward value-based care led by passage of MACRA and its accompanying regulations. This guidance outlines the use of MIPS re-porting and development of Alternative Payment Models (APMs).

A well-led CIN provides the infra-structure to efficiently, effectively and comprehensively address the known issues in health care for the foresee-able future, and an established physi-cian-led, physician-owned network to efficiently address the unknown health care shifts of tomorrow.

In a physician-owned and physi-cian-led CIN, physicians are not only “at the table,” but are creating and im-plementing the local approach collec-tively. The more physicians understand the value of physician-driven networks, the more successful and sustainable they will be as health care leaders. It also will increase professional satis-faction – a very important part of who physicians are, and something that has recently been at an all-time low.

The ultimate goal is for CINs to serve as the high-performing, local catalysts for greater value for the health care dollar, while rewarding participating physicians for their work. PAMED plans to advance these net-works by providing physicians with the knowledge, tools and confidence that

Survival of physicians in a value-based world

Special Report


patients are receiving the best, most appropriate care possible throughout the entire continuum of care provided.

This means physician engagement must occur at a granular level. Physi-cian-created initiatives, with input and buy-in from the entire network, and resulting in better overall coordina-tion, is a cornerstone of success. This will allow physicians to directly affect health outcomes for large populations of patients while also being able to bend the cost curve, as the market so desperately needs.

PAMED must and will support physi-cians during this transition through use of services offered through the MSO or CINs. PAMED is looking to engage

Pennsylvania physicians; provide the necessary education, clinical tools and data; and offer hands-on practice sup-port to assure successful transitions. This is the value of becoming part of a CIN, and of being a PAMED member.

If you would like additional in-formation about PAMED’s Practice Options Initiative, please contact Dennis Olmstead, PAMED’s senior advisor of health policy and economics, through PAMED’s Knowledge Center at 855-PAMED4U (855-726-3348) or [email protected].

If you haven’t already, check out PAMED’s online, on-demand CME series – “Addressing Physician Uncer-tainty about Payment Reform: Skills

for Success in Value-Based Delivery Systems.” Free to PAMED members, this series is facilitated by Ray Fabius, MD, a PAMED member and a nation-ally respected expert in the field of population health. It covers a variety of important topics, including practical health informatics, using a data toolbox in your practice, quality management, process improvement, lessons learned from the managed care era, and popu-lation health. Access the CME at www.pamedsoc.org/valuebasedcare.

A version of this article first ap-peared in the summer 2016 issue of Pennsylvania Physician and was updated Dec. 13, 2016.

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