Chester County Medicine | Summer 2015

“Pears and Pansies” by Mark Dance FEATURED ON PAGE 22PROTECTING PATIentS

SODIUM RESTRICTION: A TIME-HONORED DOGMA OR AN EVIDENCE-BASED PURSUIT?

IN CHESTER COUNTY FROM ONE-SIZE-FITS-ALL HEALTHCARE

THE ART

of

Chester County

Your Community Resource for What’s Happening in Health Care

Summer 2015

Chester CountyThe Art of

Chester County Overdose Deaths:Increasing Awareness of a Preventable Problem

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Cost:

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Educational SessionsEnhancing Cultural and Linguistic Competencies: Improving Health Care and Building Effective Teams Horace DeLisser, MD

Healthy Teams, Healthy You: Interpersonal Skills to Reduce Stress and Improve Interactions with Patients, Providers and Peers David Steinman, MD

Meta Leadership 2.0: Swarm Intelligence Leonard Marcus, PhD

Finding Purpose and Pleasure in Medicine: Better Patient Care and Improved Physician Well-Being Bruce Bagley, MD

Physician Advocacy 2.0 Michael Fraser, PhD, CAE; Larry Light

Opioid Abuse: Addressing the Crisis Scot Chadwick, JD

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Chester County Medicine is a publication of the Chester County

Medical Society (CCMS). The Chester County Medical Society’s mission

has evolved to represent and serve all physicians of Chester County and

their patients in order to preserve the doctor-patient relationship, maintain safe and quality care, advance the practice of medicine and enhance

the role of medicine and health care within the community, Chester

County and Pennsylvania.

The opinions expressed in these pages are those of the individual

authors and not necessarily those of the Chester County Medical Society. The ad material is for the information

and consideration of the reader. It does not necessarily represent an

endorsement or recommendation by the Chester County Medical Society.

Chester County Medicine ispublished by

Hoffmann Publishing Group, Inc.,Reading PA 19608

HoffmannPublishing.com For advertising information,

contact Karen Zach610.685.0914

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2013-2016CCMS OFFICERS

PresidentWinslow W. Murdoch, MD

President-Elect

Mian A. Jan, MD, FACC

Vice PresidentBruce A. Colley, DO

Secretary

David E. Bobman, MD

TreasurerLiza P. Jodry, MD

Board Members

Mahmoud K. Effat, MD

Heidar K. Jahromi, MD

John P. Maher, MD

Charles P. McClure, MD

Susan B. Ward, MD

Chester County Medicine is published by Hoffmann Publishing Group, Inc. Reading, PA I HoffmannPublishing.com I 610.685.0914 I for advertising information: [email protected]

SUMMER 2015Contents

w w w . c h e s t e r c m s . o r g

PAMEDCONFERENCE

ANNUAL EDUCATION

OCTOBER 23 —24, 2015

Who can attend: All Pennsylvania physicians

Where: Hershey Lodge, Hershey, Pa.

When: Friday, Oct. 23, 2015 – Saturday, Oct. 24, 2015

Cost:

• PAMED Members: Free!

• Nonmembers: $149

Educational SessionsEnhancing Cultural and Linguistic Competencies: Improving Health Care and Building Effective Teams Horace DeLisser, MD

Healthy Teams, Healthy You: Interpersonal Skills to Reduce Stress and Improve Interactions with Patients, Providers and Peers David Steinman, MD

Meta Leadership 2.0: Swarm Intelligence Leonard Marcus, PhD

Finding Purpose and Pleasure in Medicine: Better Patient Care and Improved Physician Well-Being Bruce Bagley, MD

Physician Advocacy 2.0 Michael Fraser, PhD, CAE; Larry Light

Opioid Abuse: Addressing the Crisis Scot Chadwick, JD

REGISTER ONLINE ATwww.pamedsoc.org/Conference15

#PaDocs15

8

Features

When Johnny Comes Marching Home AgainWhat Primary Care Physicians Need to Know, Ask, and Evaluate

14 Foundation Offers Scholarshipsto PA Medical Students

Chester County Overdose Deaths:Increasing Awareness of a

Preventable Problem

19

8

In Every Issue

10 Somewhere Under the Rainbow26 Anti-Thrombin Agents Blessing or a Curse? Part II30 From Volume to Value: BE PREPARED34 ICD-10 is here. Is Your Organization or Practice Ready?

36 CCMS Membership: Resources You Need

6 President’s Message16 PAMED Legislative Update22 The Art of Chester County38 Membership News & Announcements

C H E S T E R C O U N T Y 6 M E D I C I N E


We spend more than enough time on external factors that encroach on our professional lives. In order to stay

relevant, it has become paramount to create shortcuts for all of us who choose to engage, as patient and doctor advocates. With the help of the Chester County Medical Society (CCMS), Pennsylvania Medical Society (PAMED), your specialty societies, and the American Medical Association (AMA), we can make a difference by being involved at any level. All of these organizations strive to provide physicians with efficient tools and information needed to advocate and join the conversation.

County Level CCMS works with PAMED on growing and maintaining strong relationships with our county legislators. We act as a resource of familiar faces for questions pertaining to public and community health, issues specific to practices in Pennsylvania, physician employment issues, and draft legislation. Several CCMS board members have regular conversations with our electorate and stay engaged. PAMED also keeps an eye out for opportunities to support or have conversations at the local level and works collaboratively with CCMS. If you are interested in participation, especially if you have contact with legislators or their staff already, or just want to get involved, please let us know. Most of the issues that create pebbles in our shoes, as well as threats to our profession and our patients, need to be dealt with at a state or federal level. Awareness about the issues, urgency to address them, and action starts with each of us. You would be surprised to learn that PAMED is already toiling on your behalf on countless issues. If you have an issue that needs to be addressed, please make sure to also contact us at the county level. We can be your advocate. It is the job of CCMS to work with and task

President’s Message

Make a Difference: Advocate for Our Patients and Our Profession

PAMED, which has expert and administrative staff, to find answers, give you a status update, or at least let you know how or who can take it to the next level. To keep our physician community engaged, CCMS invited all doctors who live or practice in Chester County to call in to our open forum July 29. Scot Chadwick, JD, PAMED’s legislative counsel, gave an overview of maintenance of certification (MOC) overreach, Pennsylvania’s

Controlled Substance Database, Opioid Prescribing Guidelines, Pennsylvania’s new naloxone law, and more, with an excellent Q & A discussion. Don’t forget CCMS’s annual “Clam Bake” meet and greet with your legislators. This year, it will be at the Radley Run Country Club in West Chester on Friday, September 11. We have assigned some doctors to sit with the legislators, to continue the conversation and discuss issues with family, friends, and communities. If you have an existing good relationship with an elected official, we are happy to make arrangements for you to have a seat at his or her table, adding familiarity to the conversation. Please RSVP “yes” to our yearly event!

State Level The PAMED full-time legislative affairs team is tasked to track hundreds of health-care related bills. In doing so, they establish long-term relationships with legislators and their equally important staff. They keep us up to date on important conversations at the Capitol, which influence our businesses, hospitals, payers, and practice. Conversations and bill sausage making drafts take many months. Our team assists in facilitating your inclusion in some of those discussions. “Capitol Update” is a weekly blog, written by Scott Chadwick, JD, and Angela Boateng. Go to www.pamedsoc.org under the Advocacy tab on the PAMED homepage. In addition, PAMED also sends out the “Daily Dose,” a


S U M M E R 2 0 1 5

brief daily e- newsletter. Feel free to sign up for the email newsletter at www.pamedsoc.org/recap or call us at CCMS or PAMED and ask to be added. Practice management support, legal and contract advice, CME, physician health programs, leadership training, and more are also readily available through PAMED and its Foundation.

National Level PAMED and your specialty societies send elected delegates to the American Medical Association national meetings. They collaborate to set the agenda for the AMA. PAMED has been very active at advocacy this past year, especially concerning MOC. Additionally, every year in mid-February, the AMA sponsors a legislative dinner in Washington, D.C. Pennsylvania Medical Political Action Committee (PAMPAC) members and AMA members are encouraged to attend and support their state senators and become a resource for our national legislators. While there, PAMED members scheduled meetings with state senators and representatives organized around key issues. If you are interest in attending, please let us know how you wish to contribute.

Become a Member of PAMPAC PAMPAC uses member contributions to support election and retention of pro-medicine, pro-physician candidates. You can learn more by going to www.pamedsoc.org/pampac. PAMPAC endorses candidates based primarily on how they stand on one or a few upcoming legislative medical issues (agreed upon by the PAMPAC Board of physicians with the help of PAMED legislative staff input), as well as their potential electability. If you are interested in sharing your voice as to how to direct contributions, or serving on the board, contact us at CCMS or Bryan Troop at PAMED.

Utilize Voter Voice On priority issues, PAMED supplies sample text which you can use or customize to include personal stories and experiences. You can access Voter Voice today: www.pamedsoc.org/votervoice. When we all speak together, we are a powerful force, reversing the decline in the quality of our professional lives, as well as best serving the needs of our patients. Let us help you find your voice.

Winslow W. Murdoch, MD, practices family medicine in West Chester. He is president of the Chester County Medical Society. Contact Dr. Murdoch at [email protected].

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When Johnny Comes Marching Home AgainWhat Primary Care Physicians Need to

Know, Ask, and Evaluate

More than in the past, and for a host of reasons, current or former military personnel (whether active, reserve, National Guard, or discharged

veterans) may want to seek medical care through their local civilian providers. Sometimes they are afraid that certain diagnoses could negatively affect their military careers if such problems were made part of their official military records. Sometimes they may live too far from the nearest Veterans Administration hospital, or that particular facility may not provide the specialty care they may need. Other times they may have been turned off by reports of VA hospital scandals, or by reports of inadequate, incompetent, or excessively delayed care at a particular center. Whatever the reasons, the care and treatment of veterans and returning military personnel has become an entire field of medicine in itself. It is marked by unique exposures, traumatic situations, and signs and symptoms that can be acute, chronic, or intermittent, and can even present with delayed onset weeks, months, or sometimes years after the initiating factors. Consequently, it is more important than ever that physicians—especially first-line, primary care physicians—make themselves aware of these all-important aspects, develop protocols for interviewing these patients, and recognize the possible relationship of their problems to their military experiences. Seemingly commonplace signs and symptoms can reflect hidden or repressed deeper issues. Recognizing and evaluating these underlying problems, and then knowing what to do about them (not the old traditional “treat ‘em and street ‘em” approach) requires awareness of their ubiquitous occurrence in this population group, and especially knowledge of what local, regional, or national resources are available to assist in treating, stabilizing, and possibly referring these “wounded warriors” to the necessary follow-up treatment sources.


Feature

To start with, physicians must be aware that such patients may not come to you in uniform, nor specifically complain about combat- or deployment-related exposures. They may not even realize themselves the connection of their current problems to their military experiences. Sometimes you may surmise by their haircut or demeanor that they are/were military. More than 20 million veterans currently live in the U.S., according to the VA. Some never saw combat but may have been exposed to toxins in the water and soil of their training bases. But, by now (2015), with perhaps hundreds of thousands of veterans of all ages, both male and female, survivors of Korea, Vietnam, Kosovo, Iraq, and Afghanistan, residing in the local/regional population, every medical history form should include the basic question: “Are you, or were you ever, in the military?” If the answer to that question is affirmative, that should automatically trigger a host of related questions (what the EMR techs would call a “drop-down menu” list). Following is a possible model for that list of questions, every one of which has potentially important significance depending upon the patient’s presenting complaint and the answers to these questions. You can ask them directly, or administer them as a preprinted questionnaire:

• What branch of service were you in (Army, Navy, Marines, Air Force, etc.)?• What years did you serve?• Where did you receive your training?• Are you now an active, reserve, National Guard, or discharged veteran?• Where do you live? Are you homeless just now?• What is/was your MOS (military occupational specialty): were you combat infantry, sniper, pilot, nurse, mechanic, explosive ordinance, “special or black ops,” etc.?• Were you deployed overseas? When, where, and how often?

BY JOHN P. MAHER, MD, MPH


• Were you exposed to any sexually transmitted or “tropical” diseases?• Were you in combat, fire fights, ambushes, or crashes?• Were you wounded, captured, interrogated, or tortured?• Did you experience firsthand the injuries/deaths of buddies?• Were you close to/affected by explosions, IEDs, RPGs, etc.?• Were you close to, or exposed to, any toxic substances, chemicals, gases, smoke (e.g., Agent Orange, burn pits, burning oil wells, CBR agents such as nerve gas, depleted uranium ammunitions, etc.)?• Did you ever witness or participate in any actions/ events so horrible that you cannot now think or talk about them?• For both sexes, but especially for female troops, were you ever sexually assaulted, molested or harassed?• Since your return, have you experienced or exhibited any unusual agitation, sleeplessness, nightmares, flashbacks, survivor guilt, thoughts of persecution or of self-destruction, substance abuse, difficulty concentrating, memory deficits or slowness of thought, or fits of anger or domestic abuse?

S U M M E R 2 0 1 5

This list may not be all-encompassing, but it does cover a wide spectrum of potential service-connected problems and will give the physician leads as to what is most important for this particular veteran. If you find yourself out of your depth, that may be a good point at which to start a non-judgmental “teaching moment” to let the patient know you empathize and want to get him or her the best care and treatment they truly deserve. Official sources of care for such individuals may be found online at the US Department of Veterans Affairs (www.VA.gov), by contacting the nearest VA Medical Center (e.g., Coatesville VAMC at www.coatesville.va.gov/services/index.asp), a VSO (veterans service officer) through any of the major veterans’ organizations (American Legion, VFW, Vietnam Veterans of America, Marine Corps League), the Chester County Office of Veterans Affairs, or, especially crucial if there is any suggestion at all of suicidal ideation, the VA’s Crisis Line at 1-800-273-8255.

John P. Maher, MD, MPH, is the former director of the Chester County Health Department, a long-time member of the Chester County Medical Society Board of Directors, and a Vietnam veteran.

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Feature

Each generation of American warriors has apparently had its own unique kinds of toxic exposures. In World War I the use of chlorine gas and blister agents was rampant. World War II saw the widespread use of napalm, white phosphorous, poison gases in the concentration camps, and ultimately nuclear weapons. Soldiers deployed to Iraq were heavily exposed to the toxic fumes and smoke of multiple burning oil wells set ablaze by Iraqi troops, to American ammunition containing depleted uranium (or DU), burn pits, burning vehicles and diesel fumes. Further, the U.S. Department of Defense (DoD) estimates that up to 100,000 soldiers may have been exposed to low-level nerve gas residues after American troops uncovered, and destroyed, the storehouse of chemical-filled rockets at Kamishayah, Iraq. The medical controversies over the requirements for deployed troops to receive mandatory anthrax and smallpox vaccinations, and to use an anti-malarial medication with worrisome side effects, are generally well known and will not be discussed here. We would be remiss, also, if we failed to at least mention the heavy use in all our recent wars of alcohol, tobacco, marijuana, and heroin, easily available to soldiers for purchase through the local population, particularly in Southeast Asia and the Middle East.

Somewhere Under the Rainbow BY JOHN P. MAHER, MD, MPH

One of the more important questions when performing a medical screening of current or former U.S. military is whether the patient had been exposed to any toxic chemicals, smoke, or residue. The reason for that question, and the need for the physician’s awareness, has become clearer with the passage of time and the slow amassing of (suggestive if not probative) data related to subsequent health issues, not only of the exposed soldiers themselves but now even the potential health effects among their children (2nd generation effects) and grandchildren (3rd generation effects).


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Maher

The main focus of this article is on the so-called “rainbow chemicals,” a spectrum of powerful herbicides sprayed heavily in rural Vietnam, especially during the years 1962 through 1971 in the strategic U.S. plan the military called “Operation Ranch Hand.” Allegedly inspired by the British use of such chemicals as part of their “Malayan Emergency” in the 1950s, Operation Ranch Hand used C-123 and C-47 aircraft equipped with specially designed spray tanks, each with a capacity of 1,000 gallons, in an attempt to defoliate huge areas of Vietnam and thus deny the Viet Cong cover and concealment and expose them to allied attacks and firepower. Every Ranch Hand foray consisted of 3 to 5 planes, flying side-by-side, each spraying a swath of land 80 meters wide by 16 kilometers long in about 4.5 minutes. Not only forest canopy, but soldiers, civilians, field crops, water supplies, and farm animals, as well as any “insurgents” in the area, would be affected either directly or indirectly. Official U.S. estimates state that 20 million U.S. gallons of herbicides (in amounts often 50 times their intended agricultural use) were sprayed on rural areas of Vietnam. Over the length of the war, some 2.8 million

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American military were rotated through the country (“boots on the ground”), exclusive of Navy, Air Force, and outside support personnel. The agents used made up a spectrum of herbicides known as the “Rainbow Herbicides” because the different chemicals were identified/recognized by the specific color bands around the barrels of toxins. The list included: Agent Pink, Agent Green, Agent Purple, Agent Blue, Agent White, and, of course, Agent Orange. Of most frequent concern are Agent Blue and Agent Orange. Agent Blue was a mixture of two potent arsenic compounds, cacodylic acid and sodium cacodylate, used from 1961 to 1971. Agent Orange comprised a mix of 50% 2,4-D, and 50% 2,4,5-T, used from 1965 to 1970. A large percentage of the 2,4,5-T was also contaminated with tetra-chloro-benzo-dioxin, a known human carcinogen. Veterans’ diseases and conditions, if related to their active service, deserve to be identified and made part of their records so they can receive the care and compensation due them. So, now, in 2015, the list of Presumptive Service-Connected Illnesses Recognized by the U.S. Department of Veteran Affairs (VA) as connected to actual in-country service (and by inference to such herbicide exposures) includes the following:

• Acute, sub-acute, or chronic peripheral neuropathy• Adult onset Type II diabetes mellitus• AL amyloidosis• Amyotrophic lateral sclerosis• Chloracne• Hodgkin’s disease• Parkinson’s disease



• Porphyria cutanea tarda• Spina bifida (open in children born with VN exposure)• Numerous types of cancers, especially prostate, respiratory, and soft tissue sarcomas• A variety of birth defects in children of female veterans

For a list of the specific entities covered, check the VA website for updated information. Recent genetic and epigenetic research is causing increased pressure on the VA and DoD to recognize the potential for patrilineal telomeric transmission of many congenital defects and malformations in offspring of male veterans without causing changes in the underlying DNA sequences of the cells. This issue is not closed, but as Vietnam veterans age and die off, there are fewer and fewer remaining alive to participate in the necessary research to provide proof of such second and third generation effects. Meanwhile, the VA’s list also shows numerous other conditions claimed by veterans as putative effects of Agent Orange, but for which there is no real proof at this time. Many veterans claim that some of the worst affected were either killed in combat or died or committed suicide since the war so their evidence has been lost. Those interested may find much more information at the websites of the VA, DoD or VVA.

John P. Maher, MD, MPH, is the former director of the Chester County Health Department, a long-time member of the Chester County Medical Society Board of Directors, and a Vietnam veteran.

Maher

Somewhere Under the Rainbow Continued from page 11

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Feature

Foundation Offers Scholarships to PA Medical Students

Applications Accepted July 1–Sept. 30, 2015

The Foundation of the Pennsylvania Medical Society offers several scholarships available to Pennsylvania residents enrolled in fully accredited medical schools.

“We recognize that medical students play a vital role in the future of medicine in Pennsylvania so we proudly administer scholarships to deserving students across the commonwealth,” said Executive Director Heather Wilson. Additional scholarships are offered throughout the year and information can be found on the Foundation’s website at www.foundationpamedsoc.org. The following scholarships accept applications July 1 through Sept. 30, 2015:

ACMS Medical Student Scholarship Application Available Allegheny County Medical Society (ACMS) Foundation, in conjunction with The Foundation of the Pennsylvania Medical Society, is offering a $4,000 scholarship to third- or fourth-year Pennsylvania medical students from Allegheny County. Applicants must be U.S. citizens enrolled full time in an accredited Pennsylvania medical school. Allegheny County Medical Society’s mission is to provide leadership and advocacy for patients and physicians. The Foundation of the Pennsylvania Medical Society administers the fund for the ACMS Foundation, which encourages physicians to contribute to the scholarship to help area students offset the cost of medical education.

ACMS Foundation established the scholarship in 2004 and distributed its first award in 2007.

Scholarships Available for Blair County Residents Blair County Medical Society (BCMS), in conjunction with The Foundation of the Pennsylvania Medical Society, is offering two $1,000 scholarships to medical students who are residents of Blair County. These awards are available to second-, third-, and fourth-year medical students enrolled full time in an accredited U. S. medical school. BCMS established the fund in September 2013. The purpose is to assist Pennsylvania residents from Blair County with the cost of attending medical school.

Scholarship Available to Lehigh County Residents The Foundation of the Pennsylvania Medical Society in conjunction with the Lehigh County Medical Auxiliary’s Scholarship and Education Fund, Inc. is offering its $2,500 LeCoMASE Medical Student Scholarship award. Medical students who are residents of Lehigh County are eligible to apply. Additionally, students must be enrolled full time in an accredited U.S. medical school. The Lehigh County Medical Auxiliary’s Scholarship and Education Fund, Inc., established this fund within the Foundation to assist Lehigh County residents with the cost of attending medical school. Individuals are invited to contribute to the fund to secure its future.


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Scholarship Available for Lycoming County Residents Lycoming County Medical Society, in conjunction with The Foundation of the Pennsylvania Medical Society, is pleased to announce the availability of the 2015 Lycoming County Medical Society Scholarship. Multiple $3,000 awards are available to first- through fourth-year medical students who are residents of Lycoming County and enrolled full time in an accredited U.S. medical school. Lycoming County Medical Society established the scholarship within the Foundation and presented the first award in 2002. Contributions from Lycoming County physicians made the fund possible. The society provides education, networking, and legislative support for member physicians.

Scholarships Available for Montgomery County Residents Montgomery County Medical Society (MCMS), in conjunction with The Foundation of the Pennsylvania Medical Society, is offering two $2,500 scholarships to medical students who are residents of Montgomery County. These awards are available to first-year medical students enrolled full time in an accredited U.S. medical school.The awards are possible thanks to contributions from MCMS and area physicians. The MCMS mission is to represent and serve all physicians of Montgomery County and their patients in order to preserve the doctor-patient relationship; maintain safe, quality care; advance the practice of medicine; and enhance the role of medicine and health care within the community and across Montgomery County and Pennsylvania.

Foundation Offers Medical Student Scholarship to Berks, Lehigh, and Northampton County Residents The Foundation of the Pennsylvania Medical Society is offering its annual $1,000 Myrtle Siegfried, MD, and Michael Vigilante, MD, Scholarship to first-year medical students who are residents of Berks, Lehigh, or Northampton counties. Requirements include full-time enrollment in an accredited U.S. medical school. To help local medical students offset the cost of education, former Foundation trustee, Elena Pascal, and her sister, Carla Vigilante, established this scholarship in 1999 in memory of their parents who were prominent Allentown physicians. Scholarship for Students of South Asian Indian Heritage The Foundation of the Pennsylvania Medical Society is offering a $2,000 scholarship from the Endowment for South Asian Students of Indian Descent. Students must be of South Asian Indian heritage and enrolled full time in their

second, third, or fourth year at an accredited Pennsylvania medical school. Jitendra M. Desai, MD, and Saryu J. Desai, MD, Sewickley, Pa., initiated this scholarship within the Foundation in 2002 to provide an opportunity for South Asian Indian students who demonstrate academic excellence. They invite others to contribute to the fund to secure its future. In 2014, the Foundation awarded 21 scholarships totaling $50,500. The Foundation provided $445,000 in loans to 78 students across Pennsylvania. Since 1948, more than $19.1 million has been awarded to nearly 4,450 students in the form of loans and scholarships to assist with education costs. For information about these scholarships, call the Foundation’s Student Financial Services office at (717) 558-7852, or visit www.foundationpamedsoc.org.

The Foundation, a nonprofit affiliate of the Pennsylvania Medical Society, sustains the future of medicine in Pennsylvania by providing programs supporting medical education, physician health, and excellence in practice. It has been helping to finance medical education for nearly 60 years. The Foundation offers scholarships and low-interest loans for medical students.

Letters to the Editor:

If you would like to respond to an item you read in Chester County Medicine, or suggest additional content, please submit a message to [email protected] with “Letter to the Editor” as the subject. Your message will be read and considered by the editor, and may appear in a future issue of the magazine.


PAMED Legislative Update

For the first time since 2010, Pennsylvania did not have a new state budget in place when the fiscal year ended on June 30. Gov.

Tom Wolf, a Democrat, and the Republican-dominated state House and Senate remained far apart on several significant issues, including the state income tax, the state sales tax, a natural gas extraction tax, property tax reform and education spending, liquor privatization, and pension reform. On June 30 the House and Senate passed a no tax increase budget that did not address the governor’s proposed tax and spending increases, which Wolf promptly vetoed. Budget stalemates like these are not uncommon when control of state government is divided between the two parties, and while some are resolved quickly, others drag on for months. As of this writing, there is no way to predict how this will play out. However, while the budget debate continues, there has been movement in the House and Senate on a number of health care-related measures.

Pennsylvania Medical Society Quarterly Legislative Update

BY J. SCOT CHADWICK


Expanding Punitive Damages Cap

In 1996 the General Assembly enacted a cap on punitive damages that can be assessed against physicians in medical liability actions, limiting those awards to no more than 200 percent of compensatory damages. In other words, if a jury awarded a plaintiff $100,000 for medical bills, lost wages, and pain and suffering, an additional award of punitive damages, if warranted due to egregious conduct by the defendant, could not exceed $200,000. Although punitive damages are rarely awarded against physicians in medical liability actions, this provision can play an important positive role, primarily in settlement negotiations, by eliminating the calculation that a runaway jury might issue an award that bears little or no connection to the seriousness of the injuries suffered by a plaintiff. On June 25, 2015, the Senate passed SB 747, legislation that would extend this protection to personal care homes, assisted living communities, and long-term care nursing


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Chadwick

facilities, by a vote of 40-9. Three days later the House Judiciary Committee approved the bill, setting the stage for consideration by the full House. These entities have been under assault from personal injury lawyers in recent years, and are seeking the same protection extended to physicians 19 years ago. While PAMED supports the bill, we’re watching it closely to make sure it doesn’t also become a vehicle for trial lawyer-generated amendments that would be counterproductive and poor public policy.

Licensure Board Reporting

SB 538, which would impose new reporting requirements on state licensees (everybody from crane operators to landscape architects to physicians and other health care professionals) who run afoul of the criminal law or another state’s licensing body, is one step away from the governor’s desk. The bill will require anyone who holds a license, certificate, or registration issued by the Bureau of Professional and Occupational Affairs to, as a condition of licensure, certification or registration, report to their licensing board or commission within 30 days (1) any disciplinary action by a licensing agency of another jurisdiction; and (2) a finding or verdict of guilt, an admission of guilt, a plea of nolo contendere, probation without verdict, a disposition in lieu of trial, or an accelerated rehabilitative disposition (ARD) of any felony or misdemeanor offense and any drug or alcohol related summary offense. Depending on the nature of the action reported, the licensing boards and commissions would be authorized to issue temporary suspensions where warranted. In the case of a legal commitment to an institution due to mental incompetency or a felony conviction under Continued on page 18

the Controlled Substance, Drug, Device and Cosmetic Act (or its equivalent in another state), the suspension would be automatic. Approved 49-0 by the Senate on June 9, and 192-0 as amended by the House on June 28, all that remains is a Senate vote to concur with the House amendments. If enacted, the measure would go into effect in 60 days.

Oral Chemotherapy Insurance Coverage

Another bill that moved a step closer to enactment is HB 60, which provides that whenever a health insurance policy contains coverage for intravenously administered or injected chemotherapy medications to treat cancer, the policy may not provide coverage or impose cost sharing for an orally administered chemotherapy medication on a less favorable basis than the coverage it provides or cost sharing it imposes for intravenously administered or injected chemotherapy medications. The legislation would not preclude health insurance policies from requiring an enrollee to obtain prior authorization for the oral medication, and it only applies to oral chemotherapy medications where an intravenously administered or injected chemotherapy medication is not equally effective. That last point is controversial though, which could slow the process down. The bill, which passed the House 197-3 in February, was amended and approved by the Senate Banking and Insurance Committee on June 25, putting it in position for full Senate ratification. Senate approval would send the bill back to the House for concurrence in Senate amendments, a necessary step before the bill reaches the governor’s desk.


The same language is contained in SB 536, which passed the Senate 49-0 on June 28, and is now in the House Health Committee. As both chambers have overwhelmingly passed identical language, though in separate bills, it is clear that the measure has bipartisan, bicameral support, and one or the other is likely to reach the governor’s desk.

Pharmacists Administering Influenza Vaccine to Minors

On June 15, the Senate unanimously passed HB 182, legislation that will allow pharmacists to administer influenza vaccines to minors age nine and older. Because the upper chamber did not change the already House-passed bill, it went straight to Gov. Wolf, who signed it into law on June 26. Under the measure, pharmacists will have to obtain parental consent before administering influenza vaccine to anyone under age 18, and notify the minor’s primary care provider, if known, within 48 hours after administration of either injectable or needle-free vaccine. Finally, pharmacists who administer influenza vaccine to minors will have to carry professional liability insurance coverage in the minimum amount of $1 million per occurrence or claims made. PAMED had opposed earlier bills that were far broader in scope, but does not object to HB 182 in its current form. The bill will go into effect in 60 days, in time for the fall influenza vaccine push.

Impersonating a Physician Another bill signed into law by the governor is SB 485, which will increase the penalty for impersonating a physician. Under existing law, impersonating someone holding a professional license is a misdemeanor of the second degree, unless the intent of the actor is to harm, defraud, or injure anyone, which makes it a misdemeanor of the first degree. SB 485 makes impersonating a physician and then providing treatment or medical advice a first degree misdemeanor, regardless of whether or not the other person suffers harm. A second degree misdemeanor is punishable

by up to two years in jail and a fine of up to $5,000. A first degree misdemeanor is more serious, carrying a possible prison term of up to five years and a maximum fine of $10,000. The bill will take effect in 60 days.

Banning E-Cigarette Sales to Minors

Progress was also made during the June flurry on legislation restricting the sale of e-cigarettes. On June 15 the House unanimously passed PAMED-endorsed legislation that would ban the sale of e-cigarettes to minors. HB 954 would simply add “nicotine delivery systems,” specifically including e-cigarettes, to the existing law prohibiting the sale of tobacco products to minors. The following day the Senate moved a similar bill, SB 751, into position for consideration by that chamber in the near future, signaling that one of the two bills stands a good chance of making it to the governor’s desk.

Controlled Substances Database Update

On October 27, 2014, Gov. Corbett signed Senate Bill 1180 (now Act 191 of 2014) into law, authorizing the creation of a statewide controlled substance database. The system, which will be a valuable tool for prescribers and dispensers of opioid medications to identify doctor-shopping patients, was supposed to be up and running by June 30, 2015. However, the legislature did not appropriate any money to fund the construction and operation of the database, and the process is behind schedule. Gov. Wolf has included $2.1 million in the 2015-2016 state budget to cover those costs, and legislative leaders seem to be supportive. However, those funds may be held up until the budget battle is resolved. Administration officials have signaled that they hope to have the database operational by the end of the year.

J. Scot Chadwick is legislative counsel for the Pennsylvania Medical Society.


Chadwick

Pennsylvania Medical Society Quarterly Legislative Update Continued from page 17

Chester County Overdose Deaths:Increasing Awareness of a Preventable Problem

BY KIMBERLY E. STONE, MD, MPH

Did you know that there were more deaths from overdoses than from motor vehicle crashes in Pennsylvania in 2011? While heroin and other illicit drugs account for many

overdoses, prescription pain medications are often involved as well. Nationally, prescription medications were responsible for more than half of all drug overdose deaths in 2013. While some may obtain these medications illegally, prescriptions for opioids have quadrupled from 1999–2013, thus many benzodiazepine and opioid drugs are obtained by prescription. An increase in overdose deaths has mirrored the increase in prescription painkillers over the same time period (see graph.)

This is the first article in a three-part series focusing on the local impact of the overdose epidemic.

Stone


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Feature


Chester County Overdose Deaths Continued from page 19

Overdose deaths are a growing problem in Chester County as well. In 2014 there were 82 overdose deaths reported in Chester County, a sharp increase from the previous two years. Close monitoring of Chester County coroner data is ongoing to determine if this trend will continue. Over half of those individuals who overdosed had opioids in their system at the time of death. Another growing concern is the combination of opioids with sedatives, such as benzodiazepines and alcohol. These combinations can increase the respiratory depressive effects of opioids and increase the risk of death from overdose.

Source: PA State Coroners’ Association Drug Report 2014



Feature

Chester County, while one of the healthiest in the Commonwealth, is not immune to the problem of overdose. The first step in solving a problem is being aware that one exists, so please share this information with your staff and your patients. Together we can decrease this preventable cause of death and improve the health and well-being of Chester County residents.

The Overdose Epidemic Watch for the continuation of this series in the Fall 2015 and Winter 2016 issues of Chester County Medicine.

• Part 2: Review of Pennsylvania Legislation and Opioid Prescribing Guidelines: The Impact on Health Care Providers in Chester County• Part 3: Chester County Drug & Alcohol Services: Prevention and Treatment using a Multidisciplinary Approach

Resources:1. PA State Coroners’ Association Drug Report 20142. PA State Coroner’s Heroin Drug Report 2009-20133. Chester County Coroner’s Report: 2012, 20134. Heroin: Combating this Growing Epidemic in Pennsylvania, September 20145. www.cdc.gov/drugoverdose6. www.getnaloxonenow.org7. http://www.cdc.gov/vitalsigns/heroin/index.html

Kimberly Stone MD, MPH, is the public health physician for the Chester County Health Department. She is a pediatrician with a master’s in public health in injury prevention and volunteers at Community Volunteers in Medicine. You can contact her at 610-344-6230 or [email protected].

Continued from page 19


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Stone


The Art of Chester County

BY BRUCE A. COLLEY, DO

Mark Dance’s life has been shaped by an artistic heritage that began in the 1700s and continues to the present day. Dance

is a direct descendant of the 18th century English artists and architects, Nathaniel and George Dance. Nathaniel Dance, a founding member of the Royal Academy, is known for a portrait he painted of King George III and his Queen as well as Captain James Cook. Nathaniel’s son, George, painted a well known portrait of Captain William Bligh and succeeded his father as city surveyor and architect in 1768. These early Dances influenced as much as 30 percent of London’s architectural layout. “The Brandywine Tradition” has been a constant influence for Mark Dance throughout his life. Mark’s father, Robert Dance, studied at the Philadelphia Museum College of Art, where he thrived under the instruction of Henry Pitz, the well-known early 20thcentury illustrator who authored books on Howard Pyle and the Brandywine School. Robert Dance is today known to be one of America’s premiere maritime realists.

Chester County


The Art of

“Draper’s Barn” 36" x 30" oil on canvasThis barn has stabled horses for many generations. It sits overlooking the Twin Bridges meadow on the Brandywine River in Chadds Ford.

On Cover: “Pears and Pansies” 13" x 10 ¼" oil on masonite After sitting in on a few painting sessions with Chester County artist Sarah Lamb, I returned to my studio and set up this still life. Fresh from Sarah’s kind guidance, this painting came quite quickly and with ease. I doubt I could paint one again with such enthusiasm. I encourage anyone to look at Sarah Lamb’s work. Only a few can equal her talent.

“Chester County Morning” 30" x 36" oil on canvasThis is a view from my home looking towards Chadds Ford. It is a very hazy morning, themist of the Brandywine river slowly lifting in the distance and a sliver of sun is breakingthrough an overcast sky. A farmhouse and distant hillside is the first to be warmed by its light.


Colley

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“Southern Belle” 14" x 11" oil on masoniteThis is the mantle above our fireplace. The beam is hand hewn and I tried to capture the characteristics of how a workman, an artist, has shaped the beam. On the beam sits an 18th century wrought iron “courting candle” and below stands the bell.

“A Shady Field” 13" x 9" watercolor What traveler ventures through Chester County without appreciating the land that is set aside for farming or equine enthusiasts. We are truly fortunate for the many properties that are protected by the BrandywineConservancy and their efforts ensuring open space for future generations.

“Evening Above the Big Bend” 50" x 48" oil on canvasThe moment passes in an instant, a moment just before the sun sets over the hills ofthe Brandywine Valley. The end of Winter. An energy and life force has been stored inthe tree’s branches and Earth’s ground once frozen solid, about to explode inanticipation of Spring.




Colley

After receiving his bachelor of fine arts degree from Virginia Commonwealth University, Mark began painting in Chester County and came under the guidance of Rea Redifer. Redifer attended the Wyeth School in Chadds Ford with Carolyn Wyeth. Today, Mark paints in his studio in West Chester, Pennsylvania where his lives with his wife, Kristin, and their children, Caroline and Spencer. Summer in Chester County is captured in both oil and watercolor by Mark. Most Chester Countians live within walking distance to green fields, farms, or walking paths. The warm humid days emit the pungent effluvia of the lush vegetation; soft breezes propitiously trigger bellows

of strawberry or honey that tumble through the air. Time seems to slow down in the summer. The close warm air forbids intense motion. Mother Nature is directing us to be still for a time and immerse and direct all our senses toward the air, light, and smells of summer. Mark captures the summer season of the Brandywine Valley’s bounty and fertile ground with a palate that is breathtaking. Enjoy his art, and take time to seek out a Chester County “summer place” of your own.

Bruce A. Colley, DO, is vice president of the Chester County Medical Society.

“Pennsylvania Landscape” 30" x 28" oil on canvasThis is a painting that began as a study of the wonderful reds and purples during the approach of Fall. Then it became a never ending struggle of cloud formations and shadows upon the hillside. I eventually burned this painting because it became a tug of war between two ideas. Looking back, I feel strongly that fire can be a cleansing remedyto an endless effort in futility. I’ve burned my easel before.

“Twin Bridge Over the Brandywine” 24" x 28" oil on canvasThis bridge spans the Brandywine river in Chadds Ford. Its meadow is a compliment of wildflowers at all seasons of the year.

The Art of Chester Continued from page 23

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Anti-Thrombin AgentsBlessing or a Curse?

Part IIBY ZARSHAWN AND MIAN JAN

In part one of this article, which was published in the spring 2015 edition of Chester County Medicine, we discussed the anticoagulants. In part two, we are

going to present the new anti-platelet agents. In figure 1 we have listed both generic and trade names of these drugs; it is important to remember both because nomenclature exists in either form. Acute coronary syndromes, which are a spectrum of unstable angina, non STEMI, ST elevation MI, and stroke, are the biggest killers in the western world. As figure 2 states, there are 525,000 new MIs and 190,000 recurrent MIs each year; there is also one MI every 44 seconds and one person dies every four minutes from an MI. Grace’s observational study of almost 47,000 patients also showed that even in the first 180 days after an event mortality is high, at 6.2% for non STEMI and 12% for STEMI.

Pathophysiology

Atheromatous plaque builds over decades but only becomes life threatening when it becomes unstable and ruptures. Platelets play a major role in this process. Platelets rush to the site of rupture and adhere to the site and become activated, activation results in formation of spikes on the surface of platelets and the natural ovoid shape is transformed. When activated ADP is released, which stimulates and enhances P2Y12 receptors on platelets to link, which results in aggregation; and ultimately thrombus formation, which results in ACS. Anti-platelet agents play a major role in inhibiting and preventing this process.

Figure 3 is a cartoon presentation of this process and figures four through seven are micro images of the cycle.

Figure 1: Oral Anti-Thrombin Agents.

Figure 2: Acute Coronary Syndromes.

Figure 3: Pathophysiology of ACS.



Feature Jan & Jan


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Figure 5: Platelet Aggregation.

Figure 6: Platelet Activation.Figure 7: Cardiovascular Death.

Figure 8: Timeline of FDA Approval of Select OAP’s in the Treatment of ACS.

Figure 9: Mechanism of Action of Oral Antiplatelet Therapies.

Figure 4: Plaque Rupture.

Mechanism of Action Figures 8 and 9 list the oral anti-platelet agents available to us and when they were approved along with their site of action. Aspirin irreversibly inhibits cyclooxygenase (COX). Inhibition of COX 1 results in erosions in the stomach and inhibition of COX 2 results in decreased prostaglandins and inflammation, and thus less pain. Cyclooxygenase inhibits thromboxane A2, which enhances platelet aggregation. The newer agents, clopidogrel, prasugrel, and ticagrelor, although pharmacologically different, have somewhat similar mechanisms of action on P2Y12 receptors and aggregation of platelets as explained before. Prasugrel and clopidogrel are thienopyridines and ticagrelor is a cyclopentyl-triazolo-pyrimidine.




Figure 10: CURE Trial. Figure 11: Trials of Clopidogrel.

Figure 12: Triton-Timi 38. Figure 13: Triton-Timi 38.

Trials of Newer Anti-Platelet Agents

Clopidogrel CURE was the landmark trial which led to the approval of clopidogrel in acute coronary syndrome. CURE showed an additional 20% benefit over aspirin in ACS. Since CURE, multiple trials (figure 11) have shown benefits of clopidogrel.

Prasugrel

Triton-Timi 38 was a randomized double blind trial of over 13,000 patients with primary end point of cardiovascular death, MI, and stroke, and safety end point of major bleeding, comparing clopidogrel with prasugrel. The trial was very favorable towards prasugrel (figure 13) and showed a decrease in MACE from 11% to 8.3% and was thus approved for patients with ACS that went to an invasive strategy.

Anti-Thrombin Agents Blessing or a Curse? Continued from page 27

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Jan & Jan


Zarshawn Jan is a first-year medical student at Drexel Medical School, who wrote this article under the guidance of Mian A. Jan, MD, an interventional cardiologist practicing in Chester County.

Figure 14: PLATO Trial.

Figure 15: PLATO Trial.

Ticagrelor

PLATO was a randomized double blind trial of over 18,000 patients, comparing ticagrelor with clopidogrel; again primary end point was cardiovascular death, MI, and stroke. The safety endpoint was major bleeding. At twelve months there was 16% relative risk reduction in the ticagrelor group and 89 fewer deaths occurred in comparison to clopidogrel. The stent thrombosis was also reduced by 33%. The drug was effective both in invasive and medical strategy.

Side Effects & Warnings

All anti-platelets increase bleeding risks. As seen in figure 13 of the TITRON trial prasugrel increases the bleeding risk from 1.5 to 1.9%. Similarly, ticagrelor increases the bleeding risk from 11.2 to 11.6% over the duration of the PLATO trial. (A different criteria of bleeding were used for the TRITON and PLATO trials). Prasugrel should also not be used on patients with body weight less than 60kg, age more than 75 years, and in patients with history of stroke. Ticagrelor should only be used with aspirin doses of less than 100mg and should not be used on patients with moderate to severe hepatic impairment. Both of these drugs should be avoided in inhibitors and inducers of CYP3A4 (anti-fungal, anti-viral, anti-convulsant drugs). Dose of statins Simva and Lova should not exceed 40mg. Two side effects that need to be watched with ticagrelor are dyspnea and bradycardia, which were increased and maybe related to its ADP effect.

Summary

The newer anti-platelet agents have considerably increased our capability against acute coronary syndrome, but need to be used with caution since the bleeding side effects have also increased with increased anti-platelet effect. In circumstances where ACS does not have high risk features, we should continue to use the old gold standard of clopidogrel, which is also economically prudent.



From Volume to Value: BE PREPARED

BY RACHEL DAMRAUER, MPA

Many physicians — regardless of practice type, setting, specialty, or geographic location — are filled with uncertainty due to the multitude of changes to the health care delivery system. One of the new buzz phrases physicians and other health care providers have been hearing more of lately is “volume to value.”

Since the inception of the Affordable Care Act, we have seen an evolution in health care delivery models involving value-based reimbursement. The transition from volume to value denotes many things, but in short, it means the methodology behind physician reimbursement is changing. For the first time in the history of the Medicare program, in January 2015, the U.S. Department of Health and Human Services announced goals and a timeline to shift Medicare reimbursement toward paying providers based on the quality of care they give their patients, rather than quantity (fee-for-service).



Feature


Publishing GroupHoffmannPublishing.com

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“Pears and Pansies” by Mark Dance FEATURED ON PAGE 22

PROTECTING PATIentS

SODIUM RESTRICTION:

A TIME-HONORED DOGMA OR

AN EVIDENCE-BASED PURSUIT?

IN CHESTER COUNTY FROM

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Chester County Overdose Deaths:

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and Practice Managers, and 25,000+ Engaged Consumers

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Bottom-line: The transition from volume to value is coming and faster than many anticipated, and it will take investments of your time, energy, money, and the learning of new skill sets to be successful. Value-based reimbursement also requires sophisticated, data-driven business decision making, with an emphasis on improving quality and the cost effectiveness of care. “A practice moving from volume to value needs people with many skill sets — someone focused on data interpretations; someone to predict financials; a clinical, quality-focused individual; and someone who is good at project management — to move forward,” said Tracey Glenn, director of practice management consulting for PMSCO Healthcare Consulting, a subsidiary of the Pennsylvania Medical Society (PAMED). Glenn says the key strategies for success in moving from volume to value include:

• Choosing a leader or leadership team who can clearly identify goals and move the organization toward achieving them• Communicating clearly and regularly with the entire health care team• Developing a dashboard or using your EHR’s dashboard functions to share data with everyone• Creating a positive culture focused on continuous quality improvement in patient care and outcomes

• Offering professional development and training to assist in achieving goals• Including staff in redesigning the processes needed to achieve goals• Celebrating successes and revisiting areas that need work

To implement new care delivery models successfully, providers also need to develop a set of core strategic competencies. According to IBM Global Business Services, these include:

• Empowering and activating patients to assume more accountability and make better, more informed health and lifestyle decisions• Collaborating to integrate health care delivery across traditional and non-traditional care venues• Innovating in operational processes, business models, products, services, and organizational culture• Optimizing operational efficiencies in both administrative and clinical processes• Enabling information technology in order to achieve high-value care, efficient operations, and effective management and governance

“Of course, implementing these core strategies also takes money, time, and the acquisition of new skills for

From Volume to Value: Be Prepared Continued from page 30

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physicians, while simultaneously placing constraints on the payment rates dictated by current law,” said Dennis Olmstead, chief strategy officer and medical economist at PAMED. “All alternative payment models and payment reforms that seek to deliver better care at lower cost share a common pathway for success. Providers must make fundamental changes in their day-to-day operations that improve the quality and reduce the cost of health care. Skills will be needed by all providers to navigate these new delivery systems and payment strategies.”

So, how can you prepare yourself and be ahead of the curve?

A new innovative educational series of online, on-demand courses and live workshops from PAMED can help ensure you have the skills necessary to succeed in the transition from volume to value. Learn more, including the curriculum, and register at www.pamedsoc.org/valuebasedcare. Earn up to 1 hour of CME for each online course and up to 5 hours of CME for each live workshop. This series is facilitated by PAMED member Ray Fabius, MD, a nationally respected expert in quality and population health. Dr. Fabius was spurred to action several years ago when, as a practicing pediatrician in Philadelphia, he was visited by a local medical director. “I was stunned when I learned that this medical director knew more about my practice than I did,” Dr. Fabius said. “He had information that compared my performance on quality, on utilization, and even information on my patient satisfaction. I never again wanted to have someone else know more about my practice than I did.” Learn more at www.pamedsoc.org/Fabius. This series is designed to help prepare health care providers for the future when reimbursement is based on outcomes, data and analysis are paramount, and population health is the focus. “As we move toward value-based delivery systems, the focus shifts from volume to cost and quality,” said Pittsburgh Regional Health Initiative’s Chief Medical Officer Keith Kanel, MD, MHCM, FACP. “Physicians must outfit themselves with new skills for modern challenges, and the PAMED program will provide the toolkit.”


Damrauer

What’s leadership got to do with it and where can I hone my leadership skills?

“What’s needed [to be successful in the transition from volume to value] to tie all of these team members and skill sets together is a strong leader,” said Glenn. In addition to the volume to value educational series, PAMED also offers many leadership resources to Pennsylvania physicians through its Leadership Skills Academy. The Leadership Skills Academy includes a year-round leadership academy; online, on-demand courses; onsite training; and discounts on national seminars and conferences. Learn more at www.pamedsoc.org/leadershipacademy. “If we [physicians] don’t lead or at least participate in change, it will occur without us, and I’ll wager to our detriment,” said Gus Geraci, MD, consulting chief medical officer at PAMED.

Rachel Damrauer, MPA, is associate director of communications for the Pennsylvania Medical Society.



Feature

ICD-10 is here.

BY SIVA MAHALINGAM

After being delayed twice, ICD-10 is finally supposed to be implemented by all healthcare organizations by October 2015. There are many enhancements and improvements

to ICD-10 compared to ICD-9. Although ICD-10 has been around for nearly two decades, we are adopting it only now. The new ICD-10 will have more than 68,000 codes compared to approximately 18,000 codes in ICD-9. Some major advantages of ICD-10 include:

• Improved disease management• It is very specific to the body part and site• Addresses the issue of laterality (right or left)• Improved coding accuracy and richness of data for analysis• Improvement in medical research• Supports interoperability and exchange of health data among different systems• HIPAA compliant

There are significant differences in classification, terminology, meaning and definitions between ICD-9 and ICD-10. Implementing ICD-10 will be no easy task. It takes a great deal of planning and execution, and time, money and resources to get it implemented by the deadline. The Center for Medicare and

Medicaid (CMS) has come up with the following implementation plan with six phases:

1. Planning2. Communication and awareness3. Assessment4. Operational implementation5. Testing6. Transition

For a better understanding of the challenges facing U.S. Markets, we can review a list of expected and unexpected outcomes from Canada‘s implementation of ICD-10 between 2001 and 2005.Unexpected outcomes

• Underestimation of how much work was involved • Both timelines and budgets were grossly underestimated • Magnitude of change was underestimated

Expected outcomes • Training of coders alone is not sufficient • Physician involvement is crucial • Physician should correctly document all clinical aspects of the patient

Is Your Organization or Practice Ready?


ICD-10 is here. ICD-10 will impact the following people and technology: • Physicians • Billers and coders • Clinicians • Information system and technology • Software vendors • Billing system • Documentation

All current systems that use ICD-9 will be affected by the change, as it includes applications, software interfaces, state, federal and other reporting, vendor applications, internal and external interfaces, etc. It will also impact processes, systems, operations and finances. Of special note, financial impacts include:

• Initial revenue decrease • Payment error rate due to errors in implementation • Payment delays due to claim rejections

Enterprise outreach, education and communication is very crucial to the success of the project. We recommend you complete your own enterprise readiness self-assessment questionnaire, as it’s not too early to prepare for the ICD-10 transition.

Are You Ready?• My facility has an implementation timeline • My facility has an interdisciplinary steering committee • Executive management is aware and supportive • My facility has a communication plan • My facility has completed an inventory of all systems affected • My facility has created a budget for implementation • My facility has a training plan

Your assessment should include a full review of your systems and applications, vendor readiness, ICD-10 training, technology, people and processes.

Siva Mahalingam is the President of Cube Info Solutions, an IT consulting firm specializing in healthcare IT.

Mahalingam

Ask a Physician:

If you have any medical questions for a physician member of the Chester County Medical Society, please submit an inquiry to [email protected] with “Ask a Physician” as the subject. Your question will be forwarded to a physician and may be featured with an answer in a future issue of the magazine.



Feature

PAMED and Chester County Medical Society (CCMS) membership supports you and your community in many ways. Membership in both Societies provides an indispensable resource for information, continuing education, distance learning, professional contact, and networking.

PAMED offers practice management courses and refreshers on patient care. As leadership development is hard to find, PAMED presents webinars, online courses, conferences, and seminars for the benefit of its physician members. PAMED advocacy has an inside track on legislative and executive proposals on need-to-know issues so we can keep members like you fully informed.

CCMS works collaboratively with PAMED, but its focus is on the local Chester County community. Some specific benefits of membership in CCMS include:• An opportunity to sign up for the PAMED “Find a Physician” program to promote your practice• Representation with local legislators• An annual meeting which provides you with the opportunity to impact your Society’s activities and goals• A legislative dinner, known as “The Clam Bake,” where you can meet with local legislators in an informal setting• An automatic subscription to Chester County Medicine magazine, the Society’s new twist on its longtime quarterly publication, and• Access to DocBookMD®, an exclusive HIPAA-secure messaging application for smart phone and tablet devices.

CCMS Membership: Resources You Need

Building

Better

Practices

and Stronger

Communities

One Member

at a Time

For additional information about becoming a PAMED and CCMS member, visit

http://www.pamedsoc.org/membership and click “Join PAMED,”

email [email protected], or call ( (717) 909-2684.

To renew your current membership, visit http://www.pamedsoc.org/membershipand click “Renew your membership.”

Membership is available only for physicians licensed to practice in Pennsylvania.

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FOR RESIDENCY & FELLOWSHIP, YOU MUST GIVE ACTUAL OR PROJECTED ENDING MONTH & YEARBEGIN DATE END DATE

Residency__________________________________________________________________ __________ -_________Fellowships_________________________________________________________________ __________ -_________License: PA No. Date Issued

PROFESSIONAL DATAPresent Type of Practice (Check Appropriately): Owner of Physician Practice Group Name ___________________________________________________ Employed by Hospital/Health System Employed by Physician(s) Group Name ___________________________________________________ Employed by Industry or Government Independent Contractor Other (specify) _________________________________________________

Specialty:

Within the last 5 years, have you been convicted of a felony crime or is your license to practice medicine actively suspended or revoked? If yes, please provide full information._________________________________________________________________________________________________________________________________________________________________________________

Yes No

DATE SIGNATURE

RETURN TO: Pennsylvania Medical SocietyATTENTION: Member Services

QUESTIONS? Call (800) 228-7823

FAX: 717-558-7840MAIL: 777 East Park Drive

PO Box 8820Harrisburg, PA 17105-8820

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Frontline GroupsFrontline Groups with 100 percent membership in CCMS are the backbone of the society. We are thankful for their total commitment to CCMS. This list reflects the Frontline Groups as of July 13, 2015.

Members in the News

To publish photos ofnew CCMS member physicians, please submit digital copies to [email protected]

We would like your help in touting the accomplishments of Chester County physicians. If you receive an

award or certification or have other good news to share, please submit it to [email protected].

Academic Urology-West Chester

Brandywine Gastroenterology Associates Ltd.

Cardiology Consultants of Philadelphia-Main Line

Cardiology Consultants of Philadelphia-Paoli

Cardiology Consultants of Philadelphia-West Chester

Chester County Eye Care Associates PC

Chester County Otolaryngology & Allergy Associates

Clinical Renal Associates-Exton

Family Practice Associates of West Grove

Gateway Endocrinology Associates

Gateway Family Practice Downingtown

Gateway Internal Medicine of West Chester

Gateway Medical Colonial Family Practice

Gateway Myers Squire & Limpert

Great Valley Medical Associates PC

Levin Luminais Chronister Eye Associates

Main Line Dermatology

Medical Inpatient Care Associates

Plastic & Reconstructive Surgery of Chester County PC

Village Family Medicine

West Chester GI Associates PC

Membership News & Announcements

Save the DateThe annual Chester County Medical

Society Clam Bake is an opportunity for the legislators and physicians of Chester County to discuss current medical policy issues and

enjoy a casual sumptuous dinner.

Join usFriday, September 11, 2015

6:00 pm - 9:00 pm

At the beautiful Radley Run Country Club Clubhouse Dining Room

https://www.radleyruncountryclub.com

Refreshments and hors d’oeuvres will be servedon the patio at 6:00 pm, followed by a delicious

buffet of clams, filet mignon, shrimp, crab, tilapia,chicken, and fabulous desserts.

Mark your calendar now and watch for registration information soon.




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Documents

Chester County Medicine | Summer 2015