Memphis Medical News November 2014

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FOCUS TOPICS RADIOLOGY/IMAGING HEALTH EDUCATION MENTAL HEALTH

BY RON COBB

At the Endocrine & Diabetes Clinic in Cordova, you can call Joe Chiarella the prac-tice manager, the offi ce manager, the offi ce director or the practice director, but fi rst and foremost call him a leader.

“I’m not going to tell you I think I’m a born leader,” he said. “That kind of seems like I’m breaking my arm patting myself on the back. But I’ve never had any issues with

people following me. Anytime I’ve been put in a leadership position, I’ve succeeded.”

Chiarella, 40, joined the clinic in January. It is his fi rst civilian job since he was in high school in Rockland County, New York, where he was raised by his single father, a butcher by trade. In the intervening 23 years, Chiarella served as an Army medic for 15 years, includ-ing tours in Kosovo and Iraq, and then as a military instructor teaching such skills as tacti-

(CONTINUED ON PAGE 6)

HealthcareLeader

Joe ChiarellaWar vet brings military-style leadership to clinic

Daniel S. Boyd, MD

PAGE 3

PHYSICIAN SPOTLIGHT Doctors, Patients Feel

Sting of BCBS CutsContract amendment imposes diffi cult decision on physicians

BY EMILY ADAMS KEPLINGER

Health insurance is costing everyone more these days, and physicians are no exception.

In fact, the pinch for many Memphis-area doctors has been quite painful indeed.Physicians received notice from Blue Cross Blue Shield of Tennessee (BCBSTN) last

November that the insurance company was making a unilateral amendment to its contract with physicians. The amendment stated that physicians would receive a 48 percent reduction in the reimbursement cost, set by 2013 Medicare payments standards, for all services deemed “in-offi ce physician lab services” by BCBSTN.

The amendment went into effect on Jan. 1 of this year. At the time of the notice, physi-cians were given until Dec. 20, 2013, to decide whether they would accept the amendment ... or not. And if not, they would no longer be in the BCBS system. The threatened termination from the network was for all services, not just for lab services.

Approaching the one-year anniversary of this contractual change, the impact of this amendment is clear.

For most physicians, the choice was not a choice at all. Blue Cross Blue Shield is the largest insurance carrier in Tennessee. The average patient load for physicians’ practices includes 30 to 50 percent BCBSTN patients. Not acquiescing to the unilateral amendment change meant that doctors’ patient loads were going to be signifi cantly reduced. That was a gamble that most physicians were not in a position to make.



Memphis Doctor’s Novel Paints Gloomy Picture of HealthcareOne look at the chapter titles in the novel The End of Healing by Jim Bailey, MD, makes pretty clear his grim message about the current state of the American healthcare system ... 7

Use of Scribes to Give Doctors Relief Is on Upswing How are front-line Memphis doctors going to continue to maintain good medical practice, avoid burnout, increase revenue and maximize patient-doctor interaction in the new era of dwindling reimbursement, primary care physician shortages, increased numbers ... 10

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Daniel S. Boyd, MDYoung patient’s intriguing story drew Memphian to psychiatry

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Addressing Complexity with Certainty

BY RON COBB

Daniel S. Boyd, MD, knew growing up in Memphis that he could scratch pro-fessional basketball from his list of career choices.

At Presbyterian Day School, he said, “I was the only one who distinguished him-self with having scored an equal number of baskets for the opponents – two points for them – followed three years later by my re-deeming hoop for the right team.”

But medicine was always a strong possibility, he said, “given my father.”

Boyd’s dad was a neurosurgeon. His mother was an English teacher until she stayed home full-time to care for him and his sister, Lundy.

“He introduced me, but did not push me, to medicine,” Boyd said, “reminding me of Tennyson’s Ulysses, who said of his son, ‘He works his work, I mine.’”

Boyd is a psychiatrist and, since 2011, medical director of the Neuroscience Cen-ter at Lakeside Behavioral Health System in northeast Shelby County. His primary duties there are supervising the transcra-nial magnetic stimulation (TMS) and elec-troconvulsive therapy (ECT) services.

Boyd decided on psychiatry as a spe-cialty during his pediatric internship.

“It crystallized for me when I was tak-ing the history of a 14-year-old who had just overdosed,” he said, “and I found her story much more intriguing than her labs.”

His father had been his role model, “but also his many physician friends whose stories fi lled our lives,” he said.

Aside from his internship at Baylor in Houston and residency at Vanderbilt, he has been in Memphis nearly his whole life, including medical school. However, his fi rst fi ve years of life included living

in Philadelphia while his father was in his internship at the University of Pennsylva-nia Graduate Hospital and in Minnesota while his father was in neurosurgery resi-dency at the Mayo Clinic.

After Vanderbilt, Boyd completed an 18-month contract with Chamberlin Clinic and then worked at Baptist’s and Methodist’s downtown locations.

“I slipped out the back door of down-town Baptist just before it imploded and headed to Lakeside,” he said. With roots sunk deeply in Memphis, he wasn’t going anywhere else. Not long after arriving at Lakeside, he married Teresa, his wife of nearly 16 years.

Lakeside, a 305-bed facility on 37 acres, opened in 1967, and its Neurosci-ence Center is in its fourth year. Boyd and three other psychiatrists at the center – Carl DaCunha, MD, John Harris, MD,

and Christopher White, MD – are all cer-tifi ed by the ISEN (International Society of ECT and Neurostimulation).

ECT has been around for more than a half-century, while TMS was approved only six years ago by the FDA for the treat-ment of depression. Boyd is enthusiastic about both, in the case of ECT “because of its robust effi cacy” and TMS “because of its excellent tolerability.”

Boyd called it a pleasant surprise when former Lakeside CEO Shelley Nowak brought in Charles H. Kellner, MD, for a full day of lectures to the staff on ECT. Kellner is a professor of psychiatry and director of the ECT service at Mount Sinai Hospital in New York. According to Mount Sinai, Kellner has dedicated his career to the study of ECT.

“He literally helped write the book on ECT,” Boyd said. “It was a delight to learn from such a great researcher and educator of national renown in the world of ECT.”

Boyd calls ECT the “ace in the hole for treatment of resistant depression, se-vere suicidal depression, psychotic depres-sion and catatonia from any cause.”

Most commonly, patients at Lakeside are treated for clinical depressions, bipolar disorders, addictions, dementias, PTSD and schizophrenia.

ECT hasn’t always been widely ac-cepted, at least in the public’s view, not to mention the stigma that depression carries. Just 42 years ago, Missouri Sen. Thomas F. Eagleton was dropped as pres-idential candidate George McGovern’s running mate when it came to light that he had received electroconvulsive treatment for depression.

“There is a lot of misinformation from Hollywood and the Scientologists,” Boyd said. “However, contrasting the vice presidential experience to which you refer is Kitty Dukakis writing a book about her being rescued by ECT.

“Another resource is Carol Kivler’s Will I Ever Be the Same Again? Transforming the Face of ECT, which is her personal posi-tive experience with ECT.”

Kivler was diagnosed with mental illness in 1990. She founded Courageous Recovery and, according to its website, now is a professional speaker and author seeking to “raise awareness to remove the stigma of mental illness and instill hope in those who live with it. . . (Kivler) suffers from periodic acute bouts of medication-resistant depression, which in her case is only responsive to ECT.”

In regard to the newer TMS, Boyd said “like the CT machines in the 1970s, TMS machines started where the money was, such as the Northeast and California, and gradually made it to the Mid-South. Our fi rst patient was the fi rst to be treated in Memphis, in 2011.

“TMS offers a different mechanism of action, low side-effect burden and a unique way to augment other treatments of depression, such as exercise, psycho-therapy and antidepressants. It requires no anesthesia and has no systemic side ef-fects, such as drowsiness, sexual dysfunc-tion, weight gain, etc., as can be given with medications.”

Still challenging, however, according to Boyd, is “getting insurance companies, other than Medicare, which already pays for TMS under certain conditions, to pay for TMS.”


Let’s look at the different benefits to the different stakeholders in the healthcare business. Remember, healthcare is a business, and in business you always follow the dollar.

In a letter to the New York Times, Jeremy Lazarus, MD, former president of the American Medical Association said, “We agree that Congress must pass a permanent solution to the broken physician payment problem that plagues Medicare with frequent scheduled cuts, but eliminating this problem by putting in place other physician cuts rather than true payment reforms will only continue to threaten patients’ access to care. Medicare physician payments have already been nearly frozen for a decade, while the cost of caring for patients has increased by more than 20 percent. More cuts are not the answer. They would compromise physicians’ ability to participate in new models of care delivery.”

The escalating cost of healthcare puts tremendous pressure on an already teetering system in which the threat of reduced Medicare reimbursement to address over-spending against the Sustainable Growth Rate continues to loom large. The SGR was established by

Centers for Medicare and Medicaid (CMS) to set a budget trajectory for Medicare expenditures each year. That spending trajectory has been surpassed every year since 2002, without Congressional action.

An American Medical Association letter to Congress in September, 2011, summed up the situation this way, “Continued delay in replacing the SGR has escalated the cost of permanent payment reform from $48 billion in 2005 to nearly $300 billion today. We estimate additional short-term interventions will double the cost to approximately $600 billion by 2016.” (An additional failure by Congress)

Oh, and by the way, according to Congressional Research Services, out of a total of 435 U.S. Representatives and 100 Senators (535 total in Congress,) 170 members of the House and 60 Senators are lawyers. So lawyers compromise the biggest voting block of one type, making up 43 percent of Congress. This ratio is much too large.

ICD-10 and Reimbursement CutsThe ICD-10 code sets are not a

simple update of the ICD-9 code set. The ICD-10 code sets have fundamental changes in structure and concepts that

make them very different from ICD-9. When examining the differences in

the code sets, one thing is clear: there will be a need for detailed training to prepare for the transition because of the complexities of converting to the ICD-10 codes.

Justification of the need to make this transition is the concern with the lack of specificity of the information conveyed in the ICD-9 codes. Another issue with ICD-9 is that some chapters are full and impede the ability to add new codes. In some cases, new codes have been assigned to different chapters making it difficult to locate all available codes.

ICD-10 codes have increased character length, which greatly expand the number of codes that are available for use. With more available codes, it is less likely that chapters will run out of codes in the future. Other issues that are addressed in ICD-10 include the use of full code titles and appropriately reflecting advances in medical knowledge and technology. (ICD-9 = 13,000 codes ICD-10 = 69,000 codes)

The move to ICD-10 will not be easy. It will include greater detail, changes in terminology, and expanded concepts for injuries, laterally, as well as other related factors. The complexity of ICD-10 provides many benefits because the increased level of detail conveyed in the codes. Again, the complexity also underscores the need to be adequately trained on ICD-10 in order to fully understand reporting changes that will come with the new code sets.

ICD-10 codes have been in the works for years. Work on the codes began in 1983 and was completed in 1992. Other countries have already adopted the new codes. They include:

• Canada – 2000• China – 2002• Korea – 2008• Dubai – 2012• U.S. -2015?Considering the costs involved

for American physicians to make the transition in 2015, Dr. Lazarus’s words become even truer, “More cuts are not the answer. They would compromise physicians’ ability to participate in new models of care delivery…”

To identify, develop, support, and evaluate additional models of payment and care delivery, the government instituted the CMS Innovation Center. (Opposite of innovation is stagnation.) I prefer to call it the “Sinner of Innovation.” Some of the payment reform provisions developed by the Sinner that will that will have an impact on providers over the next few years are:

• Medicare bonus payments to physicians who participate in quality reporting

• Reduced Medicare payments to hospitals with high readmission

rates• Bundled payment pilot program

with four models of payment• Hospital value-based purchasing

program, with payments• Higher federal Medicaid matching

payments for states that pay for care coordination services (ends December 31, 2014)

“Value index” based on quality and costs added to Medicare physician payment methodology; reduced Medicare payments for physicians not participating in Physician Quality Reporting Incentive program; and reduced Medicare Payment rates for hospitals with high rates of hospital-acquired conditions

In 2016, Medicare will launch a pay-for-performance pilot program

Private payers are highly motivated to cut healthcare costs, since they are responsible for treatment costs not covered by government programs or paid directly by patients.

Private payers are trying a variety of payment reforms – none of which are likely to emerge as the dominant model but serve, nevertheless, as steps along the way to the ultimate shape of payment reform. As an example, more than 25 health plans now incorporate Patient-Centered Medical Home recognition into their own programs, and many will offer financial incentives to practices that adopt the model.

“In a scathing study published in JAMA, RAND researchers compared 32 (National Committee for Quality Assurance, NCQA) recognized practices in southeast Pennsylvania with 29 that were not. During a three-year period, a significant difference was found in only one of the 11 quality measures and there was no robust association with utilization of costs. The NCQA recognizes more than 6,800 physician practices as medical homes.” (J.William Appling, “CMS Hasn’t Got a Clue! Memphis Medical News, April, 2014)

It may take a decade or more for healthcare to shift entirely away from fee-for-service, but, with a debt crisis, we have reached the point where payment reform is inevitable. No one knows how payment reform will evolve over time, which programs will succeed and which will fail, but there are a number of common threads.

While reimbursement remains cloudy, some trends stand out: Markets are aligning around value-based healthcare; major initiatives are focused on changing provider and patient behavior; and quality measures are taking hold.

Navigating Payment Reform BY BILL APPLING

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Bill Appling, FACMPE, ACHE, is founder and president of J William Appling, LLC. He is a national speaker, presenter and a published author. He serves as an adjunct professor at the University of Memphis and is on the boards of Hope House and Life Blood. For more information contact Bill at [email protected].


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cal combat casualty care.He has brought a military-type man-

agement style to the small clinic during a time of transition. As of October 1, it be-came part of Consolidated Medical Prac-tices of Memphis – a move that Chiarella says will “open the door to a potentially greater referral base and hopefully greater revenue.”

He and his wife, Annberly, were living in Cordova with their two small children when, as Chiarella puts it, Mo-hammad Qureshi, MD, “took a chance” and hired him at the Endocrine & Diabe-tes Clinic.

“He saw that military members usu-ally have drive and discipline,” he said. “My house is four miles from here at the clinic. The school is in between here and my house. So everything fell into place.”

Now many of the clinic’s staff of 12 fi nd themselves doing everything but lin-ing up in formation for inspection.

“I have a very militaristic way of dealing with things,” Chiarella said. “I re-fuse to lower standards. If you can’t meet them, that’s fi ne, you’re just not going to work here.”

His two guiding principles are punc-tuality and discipline.

“My defi nition of discipline is doing the right thing even when no one is watch-ing,” he said. “When you’re supposed to be here at 8 o’clock, it doesn’t mean pull up in the parking lot at 8. It doesn’t mean check in and go get a cup of coffee at 8. It means you’re at your desk and ready to start working at 8. It’s something that’s hard for civilians to understand.”

His approach may sound harsh, but Chiarella insists the staff is more than OK with it.

“I can’t speak for them, but I think they appreciate it,” he said. “They appre-ciate being held to a standard. I have a great relationship with all of my employ-ees.

“Teamwork makes the dream work. That’s what I always say. It’s about get-ting a good staff, which I believe we have here, who can make the patients happy and coming back.

“So I kind of envision the clinic as kind of a Special Forces ‘A’ team. That’s the staff I try to hire.”

When he signed up for the Army at age 17, Chiarella said, he told them he would be a medic or he wouldn’t join. He had become hooked at age 15 when a cousin, a paramedic, gave him a blood

pressure cuff and a stethoscope for Christ-mas.

He became a medic with an infantry platoon in Germany, then with Air As-sault Infantry at Fort Campbell, then on to Alaska and back to Fort Campbell as a fl ight medic. He went to help with a rag-ing wildfi re in Montana, where he won an award for saving a fi refi ghter’s life after her car fl ipped as she was driving home after a long shift.

Then it was on to Iraq as part of a long-range surveillance detachment. His equipment consisted not only of a medical bag but also an M4 automatic assault rifl e with a 40mm grenade launcher mounted to the bottom and a Beretta 92F 9mm pis-tol.

When asked if he ever had to fi re those weapons, he said, simply, “yes.”

The next stop was Fort Bragg for a special operations medical course.

“Shortly thereafter I got into a Harley Davidson accident and that pretty much ended my Army career,” he said. Having also sustained injuries in Kosovo, Chi-arella was medically discharged in 2005.

Now he is happily ensconced in Cor-dova, where his life revolves around his family, the clinic and his church. He can’t speak highly enough of the clinic’s staff, its physicians and particularly Qureshi.

“Taking nothing away from the other providers here – they’re great, too – but you couldn’t ask to work for a better phy-sician than Dr. Qureshi,” he said. “The patients love him.”

Chiarella and Annberly are active in the Life Church and its outreach pro-grams. They serve on the security team, and every Thursday night they and their children help pack bags of groceries to be distributed and “feed 3,300 kids a week, every week, all year, at several elementary schools,” he said.

When asked what he considers his greatest accomplishment, Chiarella fi rst said Annberly and his children. But as far as career, he said, “just getting to be a soldier, period. We have a wall in my offi ce at home that has our family on it. My wife’s grandfather was a World War II veteran and a POW; my grandfather was a World War II veteran; my dad was a Vietnam veteran; both of my uncles were Vietnam veterans.

“My wife is an Afghanistan veteran and I’m an Iraq veteran. It’s an honor to be part of my family – seven combat vet-erans over four wars.”

When asked if he would answer a call to duty if it came again, Chiarella said, “I was medically retired. My right ankle is fused shut at a 90-degree angle for the rest of my life. My left wrist has a ton of metal in it, and I have a heart condition.

“But I wouldn’t let any of that stop me if they gave me a choice. As much as my wife would shoot me over it, I’d say, ‘Gear me up, give me a gun and let’s go back to dealing with death again.’

“I’d go back in a heartbeat, yeah.”

Joe Chiarella, continued from page 1

Memphis Medical News

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BY LAWRENCE BUSER

One look at the chapter titles in the novel The End of Healing by Jim Bailey, MD, makes pretty clear his grim message about the current state of the Ameri-can healthcare system.

Chapters such as “Insti-tutionalized Gluttony,” “The Plan of Healthcare Hell,” “Medical Violence,” “Proce-dures for Profit,” “White Coat Hypocrites” or “Counterfeit Care” all foreshadow the next harrowing episode in a young physician’s education.

That excursion into an out-of-control medical industry driven by profits rather than by healing is not unlike Dante’s excursion into hell, Bailey writes in his 489-page novel.

“We have a system that is really per-versely organized and often does little to promote health,” said Bailey, a fellow in the American College of Physicians and a professor of medicine at the University of Tennessee Health Science Center, where he directs the Center for Health Systems Improvement.

“We’ve organized the system around rescue-sickness care, waiting until things have gone very badly and then pulling out all the stops when things are most expen-sive. Most disease and premature deaths today are caused by avoidable evils: over-eating, inactivity and smoking. We are los-ing the struggle to overcome the plague of plenty, and the penalty is obesity, diabetes and cardiovascular disease.”

Bailey’s novel was 10 years in the mak-ing, a project he began while on sabbatical in Florence, Italy. There, while he studied the Italian healthcare system and the history of medicine, he also began his first venture into fiction writing with a story featuring an idealistic young physician who is horrified when he suddenly comes to realize that de-spite his Hippocratic vow to do no harm, harm has become his business.

The book likens the doctor’s journey into the healthcare business to Dante’s In-ferno, a descension into hell complete with the dire warning to “abandon all hope, ye who enter here.” But the young doctor abandons his cardiology dreams and de-cides to accept the challenge of an icono-clastic professor to “follow the money” and seeks to understand the dark secrets driving the healthcare industry.

“The Inferno catalogs every type of sin and grades them as he descends into the depths of hell,” said Bailey, who stud-ied the classics, philosophy and math at St. John’s College in Maryland. “All those same types of mistakes occur in the health-care industry.”

Bailey, through his young protago-nist, Dr. Don Newman, takes the reader through a virtual healthcare hazing: proce-dures for profit, drug reactions, medication errors, hospital infections, lack of health

insurance, unnecessary surgery, piles of pa-perwork and healthcare profiteers, all con-tributing to hundreds of thousands of lost lives annually.

Bailey notes that in the United States in 2012, some $30 billion was spent on hospitalizations that basic primary care could have prevented. Heart surgeries are often near-miraculous proce-dures, he adds, but a better ap-proach would be to promote a healthier lifestyle that would make that surgery unneces-sary.

The novice author turned to fiction writing in hopes of reaching a larger audience for his message about the need to

heal an unhealthy healthcare industry.“As a researcher and writer of scien-

tific articles, I was not accomplishing what I wanted,” said Bailey, who earned a master of fine arts degree before enrolling in medi-cal school at the University of Alabama. “I could write journal articles until I was blue in the face, but it wasn’t going to have a large influence on building awareness in the general public which I came to realize was essential. The truth is people need a story.”

He notes that nearly one in five Ameri-cans has no healthcare insurance and ends up with expensive emergency room treat-ment at taxpayers’ expense. One of every three dollars spent on healthcare goes to paperwork.

Bailey says an average of 15 medical tests are performed each year on every man, woman and child in the United States. Most of those tests, he adds, are useless.

He says his colleagues in the medical community have been supportive of his work, which, he wants to make clear, is aimed at the healthcare system and not at those who work in it. Most of them, he adds, know the system is broken.

“It’s not about bad doctors or nurses or even pharmaceutical reps or insurance company executives or hospital admin-istrators,” Bailey said of his novel. “All of those people are out there working, trying to improve the piece of the system they’re working in, and they’re working often he-roically in this dysfunctional system to try to provide the care people need most. It’s not about people, but a systems-organization problem.”

Bailey wrote the first few chapters of his book in 2004 and five years later thought he had completed his novel and was eager to have it published. His wife, Sharon, who was his critic, editor and sup-porter, disagreed and told him it needed more work.

“Thank God she hasn’t left me be-cause I’ve tormented her with this book,” Bailey said with a laugh. “This has been a compulsion for me. For awhile I was wor-ried that everything would be fixed before I finished the book. There was no need to worry about that.”

Memphis Doctor’s Novel Paints Gloomy Picture of Healthcare

Dr. Jim Bailey

Doctors Drive Demand For Luxury Technologyby Brad Parsley, co-owner at Audio Video Artistry

Today, we use smartphones and tablets for all sorts of purposes. These devices put a wide range of functionality and resources at our fingertips and we couldn’t imagine going without them. Virtually everyone is now accustomed to going to a single device for email, text, entertainment, internet, and apps that do pretty much anything you can think of. Oh, and of course they make phone calls too!

It’s all about convenience and control. So, I’m surprised daily why so many homes don’t offer this same level of convenience and control. I visited a doctor’s brand new home the other day to talk with him about implementing some entertainment options. It was built by a “custom” builder and was just south of seven figures. Evidently this builder had not considered technology as a major consideration to the home.

The home was not wired much differently than it would have been if it were built in 1980! In 2014, we might expect that in a Habitat for Humanity home, but not in a million dollar luxury home. We wouldn’t dream of buy-ing a new car without all the latest technological offerings but don’t give it a second thought in our homes where it’s perhaps most important. Even the most “technically challenged” of homeowners would place importance on speed and flexibility when it comes to computers and networked devices in their homes. Very few will refuse to own a television or at least occasionally listen to music. We are all candidates for technology on some level and it’s impossible to ignore completely.

Security, lighting, climate, televisions, and music are just a few of the things we should be able to access and control in our homes from a single point of control. The smartphone or tablet you already own is perfect for this! The level of convenience, safety, and energy efficiency this affords is the very definition of luxury. While this technology can certainly be retrofitted into any existing home, it’s a shame that so many sparkling new homes lack something that should be a standard offering.

Doctors are a large segment of our clientele. With doctors experiencing new technology every day in their professional life, it is natural that they also want to carry over the new technology in their homes. We are here to advise. Many of you will buy or build new homes in the near future and you’ll want to know what options are available to you.

While technology may be a necessary part of our lives, few of us want it dominating our homes decor or adding complexity to our lives. Our compa-ny’s ability to make technology disappear has made Audio Video Artistry a favorite with women as much as men, as well as the go to choice for the region’s top architects and interior designers. Additionally, we design our systems from the client’s perspective where ease of use and reliability are the top priorities.

Audio Video Artistry has created a design studio that, in less than thirty minutes, will enable homeowners to experience all the latest trends in home technology. Instead of just handing our customers brochures or talking to our customers about the latest trends, you can experience all of the options for yourself and determine what is right for you and your lifestyle at the AVA Design Studio. Here, you are able to put your hands, eyes, and ears on the most amazing technologies ever assembled in one place in Memphis.

Our homes should be as efficient, convenient, and entertaining as every-thing else in our life is designed to be. Luxury homes in our area should be updated just as they are in so many other parts of our country. We believe that busy medical professionals deserve to know what their best options are in home technology. We hope to see you soon!

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Yarnell Beatty, in-house counsel for the Tennessee Medical Association (TMA), explains, “There were some medical practices and clinics that were big enough in their markets that they could say no — but they were few and far between. Both in rural and urban settings, only those practices that BCB-STN deemed ‘essential to the network’ — area IPAs (Independent Practice Associations) and large specialty practices – had enough clout to not accept the new terms. The largest groups of physi-cians who were negatively impacted were primary care providers, pediatricians and family practice groups.”

The TMA responded to BCBSTN, urging the insurance carrier to rescind the cuts or reduce the sting of a mid-contract, dramatic decrease in rates.

In a letter to BCBSTN, the TMA re-layed concerns expressed by its members:

• Having to outsource lab services, even driving revenue to out-of-state lab providers and laying off their own staff, because the cuts are un-tenable for their practices

• Inconveniencing patients and their employers by having to send pa-tients to other facilities to obtain lab services

• Delay in care and liability issues• Reducing access to care by possible

closures of satellite clinics in rural areas

• Reducing patient compliance with their treatment because of added burdens of being diverted to other facilities for their labs

• Confusion as to scope and applica-bility of the amendment

• The drastic nature of the cuts com-pared to other payers.

So in January of this year, physicians continued to carry the same overhead ex-penses for their practices, ordered the same lab work, yet began receiving 48 percent less of their previous lab reimbursement from BCBSTN.

It is the feeling of some physicians that Blue Cross is intentionally forcing some of the liability back on the medical practitio-ners to either provide the service at a loss, or bear the liability of the delay in treat-ment. In cases where the patient might be compromised by a delay, physicians believe that Blue Cross knows that doctors will provide the necessary service, including in-house lab work, and eat the financial loss.

Another negative impact being faced by smaller practices involves supplies. The cost of the lab reagent necessary to run lab tests actually is more than the reimburse-ment given by Blue Cross, so physicians are continually operating at a loss.

Regardless of the practices’ size, in most cases clinics had their 2014 budget in place well before they received notice of this reimbursement change. The managing partners had reviewed their budgetary line items such as staff salaries, health benefits, anticipated expansion and modernizing

equipment, but now they were faced with meeting their budgets with less than half of the expected income from lab reimburse-ments.

And the impact didn’t stop with the physicians; the changes also affected pa-tients. In some cases, primary care physi-cians were forced out of business. Without access to their doctors, patients had to choose between going to an emergency room for care or going without care and running the risk of getting sicker. The latter choice carried the added risk of being hos-pitalized for extended care. Either option incurred higher expenses for the patients — and was counterproductive in terms of patient care.

Tom Reed, former executive director of West Tennessee Physicians Alliance and West Tennessee Primary Care IPA, said, “In rural Tennessee, outside of Shelby County, doctors in independent clinics have banded together under the umbrella of an IPA as a means of being protected from antitrust scrutiny. These physicians use a Messenger Model to facilitate con-tracts. As BCBSTN contracts with employ-ers to be their insurance provider, a list of participating doctors is provided. For those who opted not to accept the amendment, they were forced out of the BCBSTN net-work. This translated to employers no lon-ger being able to provide access to some of the physicians that employees signed up for when they selected their healthcare plans.”

Beatty adds, “For some patients, it came down to seeing their doctor out of network and therefore paying more out of pocket, or being forced to select a new phy-sician who was within network.”

Beatty continues, “A medical practice is a business. You can’t keep your doors open if you can’t pay your rent and retain your staff. The situation is disheartening to a lot of physicians who just want to take care of patients but are constrained by these types of decisions that are being made by those holding the purse strings.

“For example, a pediatrician sees a child and needs lab work to make a diag-nosis. With in-office service, labs can be handled right then and there, allowing the doctor to make a diagnosis and a treatment plan and if necessary order a prescription. After the cuts to lab reimbursements went into effect, doctors had to decide if they

were going to do as before and lose money, or take the option to send the lab work off campus, to Quest Diag-nostics or somebody out of state, where the cost is cheaper due to volume. But the latter option means the patient walks out of the office and will have to come back or get a call from the doctor to learn the lab results. For the patient, it is a hassle that translates to additional time off of work for parents and more time missed at school for children. There’s a clinical downside, as well as an economic downside, for Tennesseans.”

Mary Danielson, director of corporate communications for Blue Cross Blue Shield in Chattanooga, said, “BCBSTN’s stated reason for the decrease was to put BCB-STN costs at market rate. Approximately 9 out of 10 of our total provider popula-tion accepted the lab amendments. Those who did not accept were removed from our provider network or have had (or will have) their lab reimbursement addressed during scheduled negotiations in order to allow our members access to these services at more market competitive rates.”

In a letter sent to BCBSTN in response to the amendment, the TMA stated, “Uni-lateral changes to rates affect a business’s bottom line, which determines jobs, supply purchases and the volume of medical ser-vices that can be delivered to patients — your company’s covered lives. TMA sees this as stymieing the growth of medicine and limiting access to healthcare in Ten-nessee. … The message we have inferred from senior BCBSTN officials is that the curtailment of in-office lab services is ac-ceptable because it will result in lower costs to BCBSTN.”

Insurance providers’ contracts rou-tinely incorporate wording that effectively says they can change rates, payment meth-odologies and policies anytime they want … and if providers don’t want to accept the changes, they risk being out of the net-work. There have been “nickel and dime” changes from TennCare MCOs and other commercial insurance plans that have re-sulted in cuts. However, some clinics say they are facing unrivaled challenges from this BCBSTN amendment.

Doctors, Patients Feel Sting of BCBS Cuts, continued from page 1

Yarnell Beatty Mary Danielson

N E E D A G I F T

S H E W I L L

L O V E ?H E R S O U T H . C O M


BY CINDY SANDERS

With 8.7 percent of residents suffering from chronic obstructive pulmonary dis-ease, Tennessee has one of the highest rates of COPD in the country. During Novem-ber, National COPD Awareness Month, it seemed appropriate to share data and in-sights into the third leading cause of death in the United States and in Tennessee.

Unlike most major illnesses, chronic lower respiratory diseases have actually increased in frequency over the past three decades, and the numbers rise even higher when factoring in those who are misdiag-nosed or underdiagnosed. Currently, close to 15 million Americans are living with known COPD. However, Jamie Sullivan, senior direc-tor of Public Policy and Outcomes for the COPD Foundation, noted, “The NIH estimates there are about 12 million nation-ally who have COPD symptoms but haven’t received a diagno-sis.”

Sullivan continued, “There tend to be more women who are misdiagnosed than men.” Compounding the issue, COPD tends to affect women disproportionately

with a national average of 6.7 percent hav-ing COPD compared to 5.2 percent of men. “That disparity between men and women is actually worse in Tennessee than in the nation.” Sullivan said data from the Behavioral Risk Factor Surveillance Sys-tem shows the COPD rate for women in Tennessee is 11.7 percent compared to 6.7 percent for men.

The Volunteer State, she added, has the third highest rate of COPD overall in the country at 8.7 percent compared to the national average of 6.3 percent. Tennes-see trails only Kentucky and Alabama in prevalence.

Deb McGowan, senior director of Health Outcomes for the COPD Foun-dation, noted the rea-sons behind Tennessee’s higher rates are multi-factorial including en-vironmental issues and smoking rates in the South. Although Tennes-see has made significant strides in sharing smoking cessation strategies, nearly a quarter of the state’s adult men (24.7 percent) and one-fifth of the state’s adult women (19.7 percent) still smoke.

While there can be a genetic compo-nent to COPD, McGowan said smoking

leads the way as a key contributor to the chronic illness. A quarter of those with COPD have never smoked with the condi-tion likely linked to genetics, occupational and environmental pollutants, leaving the other 75 percent related to smoking.

Sullivan added, “Definitely exposure to tobacco is the main risk factor, but it’s not just current smokers who are at risk, it’s people who had a history of smoking.” She noted these are individuals who followed the recommendations and quit smoking but 10-15 years later begin to have trouble with their breathing.

The COPD Foundation embarked on a listening tour this past summer and spent time in East Tennessee to learn more about the incidence rates for COPD. Sullivan said one thing they heard over and over again was the air quality in the valley exac-erbated asthma and the ability to breathe easily. The problem isn’t limited to the east-ern part of the state, however. The Asthma and Allergy Foundation of America rou-tinely includes Tennessee’s largest cities in its annual list of “Most Challenging Places to Live with Asthma.” In 2014, Memphis ranked second, Chattanooga sixth, Nash-ville 38th and Knoxville 41st.

In addition to smoking history and en-vironment, Sullivan said other risk factors include a history of asthma, early nutrition

and prenatal events, early childhood infec-tions, age, and socio-demographic status. She noted nearly one in five adults with an-nual incomes under $15,000 (19 percent) have COPD.

As with most chronic diseases and conditions, early detection, intervention and education improve quality of life and reduce healthcare costs and economic bur-den. McGowan said providers could help by being more aware of COPD when tak-ing a patient’s personal history. Instead of asking if someone smokes, McGowan urges physicians and nurses to ask if an individual has ever smoked. “Around 100 cigarettes lifetime is where you start thinking differ-ently,” she said of risk factors for COPD. Additionally, McGowan said providers should be attuned to any respiratory symp-toms that seem to be ongoing.

“We don’t have to have a patient hit the hospital before we test them,” she noted of diagnosing COPD. “You do that through spirometry testing. It’s a simple breathing measure and can be done in a primary care office.”

Although billable, McGowan said most outpatient clinics and practices are not aggressively utilizing the test to screen appropriate patients with symptoms. Many practices don’t have spirometers … or if

Short of BreathCOPD Foundation Sheds Light on State’s High Rate of Progressive Lung Disease

Jamie Sullivan

Deb McGowan



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How are front-line Memphis doctors going to continue to maintain good medi-cal practice, avoid burnout, increase revenue and maximize patient-doctor interaction in the new era of dwindling reimbursement, primary care physician shortages, increased numbers of patients and electronic medical records?

Some experts propose the use of medi-cal scribes. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) defines a scribe as “an unlicensed individual hired to enter information into the EHR or chart at the direction of a phy-sician or licensed independent practitioner (physicians, advanced practice registered nurses, physician assistants).”

“Previously, scribes were being used in emergency departments to allow the maximum involvement of the physicians with the patients,” said Soumitra Bhuyan, PhD(C), MBBS,

MPH, professor of health administration at the University of Mem-phis. “Now we are wit-nessing an increased use of scribes in other areas like hospitals and physician of-fices. This is an interesting trend. It is partly due to federal government’s push for adop-tion of EHRs.”

Alan Flippin, MBA, CMDS, has been a medical practice consultant in Memphis for 21 years. He serves medical offices and forecasts that the use of scribes within his cli-entele will increase from 15 to 50 percent in the next one to two years.

“For revenue generation in a doc’s of-fice at this time, it’s one of the best things they can do and not change their practice,” he said. “Before, they would see 25 patients a day; now they really need to see 35 to make the same amount of money since reimburse-ments have gone down. Anytime doctors are typing, they are not seeing patients.”

He also said there is the benefit of not facing dictation at the end of the day. The time saved can be used to study the latest treatments, drugs and technology emerg-ing. He added that studying the 50,000-plus additional ICD-10 codes to be enacted Oct. 1, 2015 is not a good use of doctors’ time. Flippin said some of his clients are adding exam rooms to meet the demand of extra patients seen as a result of the efficiencies of using scribes.

The Feb. 12, 2014 issue of Information Week: Health Care reported that the numbers don’t always work in the positive for doc-tors. Citing an internist who maintained his own EHRs, the story said he could not justify scribes for primary care due to lower income. It is too early to tell whether scribes can boost physician productivity outside emergency departments where they are more commonly used, said an Aug. 24, 2013 article in Modern Healthcare.

Use of medical scribes also brings up other issues, according to Bhuyan. “As this profession is not fully grown, there are still concerns about patient confidentiality among other legal issues,” he said. “Some patients might not like the idea of the pres-ence of a third person in the exam room, which may negatively impact their commu-nication and sharing relevant information with their physicians.”

He also said scribes might not have a clear understanding of terminologies and disease management, which could result in documentation errors. Lastly, he said that scribes are still an unlicensed profession, so the physician clinic or hospital employing them must ensure that scribes follow the pa-tient care documentation guidelines.

A quick survey of scribe usage in larger Memphis hospital emergency departments showed St. Francis with no comment, Re-gional One not using scribes, Baptist using a scribes agency and Methodist self-hiring them.

“We grow our own and teach them ourselves,” said Ray Walther, MD, medical director, emergency department, Method-ist University Hospital. “We employ about 25 here, a few full-time ones and most part-time. They are pre-med or pre-physician’s assistant.”

Walther said they find the use of scribes cost-effective because it makes physicians more efficient and provides reminders of when test results are back. He said it also gives them extra time with patients. He said he had tried EHRs with voice recognition technology and all the advances in software, and he was still not satisfied and preferred scribes.

Walther sees the use of scribes enduring with the fast pace of the ED.

One hospital spokesperson said he thought scribes were temporary, or a stop-gap measure until older physicians retire and younger, more technology-proficient physi-cians enter the workforce.

Bhuyan agreed it might be true that younger and more tech-savvy physicians will find it easier to use EHRs. But, he pointed out, with the Affordable Care Act, more Americans have access to health insurance, many for the first time, and the transition to ICD-10 codes will be challenging. Use of EHRs can add to this stress, he said, with time-consuming data entry and interference with face-to-face patient care.

He cited a study published in Journal of the American Medical Association in October 2012 that said nearly 46 percent of physi-cians in the study had at least one symptom of burnout. The study reported that burn-out is more common among physicians than other U.S. workers, and the highest rates were found in internal medicine, fam-ily medicine and emergency departments – where scribes are more likely to be used.

“If medical scribes can contribute to reduce the physician’s stress associated with EHR use, I think it will continue to grow in the future,” he said.

Use of Scribes to Give Doctors Relief Is Steadily Increasing

Dr. Soumitra Bhuyan


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Ebola Preparedness UpdateExpert Briefings & More

Dr. James Crowe, Jr. (R) looks on as graduate student Andrew Flyak adjusts equipment in the Vanderbilt Vaccine Center used in the production of anti-Ebola antibodies.

BY KELLY PRICE &

CINDY SANDERS

Ebola Drug TherapiesVanderbilt University researchers

have partnered with Mapp Biopharma-ceutical Inc. to develop their new human antibody therapies to provide short-term protection for people exposed to the deadly Ebola and Marburg viruses. These hemorrhagic filoviruses kill, in part, by causing massive bleeding.

The San Diego-based company has developed an experimental treatment, called ZMapp, which contains antibod-ies manufactured in plants. ZMapp has prevented lethal disease in rhesus mon-keys but has not yet been tested for safety and efficacy in humans. At Vanderbilt, researchers are using a high-efficiency method to isolate and generate large quan-tities of human antibodies from the blood of people who have survived Ebola and Marburg infections and are now healthy. No live virus is used in the research.

“We’re the only lab in the world that has a high-efficiency human hybridoma technique for isolating human monoclonal antibodies,” explained James Crow, Jr., MD. He said Vanderbilt has been isolat-ing antibodies to major human pathogens to better understand the basic science of

immunity.“However, with the current urgent

medical need for treatments for Ebola in-fection, we are thrilled to be working with Mapp Biopharmaceutical to produce the antibodies we have discovered as antivi-ral drugs that may benefit patients and healthcare workers facing this terrible epi-demic,” Crowe said.

Notes from the TDHLast month, Tennessee Depart-

ment of Health Commissioner John

Dreyzehner, MD, MPH, FACOEM, led a media briefing regarding the state’s level of preparedness and response to Ebola.

While stressing there had been no confirmed or suspected cases of the deadly virus in Tennessee, Dreyzehner said should the need arise, “We’re confident we can provide patient care and mitigate transmission to others.”

He added the TDH had been provid-ing guidance to hospitals and facilities for several months … not only on Ebola but on MRSA and other contagions, as well.

“In addition, we’ve been encouraging hos-pitals to conduct response exercises.”

Dreyzehner noted, “Fear, mistrust and stigma are really thriving with this epidemic.” For that reason, he said it was critically important that healthcare pro-viders and media outlets help the public understand the facts about Ebola includ-ing that it can’t be spread through the air, by mosquitos, in the water and typically not through food. Instead, it is spread through bodily fluids or on items grossly contaminated by bodily fluids, such as a needle. “Ebola cannot live long outside the human body and is easily killed by common disinfectants,” he said.

Asymptomatic patients and those who have recovered from the disease are not a public health threat. However, once someone shows symptoms, Dreyzehner said the viral load increases as the person becomes sicker. While the incubation pe-riod is generally three weeks, days 8-10 are often the time when symptom onset oc-curs. Some individuals have taken longer than 21 days to test positive for the virus, and Dreyzehner said it appears people are capable of transmitting Ebola for about 90 days through semen.

Since bodily fluids can transmit through open wounds or through the



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eyes, nose, mouth and skin, it is critically important for healthcare providers to pro-tect themselves. “The most basic thing we can do is washing our hands,” Dreyzehner said. “We touch our faces about 16 times and hour,” he added to emphasize the im-portance of killing germs through proper hand-washing protocols.

Equally, he said, healthcare provid-ers need to be sure to follow the specific order of putting on and taking off personal protective equipment (PPE). “I know as a healthcare provider myself, we don’t al-ways put as much attention as we should on putting on and taking off personal pro-

tective equipment,” Dreyzehner said. “Let he who has never snapped their glove in the trashcan cast the first aspersion,” he added wryly.

Recently, the CDC (cdc.gov) updated PPE guidelines to more closely match protocols in place by Doctors Without Borders, which has a successful history of fighting Ebola and other contagious dis-eases around the world.

On home soil, Dreyzehner lauded the depth and breadth of public health experi-ence in the state. “I have great confidence in Tennessee’s ability to respond to this or any other threat,” he concluded.

HCA’s GiftIn late September, HCA made a $1

million cash donation to the CDC Foun-dation’s Global Disaster Response Fund to help support international Ebola re-sponse efforts involving the CDC and their work with partners on the ground in West Africa.

HCA has a long history of supporting relief efforts including those following the earthquake in Haiti, the Indonesian tsu-nami, Hurricane Katrina and Typhoon Haiyan in the Philippines. The donated funds will be used to provide much-needed supplies and equipment to aid workers in-

cluding personal protective equipment, infection control tools, ready-to-eat meals, generators, exit screening tools and sup-plies at airports such as thermal scanners to detect fever.

“Ebola continues to spread rapidly in West Africa, and CDC and others have made it clear that the window of opportunity to contain the virus is closing quickly,” said R. Milton Johnson, presi-dent and CEO of HCA. “The time to act is now, and we strongly encour-age other companies, particularly those in the healthcare industry, to join us in this im-portant effort to save lives.”

Waller Launches Ebola Legal Resource Site

In late October, Waller Lansden Dortch & Davis, LLP announced the launch of a comprehensive online resource to help healthcare leaders and other or-ganizations impacted by the Ebola virus navigate diverse issues pertaining to the arrival of the virus in the United States. The website can be accessed at EbolaLe-galResource.com.

“The immediate and long-term legal implications of the Ebola virus on all fac-ets of hospital, clinic and practice man-agement must be seriously considered,” said Mark Peters, a partner in Waller’s Labor and Employment practice who works extensively with healthcare employ-ers. “Waller’s Ebola legal resource website comes in response to the many questions we’ve received from clients. Preparation in this situation is important, whether an Ebola patient walks through your doors or if you are simply dealing with the climate it has created.”

The site launched with a compila-tion of media articles, links to outside re-sources, and original articles from Waller attorneys including:

• The Role of Healthcare Employers during the Ebola Crisis,

• Patient Privacy Concerns,• FAQs on Employee Discipline, Dis-

crimination & Harassment,• Workers’ Compensation for those

Contracting Ebola, and more.The site, which will be updated as

new information becomes available and is analyzed, is tailored to healthcare ex-ecutives, board members, risk managers, human resources professionals and others who are asking what Ebola means, from a legal perspective, for their organization, employees and patients.

Ebola Preparedness Update, continued from page 11

R. Milton Johnson

Memphis Medical News

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BY CINDY SANDERS

Although WGU Tennessee officially launched in July 2013, “The University of You” has a history of offering targeted, com-petency-based, online curriculum that dates back 15 years.

Western Governors Uni-versity was the brainchild of 19 governors who met regularly to discuss common concerns. “Their vision for WGU, when they ini-tially founded it, was a university that would focus on workforce areas where they needed more graduates … areas of workforce shortages,” explained WGU Tennessee Chancellor Kimberly Estep, PhD. Those four areas, she continued, were information technology, nursing, business and teacher education (particularly STEM and special education).

With a focus on working adults, the curriculum had to accessible at the stu-dent’s convenience. The university had to be affordable, and it had to truly provide a return on investment for students by teach-ing them the hands-on skills required in the real world to move their careers forward.

The result was a private, non-profit, online, accredited university focused on mastering concepts rather than requiring a set amount of time in a classroom. “We’re really pioneers in competency-based learn-ing,” Estep said. While the concept is be-ginning to spread, she added, “We’re the only competency-based university at scale.”

Estep said the average age of their students is 37 with most working full time.

“It’s very difficult for them to access traditional higher educa-tion,” she pointed out. Nation-ally, WGU has 50,000 students. In Tennessee, Estep said that number is about 1,500 but grow-ing monthly.

For undergraduate pro-grams, prospective students do not have to have completed an associate’s degree to start any field of study with the exception of nursing, which is an RN to BSN program. However, every student must complete an en-trance interview and take a readi-ness assessment if they don’t have their two-year degree. A number of undergraduate programs have a healthcare emphasis including health informatics and healthcare

business management. For those who have already earned a bachelor’s degree from an accredited university, master’s program-ming is also available including an MBA in healthcare management and MS in nurs-ing education and nursing leadership and management.

Mastering ConceptsEstep said the beauty of competency-

based learning is “it’s really designed to honor the knowledge students bring to the table.” For those studying in their field of work, they can leverage that practical knowledge to move more quickly through the program.

“You can go as fast as you want … but you can’t go as slow as you want,” she added with a laugh. “You need to make satisfactory progress.”

Students can, however, spend more time in areas that prove to be challenging. Online lectures allow students to pause, re-wind, and hear material as often as needed. Once the concept is learned, the student demonstrates mastery. Estep said WGU doesn’t give letter grades, per se, but the pass rate is generally set at what would be comparable to a B or higher.

“All of our students have to reach the same level of competency before moving forward in the program,” Estep said. Set-ting the bar high gives employers the com-fort of knowing the WGU graduate has demonstrated strong capability throughout their program. “It provides transparency and consistency,” she added.

Although WGU students must be independent learners, Estep was quick to say they certainly aren’t alone on their

WGU’s Competency-Based Curriculum Enhances Tennessee’s Healthcare Workforce

Dr. Kimberly Estep and Shannon Tucker at graduation this past May.



Expanding HorizonsA Recent WGU Grad’s Experience

When Shannon Tucker began working on her MBA at WGU, she already held an undergraduate degree from Trevecca Nazarene University and a master’s in Communication Disorders from Tennessee State University.

In fact, she had a successful career with TriStar Skyline where she had been employed since 2001. For many years, Tucker worked as a speech language pathologist focusing primarily on stroke patients. It was a promotion to director of Rehabilitation Services at the hospital that made her begin thinking about a second master’s degree.

In her very first meeting with Dustin Greene, COO of TriStar Skyline, Tucker recalled he told her she was the ‘CEO’ of Rehabilitation Services. “I didn’t feel like my clinical training really prepared me to be the CEO,” Tucker said. “I would go to talk to hospital administrators, and I sometimes felt like I was speaking a different language. I could say why we needed XYZ clinically, but I couldn’t make the business case for it.”

Wishing to boost her business acumen, and with the encouragement of TriStar colleagues, she embarked on her MBA program. “I was a weekend warrior,” she said of her WGU schedule. “I’d go to school Friday evening, and I needed to pretty much wrap up on Sunday.” Then, she continued, “I could take what I learned and apply it on Monday … and I did.”

Like many students, Tucker cited cost and timing as two appealing factors in selecting the online, competency-based program. “I could make WGU fit into my life instead of making my life fit into WGU’s schedule,” she said. Tucker completed her MBA in two years using primarily weekends. Some areas she mastered quickly, others took more time. “Financial management took me like eight weeks. That was my shortcoming, but I knew that going in.”

However, it isn’t a shortcoming anymore. Her studies gave her the confidence and tools to balance both sides of her job. “I could connect the dots between the clinical needs of the unit and the business case,” she said of her enhanced skill set.

In fact, she now has a new job at the corporate level. After graduating from WGU in May, Tucker was promoted the following month to assistant vice president for Rehabilitation Services at HCA, TriStar’s parent company.

“It wasn’t that the MBA was required for this position … I already had my master’s,” Tucker said. “But it made me more well rounded, and it made me more successful. I started making great strides at Skyline and in my department, and that caught the attention of corporate.”

Shannon Tucker gives the commencement address at her WGU graduation.

journey. All students have a faculty men-tor who works with them throughout their degree program. Additionally, students have a number of course mentors, faculty members with terminal degrees in their field, who are there to help provide course-specific expertise.

Cost & TimingUnlike most universities that base rates

on course credits, WGU tuition is set at a flat rate for a six-month term. Basic tuition is $2890 for most degree programs and $3,250 for nursing and MBA programs. Additionally, there are fees that apply to specific programs. “We have not raised tu-ition at WGU since, I believe, 2008,” Estep said of the affordability factor.

Another difference is the timing of ‘se-mesters.’ The six-month term doesn’t have a set start date. Instead, Estep explained, “We start new students every month. Every student has their own six-month term be-

ginning when they do.”The ending point is largely up to the

student. Estep noted that a typical RN can-didate finishes their WGU degree in 18 months. “Because it’s competency-based, some may take two years. Some may do it in as little as a year. It really puts the student in the driver’s seat in a way traditional pro-grams can’t do.”

Drive to 55“We want to do everything we can to

help Gov. Haslam reach his goal of Drive to 55,” Estep said of the statewide initiative to have 55 percent of Tennesseans with an associate degree or higher by 2025.

She added the governor’s office es-timates 940,000 Tennesseans have some college but haven’t finished a degree pro-gram. “We’re trying to give them a good way to come back and complete a degree,” she concluded.

WGU’s Curriculum, continued from page 13

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A little more than a year ago, the American Medical Association an-nounced $11 million in grants to 11 academic medi-cal centers to fundamentally change the way physicians are educated and trained.

“There has been a universal call to transform the teaching of medicine to shift the focus of edu-cation toward real-world practice and competency assessment, which is why the AMA launched the Ac-celerating Change in Medi-cal Education initiative,” AMA President Robert M. Wah said in a statement. “Over the last year, we have made signifi-cant progress in transforming curriculum at these medical schools that can and will help close the gaps that currently exist be-tween how medical students are trained and the way healthcare is delivered in this country now and in the future.”

In late September, a consortium of thought leaders from the 11 academic cen-ters convened on the campus of Vander-bilt University School of Medicine in Nashville to discuss progress and barriers in implementing individual projects, offer insights and innovations, give and receive feedback on the conceptual model for the master adaptive learner, and share other lessons learned in the first year. Much of the meeting’s focus was centered on the master adaptive learner (MAL), which is the AMA consortium’s term for an expert, self-directed, self-regulated, lifelong work-place learner. Developing this type of skill is considered critical to prepare physicians for careers in a healthcare environment that is constantly changing and evolving.

During the two-day event, Susan Skochelak, MD, MPH, group vice presi-dent of Medical Education for the AMA, and Bonnie Miller, MD, senior associate dean for Health Sciences Education and associate vice chancellor for Health Affairs at Vanderbilt, hosted a media roundtable to discuss the transformative initiative.

Skochelak said it makes sense for the AMA to be at the forefront of such an ambitious project. Upon being founded in 1847, the physician’s organization under-took two major tasks — to write the first code of professional ethics and to set the standards for medical education.

She added the AMA again took a lead role 100 years ago when there was a major movement to change medical edu-cation. Skochelak said the AMA published the standards of what medical education should look like and that became the basis for the Flexner Report.

“The Flexner Report really changed medical education to say it has to be sci-ence-based, and it has to be connected

with knowledge generation,” she ex-plained. “It made a great leap forward in the quality of medical education. But here we are a century later, and our format for training physicians remains almost iden-tical to the structure that we described a hundred years ago.”

Skochelak added, “It’s not that the training is broken, it’s just that it hasn’t kept up with what’s going on in healthcare delivery today.”

She said the work being done as part of the Accelerating Change in Medical

Education initiative is built on recommendations for change that have been well accepted for more than a decade by the medical education community. “We’re working in a great sense of consensus,” Skochelak noted. However, the fact that there has been broad agreement but little change points to impediments that must be addressed. “If it was easy, it would have already been done.”

To address the barriers and make it possible to move forward, Skochelak said, “The AMA wanted to provide resources and leadership to schools that are re-ally ready to make the change.”

That decision led to the grant program now in place for the 11 lead schools in the initiative.

In choosing the academic medical centers, Skochelak said the AMA was looked for programs that concentrated on key areas, including:

• Getting students into the real world environment early on so they understand healthcare systems in a way that isn’t cur-rently happening;

• Emphasizing important core con-cepts in medical school education like

team-based care, patient safety and out-comes, patient-centered approaches to care, and population management; and

• Changing the way students progress through the educational system to provide more flexibility and individualized learn-ing.

Miller, a general surgeon by train-ing, has been involved in shaping medi-cal education at Vanderbilt for more than 15 years in an official capacity and even longer as a faculty member. She noted Vanderbilt had already undergone a major transformation to their traditional curriculum from 2004-2007. Yet, she added, it became clear that even more needed to be done to support continuous learning throughout a career.

“We came to the conclusion that in order to do that you really did have to start at the beginning … that we couldn’t put our learners through our programs as usual and then expect magically at the end of their training they would be expert lifelong learners if we didn’t start to build those habits from the start,” Miller said of the decision to rework Vanderbilt’s pro-gramming for a second time.

“Curriculum revision is hard work,” she continued. “It’s not just a matter of de-veloping new lesson plans. It really is a lot

The Transformation of Med EdAMA continues quest to accelerate change in physician training

Dr. Susan Skochelak at the podium addressing the consortium meeting at Vanderbilt.



about culture change. We really felt that it was important to go back to the draw-ing board and start something new right away.”

Miller continued, “One of the things we thought a lot about was the context of learning. We felt that all learners need to work so that you’re really rapidly applying what you’re learning in the workplace … and that all workers need to learn.”

That mantra became a foundational principle of Vanderbilt’s Curriculum 2.0. Miller added other tenets of the program-ming was that it should be team-based, interprofessional, modular to allow for dif-ferent entry and exit points, and include

new content areas to help students under-stand the context of healthcare delivery, as well as what is happening on a molecular and genetic basis. The new curriculum rolled out last year with the incoming class of 2013.

During the recent consortium meet-ing, Vanderbilt and other participants shared their progress and discussed barri-ers to change. Skochelak said that unlike a research grant, where a recipient is given money and works on an individual project, the AMA initiative was designed to pool in-formation and work in collaboration.

“We told the schools if you receive grant monies, you will be part of a consor-

tium of schools. Right from the beginning we’ll work together, and we’re going to share ideas because we want your projects to benefit from each other … and our ul-timate goal is to share this with all of the schools,” Skochelak said.

Over the next four years, the AMA will continue to track, gather data and report on the progress of the 11 medical schools and their collective work in order to identify and broadly disseminate best practices to retool medical educational models across the country. Skochelak added the lessons learned would be shared with institutions educating other health professionals, as well.

The Transformation of Med Ed, continued from page 15

Participating Programs•Indiana University School of

Medicine

•Mayo Medical School

•NYU School of Medicine

•Oregon Health & Science University School of Medicine

•Penn State College of Medicine

•The Brody School of Medicine at East Carolina University

•The Warren Alpert Medical School of Brown University

•University of California, Davis School of Medicine

•University of California, San Francisco School of Medicine

•University of Michigan Medical School

•Vanderbilt University School of Medicine

they do, too often the equipment is sitting on a shelf collecting dust. Yet, she noted, getting that early diagnosis is critical to properly educating and treating patients. She added a number of studies have shown “patients who are uneducated and not ac-tivated in their care are twice as likely to be admitted to the hospital.”

Unfortunately, she continued, “We find a lot of patients don’t even know how to use their inhalers correctly. Not all in-halers work the same.” She added patients should call their doctor if they aren’t get-ting relief from their inhaler, have a fever, stronger cough, more productive cough, or noticeable discoloration in mucus. “All those signs and symptoms indicate you’re heading down the wrong path.”

McGowan said a common, easy way for patients to think about COPD is to use the ‘green, yellow, red light’ approach. The green light, she explained, is no change in what a patient is able to do. A yellow light means a patient is showing some symptoms and signs and should call a doctor. The red light means nothing is working, and the patient should proceed directly to the ER. “It’s more about taking care of yourself and being aware of your body every day,” she said of managing COPD.

Sullivan added, “We do have resources that are designed for healthcare providers. We also have resources they can use with their patients.” The Pocket Consultant Guide (PCG) even has an app attached to it for information on the go. Physicians could also join a moderated online community with discussion about particularly difficult cases and various treatment options. Addi-tionally, there is a quarterly digital maga-zine tailored to providers. To sign up for the magazine or access other resources, go online to copdfoundation.org.

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BY CINDY SANDERS

Perhaps it is only appropriate the Cen-ters for Medicare & Medicaid Services is scheduled to announce its highly anticipated coverage decision for low-dose computed tomography (LDCT) lung cancer screen-ing in November. After all, this is officially ‘National Lung Cancer Awareness’ month.

For proponents of using the diagnostic imaging study for early detection, the cost/benefit analysis is simple … LDCT saves lives in a cost efficient manner among a targeted, high-risk population. Medicare already covers broad-based screenings for colon, breast and prostate cancers. Accord-ing to the American Cancer Society Cancer Facts & Figures 2014, the combined esti-mated annual deaths from those three types of cancer is still significantly less than deaths from lung cancer (120,220 vs. 159,260).

One of the most vocal supporters for extending coverage to Medicare beneficia-ries is Ella A. Kazerooni, MD, MS, FACR, associate chair for Clinical Affairs and divi-sion director for Cardiothoracic Radiology at the University of Michigan. “I firmly believe that screening for lung cancer with CT saves lives,” she stated. An expert in the field, Kazerooni’s long list of credentials in-cludes serving as a trustee on the American Board of Radiology, chair of thoracic im-aging for the American College of Radiol-ogy’s Commission on Body Imaging, chair of ACR’s Committee on Lung Cancer Screening, vice chair of the National Com-prehensive Cancer Network’s Lung Cancer Screening Panel, and past president of the American Roentgen Ray Society.

“Medicare received two formal re-quests for a national coverage decision,” she explained of actions taken earlier this year precipitating the CMS determination. “They statutorily have until Nov. 10 to post their draft coverage decision,” Kazerooni continued, noting a final decision was ex-pected in February 2015 following a com-ment period.

The ScienceWhile CMS will complete the coverage

decision process in a 12-month period, pro-ponents say the science supporting CT scans for diagnosing lung cancer goes back several decades. Considering the current poor sur-vival rates, this delay in integrating the scien-tific research into routine practice has been particularly frustrating for providers.

Kazerooni said more than three-quar-ters of lung cancers are found in a late stage when the disease has spread, making sur-gical intervention ineffective or impossible. Patients are typically asymptomatic until the disease has progressed, which contributes to dismal survival rates. Currently, more than 90 percent of those diagnosed annually with lung cancer will die from the disease.

Research from the International Early Lung Cancer Acton Program (I-ELCAP), which was formed in 1992, has shown an-nual CT screening to be an effective tool.

In the original study, more than 1,000 high-risk, asymptomatic patients were screened. Of those who received a lung cancer diag-nosis, more than 80 percent were at a clini-cal Stage 1.

Subsequently, findings from a much larger international pool were published in several publications in 2006 after long-term follow-up of more than 31,000 asymptom-atic study participants. While less than 2 percent of those screened received a lung cancer diagnosis, 86 percent were found in Stage 1 with an overall cure rate of 80 percent.

Similarly, the National Lung Screening Trial (NLST), one of the largest and most expensive clinical trials ever undertaken in the United States, evaluated the impact of screening methods on survivability. The trial, which ran from 2002-2010 and in-cluded more than 53,000 participants, compared outcomes when screening with standard chest x-ray vs. LDCT. The results published in 2011 in the New England Jour-nal of Medicine demonstrated a 20 percent reduction in lung cancer mortality for those screened by LDCT.

In both arms of the trial, more than 94 percent of positive screening results turned out to be false positives upon further test-ing, which is one of the arguments against annual screening. It should be noted, how-ever, that the false positive difference be-tween LDCT and conventional x-ray was less than 2 percent, yet decreased mortality with LDCT was 20 percent.

The available science led the United States Preventive Services Task Force (USP-STF) to assign a grade of B to lung cancer screening among high-risk patients —current or former heavy smokers, ages 55-80, with a smoking history of at least 30 pack-years. The USPSTF website defines the evidence behind a grade of B as being strong enough

to recommend the service be provided.The task force isn’t the only organiza-

tion to support LDCT screening for high-risk patients. In fact, Kazerooni said most every major clinical healthcare professional society, including the American Medical Association, has stepped up to voice support for CMS adopting coverage.

“There’s overwhelming professional support,” Kazerooni said. “We also have a lot of support from the House and Senate,” she added, noting congressional support is bipartisan.

The DecisionThe irony, Kazerooni continued, is the

USPSTF recommendation led to a screen-ing inclusion in the federally mandated Affordable Care Act requiring third party payers cover LDCT for those at high risk of developing lung cancer. “It’s not a ‘rec-ommended;’ it’s not a ‘they should;’ it’s a ‘must,’” Kazerooni said of the screening becoming a covered benefit beginning Jan. 1, 2015.

If CMS doesn’t reverse current pol-icy, then those who have received annual screenings for as much as a decade will abruptly lose the benefit when they hit 65 and qualify for Medicare coverage.

“The average age of lung cancer di-agnosis is 70 so to not offer lung cancer screening as they enter their peak years of risk would be a tragedy,” Kazerooni stated.

Among the issues being weighed by CMS are patient safety, frequency of testing, impact of false positive results, consistent quality across screening facilities, evidence-based data to identify eligible patients and inform follow-up and treatment, and cost of screening in relation to improved outcomes.

Kazerooni noted CMS is undertak-ing the normal due diligence that goes into releasing a national coverage analysis deci-

sion. She and colleagues across a number of medical specialties have provided informa-tion and parameters for the screening. For example, she noted, the American Associa-tion of Physicists in Medicine has created specific exam protocols. The ACR, which is one of three bodies that accredits CT facili-ties, has developed a practice standard for the screening. Proponents, she stressed, are specifically calling for low-dose, rather than standard dose, scans to improve the safety profile. Providers also agree smoking cessa-tion counseling should be part of the overall professional intervention for all high-risk in-dividuals who qualify for screening.

As for cost, Kazerooni said, “Low-dose CT screening is at least as cost effective, if not more so, than breast cancer screening. When you’re talking about breast can-cer screening, you’re talking about every woman of a certain age. Even though CT scans are more expensive, we’re targeting resources to a smaller, high-risk group.”

Bolstering that assertion, a study pub-lished in August in American Health and Drug Benefits found LDCT to be cost ef-fective in the Medicare population. The re-searchers found implementing the screening cost less than $20,000 per life-year saved, which is less than the costs associated with cervical and breast cancer screening.

Kazerooni is favorably encouraged CMS will follow suit with private payers and cover LDCT screenings for those with the necessary inclusion criteria who are not suf-fering from another medical condition that would significantly limit life expectancy. However, she added, she is interested to see what conditions CMS attaches to approval.

“It’s hard to believe they would do anything else but cover it,” she concluded of CMS. “There is a huge need for this, and we want to see it brought forward to benefit individual patients and the public at large.”

The Case for Covering Low-Dose CT Lung Cancer Screening


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GrandRounds

Baptist Names New Chief Medical Officer

Baptist Memorial Health Care re-cently promoted Dr. Mark Swanson to vice president and chief medical officer for the or-ganization. He came to the organization in March as the chief quality officer.

As CMO, Swanson will play a key role in strategic planning for the Baptist system, focusing efforts on communication and collaboration be-tween physicians and Baptist leadership to provide the best possible patient care. He will help develop and carry out a vision for performance enhancement across the Baptist system to position Baptist as a leader in quality and patient safety. Part of that vision includes creating an envi-ronment conducive to implementing best practices and resulting in measurable im-provements in clinical care outcomes, pa-tient safety, efficient use of resources and top-quality delivery of service.

Before coming to Baptist, Swanson spent 28 years at Orlando Health, an eight-hospital, not-for-profit health care system. Most recently, he served as chief quality officer of the organization’s physi-cian group and physician clinical integra-tion initiative. Before that, he was chief medical officer of the Arnold Palmer Hos-pital for Children, medical director of the Nemours Children’s Clinic, medical direc-tor of pediatric services for the Arnold Palmer Hospital for Children and Women and pediatrician-in-chief of the Nemours Children’s Clinic.

After earning a Bachelor of Science degree from Old Dominion University in Norfolk Va., Swanson earned a medi-cal degree from Eastern Virginia Medical School in Norfolk, Va. He received his pe-diatric residency training at the U.S. Naval Hospital in Portsmouth, Va., where he also served as chief resident. Upon comple-tion of his residency training he accepted a fellowship in pediatric critical care and anesthesia at the Children’s Hospital at the Harvard Medical School in Boston. He has received additional training in man-agement and physician leadership from the College of Physician Executives, the Harvard Law School, the American Board

of Quality Assurance and the Institute for Healthcare Improvement. Before going to Orlando Health, he served in the U.S. Navy, spending five years working in naval hospitals. He has been actively engaged in academic medicine, serving 11 years as a clinical assistant professor of pediatrics at the Florida State University College of Medicine while on staff at Orlando Health.

In 2006 he was awarded a Master of Science degree in health care manage-ment from the Harvard School of Public Health. He has won numerous awards in-cluding the Gold Service Award from the American Heart Association, The Alfred I. DuPont Physician award and the Navy Medal of Commendation. Swanson has been recognized by Who’s Who in Health and Medical Services and has been on the list of The Best Doctors in America, Southeast Region each year since 1996.

Clint W. Snyder, PhD, MBA, Named Senior Associate Dean and Chair

David M. Stern, MD, Robert Kaplan Executive Dean of the University of Ten-nessee Health Science Center (UTHSC) College of Medicine, has announced the appoint-ment of Clint W. Snyder, PhD, MBA, as the senior associate dean and chair for the new Department of Medical Education in the UTHSC College of Medi-cine. Dr. Snyder joined UTHSC on October 1.

In his new role as senior associate dean, Dr. Snyder oversees the Office of Medical Education, which is responsible for undergraduate medical education. He will oversee curriculum planning, evalua-tion and management for the four-year medical program, as well as accredita-tion requirements and processes for the College of Medicine. As chair of the De-partment of Medical Education, Dr. Sny-der will recruit, provide guidance, and promote faculty development in teach-ing and educational research. UTHSC is poised to bolster its curriculum integra-tion and active learning while increasing emphasis on its service-learning activities and required research initiatives.

The senior associate dean and chair will report directly to Dr. Stern in his role as executive dean for all four UTHSC Col-lege of Medicine locations – Memphis, Knoxville, Chattanooga and Nashville.

Before joining UTHSC, Dr. Snyder spent more than 22 years in academic medicine at several prominent Ohio uni-versities. Most recently, he was with Case Western Reserve University in the Depart-ment of Family Medicine and Community Health, where he served as interim chair, professor and vice chair. Among his other positions at Case Western, he previously worked for four years as interim vice dean for Education and Academic Affairs in the School of Medicine. Prior to joining Case Western, Dr. Snyder was with Northeast-ern Ohio Universities College of Medi-cine. While there, he served three years as associate dean for Medical Education; four years as associate dean for Health Professions Education; and six years as professor for Behavioral and Community Health Sciences. Dr. Snyder has also held various teaching positions at Kent State University, including adjunct professor of sociology, adjunct assistant professor and instructor.

After earning a Bachelor of Science from Youngstown State University with a double major in combined science and sociology, Dr. Snyder went on to obtain his MA and PhD in medical sociology from Kent State University. In 2011, he earned an MBA from the University of Akron with a dual focus in health care management, and management and personnel.

Having published or contributed to some 25 manuscripts, book chapters or book reviews, and having provided presentations at more than 45 scholarly meetings, Dr. Snyder has received sev-eral honors and awards for his work as an administrator and instructor. He has also garnered more than $10 million in grant funding, contributed extensively as a reviewer to various medical education journals, and led some 20 workshops and invited lectures.

Fertility Associates of Memphis Announces New Physician

Fertility Associates of Memphis an-nounced today that Dr. Amelia Purser Bailey, a reproductive en-docrinology and infertil-ity specialist, has joined the practice as Director of Minimally Invasive Surgery.

Dr. Bailey, a Missis-sippi native, recently com-pleted her fellowship in Reproductive Endocrinol-ogy and Infertility at Brigham and Wom-en’s Hospital / Harvard Medical School. She earned her medical degree from the University of Mississippi School of Medi-cine and completed residency in Obstet-rics and Gynecology at the University of Virginia Health System in Charlottesville. Dr. Bailey completed her undergraduate studies at the University of Mississippi in Oxford.

In addition to treating all areas of infertility, her special interests include robotic surgery. She is board certified in obstetrics and gynecology.

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GrandRounds

Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.

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DIgital Pathology Advancements At Trumbull Laboratories, LLC

The physicians of Pathology Group of the MidSouth have announced an advancement in lab technology with the installation of the Ventana iScan Coreo, a digital pathology whole slide scanner at Trumbull Laboratories, LLC.

A technology made available by Ven-tana Medical Systems, Inc., a member of Roche Tissue Diagnostics, the Ventana iScan Coreo provides advanced image quality for improved diagnostics and prognosis. Equipped with high speed brightfield slide scanning, the iScan Coreo slide scanner provides advance-ments including improvements to lab efficiency, pathologists productivity and diagnostic quality; anywhere/anytime ac-cess to digital cases and images; telepa-thology and case sharing; image analysis, proficiency testing and academic case sharing; and integrated patient reporting.

Paired with Virtuoso digital patholo-gy software, iScan Coreo provides pathol-ogists with a complete digital pathology solution from image acquisition through customized reporting, increasing opera-tional efficiencies and productivity in the lab.

In response to a growing demand for digital pathology and personalized medicine in clinical practice, Trumbull Labs has installed the iScan Coreo scan-ner with hopes of enhancing the practice of pathology. The primary use of the iS-can Coreo at Trumbull Labs will be to op-timize workflow and provide the ability to scan multiple breast cases per day. The scanner auto detects a tissue specimen placed on the slide, adds focus points and scans the specimen.

The iScan Coreo will replace exist-ing scan for positive breast biopsies and will provide an extra layer of safety for the patients. Trumbull Labs is the first labora-tory to implement this technology in the Memphis and MidSouth area.

Baptist Plans System-Wide Cost-Cutting Measures

Baptist Memorial Health Care an-nounced a system-wide plan across its three-state service area to reduce costs and expand services for patients. The or-ganization was able to find significant sav-ings by reducing supply expenses, elimi-

nating non-essential items and improving processes. As a part of the plan, Baptist announced the elimination of 112 posi-tions, most in corporate services.

Jason Little, president and CEO of Baptist said that it is difficult to lose talent-ed and valued team members but they are focused on being the high quality and low cost provider in the region.

According to Little, the changes an-nounced are designed to adjust to the changing healthcare environment by ex-panding services and improving opera-tional efficiencies as a national leader in health care.

Dr. Paul J. Katz Elected ACP Fellow

Paul J. Katz, M.D., FACP, an internist practicing with PennMarc Internal Medicine, part of Methodist Primary Care Group, has been elected a Fellow of the Ameri-can College of Physicians (ACP), the society of inter-nists. This distinction, des-ignated by FACP, recog-nizes achievements in internal medicine, the specialty of adult medicine.

Dr. Katz was elected upon the rec-ommendation of peers and the review of ACP’s Credentials Subcommittee.

He is affiliated with Methodist Le Bonheur Healthcare and is certified in in-ternal medicine by the American Board of internal medicine. Dr. Katz is a member of the Memphis Shelby County Medical Society and the Tennessee Medical As-sociation.

A graduate of Christian Brothers Uni-versity, Dr. Katz earned a medical degree from the University of Tennessee Health Science Center.

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Expertise. Uniquely, Dr. Mroz and her associate, Dr. Ron Mattison, are Surgeons certifi ed by the FDA and the American College of Radiology as Supervising Interpreting

Physicians, Case Managers and UltraSonographers. They read their own mammograms and formulate and execute the treatment plan.

Experience. After treating over 45,000 new patients over the past 20 years, we’ve gained the experience to diagnose and offer your patient a treatment plan in one day…not weeks or months, and without needless biopsies.

Documents

Memphis Medical News November 2014