Nashville Medical News July 2016

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By CINDy SANDERS

According to a recent analysis of the U.S. healthcare real estate market by Col-liers International, all signs point to full steam ahead. Michael Roessle, director of office research for the USA and author of the report, noted, “In 2016 and beyond, there will continue to be strong demand for medical office space as healthcare spend-ing rises and demand from an aging population grows.” He went on to say, “Investor appetite is driven by higher yields compared to other asset classes, low interest rates and a stable tenant base with strong credit.”

The report also noted medical office building inventory continues to be low with vacancy rates under 10 percent nationally. While working with an expert in healthcare realty has benefits for providers at any time, tapping into that insight is particularly

(CONTINUED ON PAGE 10)

Antonio Granda, MD

PAGE 2

PHYSICIAN SPOTLIGHT


Public Health 3.0: Building Partnerships to Improve Population Health

By CINDy SANDERS

Public Health 3.0: It’s time for an upgrade.

Last month, the Metro Public Health Depart-ment and NashvilleHealth co-hosted a daylong event dedicated to the social de-terminants of health that in-cluded U.S. Department of Health and Human Services Acting Assistant Secretary for Health Karen B. De-Salvo, MD, MPH, MSc.

DeSalvo has been tour-ing select communities to advance the cause of Public Health 3.0, billed as a major upgrade in public health practice to emphasize cross-sectional environmental, policy and system-level actions that directly affect the social determinants of health and ad-

vance health equity. The Pub-lic Health 3.0 initiative builds on the work of Healthy People 2020.

The event kicked off with a welcome from Bill Paul, MD, MPH, director of Metro Public Health. While Nashville is the 13th healthiest city in Tennes-see, he pointed out the state ranks 43rd in the nation. And despite this country’s vast re-sources, Paul noted the United States doesn’t even crack the top 20 when it comes to health-iest nations in the world.

“We should do better. We can do better, and I

think that’s part of the reason we’re here,” Paul stated. He added the task of improving the health and wellbeing of all Davidson

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Gut InstinctIt’s no secret that reflux, irritable bowel syndrome and inflammatory bowel disease have reached epidemic proportions in America. We asked some of Nashville’s top GI specialists to break down the latest news and myths on some of the most common diagnoses ... 4

CON UpdateAfter years of lively debate, Tennessee’s CON law gets a major update ... 5

Pain Management Options & OpportunitiesTrying to find the right mix of medication, non-pharmacologic modalities, and tempered expectation is a delicate balancing act that many physicians – from primary care providers to pain specialists – face under the glare of rising opioid and heroin addiction nationwide ... 7

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2 > JULY 2016 n a s h v i l l e m e d i c a l n e w s . c o m

By MELANIE KILGORE-HILL

Antonio Granda, MD, is passionate about saving lives. The gastroenterolo-gist has been a pillar in Middle Tennes-see’s medical community since 1979, when he joined the staff at St. Thomas Medical Group. While a lot has changed in Nashville since the Carter administra-tion, Granda’s commitment to his patients hasn’t waivered.

Humble BeginningsThe son of a respected Cuban pedia-

trician, Granda arrived in America as a refugee at age 13. As the family worked to rebuild their lives in Wilmington, Del., Granda committed to following in his father’s footsteps, delving into medical books at a young age.

“I kept working and received a lot of help from my teachers in high school, col-lege and medical school, who were a great inspiration to me,” Granda said of those early years. “I had nothing coming from Cuba, and I had this opportunity to give back to this country and the people who live here.”

He went on to receive his under-

graduate degree at the University of Dela-ware in 1968 and his medical degree from Jefferson Medical College in 1974. The following year, Granda arrived in Nash-ville where he completed his internship, residency and gastroenterology fellowship at Vanderbilt University School of Medi-cine. Board certifi ed in internal medicine and gastroenterology, Granda now treats the children and grandchildren of many

long-time patients, simply called “friends” today.

Road to GastroenterologyHow does a pediatrician’s son end

up in gastroenterology? “I was a student when fi ber optic instruments were de-veloped as part of space exploration,” Granda explained. “The endoscope had recently been developed, and it was at the center of this ability to see inside people safely. I was fascinated by that.”

Then there was another unexpected catch. “I was left handed so I couldn’t be a surgeon,” Granda joked. “The scope was my opportunity to do surgery.”

His fascination soon deepened into passion as Granda recognized the ability of the fi eld to dramatically change lives. “I enjoyed explaining to patients the re-sults and how I could teach them to re-gain health from fi ndings I had,” Granda said. “I felt that many times doctors gave results but didn’t teach the patient what they needed to do to get better. My role is to be a part of the team.”

It’s a role he takes seriously, although he readily uses humor to drive home a message. In 2015 he helped create a You-Tube web series, “Keeping up with the Kolonoscopy,” which chronicled a fam-ily’s experience through the colonoscopy experience. The humorous series was a light-hearted attempt to tackle a very real problem.

“When I fi rst began practicing, 60,000 Americans died of colon cancer every year,” Granda said. “After all these years, there are still 40,000 dying because we still can’t get people to get colonoscopies. We don’t know how to make it happen.”

IBSchekGranda also treats countless patients

who’ve gone doctor-to-doctor and un-dergone countless tests before receiving a diagnosis of IBS. The problem, he said, was the lack of defi nitive testing for irri-table bowel syndrome, once thought to be a psychological condition. Today, he frequently touts the benefi ts of a new test that claims IBS is not only a real condition but also one with a naturally known cause.

New data suggests that IBS may be brought on by food poisoning – the fi rst scientifically proven cause of the dis-ease. In some individuals, food poisoning can cause the immune system to produce antibodies directed against the proteins in the bacteria causing food poisoning. In ad-dition to attacking the bacteria, antibod-ies can also attack a naturally occurring protein located in the lining of the intes-tinal tract. This antibody attack is part of an autoimmune reaction and may even-tually lead to the generation of clinical symptoms associated with IBS.

As a result, the presence of either of these two antibodies in the bloodstream is considered to be a biomarker (anti-CdtB or anti-vinculin) for IBS. The identifi ca-tion of the presence of these antibodies al-lows for a quick and reliable diagnosis of IBS using IBSchek™, the new blood test based on this scientifi c discovery.

“This test is important because if it is positive, patients know how they got sick and that it’s not anything they’re doing,” Granda said. “They know it’s not in their minds, and it’s not their jobs or stress caus-ing it. It’s very helpful to know.”

IBS in NashvilleA 2016 survey from the Wakefi eld

Group showed that IBS sufferers in Nash-ville saw an average of two doctors and underwent three or more unnecessary di-agnostic tests over fi ve years before fi nally receiving a diagnosis of IBS.

Almost 90 percent of IBS sufferers in Nashville said IBS has impacted their productivity at work, and 40 percent have not told family members about their condi-tion. A hefty 69 percent of people with IBS felt like family or friends thought they were imagining or exaggerating their symptoms before receiving an IBS diagnosis. Ad-ditionally, 86 percent of IBS sufferers in Nashville say their social lives have been negatively impacted by their symptoms, including missing out on activities with friends, traveling or going out to dinner due to concerns or issues with their condition.

“I see patients in their 70s who’ve been miserable with IBS symptoms their entire lives,” Granda said. “They’re glad there’s an explanation for symptoms, and we can deal with the diagnosis. It provides peace of mind for patients who want a bet-ter quality of life.”

A Gift for Gastroenterology Dr. Antonio Granda Brings Heart, Humor & Passion to his Field

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Colorectal cancer is the third most common cancer diagnosed in both men and women in the United States (skin can-cer aside). The American Cancer Society anticipates 95,270 new cases of colon can-cer in 2016 and more than 49,000 deaths from the disease.

Fortunately, death rates tied to colon cancer are actually on the decline thanks to increased awareness, earlier screen-ings and advances in medical therapies. Those breakthroughs were highlighted during the annual American Society of Clinical Oncology (ASCO) conference in June. Oncologist Johanna Bendell, MD, director of the GI Cancer Research Program and associate director of the Drug De-velopment Program at Sarah Cannon Research Institute, said findings pre-sented at ASCO would be a game changer for oncologists and colon cancer patients.

Immunotherapy The most promising news in the treat-

ment of colon cancer revolves around im-munotherapy, or using the body’s own system to attack cancer. Bendell said pa-tients with microsatellite instable metastatic colon cancer could derive the greatest ben-efit from immunotherapy.

What is Microsatellite Instability?MSI is a change that occurs in the

DNA of certain cells, such as tumor cells, in which the number of repeats of microsatel-lites (short, repeated sequences of DNA) is different than the number of repeats that was in the DNA when it was inherited. Ac-cording to the National Cancer Institute,

the cause of microsatellite instability may be a defect in the ability to repair mistakes made when DNA is copied in the cell.

Approximately 15 percent of MSI patients also have hereditary nonpolyposis colorectal cancer (HNPCC), or Lynch Syn-drome. HNPCC is a genetic condition that can encourage growth of additional cancers through the GI tract, making treatment even more critical for the MSI population. Bendell said 25-50 percent of MSI patients studied have shown an incredible response to immunotherapy. While patients with MSI represent only five percent of overall metastatic colorectal cancer cases, Bendell urges gastroenterologists to test all cancer patients for MSI. “In my practice that’s the first question I ask,” she said.

Non-MSI PatientsWhat about the 95 percent of patients

without microsatellite instability? During the June ASCO conference,

Bendell and her colleagues presented data on the use of MEK inhibitory drugs, al-ready approved by the FDA for treatment of melanoma. When used in non-MSI patients, the drug can increase T-cell pro-duction and essentially rev up the immune system, triggering a similar response as MSI patients to immunotherapy.

Twenty percent of non-MSI patients who received a combination of MEK in-hibitors and immunotherapy responded to treatment. That means a 20-30 percent response rate to immunotherapy across the colon cancer population.

“The next big question in drug de-velopment is, ‘How can we make more people respond to immunotherapy?’” said Bendell, who’s been involved in the trial for two years. “Our presentation was just the beginning of the wave examining this treatment.”

Next generation immunotherapy trials

are now underway to examine the use of other agents in combination with immu-notherapy. The data is so promising that a randomized study has begun for FDA approval, with the first trial sites already opening.

Left or Right?Doctors have long known that patients

with left-sided metastatic colon cancers live longer than those with right-sided, and now researchers are beginning to learn why. “We used to think it was because we caught them earlier beccause they become symptomatic sooner, but now we see there are biologic distinctions between tumors on the left and sideright sides,” said Bend-ell, who noted that patients with left-sided colon cancer often live 15 months longer than those with right-sided.

Typically, right-sided colon cancers carry the BRAF mutation and have hyper-methylation, which carries a poor progno-sis. Recent We have even seenmicrobiology studies also show different bacteria present in left and right sides can affect the molecu-lar profile of the area of the colon where the bacteria live.

“We think that bacteria has a role in a tumor’s molecular profile, and data pre-

sented from a large study of chemo using two different target agents has led to a dis-cussion of the optimal first line treatment for colon cancer,” Bendell explained. “We saw that for patients with right- –sided colon cancer they did not appear to benefit at all from the use of a certain treatment. Should we use one chemo agent over an-other depending on the side affected?”

What Providers Can DoWhile researchers await that answer,

Bendell encouraged providers to note each patient’s micro stability status, BRAF sta-tus, expanded RAS testing, and the side of colon affected, as every piece of informa-tion could prove helpful for future treat-ment. She also encouraged primary care providers to take an aggressive approach in monitoring and examining patients of all ages with persistent GI symptoms, as wed-octors are seeing a rise in the development of colon cancers among the the younger patient population have an .increasing rise in development of colon cancers

“This is all super exciting news in the treatment of colon cancer and is setting the stage for how research in colon cancer will keep moving forward,” Bendell said of re-cent advances.

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ASCO Conference Sheds Light on Colon Cancer TreatmentNew Findings Mean More Hope for Patients

CRITICS Study Changing Protocol for Gastric Cancer Treatment

Less common than colon cancer, stomach cancer will be diagnosed in 26,000 individuals in 2016. Findings from CRITICS – an international, multicenter, randomized, phase III study that examined the necessity of radiation along with chemotherapy for gastric cancers – was also presented at ASCO.

“CRITICS was big news in that we haven’t really known how to best treat patients who’ve had stomach cancer removed by surgery,” explained Bendell. “We didn’t know if patients needed radiation as well as chemo to improve survival.”

The result? “We don’t need radiation therapy to treat gastric cancers,” she said.

More often than not, the benefit of radiation was to ‘clean up’ after inadequate resections during gastric surgery. That’s why Bendell emphasized the need for patients with gastric cancers to seek treatment in a specialty facility with experience in performing these surgeries. This can reduce the risk of adverse events from the surgery and help ensure the correct surgery is performed, eliminating the need for radiation.

“There’s plenty of data that correlates outcomes with the surgeon’s experience,” she said. “When you do the right surgery, you don’t need radiation. This changes the standard of care for gastric cancer patients.”


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It’s no secret that reflux, irritable bowel syndrome and inflammatory bowel disease have reached epidemic proportions in America. We asked some of Nashville’s top GI specialists to break down the latest news and myths on some of the most common diagnoses.

GERDGastroesophageal reflux disease is a

condition in which the stomach contents leak backwards from the stomach into the esophagus, irritating the esophagus and causing heartburn. While reflux hits nearly everyone on occasion, experiencing symp-toms more than twice a week for a few weeks could lead to more serious complica-tions.

“GERD is a common problem and can affect 10 percent of the population at any given time,” said Saint Thomas Medical Partners Gastroenterologist Neil Price, MD. For many, oc-casional episodes can be treated with antacids and simple lifestyle changes like elevating the head of the bed at night.

Price said GERD has been a tremen-

dous focus for researchers over the past 30 years. “Until the 1970s, antacids were the main treatment for GERD, and then we saw H2 blockers which are more effective than antacids at turning off acids for lon-ger,” Price said.

Twenty years ago Americans flocked to a newer drug class called proton pump inhibitors, proven to be more effective for severe symptoms. In fact, the now over-the-counter class represents the third most pre-scribed medication in the world. But Price said there are new concerns about the long-term use of proton pump inhibitors. That’s because patients with severe heartburn are likely to stay on the drug for life, increas-ing the otherwise minimal risk of damage to kidneys, bones and other systems.

“Overall it’s a very safe class of drugs, but it’s certainly something patients need to have a conversation about with their pro-vider,” Price said. “We try to balance the benefits with potential long-term risks.”

For many, weight loss and dietary changes are effective ways to control heart-burn long term. Pamela Duncan, MS, RD, LDN, Dietitian III at the Vanderbilt Nutrition Clinic, said patients often underestimate the role simple lifestyle changes can make in GERD treat-ment.

“I don’t look at diet as a cure but in combina-tion with medical therapy,” Duncan said. Patients should avoid acidic foods like cof-fee, tea, sodas, tomatoes, juice and alcohol. And while many eat mint to calm the stom-ach, Duncan said the herb could actually open up the lower esophageal sphincter and make symptoms worse. Exercise also can help, in part because it encourages weight loss and improves overall health. However, Duncan warns against vigorous exercise in patients with GERD and other digestive disorders and urges patients trying to lose weight to talk to their providers.

Irritable Bowel SyndromeIBS is a chronic functional disorder of

the gastrointestinal system. Patients expe-rience abdominal pain and altered bowel habits, with predominantly diarrhea (IBS-D), constipation (IBS-C) or both (IBS-M). According to the National Institutes of Health, IBS affects approximately 11 per-cent of the population, although less than 30 percent of that group seeks professional help. It affects more women than men, and absence of a definitive biomarker has led many to classify it as a symptom of psycho-logical difficulty like anxiety.

“What’s interesting now is that re-search shows a link between IBS and a number of people with intolerance to differ-ent kinds of foods and the inability to digest certain fruit sugars,” Price said. “We now believe it’s a mixture of causes.”

Since many IBS patients carry high levels of bacteria in their small intestine, Price said patients often respond well to di-

etary and antibiotic therapies. Duncan cau-tions providers against taking a “one size fits all” approach to treating IBS patients – a mistake she commonly sees in her work with GI patients.

“Each patient is an individual,” she said. “Fiber is variable and doesn’t just thicken stool so patients will react differently depending on whether they have chronic diarrhea or constipation.” She urges pro-viders to refer patients to dietitians who specialize in gastroenterology. “It’s very dif-ficult and overwhelming for a patient to be handed a sheet with ‘do’s’ and ‘don’ts,” said Duncan, who works exclusively with gastro-intestinal disease patients.

Inflammatory Bowel DiseaseInflammatory Bowel Disease is a broad

term that describes conditions with chronic or recurring immune response and inflam-mation of the gastrointestinal tract. The two most common inflammatory bowel diseases are ulcerative colitis and Crohn’s disease. Inflammation affects the entire digestive tract in Crohn’s disease and only the colon in ulcerative colitis. Both illnesses are char-acterized by an abnormal response to the body’s immune system.

“Crohn’s and ulcerative colitis are markedly different diseases,” said Sara Horst, MD, gastroenterologist at the Vanderbilt Digestive Dis-ease Center. She works exclusively with IBD patients at the Nashville specialty center, which has more than 2,500 pa-tient visits annually.

Anti-TNF drugs like infliximab have been ef-fective at achieving remission, although up to 70 percent of Crohn’s patients require abdominal surgery within 30 years of di-agnosis. However, surgery is becoming less common thanks to breakthroughs in im-munosuppresants. And in 2014 a new drug called vedolizumab was approved for treat-ment of both diseases.

While most IBD patients are well in-formed, Horst said the prevalence of new medications could make it tough for provid-ers to choose the best therapy.

“Successful treatment involves good patient-provider relationships,” Horst said. “Patients should be involved in those deci-sions and be aware of benefits and risks of each medication.”

Horst, whose research interest includes the role of stress, anxiety and depression in IBD patients, urges providers to treat the patient as a whole. That means ensuring patients are up-to-date on vaccinations and health screenings and checking for nutri-tional deficiencies, as certain therapies can increase risk of bone loss and certain can-cers.

“Gastroenterologists need to have the tools to make sure they’re dealing with ev-erything together,” she said. “It can take a long time to help patients find right medica-tions, but we’re here to help with that.”

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By CINDy SANDERS

Over the past several years, a lively conversation morphed into a hotly de-bated discussion as proponents and oppo-nents of Tennessee’s Certificate of Need (CON) law lined up their arguments. Ear-lier this year, the 109th General Assembly tackled the subject and unanimously voted for SB1842 to revise a number of provi-sions governing certificates of need that took effect July 1.

“This legislation is the most sub-stantive change to the scope of Tennessee’s CON program since its origination,” said Mat-thew Kroplin, a partner at Burr & Forman and member of the firm’s Health Care Practice Group.

He noted the original CON legisla-tion occurred in 1973, and – except for some minor tweaks and administrative changes in 2002 – this is the first time in

43 years for major changes to the rules governing how healthcare facilities are established and expanded in the state. Kroplin said the legislation removed some categories entirely from the need for a CON, added others, and narrowed the applicability in still other categories. “In essence, these reforms are an attempt to modernize the scope of the CON program to reflect the realities of today’s healthcare system,” he explained.

“It was the result of quite a bit of con-versation between various stakeholders and legislators working to craft the CON modernization bill,” noted Jerry W. Taylor, also a partner at Burr & Forman and member of the firm’s Health Care Practice Group. “There was a lot of bipartisan support,” he added. “Sometimes legislation of this magnitude takes two sessions.”

Taylor continued, “Probably the most

Updated CON Law Now in EffectJuly 1 Start Date for New Regulations

Snapshot of CON ChangesAfter years of discussing changes to Tennessee’s CON laws, the

legislative process actually moved quite rapidly. A unanimous vote by both legislative branches in April, followed by the governor’s signature at the end of April and a July 1 launch date has put the following changes in motion:

Removes from CON Coverage•Modifying, renovating or adding to a hospital or healthcare institution,•Acquisition of major medical equipment,•Discontinuing obstetric or maternity services,•Closing a hospital that has been designated as a critical access hospital

or eliminating regulated services within these hospitals, •Initiation of birthing centers, extracorporeal lithotripsy, swing beds, or

rehabilitation or hospital-based alcohol and drug treatment for adolescents provided under a systematic program of care longer than 28 days,

•Increase of up to 10 percent in licensed beds in any bed category once every three years for hospitals, mental health hospitals, and rehabilitation facilities at any one campus (but written notice still required).

Changes or Expands CON Coverage•Initiation of organ transplantation,•Establishment of freestanding emergency departments,•Initiating MRI services or increasing the number of MRI machines in

counties with a population of 250,000 or less (based on latest federal census numbers) or for pediatric patients in all counties,

•Requirement of an annual report by March 1 of each year from those providing MRI services detailing the mix of payers by percentage of cases for the prior year,

•Accreditation by the American College of Radiology “in modalities provided by that facility” for outpatient diagnostic centers after receiving a CON within a timeframe that is to be set through rulemaking, and

•Establishment of new quality standards and parameters to be measured through ongoing oversight by HSDA in conjunction with the Department of Health, Department of Mental Health and Substance Abuse, and licensing board for any CON approved after July 1, 2016.

Other•Allows applicant who is denied a CON to receive a 25 percent refund

of the filing fee upon request.

Matthew Kroplin

Jerry W. Taylor



HealthcareEnterprise

Centauri Health Deploys Solutions to Assess Risks, Drive Outcomes

By CINDy SANDERS

With offices in Scottsdale, Nashville and Orlando, two-year-old Centauri Health Solutions, Inc.SM has already enjoyed rapid growth, and the HIT solutions provider is poised for even more expansion as the team works to fill needs in a quickly evolving healthcare environment. Centauri’s suite of products and services provide comprehen-sive data management designed specifically for risk adjustment and quality-based rev-enue programs.

Headquartered in Arizona, the com-pany simultaneously opened the Scotts-dale and Nashville offices upon launching in April 2014. Nashville-based Michelle Miller, chief technical officer for Centauri, is one of four company co-founders. Miller, who has been in Nashville for more than 25 years, has past technology and management experience with Cigna-HealthSpring and Gambro/DaVita, among other healthcare entities.

She said Centauri helps national cli-ents – primarily insurance companies and risk-bearing providers, which are typically large health systems – navigate the myriad data points and compliance requirements to optimize interaction and participation with government-sponsored programs like Medi-care Advantage and Medicaid, in addition to the Health Insurance Exchange.

“We offer an end-to-end solution suite,” Miller said of managing all the mov-ing parts. Those private cloud-based solu-tions fall under the broad headings of risk

adjustment, quality and stars, and advisory services. Under each heading, a range of software offerings assists clients with every-thing from retrospective and prospective analytics to identification of quality care gaps and compliant data submission.

In the realm of risk management, Miller explained, Centauri gathers raw data from clients, pairs it with other indus-try data sources and then does a deep dive on predictive analytics to help determine which patients are likely to develop chronic conditions and which ones might be care resistant. “A lot of the work we do is making sure that patients with these chronic condi-tions are proactively managed,” she noted.

However, she continued, identifying a high-risk patient or uncovering a quality gap isn’t enough. The next step, she said, is to help clients address those problems. The services arm of Centauri will go into homes to assess status as needed and pro-vide comprehensive information to physi-cians for a complete view of the patient. “The more information, the better … and the more accurate the information, the bet-ter,” Miller said.

To expand offerings and enhance cli-ent service, Centauri has launched a growth strategy that includes acquisition to help strengthen the company’s core mission. In 2015, Centauri acquired revenue cycle management and Medicare risk adjustment company Tactile Management, Inc., which gave them a presence in Orlando. In May 2016, the firm announced Boston-based Silversmith Capital Partners had acquired a significant minority stake in the business and committed $50 million in capital to grow the company’s core platform, fund expansion of new products and services and invest in personnel and infrastructure to scale rapidly.

Last month, Centauri announced the acquisition of Nashville-based IMI Health. The IMI team will join Centauri’s new tech-nology center in Nashville where the major-ity of the company’s products and services will be developed. “We’re in active growth cycle right now,” Miller said. “We are liter-ally doubling people and revenue in every office.”

IMI, whose clients represent about

four million lives, has cloud-based products that provide real-time data-sharing to help close gaps in care and improve care man-agement and quality scores. In March, the National Committee for Quality Assurance announced IMI had earned certification for their software code related to HEDIS® (Healthcare Effectiveness Data and Infor-mation Set).

Miller noted, “IMI’s technology frame-work aligns well with Centauri’s delivery platform, allowing us to rapidly publish our combined capabilities to our clients and to continue to push innovation in the market.” In other words, she said with a laugh, “We call IMI the peanut butter to our jelly.”

By running data through the HEDIS engine, Miller said quality gaps are uncov-ered and highlighted. “The earlier we can see those, the more proactively we can in-tervene in the healthcare cycle.”

She stressed it isn’t Centauri’s job to babysit physicians who are fully capable of delivering excellent care but instead to provide them the tools and data necessary to make the most effective, efficient deci-sions based on a 360-degree view. And, she added, the company also helps make sure providers are reimbursed for their hard work through documentation and compli-ant submission solutions.

“We’re going to be an active, highly qualified partner to help them solve this risk adjustment and quality conundrum and to help them maximize these government programs they are working through,” Miller concluded.

Michelle Miller

County residents is a large one that can’t be accomplished alone. “It’s bigger than any one organization,” he said. “Improving, sustaining our health will take collaboration; it will take a combined effort.”

He continued, “One of the most pow-erful things we can do to improve health is to weave health into the fabric of the city.” Paul said you shouldn’t have to ‘be spe-cial’ to be healthy. Instead, it should be or-dinary to live a long, healthy life. “That’s part of what we want to do is change the normal so the healthy choice is the easy choice.”

On the plus side, Paul noted there are a growing number of success stories that show what’s possible with a focused effort. An initiative to change policies and practices in birth hospitals in Nashville increased breastfeeding initiation from 61 percent to 84 percent in the span of

three years. Schools have reduced sugar in chocolate milk. “The kids didn’t notice the difference, and now 52,000 pounds less sugar is going into our children each year,” Paul said.

However, on the flip side, Paul said there are neighborhoods in Nashville where the chance of dying early is four times greater than in other neighborhoods just a few miles away. “So whatever we do, when we advance health, we’ve got to advance fairness in health and how health is distributed.”

Leslie Meehan, MPA, assistant direc-tor of Primary Prevention for the Ten-nessee Department of Health, said, “Our nation, as you know, is suffering from a preventable epidemic of chronic disease enabled by the places, spaces and choices that challenge our health on a daily basis. This is truly the health crisis of our time.”

She added, “We know we cannot treat our way out, but we can prevent our way out.” To that end, the TDH launched the Primary Prevention Initia-tive in 2013, which has led to almost 2,000 projects across the state from creating park benches with anti-smoking messages to building community greenways and

gardens. “Most importantly, the Primary Prevention Initiative provides us the op-portunity to change the notion that health is only about healthcare.”

Senator William Frist, MD, former U.S. Senate Majority Leader and founder of NashvilleHealth, said that amid all the excitement of Nashville being an ‘It’ city, it was important to make sure citizens weren’t left behind. Remaining competi-tive, he noted, requires a healthy work-force. Frist said NashvilleHealth has opted to hone in on three key focus areas – to-bacco use, hypertension, and child health – to begin to flip the script on poor health.

DeSalvo told attendees taking respon-sibility for the health of a community “is something all of us, as a society, need to stand up and make a decision that better health is a critical underpinning of our vitality and quality of life for everybody.”

She said the time is right for this con-versation in part because of some of the changes happening in the country. De-Salvo pointed to recent data that shows life expectancy starting to decline in some parts of the United States, as well as wid-ening gaps by income with a difference of 15 years greater longevity for men in the

top income levels compared to those at the bottom.

“What is behind those numbers and statistics?” she questioned. Taking a closer look at the data and the underlying traits of communities that are not seeing de-clines, DeSalvo continued, “You begin to see there are some inherent characteris-tics about communities working together to create the conditions in which everyone can be healthy.”

That work, she said, goes well beyond the public health department or health-care system to a much broader shared vision, goals and actions by the larger community. DeSalvo said the social de-terminants of health – economic oppor-tunity, housing, environment, education, food, safe neighborhoods, transportation – in combination with health behaviors re-ally make up close to 70 percent of overall health, as compared to medicine, which makes up about 10 percent of someone’s overall health. For that reason, she said, it is critical in this new iteration of Pub-lic Health 3.0 to build upon past success but to upgrade to a modern version that works across sectors and puts health in all policies.

Public Health 3.0: Building Partnerships, continued from page 1

Bonus EditorialRead more online



By CINDy SANDERS

Trying to find the right mix of medi-cation, non-pharmacologic modalities, and tempered expectation is a delicate balancing act that many physicians – from primary care providers to pain specialists – face under the glare of rising opioid and heroin addiction nationwide.

Coming out of an age where there is a ‘pill to fix what ails you,’ John R. Schnei-der, MD, MA, founder and medical direc-tor of Comprehensive Pain & Neurology Center, said it’s time to change the collec-tive mentality.

“Our grandparents would complain about their sciatica and their lumbago, but they still went to work, and they were still functional. One of the things I really try and emphasize with our patients is to grasp the concept that we’re not going to eliminate all of their pain, but we’re going to try to focus on their functioning and take the edge off the pain.”

Schneider, who has a master’s in psy-chology, was working on his doctorate in that field when he decided to pursue his medical degree. He is one of the few pain specialists in the state board certified in both pain medicine and in neurology. With his background, Schneider is keenly aware of the link between depression and

chronic pain and the risk of addiction.“At the end of the day, I think what

we’re dealing with is a patient’s ability to cope with their situation,” he said. Schnei-der also noted, “I think we’re one of the only private practices, at least in Middle Tennessee, that has a clinical psychologist on board. We utilize her for our opioid risk assessments to help stratify which pa-tients are at high risk and which are at low risk for opioid abuse and misuse.”

While opioids remain a mainstay of pain management, Schneider said there are a number of options for utilizing ad-juvant therapies, encouraging activity and self-management, and dealing with the coping mechanism of having some level of pain. He also noted that not all opioids are created equally. “Some of the opioids prescribed have a little more activity in the mu receptors in the brain,” he said, adding these lead to “chemical coping” in some patients but require ever-increasing dosages to maintain a level of relief.

By the time patients arrive at a pain specialist after referrals from primary care physicians and surgeons, most have been in pain and on chronic opioid therapy for quite a while. However, Schneider noted, “A lot of the medical evidence points to the fact that opioids aren’t that effective long-term. We know there are certain lim-its and certain risks with dosages so we try and do as best we can at adding adjunctive medications.”

That said, he doesn’t dismiss opioids as part of a comprehensive pain manage-ment strategy. Schneider said for the last two decades, the pendulum swung too far to the left in terms of overprescribing opi-oids, but there is now some concern there will be an overcorrection.

“I do think there’s a role of opioids,

but you’ve really got to keep an eye on the patient and the function,” he said. “It comes down to education – educating your colleagues, educating the patient on the proper use and role of opioids.”

Schneider – who is a founding mem-ber and current secretary of the Tennessee Pain Society, treasurer of the Tennessee Society of Interventional Pain Physicians, and a member of the TennCare Drug Utilization Review Committee – said increased awareness of addiction issues combined with new innovations in neu-romodulation technology and new medi-cations in Phase 2 & 3 clinical trials also provide more treatment options. Perhaps one of the most powerful tools is education to help patients recognize the diminishing returns that come with long-term opioid use and tolerance to the medications and to enhance self-management efforts to im-prove overall functionality.

He continued, “We are an interventional practice. Some of these steroid injections, nerve blocks … these types of things … can help alleviate pain. One of the criticisms we get is these things aren’t curative. They’re not surgical procedures. They are interventions that are meant to give a duration of relief. And if patients can get several months to maybe a

Pain Management Options & OpportunitiesA Conversation with Pain Specialist Dr. John Schneider

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By CINDy SANDERS

The emotional, financial, and societal cost of dealing with chronic pain is exorbi-tant. Patients are desperate for relief. Pro-viders are desperate for a broader range of effective, reimbursable treatment options. And everyone is desperate for solutions that don’t wind up doing more harm than good.

Asked how the na-tion is doing in address-ing this complex issue, Bob Twillman, PhD, FAPM, executive di-rector of the American Academy of Pain Man-agement didn’t mince words. “Very badly … that’s how we are dealing with it,” he stated.

Scope of the Problem“The Institute of Medicine put out a

report in 2011 saying at least 100 million adult Americans have chronic pain,” said Twillman, who holds a doctorate in Clini-cal Psychology from UCLA and has spent decades working in pain management and palliative care. He noted that figure does not include those in the V.A. system, children, or individuals in long-term care facilities.

He added the report – Relieving Pain in America: A Blueprint for Transforming Preven-tion, Care, Education & Research – also esti-mates chronic pain costs the United States more than $600 billion annually in medi-cal treatments and lost productivity. “Both the number of people and the amount spent is greater than heart disease, cancer and diabetes combined,” Twillman said.

Seeking Middle Ground“Most people who have chronic pain

are being prescribed some type of medi-cation, often opioids. The others are left to ‘tough it out,’” Twillman said. “It’s just

not the right way to approach the problem on either end of the spectrum.”

He added, “The middle ground is what we used to do in the 1990s – multi-disciplinary, multimodal, integrative care for people in pain.”

However, the practice of medicine has undergone significant changes since that time period. Twillman noted most pain management isn’t provided by pain specialists but rather is addressed in the primary care setting, which doesn’t lend itself to long, complex appointments.

“To effectively treat someone with chronic pain takes much longer than 15 minutes,” he noted. “I’m fond of saying every patient is an n=1 experiment. Every patient is different. You have to take pa-tients where they are and figure out the best solution for them … and again, you can’t do that in 15 minutes.”

There are a number of reasons why prescription therapy is the first … and quite often only real … line of treatment for chronic pain. Although opioids aren’t advertised, patients see ads for other medi-cations promising a quick fix for any num-ber of problems and want that same type of solution for their debilitating pain.

Twillman said another issue is that most primary care physicians are inad-equately trained to treat pain so they often don’t know what else to do other than write a prescription. And those who do push for a multimodal solution often run into a brick wall with services either not being available (particularly in rural regions) or not being covered.

The Coverage GapTwillman said that based on evidence,

there are five key non-pharmacological therapies that the Department of Defense and the V.A. have said every veteran and active military member should have access to when dealing with pain. “Of those, only one is covered to a limited extent by Medi-

care,” Twillman noted.The five are chiropractic and osteo-

pathic manipulation (which is partially cov-ered depending on diagnosis), acupuncture, massage therapy, biofeedback, and yoga. While some commercial carriers do offer limited coverage, many follow Medicare’s lead. “We are beginning to push them on the issue,” Twillman said of advocating for everyone to cover these therapies as first-line options or adjunct care.

While physical therapy is included in most plans at some level, Twillman said the coverage is rarely adequate, and the co-pays are often so high that patients forego sessions. In addition, he noted, de-pression is highly associated with chronic pain so many patients should be referred to a behavioral health provider, as well.

The Tipping Point“Every message that’s coming out

now says that all of these other things should be done before a prescription is written,” he said. Twillman, who also serves as chair of the Prescription Moni-toring Program Advisory Committee for the Kansas Board of Pharmacy, added new guidelines and peer-reviewed articles edge society closer to the tipping point when it comes to embracing a truly inte-grated approach to pain care.

His hope is that if consumers, govern-ment agencies and providers all demand access and reimbursement for a greater range of treatment options, then the healthcare industry might gain traction in changing how pain is managed.

To a large extent, Twillman added, changing the narrative is going to depend on those in pain. “We have to do a much better job of educating patients and moti-vating patients to do a better job of taking care of themselves,” he said.

Twillman also agreed it was a neces-sary, although difficult, task to find bal-ance while standing on the edge of the

tipping point. “The problem here is we’re really wrestling with two very complex, large-scale problems – prescription drug abuse and the problem of chronic pain.”

He pointed out laws created to restrict access to opioids also have consequences. “Those same laws are causing people who have a legitimate need for medications not to be able to get them. I’m afraid that problem is going to get worse before it gets better,” he said. “When you try simple solutions to these complicated problems, that’s when you get negative unintended consequences, and that’s what we’re see-ing here.”

Ultimately, Twillman said, it is going to take collaboration across many sectors and disciplines, combined with great will, to find the right balance in addressing this growing national issue. “You have to have a complex solution to a complex prob-lem.”

The Cost of Chronic PainTaking an Integrative Approach to a Growing National Problem

Continuing the Conversation

The 27th annual meeting of the American Academy of Pain Management is set for Sept. 22-25 in San Antonio, Texas. Early bird registration discounts are available through July 15 for the conference, which offers up to 56 CME/CEU credits.

MDs and DOs make up about half the membership of the Academy with the other half coming from 30 different disciplines. Nurses, mental health professionals and chiropractors are the next three largest professional groups represented by the membership.

For more information, go online to meeting.aapainmanage.org.

Dr. Bob Twillman

significant change relates to any licensed healthcare facility building expansion or capital expenditure projects.” He noted the law previously had a $5 million capi-tal expenditure threshold for hospitals and $2 million threshold for others before the need for a CON application was triggered. “Under the reform legislation, that capital expenditure threshold is completely re-moved. That’s a major change. It will allow some projects that might not have been ap-proved before to move forward.”

The new rule, however, applies to renovations, additions and modifications on a health campus. A Nashville health system or facility still couldn’t opt to open a new facility in another county without going through the CON process.

“A second major reform relates to adding licensed beds to a hospital, men-tal health hospital or an inpatient physi-

cal rehabilitation facility,” Taylor said. Previously, adding even one new licensed bed in those facilities would have required CON approval. “Under the reform legis-lation, you can add up to 10 percent of the number of licensed beds within any particular category of beds within a three-year period.”

The increase can occur at any one campus over any period of one year for services or purposes the facility is licensed to perform. The new law states the hospi-tal, rehabilitation facility or mental health hospital cannot, however, redistribute beds within its bed complement to a dif-ferent category. While a CON applica-tion is no longer required under those circumstances, the law does state: “The hospital, rehabilitation facility, or mental health hospital shall provide written no-tice of the increase in beds to the agency

(Tennessee Health Services and Develop-ment Agency) on forms provided by the agency prior to the request for licensing by the board for licensing healthcare facilities or the department of mental health and substance abuse services, whichever is ap-propriate. “

Kroplin noted, “The reform legis-lation removed CON coverage for the initiation of MRI services except when pro-viding MRIs in counties with a population of 250,000 or less or when providing MRIs to pediatric patients.” He added a CON would be required to increase the number of MRI machines in counties of 250,000 or less with the exception of replacing or decommissioning an existing machine. In that same section, the law also addresses the need for a CON to establish a satel-lite emergency department facility by a hospital at a location other than the main

campus.One of the biggest changes to the

law, however, is the emphasis on quality. “Whereas in the past, one of the recog-nized benefits of CON in general was the promotion of high quality healthcare, this specifically puts into the law that quality is one of the considerations in whether to approve a CON … and it gives HSDA, in conjunction with the Department of Health and licensing board, continuing oversight of whether quality measures are being met,” Taylor said.

He added a number of questions re-main that would most likely be addressed in the rulemaking process including what happens if a facility fails to meet quality standards. Would there be civil penal-ties, licensure discipline or revocation of the CON? “Exactly how that’s going to be administered is still an uncertain area.”

Updated CON Law, continued from page 5


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By CINDy SANDERS

More than 350 healthcare executives gathered last month for a lively panel dis-cussion on “Shaping the New Continuum of Care.” Hosted by the Nashville Health Care Council, the featured experts repre-sented a range of service providers along the continuum of care and included ex-ecutives from start-ups to a publicly traded corporation.

Moderated by David Gruber, MD, managing director and director of research for Alvarez & Marsal Health Care Industry Group, the guest panelists were:

• Michael Burcham, founder and CEO of Narus Health,

• Paul Kusserow, president and CEO of Amedisys,

• Travis Messina, CEO of Contessa Health, and

• C. Wright Pinson, MD, CEO of Vanderbilt Health System and deputy CEO/senior associate dean for Clinical Affairs at Vanderbilt University Medical Center.

Technology and data took center stage in the discussion of how to create the most efficient system of care. Finding a way to effectively engage patients and make them

active partners in their own care was also a key point.

Gruber started the day off by observ-ing, “We live in exciting though challeng-ing times. Unlike the recent past, the total cost of care across the continuum will mat-ter to the bottom line.” He added there will be winners and losers as healthcare moves from a siloed approach to a more inclusive model that follows the patient.

Pinson noted, “We’ve always had the problem of fragmented care. We’ve always had the problem of communicating post-acute care.” However, he continued, the vision Vanderbilt has moving forward is to address those issues through electronic

health records and billing systems to collect key data and uncover patterns. “Through our network partnerships, we are using big data to engage with patients and track results on a larger scale to provider better care,” he said. “there is also huge poten-tial for medical breakthroughs as we create personalized care through genomics data.”

Messina concurred, noting his start-up – which manages home hospitalization pro-grams that allow the delivery of inpatient care in the residential environment – looks to technology to improve efficiencies and allow more time to focus on patient care. “Contessa places tremendous emphasis on support services for providers, whether that

be assisting with the interpretation of data or managing the patients episode of care,” he said. “By adding that level of support, providers can efficiently develop patient-specific protocols and ultimately have more time to engage with the patient.”

Kusserow also underscored the im-portance of data but added that data is still ‘funky’ at present. “To really do the continuum of care well, you need data,” he said. However, he continued, that data has to be shared, include predictive compo-nents and acuity levels, and be constantly monitored. “In my experience, payers are in the best position to do this because they have the most data, but the translation into coordinated execution needs work. There are opportunities for outside players from the provider side to help in this execution.”

He added that as reimbursement moves toward quality, working well with others takes on a more urgent importance. “The only way you produce quality is by having a great continuum of care,” Kusse-row said. “When people sit down together across the continuum of care and focus on the patient and do the right thing for the patient, you get great outcomes.”

Sharing data to improve outcomes has

Health Care Council Hosts Continuum of Care PanelLeaders Discuss the Changing Delivery Landscape

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By CINDy SANDERS

Neither the most strict nor most le-nient state when it comes to the practice of telemedicine, Tennessee has made sig-nificant strides in the last few years in level-ing the playing field for those who hope to expand access to care through technology.

With the signature of Gov. Bill Haslam in April 2014, Tennessee became the 21st state to enact a statewide telehealth parity law. The law, which requires commercial insurers to cover care delivered remotely in the same manner as they would in-office visits, went into effect Jan. 1, 2015.

“Essentially, you can’t treat a tele-health provider in network differently than you would a face-to-face, in-network encounter,” said Col-bey Reagan, a partner in Waller’s Healthcare Compliance & Opera-tions Group and member of the law firm’s tele-health team. “An insurer can’t exclude payment for a healthcare service solely because it was provided by telehealth.”

He added commercial payers are now also required to pay for out-of-network telehealth services under the same reim-bursement policies they would use for other out-of-network providers. Reagan noted the state’s parity laws apply to commercial payers only. “Medicare has its own rules that supersede Tennessee law,” he said.

On July 1, 2015, another new law also made it easier to practice telemedicine in the state. “The Board of Medicine has been a little reluctant to embrace this technol-ogy,” said Reagan. “That isn’t specific to Tennessee. There’s a natural inclination to be more restrictive rather than less restric-tive,” he added of a national trend.

Proposed rules issued in 2014 for Ten-nessee called for a face-to-face appointment before telehealth could be subsequently uti-lized and then required at least one in-person visit a year thereafter. “The bill that went into effect in 2015 stripped away a lot of those pro-posed restrictions and made it easier to prac-tice telehealth in Tennessee,” Reagan said.

HB 699, which was signed by the gov-ernor in April 2015, established that a li-censed provider delivering services through the use of telehealth should be held to the

same standard of professional practice as a colleague providing the same services through in-person encounters. “Essentially, you can’t treat telemedicine differently than you would any other healthcare service provider with the exception of abortion,” Reagan continued, adding the law puts providers on equal footing.

Launching a Telehealth PracticeReagan said these laws are good news

to physicians and hospitals hoping to ex-pand their reach and to patients who now face fewer barriers to receiving specialty care closer to home. “I think there are more people out there dipping their toes in the water,” he noted of a growing interest in telehealth. “If you are an entrepreneur who wants to roll this out, Tennessee’s a fine place to be.”

There are, however, several issues that deserve consideration before moving for-ward, he noted.

1) Make sure you have the capital to invest in appropriate technology. For example, Reagan said, using Skype for telehealth won’t cut it. Speed, clarity and security are all essential.

2) Make sure you are in compliance with federal and state regulations. “Just be-cause it’s telehealth doesn’t mean HIPAA isn’t in play here,” Reagan pointed out. “One of the main things I tell people is to make sure you’ve got a secure platform from a privacy view.” Similarly, out-of-state providers looking to come into Ten-nessee still must meet the state’s corporate practice of medicine rules.

3) Telehealth start-ups should be very aware of the changing reimbursement land-scape across the country. “Not everyone has parity laws,” Reagan said. “Every state is going to be different in how restrictive they are going to be on this.” And, he added, “Medicare most certainly does not pay on an equal footing as commercial payers even in states with parity laws like Tennessee.”

However, Reagan said it’s hard to conceive of a scenario where the use of tele-health doesn’t continue to grow for many years to come.

“It’s going to take a little while for practice to catch up with technology, but I don’t see a future where this hasn’t ex-panded greatly. It’s just the way of the world,” he concluded.

helpful in periods of high demand to ensure expectations for location, space, build-out and price are met.

Full-Service REITHealthcare Realty Trust, a Nashville-

based, publicly traded Real Estate Invest-ment Trust (REIT), focuses on owning, acquiring, developing, leasing and manag-ing outpatient facilities across the country with a major emphasis on medical office buildings (MOBs). Founded in 1993 with 21 healthcare facilities in the portfolio, the company now has $3.4 billion invested in nearly 200 properties, owns 14.3 million square feet in 30 states, and manages 9.9 million of that square footage internally.

Doug Whitman, executive vice presi-dent of corporate finance, said having properties on campus or adjacent to major health systems is a key focus. While many of these properties are linked to not-for-profit systems, he noted Healthcare Realty also works with HCA, CHS, Tenet and other major for-profit providers.

However, he noted, “If we’re purchas-ing an asset or developing it, we generally don’t do it in partnership with hospitals or physicians.” He added that while some physicians do still want to own their build-ing, it isn’t as common in larger projects in the post-2008 financial crisis world. “I think the financial crisis sobered up a lot of people about being overleveraged in own-ing illiquid assets like real estate.”

For Healthcare Realty, with an eye toward long-term investment and the abil-ity to finance at the corporate level, it’s a different matter. “The vast majority – 60-80 percent – of MOBs are owned by hospitals, but there are enough systems out

there to say ‘My money is better tied up elsewhere,’” he explained. “For them, it’s capital avoidance.”

Therefore, Whitman noted, their partnership with a health system is most often a working relationship, rather than financial partnership, to develop proper-ties that answer specific needs and then lease the health system space in the new facility.

Whitman said it’s typical in those situ-ations to have long-term leases, such as a 75-year lease with 10-year renewal options. With many of Healthcare Realty’s develop-ments being on or adjacent to the system campus, Whitman said, “About 55 per-cent of our properties have a ground lease where the hospital owns the land … 45 percent, we own the land.”

In addition to the financial aspect of working with a healthcare real estate de-veloper and operator, Whitman said the expertise of organizations like his is also crucial. “We’ve seen what works in terms of layout and amenities,” he pointed out.

For example, Whitman continued, it’s important to include a private entrance so a surgeon or physician can quickly and efficiently get to their office instead of walking through a crowded waiting room where the provider might easily be stopped multiple times. Similarly, mak-ing sure the layout is conducive to patient flow, creating easily accessible parking, and wayfinding – which Whitman called critical – are all skills born of experience. “We have been developing probably 20 of the 23 years we’ve been in existence,” Whitman added.

With a continuing trend toward the delivery of more care in the outpatient set-ting, he expects to see an ongoing need for new or updated facilities. Whether it’s his company or someone else’s, Whitman said it really is crucial to find someone who

has both the capital and industry exper-tise to develop, lease and maintain highly functional, highly specialized healthcare spaces.

Personal BrokerCarr Healthcare Realty, a national

firm headquartered in Denver, sits on the other side of the healthcare real estate spec-trum but with the same industry expertise.

“To break it down to its simplest terms, we are space finders,” said Matt Poppert, an affiliate bro-ker in Carr’s Nashville of-fice. “We only work with healthcare clients, and we only work for healthcare providers. We don’t rep-resent any landlords, and we don’t represent any sellers.”

That clear delinea-tion, he said, avoids any type of conflict of interest that might come from trying to represent two parties with competing inter-ests and allows the broker to negotiate ag-gressively on behalf of the provider. “The analogy I like to use is it’s kind of like going to court and having a prosecutor represent you. You’re going to get a deal done, but it’s not going to be in your favor,” he said with a laugh.

It’s equally important, Poppert contin-ued, to be represented by a firm that un-derstands the specialized needs of not only healthcare … but the subspecialties under that umbrella.

For example, he said an ophthalmolo-gist who specializes in cataract surgery, which lends itself to older patients, ideally should be located where a traffic light al-lows for easy access to the parking lot. Simi-larly, he said dental practices cost two to three times as much as a typical build out because of the complex plumbing issues.

“Every practice has a slightly different build-out cost,” he said. “As we’re negotiat-ing with a landlord, if you don’t understand those variances, it will cost the provider/tenant more,” he said.

Some of the key areas he said are easy to overlook include:

• Location: The biggest issue for healthcare real estate is one that holds true for most commercial ventures. It’s critical to be convenient and visible.

• Access: Providers need to consider how easy it is not only to get in the park-ing lot but also to get in and around the building.

• Space: Carr said carefully consid-ered dimensions of hallways and rooms are important so that providers wind up with an office that functions as intended without paying for dead space.

• Due Diligence: Understanding the terms of the lease and undertaking a rig-orous due diligence process before signing can avoid headaches down the road.

• Leverage: Carr said many clients don’t really understand the leverage they have as healthcare providers who are typi-cally financially stable and looking for a long lease. “In a lease situation, healthcare providers are the best tenants a landlord can get, but if they don’t understand how to properly posture that value back to the landlord … again, they’ll end up losing in concessions,” Poppert said.

“We tell clients all the time what a landlord thinks ‘fair market value’ means is what you are willing to pay. You have to have data to actually know what the value is,” he noted.

Poppert pointed out real estate is typi-cally the second highest expense in a prac-tice behind payroll. “Why,” he questioned, “would you risk that kind of expense in a long-term lease or purchase situation with-out representation?”

Real ty Check, continued from page 1i

Doug Whitman

Matt Poppert

Telemedicine in Tennessee

Colbey Reagaon


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year of relief with a certain procedure, well that’s great.”

Other options include utilizing medi-cations like the anticonvulsant gabapen-tin or pregabalin for the management of neuropathic pain syndromes. “It’s really important to know what type of pain your patient has. Is it nociceptive or is it neu-ropathic?” Schneider queried, noting that answer impacts medication choice.

He continued, “Along those lines, some of these muscle relaxers – and in particular, Soma – we will not prescribe in our practice. We feel like it’s more sedating than anything, and that’s the last thing you want is for some of these patients to be is sedentary.”

Schneider said his partner Mark Bilezikjian, MD, who is double board cer-tified in physical medicine and rehabilita-tion and in pain medicine, is very focused on educating patients on the need for self-management and movement. Schnei-der said the practice hopes to add physi-

cal therapy to their offerings in the near future. “It’s an important role,” he said. “The key is really getting patients active.”

The practice is also in talks with a nu-tritionist to help patients adopt a lifestyle that could result in a healthier weight that might relieve some of the strain on mus-cles and joints. However, Schneider said, “The problem is always reimbursement.” He noted it took a year to get the prac-tice’s psychologist credentialed with many insurers despite evidence that shows about 85 percent of patients with chronic pain also have anxiety and depression.

Although evidence backs a multimodal approach to managing pain, Schneider said medication, which is the cheapest route, remains attractive to payers. Changing the culture will require an across-the-board effort of physicians, payers, patients and politicians. However, he concluded, “With the new technology and new medications, there’s hope on the horizon.”

Pain Management, continued from page 7

been a challenge within the industry. The goal of taking knowledge gleaned from in-dividual data and from broader population health models and turning that information into action by engaging patients in their own health management hasn’t lived up to its full potential just yet.

Burcham pointed out the average in-dividual spends 10 to 12 hours a year with a physician and 5,000 hours on self-care. “We focus a lot of time as an industry on those 10 to 12 hours and almost no time on those 5,000 hours,” he said. “Engaging the consumer,” he continued, “is about con-

text and presence. We must pay attention to tidal wave trends, such as social media, mobile access and generational shifts that will shape the way people will receive care in the future.”

He added that those who find a way to actively engage consumers will be poised to have the upper hand. While many of those outside players might fail, some won’t. “The things that push us to change are outside disruptors,” Burcham pointed out. At first, he said, those disrup-tors are annoying … and then they be-come competitors.

Health Care Council, continued from page 9

GrandRoundsAmSurg, Envision Merger

Nashville-based AmSurg an-nounced a merger with Denver-based Envision Healthcare last month, form-ing one of the country’s largest physi-cian staffing companies, along with AmSurg’s continued operation of 250 ambulatory surgery centers and Envi-sion’s national ambulance services. The all-stock deal results in shareholders for Envision holding 53 percent of shares and AmSurg having 47 percent. In combination, the companies represent nearly $9 billion in revenue. Under the merger, which is anticipated to close before the end of 2016, the company will trade under Envision’s symbol of EVHC.

Envision CEO William Sanger will become executive chairman, and Am-Surg CEO Chris Holden will be CEO of the com-bined company. Addi-tionally, AmSurg’s Claire Gulmi has been named CFO of the combined company, while Envision’s CFO Randy Owen will become president of the ambulatory services divi-sion. Robert Coward, who was head of the AmSurg/Sheridan business unit, has been named presi-dent of the physician services division. The company will maintain co-head-quarters in Nashville and Denver.

Morrison Named TriStar Skyline CFO

TriStar Skyline Medical Center has appointed Michael Morrison as chief fi-nancial officer. In his new role, Morrison is respon-sible for managing the financial goals, internal controls and managed care services for TriStar Skyline and TriStar Skyline Madison Campus.

Morrison most re-cently served as CFO at TriStar Hen-dersonville Medical Center. At TriStar Hendersonville. Prior to that, Morrison served as CFO for Hillside Hospital in Pulaski, Tenn.

Tennessee Kidney Foundation Names CEO

The Nashville-based Tennessee Kidney Foundation has named Heather Corum Powell CEO. For the 10 years prior to ac-cepting her new post, Powell served as devel-opment director at Nash-ville’s Ronald McDonald House. Before that, she was with Habitat for Hu-manity. A graduate of Il-linois Wesleyan University, Powell holds a certificate in fundraising management from the Indiana University Center on Philanthropy.

Representatives from State and Metro Governments along with Bellevue-Harpeth Chamber of Commerce leaders joined NHC President Steve Flatt (center), Chairman Robert Adams and Speaker of the Tennessee State House Beth Harwell in cutting the ribbon at the June 8 grand opening of NHC Place at The Trace.

Brody-Waite Named EC CEOMichael Brody-Waite has been

tapped to lead the Nashville Entrepre-neur Center. His appointment comes after Stuart McWhorter stepped down from the post to return to his invest-ment firm, Clayton Associates, follow-ing his father’s death.

Brody-Waite was co-founder and

CEO of healthcare start-up InQuicker.com, which sold to a publicly traded company last year. He will be the EC’s third CEO since the accelerator was launched in 2010. Brody-Waite is set to begin his tenure at the EC on Aug. 1.

Michael Brody-Waite

Chris Holden

Claire Gulmi

Michael Morrison

Heather Corum Powell

Read More Grand Rounds online.


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Documents

Nashville Medical News July 2016