s t l o u i s m e d i c a l n e w s . c o m FEBRUARY 2014 > 1

Stuart Slavin, MD, MEd

ON ROUNDS

Preparing for ICD-10 ConversionPractice management consultant shares 8 steps for physicians to take now

An experienced practice management consultant best described the looming ICD-10 conversion “as though 19 percent of the GDP will be required to start speaking French to each other … and if grammar, pronunciation and punctuation aren’t perfect, no money will move.” ... 4

Physicians Selling PracticesTrend watch: who’s making the move now and why

Since Congress passed the Affordable Care Act (ACA) in 2010, doctors have been bailing out of practices posthaste. Exasperated by surging expenses, shrinking reimbursements ... 11

December 2009 >> $5

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by Lynne JeTer

Having just testifi ed in Maryland to the FDA advisory panel for Boston Scientifi c Corp., electro-physiologist (EP) Mauricio Sanchez, MD, was thrilled to learn the panel voted 13-1 to recommend the Watchman device for “treatment to prevent strokes in people with irregular heartbeats,” saying the benefi ts “outweigh risks associated with the surgical procedure to implant the device.” Boston Scientifi c had sought FDA ap-proval of the technology to block clots in the heart’s left atrial appendage (LAA) from causing a stroke.

“It’s the fi rst proven study showing a procedural option with a mortality benefi t better than Coumadin,” said Sanchez, an EP and principle investigator for the clinical trial at Mercy Heart and Vascular Hospital in St. Louis. “That’s powerful.”

Sanchez, who frequently performs atrial fi brillation catheter ablations, was the fi rst Missourian to use the LARIAT® device to permanently close the LAA appendage for patients who cannot tolerate blood thinners. For the Boston Scientifi c study, he’s implanted the most Watchman devices of any new operator in the U.S.

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Decreasing Stroke Risk Mercy part of landmark study showing clot-blocking procedural option in LAA with mortality benefi t over Coumadin

(CONTINUED ON PAGE 6)

(CONTINUED ON PAGE 6)

by Lynne JeTer

St. Anthony’s Medical Center celebrated the advent of 2014 by unveiling its im-proved Emergency Department (ED) with a ribbon cutting and blessing. The $1 mil-lion renovation project took Musick Construction only four months to complete and opened immediately after the commemoration.

The reconstruction project netted six new fl exible triage rooms, an EMS and Patient Flow Communications Center, a new front desk and entry way. Improve-ments were designed to alleviate a bottleneck of patient fl ow to reduce wait times and expedite the process of patients seeing a doctor sooner.

“It’s our goal to get people seen as quickly as possible after they come to the emergency room,” said Christopher Bowe, MD, FACS, president of St. Anthony’s Physician Organization.

That’s good news for the only Level II trauma center in the south portion of St. Louis and Jefferson counties, which reported 69,947 ED visits in fi scal year 2013,

Reaping Renovation Benefi ts Saint Anthony’s launches New Year with improved Emergency Department

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Jerry Power, R.N., works in the newly constructed triage area

Dr. Mauricio Sanchez

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by LUCy SCHULTZe

For Stuart Slavin, MD, MEd, the sobering national statistics about anxiety, depression and burnout among medical students didn’t relate to the eager young people he saw in his classroom.

Until, that is, their medical school de-cided to ask them about it.

“Frankly, I was surprised,” said Slavin, associate dean for curriculum at Saint Louis University School of Medi-cine, where an anonymous survey of stu-dents in 2009 helped trigger sweeping reforms of the four-year curriculum.

“The students seemed happy; they smile and seem engaged,” said Slavin, a professor of pediatrics. “But the results of the survey were just like that of every other medical school. With outcomes like that, I don’t think anyone could defend the status quo.”

Using an evidence-based approach, Slavin led the campaign for a host of changes that took effect over a three-year period. The overarching goals included reducing stress on students, better equip-ping them to deal with stress, and engag-ing them in more activities where they would fi nd meaning.

The changes were bold: The medi-cal school replaced its grading scale with a pass-fail system in the fi rst two years and cut its required curricular time by 10 percent across the board. The latter move freed up a full day every other week, al-lowing students to engage in electives and have more free time.

Students also for the fi rst time re-ceived training on how to cope with stress through resilience and mindfulness. Sur-veys taken after the changes confi rmed the positive benefi ts.

“We’ve seen dramatic decreases in the rates of depression and anxiety, so it’s had a tremendously positive impact on student mental health,” Slavin said. “And there was no negative impact on educa-tional outcomes, in the students’ perfor-mance on step one of the boards.”

More recently, Slavin spearheaded the restructuring of the medical school’s entire four-year program, shortening the pre-clinical phase and allowing students to enter the clinical setting earlier before.

“There are a dozen or so schools around the country that have made this change, and we thought it made a great deal of sense,” he said.

The reforms also included signifi cant changes to the curriculum itself — re-aligning and combining some preclinical courses, expanding the focus on clinical issues in basic science courses, and better integrating material across courses.

In 2013, Slavin’s efforts earned him one of the Association of American Medi-cal Colleges’ highest teaching awards: the Alpha Omega Alpha Robert J. Glasser Distinguished Teaching Award for signifi -cant contributions to medical education.

The task of leading such sweeping

changes calls for cooperation and com-munication between Slavin and his col-leagues. He has worked closely with the medical school’s Curriculum Manage-ment Committee and other committees to push the reforms through.

“One of the keys for me is trying to fi gure out what directions the school needs to be going,” Slavin said. “Everyone is aware of the dramatic pace of change in the overall healthcare environment, and having a medical school curriculum that doesn’t change is really problematic. It’s important that we have an educational system that is fl exible and dynamic.”

Even more important for Slavin — both for the sake of education and that of campus politics — has been the need to ground all proposals in solid scientifi c evidence.

“I don’t expect the faculty, or the students for that matter, just to trust me because I think things need to move this way,” he said.

“The politics of change is diffi cult, but I’ve been very fortunate, because the fac-ulty and students here overall have been very open to change. The key is making a compelling argument for change, and having changes that make great sense.”

A native of the St. Louis area, Slavin was raised in Clayton and received his undergraduate degree from Haverford College in Pennsylvania. For his medical degree, he returned home to SLU, where his father, Raymond, served on the faculty as an allergist and immunologist for more

than 40 years.Slavin completed his residency train-

ing in pediatrics at the University of Cali-fornia, Los Angeles. He served as a faculty member there for 17 years before return-ing to St. Louis in 2004. At the UCLA David Geffen School of Medicine, he was co-founder of the Doctoring Curriculum and spearheaded other changes in the medical school curriculum.

At SLU, Slavin remains actively in-volved in teaching medical students. He has revamped and expanded the Applied Clinical Skills course series, which spans the fi rst three years of medical school. He serves as the course director for each of the courses, and also directs a three-week re-quired capstone for fourth-year students.

Maintaining a close connection to students keeps Slavin attuned to how well curriculum reforms are working. The re-sults of SLU’s interventions to curb stress, anxiety and depression in medical stu-dents will be detailed in a paper to appear in the April issue of Academic Medicine.

“I think we’re way out ahead,” Slavin said. “The really sad thing is, this problem has been known about for 60 or 70 years, and the response of medical education has been really inadequate.”

Among the most chilling statistics

he cites: Each year, two entire medical-school classes are needed simply to re-place the some 400 physicians nationwide who commit suicide.

“I take all of this incredibly seriously,” he said. “The good news is that, with the advances in cognitive psychology over the last 10 years, there are so many tools now that we can use that are evidence-based.”

Outside of work, Slavin spends time with his family, takes on projects around the house, tends a vegetable garden and cheers on St. Louis sports teams. He and his family also work with the Dent County Animal Welfare Society to provide foster care for rescue dogs, particularly those with medical needs.

Slavin and his wife, Helene, have two daughters: Alana and Natasha.

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Suggested resources:

To learn more about coping strategies for stress, anxiety and depression, Slavin recommends “Search Inside Yourself” by Chade-Meng Tan, and the mindfulness writings of Jon Kabat-Zinn, PhD.

Read St. Louis Medical News Digital:

STLOUISMEDICALNEWS.COM

4 > FEBRUARY 2014 s t l o u i s m e d i c a l n e w s . c o m

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by Lynne JeTer

An experienced practice management consultant best described the looming ICD-10 conversion “as though 19 percent of the GDP will be required to start speaking French to each other … and if grammar, pronunciation and punctuation aren’t per-fect, no money will move.”

The “frighteningly large change” coming Oct. 1 has caught many physician practices off guard, said Jennifer O’Brien, MSOD, a practice management consultant with KarenZupko & Associates Inc. “We’re fi nding that some practices have done abso-lutely nothing to prepare.”

According to the latest Workgroup for Electronic Data Interchange (WEDI) ICD-10 readiness survey results, representing a mix of practices and hospitals, “it’s clear the industry continues to make slow prog-ress, but not the amount of progress that’s needed for a smooth transition.”

Only one in three practices were con-version-ready, with the remainder citing signifi cant obstacles to progress: competing priorities and other regulatory mandates. “All industry segments,” the report con-cludes, “haven’t gained suffi cient ground to remove concern over meeting the Oct.

1 compliance deadline.”“Apparently, there’s still a lot of hope

on the part of providers that it’ll be post-poned again,” said O’Brien. (The ICD-10 conversion was originally slated for Oct. 1, 2013. In 2012, an extension was an-nounced.) “Because of the healthcare.gov debacle, people are thinking that CMS will postpone it again. The experts are saying another postponement is highly unlikely.”

Noting that “denial is only going to make it more painful,” O’Brien recom-mended eight steps for every physician

provider to take in early 2014.Physician providers in a practice that

allows them to control their own salary or draw should reduce that amount by 25 per-cent now. “Don’t pay out the rest,” she said. “You’ll likely need it to pay yourself during the fourth quarter (Q4).” By planning for little to no Q4 revenue while also reducing the draw in the fi rst three quarters of 2014, “you can pay yourself in Q4.” O’Brien ex-plained: “Because the entire industry will make a change of such magnitude on the fi rst day of Q4, the revenue cycle is going to be disrupted. Either the practice is going to make mistakes coding, payors are going to have diffi culty processing the claims, or both. For practices that don’t adequately prepare, Q4 could be bone dry.” By com-parison, Canadian physicians reported a productivity reduction of up to 50 percent during their conversion.

Secure a substantial Line of Credit (LOC) with a bank to cover payroll and op-erating expenses in Q4. “Like an insurance policy,” she pointed out, “a LOC must be secured before needed.”

Scale back in 2014. “This isn’t the year for capital expenditures, other pur-

chasing and hiring that’s not absolutely necessary,” she said, noting the strategy ap-plies to personal expenditures also. “2014 isn’t the year for physicians to build that dream vacation home.”

Because of increased expenses and de-creased productivity, let employees know now that year-end bonuses are highly un-likely. “It’ll be a belt tightening year,” she said.

Order ICD-10-CM books, software or apps. “Physician practices don’t need ICD-10-PCS, just ICD-10-CM,” she said, noting that CPT will continue to be used to report procedures and services for phy-sicians; ICD-10-PCS is the book hospitals use to report services and procedures. (See “Quick Defi nitions.”)

Depending on the practice, run a frequency report of the top 25 to 75 most commonly used ICD-9 codes with nomen-clature. “For specialty and subspecialty practices, the most common 25 diagnosis codes should be suffi cient, but for internal medicine, emergency medicine, and other practices with a broader scope, there will likely be more than 25,” cautioned O’Brien. “Once you have the list of your most com-monly used ICD-9-CM codes, use your new ICD-10-CM books to crosswalk them to correct, complete ICD-10-CM codes. Don’t leave this up to the offi ce staff. Do it on your own or with your staff. The process of con-verting your most commonly used diagno-ses to ICD-10-CM will likely demonstrate a need for you to change your documentation of diagnoses and may show a one-to-many crosswalk. That is, what used to be covered with one code will now require additional information to select the correct code from a list of many.”

Don’t plan on leaving the conversion up to internal billing staff or an external billing service. “When asked, ‘What are you doing to prepare for ICD-10-CM?’ we’ve had physicians and managers re-spond, ‘Our billing service is going to take care of that.’ Guaranteed disaster! ICD-10-CM requires signifi cant, documented input and details from the clinician for accurate, complete codes. There’s no bill-ing service or even computer program that can crosswalk ICD-9-CM codes to ICD-10-CM codes without additional details and input from the clinician.”

Research available ICD-10-CM training. “Many national specialty societ-ies, hospitals and practice management software companies and other organiza-tions are offering ICD-10-CM training for physicians and their staff,” said O’Brien. “If your practice is large enough, it may be cost effective to hire the ICD-10-CM trainer to come to you and your staff. Plan to spend the next several months learning the ICD-10-CM coding system and changing your documentation. Don’t think you can cram for this by going to one or two seminars in the summer. This is like board examina-tions; only in this case, if you don’t study, prepare and perfect well in advance, the failure could mean fi nancial ruin.”

Preparing for ICD-10 ConversionPractice management consultant shares 8 steps for physicians to take now

Quick Defi nitions

ICD-10-CM: The clinical modifi cation of the World Health Organization’s ICD-10, which consists of a diagnostics classifi cation system. In the United States, ICD-10-CM includes the level of detail needed for morbidity classifi cation and diagnostics specifi city and provides code titles and language that complement accepted clinical practice. The system consists of more than 68,000 diagnosis codes.

ICD-10-PCS: Developed to capture procedure codes, this procedure coding system of 87,000 procedure codes is much more detailed and specifi c than the short volume of procedure codes included in ICD-9-CM. 

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Bond market volatil-ity is back. No, that’s not an oxymoron. But it is an understandable source of apprehension, and one that could tempt you to respond to short-term movements. Instead, focus on ways to prepare the fixed income portion of your portfolio to withstand more ups and downs while supporting your long-term strategy.

First, get perspective on the market action. The summer bond session got off to a heated start in late June when Fed-eral Reserve Chairman Ben Bernanke hinted that the U.S. central bank could pull back its stimulus efforts, depending on the country’s economic recovery. The remarks helped push the yield on 10-year U.S. Treasuries to two-year highs of 2.57 percent by mid-July. Since rising yields mean falling bond prices — and lost face value on maturing investments — many investors looked for the exits. They pulled more than $23 billion out of bond funds in the week following Bernanke’s comments.

“Bonds have generally gone up in value and exhibited a fairly low level of volatility lately,” says Brian Rehling, chief

fixed income strategist at Wells Fargo Ad-visors. “Perhaps that’s why investors had been lulled into a sense of security.”

Bonds tend to provide investors with smaller capital growth but lower volatility than equities or other types of investment, but as the action in that market this summer has reminded us, that doesn’t mean they never experience movement. Consider tak-ing these steps to manage how much that affects your portfolio — and your mindset.

Schedule your rebalancing Market swings are inevitable, but you

can stabilize your investment experience by scheduling a regular check-in with your Financial Advisor. Together you can spot areas where your allocation is drifting away from your preferred target and leaving you with more (or less) exposure than you had originally planned. Regular rebalancing helps make sure your investment portfo-

lio continues to reflect your tolerance for risk and your time horizon. Rehling rec-ommends taking a look every quarter or six months before making changes. “It’s also a good idea to rebalance after a major market move,” he adds. Beware of rebalancing too often, though. You might incur excess transaction costs that eat away at your invest-

ment returns. If those fees are a major cost in your portfolio, con-

sider limiting your rebalancing to an annual basis. But even with higher costs,

regular rebalancing remains an important component of your long-term investment strategy.

Return to your core valuesYou are investing and saving with the

idea of covering big costs down the line, such as a comfortable retirement or a child’s college education. When interest rates — and fixed income yields — remained low, many investors sought to generate income by investing in higher-yielding issues, such as corporate bonds. The trade-off, how-ever, is that these investors probably now carry far more credit risk than they realize, Rehling says. Investors should stay focused on their long-term goals and steadily return their portfolios to an allocation more in line with their risk tolerance.

Further, another investor exodus from the bond markets could trigger a pre-cipitous decline in prices for these riskier fixed income assets, Rehling warns. That

could expose portfolios that hold such as-sets to a steep drop in value. “That’s a big-ger risk than inflation or tapering of the Fed stimulus,” he says.

Watch your bottom line While making changes to your bond

holdings, ask your Financial Advisor about options that carry relatively low fees and expenses. If you normally buy and sell individual bonds before they mature, you may be paying more than you need to for every trade you execute. You may want to consider more cost-effective options, in-cluding exchange-traded funds and bond funds, which can provide access to several individual securities while helping keep expenses in check.

Understandably, you want to respond to market ups and downs. While doing that, try to avoid making short-term de-cisions that could undermine your long-term strategy, Rehling cautions. “Think of investing as a marathon, not a sprint,” he says. “Over time, and as part of a bal-anced asset allocation model, your bond portfolio can help you generate potential better returns with less volatility. That hasn’t changed.”

This article was written by Wells Fargo Advisors and provided courtesy of Charles Grbcich, First Vice President – Investment Officer in Chesterfield, MO at charles.grbcich@wfadvisors.com . Wells Fargo Advisors does not provide legal or tax advice. Be sure to consult with your tax and legal advisors before taking any action that could have tax consequences NOT FDIC-INSURED/NOT BANK-GUARANTEED/MAY LOSE VALUE

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6 > FEBRUARY 2014 s t l o u i s m e d i c a l n e w s . c o m

Up to Speed The panel’s endorsement was wel-

comed news after the FDA rejected the Watchman device 9-5 in 2009. The technology had been in development for nearly a decade, starting with the PRO-TECT AF clinical trial in the early 2000s that demonstrated equivalency in terms of decreased risk of stroke and patient pro-tection, said Sanchez.

Since then, Boston Scientific has collaborated with the FDA to conduct a new trial, PREVAIL, to ease agency concerns. It includes higher-risk patients, yet excludes those on chronic clopidogrel therapy. It also aims for improved antico-agulation with warfarin (Coumadin) and requires new operators to enroll at least one-fourth of patients and new investiga-tion sites to enroll a minimum of one-fi fth of patients.

Mercy Heart and Vascular Hospital, St. Louis’ only dedicated heart hospital, ranks third nationally among trial sites for the number of patients enrolled and is the only trial location in the St. Louis area. It’s one of only two hospitals in Missouri with access to this technology.

“(Mercy) tied with Cedars-Sinai for the second largest volume of implants in that trial in the U.S.,” said Sanchez, who had been following the PROTECT trial and was eager to participate in the PRE-VAIL study. “We gained a lot of experi-ence. For doctors with the right skill set, this is a terrifi c technology to allow their patients to have that decreased risk for

embolic stroke while at the same time avoiding the risks that occur with blood thinners, especially long term. Our pa-tients have done extraordinarily well and have greatly benefi tted from it.”

Early SuccessLast year, Sanchez implanted the

Watchman device in patient Edna Zan-der, who had suffered two minor strokes

and a heart attack due to atrial fi brillation. “She’s a very wonderful, sweet lady who’d had several side effects from being on blood thinners,” he said. “It had been very diffi cult for her.” Sanchez was quick to point out that “blood thinners save lives, but aren’t without inherent risks.” Zander recalled Sanchez telling her “it was more dangerous to be on (blood thinners) than what could happen if I was off.”

After having the Watchman device implanted, Zander reported a “subjec-tively higher” quality of life.

“I’m living proof that it’s a good pro-cedure with little discomfort and a chance to get off Coumadin,” Zander said. “I want others to know about the option and ask their doctors about the trial.”

Marketed by device maker Boston Scientifi c, Minneapolis, Minn.-based Atri-tech Inc. developed the Watchman LAA Closure Technology.

The trial’s next phase allows qualify-ing patients to have the Watchman device implanted without being randomized to warfarin therapy alone.

“It was a neat experience to see the process for approval … how deliberate these hard-working professionals are on the panel … how thoughtfully they re-view the totality of the data,” he said. “I felt privileged to participate and share my experience as an investigator and a pro-ceduralist.”

Decreasing Stroke Risk, continued from page 1

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The Watchman ® device is designed to keep harmful blood clots from entering the patient’s blood stream, causing a stroke. It’s inserted via catheter into a groin vein. Patients with atrial fi brillation, the most common heart-rhythm disorder affecting more than 5 million people worldwide, are at an increased risk of stroke because blood can pool in the left atrium appendage (LAA), ultimately forming clots.

Typically, patients with AF take blood-thinning medications, such as warfarin (Coumadin), for life to prevent these clots from forming in the heart. These medications require frequent monitoring and have diet and other drug interactions causing compliance issues.

Mercy, the nation’s sixth largest Catholic healthcare system, includes 31 hospitals, more than 200 outpatient facilities, 38,000 co-workers and 1,500 integrated physicians in Arkansas, Kansas, Missouri and Oklahoma, and also has outreach ministries in Louisiana, Mississippi and Texas.

making it the fourth busiest ED in the St. Louis region and the sixth busiest ED in Missouri.

“Now, we can initiate care a lot faster,” said Zachary Tebb, MD, medi-cal director, Department of Emergency Medicine.

The recently completed construc-tion project is only one aspect of moves St. Anthony’s has made to overhaul its Emergency Department,” noted Bowe, also lead partner of Bowe & Associates In-ternal Medicine in St. Louis. “We’ve seen great results.”

In November 2012, the average wait time from door-to-doctor was two hours. At its worst, the potential wait time was three to four hours if all 37 ED rooms were fi lled, said Jerry Power, RN, Depart-ment of Emergency Medicine.

By November, the average wait time had been reduced to 24 minutes, six min-utes faster than industry best practices.

“We’ve gotten that down to 20 min-utes in some cases,” said Power, noting the number of people who leave without initi-ating treatment is lower than the national benchmark of less than 1 percent. “Now we’re at .07 percent.”

Dramatic improvements before the renovated ED offi cially opened resulted from other changes implemented over the previous months.

“We knew it,” said Bowe. “Our emergency department had to change. Wait times were too high. And patient trust, too low. Many in South County – some who had never even used our ser-vices – didn’t always see us as the fi rst choice for emergency care. And here, at

St. Anthony’s Medical Center, that just wasn’t acceptable. So we spent nearly a year transforming the way our emer-gency department works. From staff to approach, we re-built everything from the inside-out.”

St. Anthony’s plan for improved ED effi ciency included:

Establishing required qualifi cations for triage RNs;

Developing a quick triage process to improve patient fl ow;

Creating a substitute team to focus on patient fl ow;

Hiring additional nurses, physician assistants and other employees to increase the quality of care and allow doctors to spend more time with patients;

Using specially trained scribes to shadow physicians, enabling physicians to focus more time and energy on patients and patients’ families;

Having Patient Liaisons to commu-nicate better with patients and patients’ families; and

Incorporating technology to improve communications between the ED and the patients’ primary care physicians

“When people are sick and come to the emergency room, they’re usu-ally scared and want to be taken care of quickly so they can relieve that fear,” said Bowe. “They’re usually very concerned that something terrible is going on. And the quicker someone can … dispel that fear and let them know they’ll be all right, that’s when the healing begins.”

Because the emergency room is the doorway to St. Anthony’s, Bowe pointed out, “we want it to be a very good experi-ence (for patients) and to take very good care of them.”

Community and provider feedback has been very positive, said Bowe.

“There’s been a tremendous change,” he said. “We have a new culture at St. An-thony’s and have really turned the page.”

Reaping Renovation Benefi ts, continued from page 1

s t l o u i s m e d i c a l n e w s . c o m FEBRUARY 2014 > 7

8 > FEBRUARY 2014 s t l o u i s m e d i c a l n e w s . c o m

by Cindy SAnderS

The Affordable Care Act, coupled with new models of reimbursement, has undoubtedly impacted the way the health-care industry conducts business today and strategically plans for the future. For some industry sectors within healthcare services, a ‘strength in numbers’ mentality has caused a marked uptick in mergers and acquisitions in comparison to a few years ago. For oth-ers, the strategy has been to take more of a ‘wait and see approach’ while trying to fig-ure out just how the new rules will impact their specific markets.

Frank Morgan, who serves as manag-ing director for Healthcare Services and Eq-uity Research with RBC Capital Markets, recently shared his thoughts with Medical News on the level of activity in 2013 and his expectations for the coming year. With more than two decades experience in eq-uity research and investment banking, Morgan primarily focuses his research on facility-based healthcare services including hospitals, skilled nursing and assisted living facilities, long-term acute care (LTAC), be-havioral health services and rehabilitation. Morgan, who has been recognized for his expertise within the health services indus-try by multiple national publications and industry rankings, is a popular speaker and participant in financial panels.

Overall, Morgan said there was a gen-eral uptick in activity in 2013 compared to 2012. That was particularly true within the hospital sector. “’13 … if not a record year … was a very good year for M&A activity,” he noted. “You really saw it on the not-for-profit side,” he added.

There are several reasons for the ‘su-per-sizing’ of hospital systems starting with implementation of ACA but exacerbated by other market forces including an increase in physicians seeking an employment model, implementation of EHR and changing pay-ment methodologies.

“The overarching uncertainty about how the world is going to play out over

the next four or five years has led to the leveraging of strengths,” said Morgan. He added the leaders of individual hospitals or small systems are faced with deciding to weather the changes on their own or join forces to be part of a bigger group that has the infrastructure in place to manage and deal with the new healthcare deliv-ery landscape.

From mergers to acquisitions to stra-tegic joint ventures, there was a lot of movement on the not-for-profit side, which makes up about 80 percent of hospitals in America. Dallas-based Baylor Health Care System and Temple, Texas-based Scott & White Healthcare completed their merger in late September to create the largest not-for-profit health system in Texas. Earlier in the year, Michigan-based Trinity Health merged with Pennsylvania-based Catholic East in one of the largest nonprofit mergers of 2013.

And some interesting partnerships oc-curred between not-for-profit hospitals and systems and publicly traded operators. Life-Point Hospitals and Duke continued to ac-quire hospitals for their joint venture. One of the largest mergers occurred between a nonprofit hospital system and a major in-surer when the Pennsylvania Insurance De-partment approved the affiliation between Highmark (a BlueCross BlueShield subsid-iary) and West Penn Allegheny Health Sys-tem, both based in Pittsburgh. After closing that deal in April, Highmark went on to add two more Pennsylvania-based hospital systems to its integrated delivery system, Al-legheny Health Network.

While a lot happened on the non-profit side, Morgan noted there were also major acquisitions within the publicly traded hos-pital space. “On the for-profit side, there

were two notable deals completed or announced in 2013 — Tenet Health-care & Vanguard

Health Systems and Community Health Sys-

tems & Health Management Associates.”

In the first deal, Nash-ville-based Vanguard was the target of Dallas-based Tenet. The latter completed its ac-quisition of Vanguard at the beginning of October in a deal valued at approximately

$4.3 billion ($1.8 billion pur-chase price plus assumption of

$2.5 billion of Vanguard debt). The second deal, Morgan said, was an-

nounced last year and is anticipated to close in the first quarter of 2014. In this case, Franklin, Tenn.-based Community Health Systems seeks to acquire HMA, which is headquartered in Naples, Fla. Just before Thanksgiving, CHS and HMA announced the companies’ proposed merger had been declared effective by the Securities and Ex-change Commission (SEC), clearing the way for a vote by HMA stockholders for or against adoption of the merger agreement. With a purchase price close to $4 billion plus assumption of debt, the overall value of the merger is anticipated to be in excess of $7.5 billion, making it the largest deal since the HCA buyout in 2006. Once the merger is executed, CHS will own and/or operate 206 facilities with more than 30,000 licensed beds.

“From and M&A perspective, I would expect to see a continued robust level of activity,” Morgan said of 2014. However, given the limited number of publicly traded companies and the amount of activity that has already occurred in that space, he said he expects much of the future activity to be in the not-for-profit world.

Behavioral health had a “decent” 2013, Morgan said. Franklin, Tenn.-based Acadia

Healthcare enjoyed another healthy year of growth. The company began the year by completing previously announced deals acquiring Behavioral Centers of America and AmiCare Behavioral Centers and then proceeded to acquire additional individual facilities in Georgia, Tennessee, Florida, and Puerto Rico during the remainder of the year. Morgan said he expected the com-pany to continue to grow in 2014.

A behavioral health “marriage” an-nounced in late 2013 is expected to come to fruition in 2014. In November, the lead-ership of Centerstone, which has a major presence in Tennessee and Indiana, and the H Group, with facilities in Illinois and Ken-tucky, announced their intent to affiliate. Although the H Group will operate under the Centerstone flag, David Guth, CEO of Centerstone of America, said the affiliation had no money or assets changing hands and was instead a joint effort to “create a stron-ger and more effective behavioral health service organization.” Earlier in November, Hazelden and the Betty Ford Foundation also announced a mega-merger in the ad-diction space.

After a slow start, Morgan noted home health saw some movement by late 2013. “In home healthcare, we did see a little bit of pick up at the end of the year,” he said, noting Louisville, Ky.-based Almost Family acquired Nashville-based SunCrest Healthcare in December. Going forward, Morgan said, “2014 could potentially be a year where you see more consolidation in the home health space.”

Other sectors, said Morgan, were con-siderably quieter in 2013. Senior housing saw some limited activity, as did dialysis. Morgan said the latter was already pretty consolidated with the two big players being DaVita and Fresenius. “Between the two, they already control about 55 percent of the domestic market,” he pointed out.

It was also a fairly quite year for labs, hospice, skilled nursing and LTACs as these sectors restructure and re-evaluate expecta-tions under ACA and the impact of post-acute bundled payments. In the lab space, Morgan noted, “They’re not redeploying capital for growth right now. They’re try-ing to pacify stockholders by buying back shares and paying dividends because of the weaker organic growth because of pricing and volume pressures.”

In general, Morgan concluded, there was good news in the equity markets for a number of healthcare sectors in 2013. “The S&P was up almost 30 percent … health-care services was up over 37 percent,” he noted. For some, the gains were even greater. Morgan said behavioral healthcare was up over 100 percent and hospitals up over 44 percent.

Looking ahead, he said, “I still think you can have really attractive returns for 2014 given valuations are still reasonable and the growth opportunities presented by the Affordable Care Act, but I think you need to pick your subsectors carefully.”

M&A Trends in the Reform EraA look back at 2013 … Look ahead in the new year

s t l o u i s m e d i c a l n e w s . c o m FEBRUARY 2014 > 9

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by Cindy SAnderS

What if gathering critical heart health information from around the world was as simple as entering a few keystrokes on a laptop or smartphone? Turns out there is an app for that … actually several apps … and researchers with the Health eHeart Study hope to turn those rich data sources into powerful tools to predict, prevent and treat heart disease and stroke.

“In my 30-year career as a researcher and physician, I’ve never seen a study as innovative as the Health eHeart Study,” said Elliott Antman, MD, president-elect of the American Heart Association (AHA) and co-chair of the study’s Scientific Advisory Board. “This is a seam-less way to participate in a research study while going about your daily activities.”

Launched las t year, the AHA has joined forces with the University of California, San Francisco (UCSF) to support this long-term, large-scale health research project. The trans-formative study is led by three USCF faculty members — Jeffrey Olgin, MD, professor of Medicine and chief of the Division of Cardiology; Greg Marcus, MD, MAS, director of Clinical Research for the Division of Cardiology; and Mark

Pletcher, MD, MPH, a cardiovascular epi-demiologist and the director of Research Consultation for UCSF’s Clinical and Translational Research Institute.

The goal is to enroll one million adults from around the globe, and the only inclusion criteria are that participants be over 18 and have access to the Internet. Researchers are seeking individuals across the spectrum … from the very healthy to those diagnosed with cardiovascular dis-

ease or other chronic conditions. Rather than having to make an appointment to see a physician to submit or update health and activity information for the study, participants can log info on the go and at their convenience via computer or mobile device. Antman and colleagues are hope-ful that the ease of participation will trans-late into more robust data collection.

Initially, participants are asked to an-swer a series of demographic questions, in-cluding information on lifestyle habits and personal and family medical history, to es-tablish a baseline. Then every six months, they are asked to answer additional ques-tions about activities and health events. Additionally, participants have the oppor-tunity to share information gathered from smartphone apps and wireless devices (such as blood sugar monitors, at-home blood pressure equipment, and digital scales) with the study’s protected data sys-tem. A number of apps are free, and sites including iHealth (ihealthlabs.com) and Withings (withings.com) have electronic health tracking devices that sync with the Health eHeart Study data collection.

“Getting a blood pressure reading or an ECG in your doctor’s offi ce is just a snapshot of the given moment, but now we’ll be able to see big data streamed almost in real time as people are going about their daily activities,” noted Ant-man. “This presents a total paradigm shift in how we learn about human health.”

Antman, a professor of Medicine at Brigham & Women’s Hospital and as-sociate dean for Clinical/Translational Research at Harvard Medical School, is clearly excited about the possibilities af-forded by such a large collection of data among global populations. “This research initiative makes use of cutting-edge digital technology to perform not only a state-of-the-art observational study but also to provide the platform to facilitate random-ization. This is really an electronic, decen-tralized cohort,” he said.

“The goal,” he continued, “is to use the big data to predict who is going to develop heart or stroke problems.” How-ever, Antman noted, the immediacy of the media also opens up possibilities to test the effi cacy of various treatments and behav-ioral modifi cations.

“This is nimble and has the potential to change the way we study health behav-iors and test interventions to modify those behaviors,” he explained.

For example, Antman noted a sub-group of participants who identifi ed them-selves as regular smokers on the baseline questionnaire could be pulled from the larger study. From that subset, one group could be randomized to receive a weekly email from a health coach reminding them not to smoke, while another group might receive a link to a website with information on how to make behavioral changes. Subsequent follow-up could show one method to be more effective than the other. That, noted Antman, is where the nimbleness of the technology comes into play by allowing researchers to quickly switch all participants to the more effective intervention.

Antman said physicians and other providers could be major allies in help-ing get patients signed up for the study. He encouraged physicians to go online to learn more about the project and to share the website information with their adult patients. Antman added the AHA has bro-chures available for distribution at clinic and offi ce sites, as well.

Again, he stressed, the goal is to in-clude everyone across the health spectrum from young, active adults to those with multiple comorbid conditions. Antman also noted that while this is a long-term commitment, participation is extremely easy. “This is a study that doesn’t impose on a person’s time the way other research studies do,” he said.

Signing up is simple, too. Just go to health-eheartstudy.org to learn more about the project and join the thousands already enrolled.

Health eHeartAmbitious research project launched to advance heart & stroke science

Dr. Elliott Antman

Join the Movement to Stop Heart Disease & Stroke www.health-eheartstudy.org

The Health eHeart Study makes it easy to log important data without disrupting the day.

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by Lynne JeTer

Since Congress passed the Afford-able Care Act (ACA) in 2010, doctors have been bailing out of practices posthaste. Ex-asperated by surging expenses, shrinking reimbursements and costly-to-cover gov-ernment mandates, frustrated physicians are citing healthcare reform-related spend-ing as a major reason for selling practices as the rollout progresses.

According to a study by Jackson Healthcare, the nation’s third largest health-care staffing agency, 12 percent of physicians who sold their practices before sweeping federal legislation became law made the change because they didn’t have appropri-ate resources to comply with the law and maintain a reasonable ROI. Within the last three years, the rate of physicians selling their practices for the same reason – espe-cially now with dwindling ways to stay fis-cally healthy – jumped to 30 percent.

“Of those now considering selling their practices, 36 percent cite the complexity of the healthcare reform law as a reason; and 24 percent say they don’t have the re-sources necessary to comply with the law,” according to Jackson Healthcare’s report. “The burdens also appear to be taking physicians away from their families. They want better work-life balance, with less time

working and more time in their private lives. Forty-three percent feel employment, rather than ownership, will give them that balance.”

Even though no statistical differential denotes the type of physicians who want to remain in private practice versus those ac-tively marketing their practice, nearly half actively seeking to sell are internal medicine subspecialists (23 percent), primary care physicians (14 percent) and surgeons (12 percent). Of those internal medicine sub-specialists, 23 percent are otolaryngologists, 17 percent are urologists, and 13 percent are cardiologists.

Reimbursement cuts (79 percent) and the cost of maintaining a practice (64 per-cent) were the most commonly cited rea-sons among internal medicine subspecialists who want to sell; 57 percent also pointed to the complexities of healthcare reform as a reason for selling, cited the report.

Three of four surgeons marketing their practices said reimbursement cuts and healthcare law complexities were contrib-uting factors in the decision to sell.

Not surprisingly, hospitals and health systems are acquiring most physician prac-tices (52 percent). Interestingly, solo practi-tioners accounted for 19 percent of physician practice buys, while physician-owned groups made 18 percent of group acquisitions. Ten

percent of doctors who sold their practices listed their buyer as “other.”

Even though physicians are leaving the ownership aspect of private practice, most aren’t departing the practice of medi-cine. Only 9 percent sold their practices be-cause they wanted to retire; 6 percent sold because they wanted to leave the practice of medicine.

“Physicians in private practice still out-number those employed, but this could be shifting as less than half of the respondents with an ownership stake say they plan to remain in private practice,” according to the report.

The last cycle of hospitals snapping up private practices occurred in the 1990s, when hospitals saw the acquisitions as a way of gaining access to more patients. As a result, physicians got sweet deals. But in this buying cycle, the deals aren’t as finan-cially rewarding. Yet the circumstances provide a way for private practice doctors to step out of time-consuming administra-tive roles while also appreciating a steady income and sometimes improved hours as employees. A post-sale downside that im-pacts physicians to widely varying degrees: adjusting to the loss of autonomy.

Simply put, the private practice model has become very expensive to operate, John Dubis, CEO of St. Elizabeth Healthcare in

Cincinnati, Ohio, explained to CNN Money. “That’s why it’s diminishing,” he said,

noting that most of the 300 physicians em-ployed by the hospital’s specialty physicians group were plucked from private practices.

In December 2012, Montana-based St. Vincent Healthcare acquired Frontier Cancer Center, established in 1982. The close-knit group of five oncologists had struggled financially pre-healthcare reform, taking a significant hit in 2003, when Medi-care changed the way it reimbursed doctors for chemotherapy drugs. Despite taking significant pay cuts, the group closed one of its four locations in 2008. With the dark cloud of bankruptcy looming, the group was happy to find a buyer.

“We have a joke,” said Patrick Cobb, MD, an oncologist in the Frontier group told CNN Money, “that there are two kinds of private practices left in America: those that sold to hospitals and those that are about to be sold.”

In a companion survey released by Jackson & Coker, a subsidiary of Jackson Healthcare, a majority of doctors want to see ACA defunded or repealed. A scant 6 percent said it should remain unchanged.

“The more physicians learn about ACA, the more they dislike it and want to start over,” said Richard L. Jackson, chair-man and CEO of Jackson Healthcare.

Physicians Selling PracticesTrend watch: who’s making the move now and why

by Lynne JeTer

Rabih Bechara, MD, says the most diffi-cult part of his job is telling patients, “You’ve got lung cancer.” Unfortunately, chances are three of four patients with lung cancer will be diagnosed at a late stage, when cure isn’t an option.

“Once you tell patients they have can-cer, no matter the stage, they’re usually very distraught,” said Bechara, chief of the pul-monary division at Cancer Treatment Cen-ters of America at Southeastern Regional Medical Center (CTA at Southeastern) and professor of medicine at Georgia Regents University. “The beauty is, if we catch it early, we can cure them.”

Bechara is a staunch supporter of the national push for lung cancer screening, hoping to see it join the ranks of the mam-mogram for breast cancer or colonoscopy for colon cancer. The trend of more non-smokers being diagnosed with late-stage lung cancer has expedited the movement.

“More people will die from lung cancer this year than any other type of cancer, in-cluding breast, prostate, colorectal and colon cancers combined,” said Bechara. “Unlike other types of cancers that are prominent among certain genders and ethnicities, lung cancer doesn’t discriminate and remains the leading cause of cancer deaths, regardless of sex or race.”

According to the most recent data from the National Cancer Institute (NCI), roughly two-thirds of all new lung cancer diagnoses are among patients who have never smoked. Some are former smokers who quit decades ago.

“Despite the harsh realities of lung cancer, it simply doesn’t grab the headlines of more popular forms of cancers,” said Bechara. “It also doesn’t get near the re-search funding as other cancers.”

Lung Cancer ScreeningsIn 2012, the American Lung Associa-

tion (ALA) released guidelines on low-dose lung cancer screenings, based on the NCI’s National Lung Cancer Screening Trial. The U.S. Preventive Services Task Force recently issued draft recommendations for annual low-dose CT screenings for patients at high risk for lung cancer, which translates to an estimated 7 million Americans, including smokers ages 55 to 79 who have consumed the equivalent of a pack a day for 30 years.

“We’re excited about launching this tool and the low-dose screenings,” said ALA president and CEO Harold P. Wimmer. “It’s a big step in the fight against lung cancer. We created this online tool to help people under-stand quickly whether they’re candidates for low-dose CT screening.”

The upside of lung cancer screening was discussed in the Sept. 5, 2013 edition of the New England Journal of Medicine. “Prob-ability of Cancer in Pulmonary Nodules Detected on First Screening CT” showed how the percentage of patients dying from lung cancer could be cut by 20 percent via a low-dose CT scan versus regular x-rays. The summary: “Predictive tools based on patient and nodule characteristics can be used to ac-curately estimate the probability that lung nodules detected on baseline screening low-dose CT scans are malignant.”

“Catching lung cancer early requires

a very streamlined and collaborative pro-cess between PCPs (primary care providers) and interventional pulmonologists,” said Bechara. “Getting the CT scan results in a timely manner and discussing the results be-tween specialists and subspecialists is vital so that patients have a ready plan when they receive a diagnosis.”

Determining who will pay for lung can-cer screening remains a question mark, said Bechara, noting that a low-dose CT scan may cost up to $400. Most insurers don’t automatically cover lung cancer screening costs, as they do other cancer screenings like mammography.

“Most screening isn’t paid for. Different institutions have taken it upon themselves to start a screening program for the benefit of patients at a reduced rate. Some offer free screenings. At Emory, we were working on (offering it free to patients) but couldn’t be-cause of logistics and other obstacles,” said Bechara, who completed training, intern-ship, residency and a fellowship in pulmo-nary and critical care at Emory University School of Medicine, and also founded and directed the institution’s interventional pul-monology program, focusing on new endo-scopic techniques for lung cancer. “Because (CTCA at Southeastern) is only 14 months old, we would probably start screening with stakeholders and their families to make sure the process is streamlined before we offer it to the general public. If there’s a fee-for-service, it will be amazingly cheap.”

Front Line Assistance“PCPs are at the forefront and play a

major role in identifying or at least raising the

knowledge of patients with lung cancer,” said Bechara. “Unfortunately, there are no spe-cific symptoms for lung cancer. Patients may cough and be short of breath sometimes, but that can happen to anyone with sinus is-sues or allergies. I urge PCPs to recommend screening for high-risk patients. They should at least be aware of the screening recom-mendation if patients come to them with non-specific symptoms they can’t explain. We can refer them to a low-dose CT scan of the chest, which identifies patients with lung problems and hopefully catches lung cancer in an early stage.”

Until recently, lung cancer was consid-ered a man’s disease; statistics show it’s now the leader of cancer deaths in both genders, said Bechara.

“The rate of smoking for the subsection of young females is on the rise,” said the fa-ther of two adolescent daughters. “They may start smoking as young as 12 or 13, mainly because nicotine is an appetite suppressant and being thin is the main goal. PCPs may tell them there are many other healthier ways to keep their bodies in shape. If we can reach them at an early age, and bring awareness to the younger generation of the consequences of choices they make early on, imagine how much cancer we can prevent down the road.”

Bechara is optimistic about curbing lung cancer. “We’re collaborating with multiple institutions and new technology,” he said. “Our aim is to look at new ways to kill lung cancer via multidisciplinary approach which includes endoscopy. It’s still in research mode, and the findings need to be validated. Definitely, more research is needed.”

Detecting Lung Cancer Earlier

12 > FEBRUARY 2014 s t l o u i s m e d i c a l n e w s . c o m

Washington University School of Medicine in St. Louis and St. Louis Chil-dren’s Hospital together are part of a new multi-institutional project that aims to cre-ate a national pediatric “learning health system” that will feature an extensive clini-cal data research network.

The Patient-Centered Outcomes Re-search Institute (PCORI) awarded nearly $7 million on Dec. 17 to institutions in-volved in forming the pediatric-specific learning health system (LHS) and the clinical data research network (CDRN). PCORI, a nonprofit organization autho-rized by Congress, funds research that provides patients, caregivers and clinicians evidence-based information to allow for informed healthcare decisions.

A learning health system involves patients, families, clinicians and research-ers who work together with the goal of providing information to help patients and families make informed decisions with their healthcare teams. The LHS now comprising Washington University and St. Louis Children’s Hospital also includes seven other of the nation’s larg-est children’s hospital health systems: Children’s Hospital of Philadelphia; Cincinnati Children’s Hospital Medical Center; Children’s Hospital Colorado in Aurora, Colo.; Delaware-based Nemours

Children’s Health System; Nationwide Children’s Hospital in Columbus, Ohio; Seattle Children’s Hospital; and Boston Children’s Hospital.

Christopher B. Forrest, MD, PhD, of Children’s Hospital of Philadelphia, is the project’s principal investigator, and the clinical data research network (CDRN) the eight health systems will create is called PEDSnet.

PEDSnet will have three condition-specific “patient-powered research net-works” focused on pediatric inflammatory bowel disease, childhood obesity and hy-poplastic left heart syndrome, a serious congenital heart condition. PEDSnet also will have two national data partners: Ex-press Scripts and IMS Health, the latter a data-analytics company.

“I am excited that we will have the opportunity to create a child-health-spe-cific network of networks that includes St. Louis Children’s Hospital, other chil-dren’s hospitals and specialty networks that can be used to transform research and quality improvement,” said Feliciano “Pele” Yu Jr., MD, the project’s principal investigator at Washington University/St. Louis Children’s, the

hospital’s chief medical information offi-cer, and an associate professor of pediat-rics at Washington University.

PEDSnet will be one of several clini-cal research data networks in an ambi-tious new resource known as the National Patient-Centered Clinical Research Net-work, or PCORnet. PCORI — which approved a total of $93.5 million for the multifaceted project — envisions PCOR-net as a secure, national data network that will improve the speed, efficiency and use of patient-centered comparative effective-ness research.

“Conducting health research effi-ciently and effectively requires data that is accessible, usable and protects patients’ privacy and security,” PCORI Execu-tive Director Joe Selby, MD, said in a news release. “We intend PCORnet to be a national resource — a collabora-tive, interoperable and secure ‘network of networks’ — that serves both the sci-entific and patient communities. The es-sential difference between PCORnet and previous research networks is the critical involvement of health-care systems, clini-cians and patients in governing and using the network resources.”

Dr. Pele Yu Jr.

Bruce Bacon, MD

Professor of Gastroenterology and Hepatology

Gabriella Espinoza, MD

Assistant Professor, Department of Ophthalmology

Residency Program Director, Saint Louis University Eye Institute

Michael Lim, MD

Associate Professor of Medicine

Co-director, Center for Comprehensive Cardiovascular Care at Saint Louis University Hospital (C4)

YOU ARE SPECIAL.Your case is unique and you don’t want to be a number, you want to get the best treatment possible by people who will remember your name. You like things done a certain way, and for someone to understand what makes you special.

WE ARE SPECIALISTS. The people of Saint Louis University Hospital are specially trained to treat your unique case. We are caregivers at every level. We are exclusively SLUCare, the physicians of Saint Louis University, and we are steeped in the Jesuit tradition of teaching and research while continuing to be focused on the future with breakthrough services and technology.

sluspecialist.com314-577-8000

School, Hospital Team to Help Create National Pediatric Research Network

GrandRounds

SSM Medical Group Adds Adult Primary Care Physician at SSM St. Mary’s Health Center

Andrea Baxter, MD, a board certi-fied family medicine physician, has re-cently joined SSM Medi-cal Group in practice at the SSM St. Mary’s Health Center campus.

Baxter has 18 years of medical experience. She earned her medical de-gree from the University of Oklahoma College of Medicine. Then spent five and one-half years in active duty for the U. S. Navy, where she served as a General Medical Officer for four and one-half years at the Naval Hospital in Great Lakes, Ill. While at the Naval Hospital, Baxter earned the Navy and Marine Corps Commenda-tion Medal and the Navy Achievement Medal.

In 2000, Baxter moved to St. Louis and completed her family medicine resi-dency at Forest Park Hospital. In 2002, she opened her private family medicine practice. Baxter also worked as an emer-gency room physician for five years and served as the medical director for the St. Louis Institute for Weight Management. She is a member of the St. Louis Acad-emy of Family Practitioners and the St. Louis Metropolitan Society.

Baxter’s healthcare services, for pa-tients from newborns through the senior years, include but are not limited to pre-ventive care and check-ups, including physicals and screenings for both men and women, and identification and man-agement of both acute problems and chronic diseases.

Esse Health Florissant Inter-nal Medicine Office Adds Nurse Practitioner

Esse Health welcomes board-certi-fied nurse practitioner Danielle Cichowic, MSN, RN, ANP-BC, to its staff. Cichowic will join the Esse Health Florissant Internal Medi-cine team in Florissant.

Cichowic is an adult health primary care nurse practitioner specializing in preventive health care and diabetes management. Previously, she served as a nurse practitioner in internal medicine and express care at the Cleveland Clinic, and prior to that was a clinical nurse at the Hospital of University of Pennsylva-nia. A member of the American Associa-tion of Nurse Practitioners, Cichowic is a graduate of Villanova University. She is the 2011 recipient of Association of Peri-operative Registered Nurses National Scholarship

The Esse Health Florissant Internal Medicine Office includes board-certified physicians Dennis Patton, M.D., John Rice, M.D., Joyce Boehmer, M.D., Julie MacPhee, M.D., Scott Anderson, M.D., and Susan Reber Adams, M.D., and reg-istered dietician Marjorie Maxwell, RD.

Dr. Andrea Baxter

Danielle Cichowic

s t l o u i s m e d i c a l n e w s . c o m FEBRUARY 2014 > 13

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GrandRounds

Tom McNeill Joins Keane Insurance Group

The Keane Insurance Group is pleased to announce that it has part-nered with Tom McNeill, former COO of MSMA Insurance Agency, to add a high-er level of service to its team of health-care specialists in Missouri and Kansas. The move combines the two largest players in the area’s medical malpractice insurance market. McNeill, a veteran in medical malpractice insurance sales, brings 33 years of experience in health-care to the Keane Group. McNeill’s ex-perience and Keane’s size and strength will provide greater service to existing physician clients as well as broaden the scope of resources available to all physi-cians in the region.

McNeill comes to the Keane Group after serving as an independent broker and COO of the MSMA Insurance Agen-cy for 10 years, where he built a book of business from the ground up, growing the business from $1,000,000 in annual written premium up to over $12,000,000 annually. He assisted in the launch of the MSMA Insurance Agency and was responsible for the agency budget, managing the sales force, and servicing a book of business.

Previously McNeill served in hospi-tal operations and management as well as physician group practice manage-ment roles. His extensive healthcare background gives him a unique under-standing of the needs of both hospitals and physicians. In the last few years the Keane Group has been expanding its services to include coverage for hospi-tals and ACOs.

At Keane, McNeill plans to use his knowledge and experience to establish new relationships with physicians and hospitals in the Kansas City area on both sides of the Missouri/Kansas border. He hopes to be a resource in helping healthcare providers navigate the new healthcare reforms and to save practices time and money.

SLU Neurosurgeon Honored for Inventing ‘StealthStation’

Richard Bucholz, MD, vice chair-man in the department of neurosurgery at SLU, has been named a Fellow of the National Academy of Inventors (NAI). The honor is accorded to academic in-ventors whose work has made a tangible impact on quality of life, economic de-velopment and the welfare of society.

Bucholz is the inventor of the StealthStation, a device he created to improve the practice of neurosurgery that subsequently became widely used by surgeons around the world.

Addressing the challenges of in-tracranial surgery, Bucholz developed a platform to improve surgeons’ ability to access the brain and navigate complex neural and vascular anatomy.

Believing existing equipment to be too cumbersome and techniques too diffi cult to master, he developed a real-time tracking system that coupled imag-

ing and tracking data for instruments, allowing surgeons to move within the brain with detailed, highly accurate posi-tioning information. This led to the even-tual world-wide elimination of equip-ment based on frames.

Today, this platform is used by a majority of hospital operating rooms to treat hydrocephalus, brain tumors, Parkinson’s disease (deep brain stimula-tion), spinal and pelvic trauma and for ENT surgery.

Established in 1836, Saint Louis University School of Medicine has the distinction of awarding the fi rst medi-cal degree west of the Mississippi River. The school educates physicians and bio-medical scientists, conducts medical re-search, and provides health care on a lo-cal, national and international level. Re-search at the school seeks new cures and treatments in fi ve key areas: cancer, liver disease, heart/lung disease, aging and brain disease, and infectious disease.

BJC HealthCare ACO Recognized

BJC Accountable Care Organization (ACO) was named to Becker’s Hospital Review annual list of “100 Accountable Care Organizations to Know.” BJC ACO was formed in July 2012 to take better and more coordinated care of seniors; it has more than 100 healthcare delivery settings and serves over 31,500 individu-als.

ACOs were selected for the “100 Ac-countable Care Organizations to Know” list based on the number of physicians choosing to join the ACO, and the num-ber of patients under those physicians’ care, as well as how long the ACO has been operating, and the number and type of contracts the ACO has with in-surers. BJC ACO and Heartland Health in St. Joseph, Missouri were the only two Missouri ACOs named in Becker’s Hos-pital Review list.

The goal of an ACO is for doctors to communicate closely with the patient’s other health care providers to deliver high-quality care and meet the patient’s individual needs and preferences. When successful, the ACO may be rewarded for meeting CMS’s quality standards and providing better value.

According to Leavitt Partners Cen-ter for Accountable Care Intelligence, there were 479 ACOs nationwide in the third quarter of 2013, covering approxi-mately 15.7 million individuals.

BJC HealthCare was the fi rst in the St. Louis area to become an Account-able Care Organization.

Becker’s Hospital Review features business and legal news and analysis relating to hospitals and health systems. It reaches an audience of about 18,500 health care leaders.

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.

14 > FEBRUARY 2014 s t l o u i s m e d i c a l n e w s . c o m

Some Brain Regions Retain Enhanced Ability to Make New Connections

In adults, some brain regions retain a “childlike” ability to establish new con-nections, potentially contributing to our ability to learn new skills and form new memories as we age, according to new research from Washington University School of Medicine in St. Louis and the Allen Institute for Brain Science in Se-attle.

The scientists arrived at the new findings by comparing gene activity lev-els in different regions of the brain. They identified adult brain regions where genes linked to the construction of new connections between cells have higher activity levels. The same genes are also highly active in young brains, so the re-searchers called this pattern of gene ac-tivity childlike.

Researchers already knew that the adult human brain generally has more activity among these genes when com-pared with other closely related species, including chimpanzees and monkeys according to first author Manu S. Goyal, MD, a fellow in neuroradiology at Wash-ington University. These new results con-nect this activity to a form of energy pro-duction known to be helpful for building biological structures, such as the new nerve cell branches needed to add con-nections in the brain.

Scientists believe that new links between brain cells help encode new memories and skills long after the brain

stops growing.The study appears Jan. 7 in Cell Me-

tabolism.Several years ago, senior author

Marcus Raichle, MD, professor of radiology, psychology, neurology, neurobiology and bio-medical engineering, was investigating the brain’s voracious consumption of sugar and oxygen to make energy and enable other functions when he noticed that a few areas of the brain consumed sugar at exceptionally high rates. He and his colleagues later showed that this was because these re-gions were actively engaged in an al-ternative energy-making process called aerobic glycolysis.

For the new study, Raichle collabo-rated with Michael Hawrylycz, PhD, a sci-entist at the Allen Institute for Brain Sci-ence. The institute’s accomplishments include creating the Allen Human Brain Atlas, a database detailing the activity of genes in different parts of the brain and from people of different ages.

As part of the study, Goyal also ana-lyzed data from earlier research by oth-er scientists to show that there is more aerobic glycolysis throughout the brain in young children.

In the adult brain, aerobic glycolysis accounts for about 10 to 12 percent of overall sugar consumption said Goyal, but in young children, aerobic glycolysis accounts for 30 to 40 percent of overall sugar usage.

Aerobic glycolysis is less efficient for energy production than oxidative gly-colysis, the alternative method that uses oxygen and sugar. But scientists think the former is a better source of energy for rapid growth.

The researchers now are studying whether problems in specific brain cells that use aerobic glycolysis contribute to neurodevelopmental problems such as autism or mental retardation or to neuro-degenerative disorders like Alzheimer’s disease.

Beverly Bokovitz Named Chief Nursing Officer

Beverly A. Bokovitz, MSN, RN, NEA-BC, has joined St. Anthony’s Medical Center as vice president and Chief Nursing Officer. Bokovitz brings with her vast experience in both clinical nursing and nurs-ing leadership.

Bokovitz joined St. Anthony’s from Akron General Health System in Akron, Ohio, where she served as Senior Vice Presi-dent and Chief Nursing Officer since 2007. Under her leadership, Akron Gen-eral’s nursing division earned Magnet Status in 2013 from the American Nurses Credentialing Center. She earned her Master of Science in Nursing from Case Western Reserve University as an Adult and Geriatric Nurse Practitioner. Bokov-itz is working on her Doctorate in Nurs-ing Leadership, which she expects to complete this year.

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s t l o u i s m e d i c a l n e w s . c o m FEBRUARY 2014 > 15

South County Needed A New,State-of-the-Art Emergency Department.

On January 1st, We Opened It.

q

q

(The New)

(Left to right) Charles Lewis, Emergency Services Director; Emergency Department;Zachary D. Tebb, MD, Medical Director;

Department of Emergency Medicine; Stephanie Austermann RN, BSN, Nursing

Manager, Emergency Department.

We knew it: Our emergency department had

to change. Wait times were too high.

And patient trust, too low. Many

in South County (some who had

never even used our services)

didn’t always see us as the first

choice for emergency care. And

here, at St. Anthony’s, that

wasn’t acceptable. So we spent

nearly a year transforming the

way our emergency department

works. From staff to approach, we re-built

everything from the inside-out. On January

1st, after countless hours of hard work and

dedication from employees, physicians, board

members and volunteers, we proudly re-opened

our emergency doors. With new ways to get

you to the right care, faster. (In fact, five times

faster than just a year ago.) Complex

trauma, heart and stroke centers

you won’t find anywhere else

in South County. New, patient

advocates dedicated solely to

improving your visit. And our

pledge to make your experience

the very best it can be. One

you’ve always deserved. One

we can now confidently deliver.

In South County, you now have one of the finest

emergency departments in all of St. Louis.

Here, in your own backyard. Emergency ser-

vices from the new St. Anthony’s. One more

part of our brand new story. To learn more,

visit southcountyemergency.com.