West TN Medical News January 2015

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Hot Button Legal Issues to Watch in 2015Already one of the most highly regulated industries in America, 2015 looks to be another active year across healthcare’s legal landscape. Two past presidents of the American Health Lawyers Association, Elisabeth Belmont and Joel Hamme, took time to share insights and predictions for the coming year. ... 8

THA, TMA Outline 2015 Priorities For Craig Becker, president and CEO of the Tennessee Hospital Association, the top priority for 2015 is securing Medicaid expansion in Tennessee … now, it looks like that could happen this year.

On Dec. 15, 2014, Gov. Bill Haslam introduced his Insure Tennessee voucher plan to provide an alternative coverage option ... 9

Thomas Bailey, MD

PAGE 3

PHYSICIAN SPOTLIGHT

FOCUS TOPICS PUBLIC HEALTH HEALTH LAW OPHTHALMOLOGY

At Five-Year Mark, ACA Remains a ‘Mixed Bag’Fallout from 2010 law continues for doctors, hospitals, insurers

By LINDSAy JONES

A patient experiences a medical emergency and is admitted to the local hospital. One of the fi rst questions he’s asked, besides his name and date of birth is . . . are you in-sured? If so, what is your health insurance plan and policy number?

So begins the time- and money-intensive dance between illness, treating that illness and paying for the privilege of treatment. It’s the bedrock of the Ameri-can healthcare system – and continues to be despite reforms introduced by the Afford-able Care Act of 2010.

“I think what we’re seeing is it’s a period of adjustment for everyone,” said Craig Becker, presi-dent of the Tennessee Hospital Association.

From a physician’s perspective, the situation has only grown murkier, and more costly, with time as “wave after wave of reg-ulations come down,” Becker said. This is especially true as require-ments continue multiplying the costs associated with patient care and

the positive outcomes demanded by the law, many observers indicate.

“Some of the regulations are crazy,” Becker said, “but some are worthwhile.”

At the heart of the issue are insurance companies, which Becker acknowledged continue to be a dominant player in healthcare delivery: how long a patient is treated, what services can (and can-not) be rendered and what is (or is not) considered acceptable along the care continuum.

During a recent budget hearing, Julie Mix McPeak, commissioner of the Ten-

nessee Department of Commerce and Insur-ance, had this to say: “The Affordable Care

Act has had a profound impact, and continues to impact, insurance providers in the state of Tennessee.

The 2010 statute has established parameters that control pro-viders’ operations, from the underwriting process right on through the benefi t packages offered to consumers.”

(CONTINUED ON PAGE 6)

By SUZANNE BOyD

As an attorney who also holds a degree in health administration, Todd Siroky has a unique insight to the challenges that face healthcare providers in West Tennessee. He has witnessed the effects various legislative measures have had on healthcare providers. As a healthcare attorney, Siroky knows that the ever-changing healthcare environment is

one that holds uncertainty and opportunities for clinics, hospitals, providers, and suppliers.

Originally a native of Chicago, Siroky moved to West Tennessee at an early age where he graduated from the University School of Jackson. He earned an undergradu-ate degree in healthcare administration with a minor in economics from the University of Kentucky in 2002. Throughout college, he

(CONTINUED ON PAGE 4)

HealthcareLeader

Todd SirokyHealthcare Attorney, Siroky Law

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By SUZANNE BOyD

When nearsightedness caused him to change his plans to apply for flight training in the Air Force, it did not stop Thomas Bailey, MD, from realizing his dream of flying. Ironically it was his nearsightedness that guided him on the path of becoming an ophthalmologist. Today, Bailey not only has his commercial pilot’s license and his own plane, he also works to give youth their first experience with flying.

A Long Island native, Bailey gradu-ated high school at 16 and headed to the Air Force Academy in Colorado Springs, Colorado to pursue aerospace engineer-ing. At 16, he was the youngest in his class. When his nearsightedness worsened to the point he was not medically qualified to apply for flight school, Bailey changed directions and decided pre-med was his path.

For medical school, the Air Force sent Bailey to Georgetown University School of Medicine in Washington, DC. “I completed a general surgery internship at the USAF Medical Center on Wright-Patterson Air Force Base in Dayton, Ohio with the intent of going into orthopedics,” said Bailey, who also served as a flight sur-geon for the Air Force. “But it was while I was in my general surgery residency there, that I knew orthopedics was not for me. One day I wandered into the eye surgery suite and watched several procedures. I was hooked and decided to switch to oph-thalmology.”

Bailey completed his residency at the Bowman Gray School of Medicine at Wake Forest University in Winston-Salem North Carolina in 1985, serving as chief resident his final year. He then was sta-tioned in the Philippines, where he was the chief of ophthalmology at Clark Air Force Base and covered all the Western Pacific.

“The Philippines was a really neat place,” said Bailey, who was almost part of history while stationed there. “During my time there, there was a coup attempt against the Aquino government. My wife and I had reservations to stay at a hotel in Manila but changed out minds when we walked in because we had heard another hotel had a better pool. An hour later, the hotel was taken over by the coup trying to overthrow the government, talk about a close call. They trashed the hotel and it all lasted about a week. There were about five such attempts while I was stationed in the Philippines, which made it an interest-ing time to be there.”

Bailey completed his time in the Air Force as the chief of ophthalmology ser-vice at Malcom Grow USAF Medical Center on Andrews AFB in Washington. He then joined a practice in Lynchburg, Virginia but relocated to Houston to com-

plete an anterior segment surgery and retina fellowship. “My time in Houston was temporary since I was really look-ing to buy the practice of someone who was retiring,” said Bailey. “I found one in Shelby, North Carolina and in my time there, I brought a multi-specialty surgical center to the area. I am a strong believer in the value of surgical centers. They are cost effective, safe and more efficient than a hospital setting for outpatient surgeries especially for older patients.”

In 2011, Bailey joined Loden Vision Center at their Paris office, becoming the first ophthalmologist to reside and prac-

tice in the area in more than 15 years. “There was such a need for me here and that was very attractive to me,” said Bai-ley. “The Paris office had been staffed full-time by Dr. Carrico, with Dr. Loden and Dr. Dougherty coming in a couple of times a month to do surgery. Now I am here full-time and do most of the surgi-cal procedures performed by our office. There was definitely a need and the prac-tice has really grown.”

While his nearsightedness led him to ultimately become an ophthalmologist, his passion to fly never dwindled and thanks to his profession, his dream became a re-

ality. “While I could not fly for the Air Force due to having to wear glasses and such, the technology evolved enough for me to get my pilot’s license more than 30 years ago and I have been flying ever since,” said Bailey.

Because he originally started out in aerospace engineering in the Air Force, Bailey put that knowledge to use in 1980 while he was in San Antonio finishing up his medical training. “I designed and built an airplane basically from scratch. I bought some of the parts, designed and built the control systems, laid out the wings and everything. I worked on it about a year and a half,” said Bailey. “I sold it to a group of investors right before it was finished as I was heading off to my residency. They finished it and were using it to fly around the country. It even made it onto the cover of Plane and Pilot maga-zine in 1983.”

Today, the instrument and multi-engine rated, FAA Certified Commercial Pilot owns a single engine plane. Bailey, who tries to fly each week, uses his skills and plane for traveling with his wife as well as to visit his six children and grandchil-dren who are scattered from the middle of the country to up and down the eastern seaboard. Bailey also uses his pilot skills and love of aeronautics as a volunteer with the Experimental Aircraft Associa-tion. “Through the Association’s Young Eagles Program, kids can get their first opportunity to fly in a plane,” said Bailey. “They can even take a ground school for free. I love being able to introduce young people to the world of flying and find it so rewarding.”

.

Thomas Bailey, MD Ophthalmologist, Loden Vision Center

PhysicianSpotlight

Dr. Thomas Bailey stands in front of his plane at the Experimental Aircraft Association AirVenture Convention


worked as a runner and a clerk for a law firm, but it was actually his health law class that sparked his interest to pursue law school after graduation.

“My health law professor at UK, Julia Costich, JD, PhD, initially got me inter-ested in the law,” said Siroky. “Dr. Costich setup a semester-long practicum working in the legal department of a managed care organization in Lexington, called CHA Health. I worked in the legal department and focused on government relations. I attended meetings and legislative commit-tee sessions at the state capital regarding healthcare reform and got an up close view of the politics behind healthcare policy.”

When Siroky enrolled at Cecil C. Humphreys School of Law at the Uni-versity of Memphis, he said he went in with an open mind on the area of law he would practice.” Besides clerking in both a private practice and government legal department, I did a semester judicial ex-ternship for Chief Judge James D. Todd in the United States District Court for the Western District of Tennessee. It was an invaluable experience and something I would recommend for any law student,” he said. “But it wasn’t until my first job after graduating in 2005 when I realized my healthcare administration studies would translate into my private law prac-tice.”

In 2014, Siroky founded Siroky Law, PLC. “I saw an opportunity to open a boutique firm and cater to small busi-nesses, which is what most of my health-care clients are,” said Siroky. “In addition to healthcare law, I counsel individuals, business owners, and institutional clients in the areas of business law, commercial litigation and estate planning.”

Over his 16 years of watching the healthcare industry, Siroky has seen many changes. For providers in Tennessee, 2015 will see more changes with the Tennessee Healthcare Innovation Initiative which is designed to transition the state health-care payment system to better reward

patient-centered, high-quality, high-value healthcare outcomes for all Tennesseans. Ultimately it will change how the state pays for healthcare services and reflects a shift from fee-for-service payments to value-based models of care.

“The initiative came as a proposal funded, in part, by a grant from the federal government to help control the unsustain-able cost of healthcare in the state while improving quality and outcomes. The state estimates savings in the neighbor-hood of $1.1 billion on healthcare spend-ing over the next five years,” said Siroky.” The initiative is modeled after the reforms adopted and implemented by the State of Arkansas in 2013 and includes the same major components.”

The initiative has three basic out-comes-based strategies: improve primary care services to focus on the delivery of preventive care and the management of chronic illnesses; retrospective episode-based payment adjustments to providers for selected conditions and procedures; and a long-term care component. Two of the plan’s two major components include retrospective episode-based payments and population health management through patient-centered medical homes. The goal of the program is that within three to five years, episodes and population-based pay-ment models account for the majority of healthcare spending.

Episodes of care focus on the health-care delivered in association with an acute healthcare event such as a surgical procedure or an inpatient hospitalization. Episodes encompass care delivered by multiple providers in relation to a specific healthcare event over a specified period during which patients may receive care from multiple providers.

With input from clinicians, insurers, and other stakeholders, the three initial episodes selected for the first wave of the initiative are total joint replacement, acute asthma events and perinatal care. In May 2014, select providers began to receive

their first reports for Wave 1 episodes from Amerigroup, Blue Cross Blue Shield of Tennessee and UnitedHealthcare, but the actual performance period does not begin until January 2015. Wave 2 initia-tives are being developed with Tennessee clinicians and stakeholders and will focus on acute and non-acute PCI, cholecys-tectomy, colonoscopy and COPD. It is anticipated that the state will roll out new waves of episodes every six months, with the goal of designing and implementing 75 episodes over the next five years.

Under this new initiative, provid-ers will continue to bill for their services and receive the same fee-for-service reim-bursements. At the end of a calendar per-formance year, providers will be subject to retroactive adjustments in the form of risk-sharing, no change, or gain-sharing based on the providers’ average cost of the episode over all episodes that fall within an episode category in the calendar per-formance year. For each episode of care there is a provider who is deemed to be the “quarterback.” This quarterback is the principal accountable provider (PAP) for the episode and is determined to be in the best position to control cost and improve outcomes of care for an episode. The PAP leads and coordinates the team of care providers and is identified by the tax iden-tification number under which services are billed. In the first wave of the initiative for perinatal episodes, the quarterback would be the provider delivering the baby (OB/GYN, nurse midwife or family practitio-ner), for total joint replacement it is the surgeon, and for an asthma exacerbation episode it is the hospital or facility where the patient went to the emergency de-partment or for an inpatient stay related to the episode. Providers affected in the initial wave are those that participate in TennCare or that treat state employees in Blue Cross and Cigna networks as well as patients covered by BCBST fully-insured commercial plans. Participation by other commercial payers will be optional but is

encouraged by the State. “The concept is that it is the quarter-

backs who carry the burden of the total cost of the episode, since they are the ones that are in the best position to affect cost and outcomes, and they will ultimately receive rewards or penalties based on the overall cost of the episode,” said Siroky. “The state sets an acceptable threshold for the average cost of each episode. Each MCO or payer sets its own commendable and gain-sharing thresholds. Basically, a quarterback’s average risk-adjusted cost for all episodes (that fall in a unique epi-sode category) in a calendar performance year determines if there is risk-sharing in the form of a financial penalty, no change in the prior fee-for-service or other pay-ment, or the opportunity for gain-sharing. If a quarterback’s average risk-adjusted cost for an episode falls above the accept-able level, there is a financial penalty. If a quarterback’s average risk-adjusted cost for an episode falls below the acceptable level but above the commendable level, the quarterback will see no change in the fee-for-service payment the quarter-back already received. If a quarterback’s average risk-adjusted cost falls below the commendable level, then the quarterback is eligible for gain-sharing in the form of a financial incentive if the quarterback also satisfies certain quality metrics.” The reconciliation will not occur for the first calendar performance year until August 2016.

This new initiative, in Siroky’s opin-ion, reflects a push toward clinical inte-gration at the state level in an effort to promote population health management across multiple providers. “Since the ini-tiative was rolled out relatively quickly, we can expect there to be a lot of unanswered questions as it is implemented. One ques-tion is ‘how are the payers going to risk-adjust for individual patient episodes that are outliers in terms of high cost because of complications or co-morbidities outside of the quarterback’s control, and whether and to what extent these outliers will be excluded from the computation of the quarterback’s average risk-adjusted cost?’ Small practices may be more affected by this change in payment methodology than larger ones,” he said. “I foresee more clin-ically-integrated networks, Accountable Care Organizations, and networks of pro-viders coming together with the common goal of controlling costs and improving quality of care so they can participate in gain-sharing and avoid financial penalties.

“The healthcare industry is con-stantly changing and adapting to new reg-ulatory constraints and 2015 is going to be no exception. We are all watching and waiting to see how things play out and it will certainly make for an interesting road ahead,” said Siroky. “West Tennessee has some truly great providers who have em-braced the adoption of the latest health information technology and are proactive about aligning their business models in re-sponse to change, so I am pretty optimis-tic about what 2015 holds in terms of our local providers’ and administrators’ abili-ties to adapt to these changes.”

Healthcare Leader: Todd Siroky, continued from page 1


By CINDy SANDERS

The Advisory Board Company, Rob-ert Wood Johnson Foundation (RWJF), de Beaumont Foundation and The Kresge Foundation recently joined forces to launch a major public health initiative known as the BUILD Health Challenge, which will award up to $7.5 million in grants, low-interest loans and program-related invest-ments over the next two years to improve health in low-income neighborhoods within cities that have a population of 150,000 or more.

Starting from a premise that good community health takes more than just healthcare, the four organizers seek to identify, accelerate and spotlight best prac-tice models and innovative approaches to addressing nonclinical factors that influence health through collaborative partnerships between hospitals and health systems, local health departments, and nonprofit commu-nity organizations. The goals of the fund-ing program are to promote health equity, reduce per capita health spending, shift resources from treating illness and chronic conditions to the upstream social conditions that impact population health, and to iden-tify and promote scalable best practices.

“Tackling today’s biggest health chal-lenges is not the work of one organization … it’s not the work of one sector,” Abbey Cofsky, senior program officer with RWJF, pointed out. “The aim of the BUILD Health Challenge really is to increase the number and the efficiency and ef-fectiveness of the types of partnerships that we know it will take to improve health. And that means bringing together hospitals, com-munity leaders and public health leaders to collaborate in efforts that are going to move the needle on health and ultimately really change the dynamic around cost.”

James Sprague, MD, chairman and

CEO of the de Beaumont Foundation, noted, “There is much work that has to be done to improve population health, and this BUILD Health Challenge, we hope, will identify promising models across the nation that will be replicable and sustain-able in order to address health problems before they get started.”

Brian Castrucci, chief program and strategy of-ficer with de Beaumont, said the United States pro-vides access to some of the best medical care in the world using some of the most advanced technologies and treatments available. However, he contin-ued, “Its (the healthcare system’s) impact is di-minished when patients return to neighborhoods with limited access to fresh fruits and vegetables, no options for safe or afford-able physical activity, or no options to fill pharmacy prescriptions.”

He noted individuals often present with chronic or complex conditions exacer-bated by lifestyle choices that are impacted by the social determinants of health. “The simple truth is that our traditional model of healthcare delivery doesn’t really work any-more.” Castrucci added, “It was designed to respond to acute illnesses like polio and typhoid and not address causes of disease that occur far beyond the clinic walls.”

Chris Kabel, senior program offi-cer with The Kresge Foundation, echoed those sentiments, noting there is a growing awareness that most of the nation’s health is determined outside of the healthcare system. “Unfortunately, health-promoting resources are not equitably distributed and tend to be least prevalent in low-income neighborhoods and communities of color,” he said.

Kabel added, “One reason why most

traditional health education campaigns have proven ineffective is they’ve done nothing to change the local opportunity infrastructure in which people live, learn, work and play.” With the BUILD Health Challenge, Kabel noted local community-based organizations are a critical compo-nent for success since their members truly understand the neighborhoods they serve including challenges, assets, obstacles and opportunities to maximize health.

Dennis Weaver, MD, chief medical of-ficer and executive vice president with the Southwind Consulting and Management division of The Advisory Board Company, highlighted the emerging role hospitals and health systems are beginning to play in building healthier communities as provid-ers move into a world of population health management.

“Most health systems are comfortable with the clinical determinants of healthcare but often don’t focus as much on the social and economic determinants of healthcare which are so critically important to popu-lation health because they feel that they can’t effect, essentially, a change in those areas,” Weaver said. He added the excit-ing part of the BUILD Health Challenge is that it brings the key stakeholders together to address those upstream barriers going forward.

Awards include up to $3.5 million in

grants and up to $4 million in low-interest loans. On the grant side, there will be up to five planning awards across a one-year pe-riod of up to $75,000 and as many as nine implementation awards of up to $250,000 each across a two-year period.

Cofsky said the planning awards are really designed for new partnerships looking to develop a well-defined community health improvement plan, whereas the implemen-tation awards are geared toward collabora-tions that are already active or have gotten past the initial thought process but need an infusion of resources to accelerate their work. The partnering hospital or health sys-tem must also agree to a 1:1 match of the implementation award with a mix of dollar and in-kind support.

Cofsky continued, “We are also ex-cited, as a part of this initiative, to have a low-interest loan pool of up to $4 million for community revitalization efforts aligned with those BUILD Health goals that could be advanced by this form of capital.” She added both forms of funding include a com-prehensive menu of support services to help the partners succeed.

The competitive awards program, which has a first application deadline of Jan. 15, culminates with the announcement of up to 14 funded collaborations on June 9, 2015. For more information, go online to buildhealthchallenge.org.

BUILD Health Challenge Issued …National collaborative awarding up to $7.5 million to improve community health

Applications & Key Dates

Information from web conferences held in December plus details about the challenge, partners, eligibility requirements and overall process are online at buildhealthchallenge.org.

To be eligible, BUILD Health applicants must include, at a minimum, a partnership between a hospital or health system, local health department, and nonprofit community organization or coalition of organizations. The nonprofit community organization must serve as the lead applicant in each proposal. Activity should be focused within a delineated ZIP code(s), census tract(s), or neighborhood(s) experiencing significant health disparities within a city of 150,000 or more residents. Also, participants must be willing to engage in a learning collaborative and openly share ideas, action plans, and results. Applications can be submitted online through the website.

Below are key dates going forward:• Jan. 16: Deadline for Round 1 applications.• Feb. 12: Invitations extended to select applicants for Round 2.• April 10: Deadline for Round 2 applications.• June 9: Winners announced.

Abbey Cofsky

Dr. James Sprague

Brian Castrucci


Frocket. A Frat-Pocket. The very fratty pocket on the front of the shirt, typically worn by Fratdaddys or Sorositutes. According to the Urban Dictionary, a common misconception of the meaning of Frocket is the front-pocket.

I like using the misconception of words like Frocket as an analogous to terms like the Patient Protection and Affordable Care Act. (We’ve shortened it to the Affordable Care Act probably because we have been leaving out the Patient Protection part. Perhaps we should add to the name and call it the Patient Protection, Affordable and Patient Accountable Care Act.)

Between the Supreme Court verdict, the re-election of President Obama and even with the past mid-term election which gave the Republicans control of both houses, it seems clear that healthcare reform is here to stay. Tweaking and changes yes, but repeal, no.

Forward and faster with the ride. In a 2013 issue of the Memphis

Business Journal, I was one of three individuals interviewed for the article, “OVERHEARD…” in which I said, “So many things have yet to be defined. When you think of how much capital the providers have put into (reform efforts), for example, you have to ask how they can afford to put even more in without knowing what the federal government is expecting. If you thought the past year was bad, 2014 is going to be bloody.

If we had looked beyond 2014, what would have followed? One thing for sure, political and ideological affiliation

continues to divide our country.During 2014, I have been critical of:The Obama Administration was

obsessed with healthcare reform policy, but oblivious to the details of implementation. I can’t leave out both Democrats and Republicans in Congress regarding being oblivious to implementation. But does it really surprise us with 43 percent of Congress being lawyers? More on this later.

CMS has done more to add to the costs of healthcare with hurdles and regulations and both HHS and CMS rely too much on processes and not on outcomes. Again, I don’t want to leave out Congress when talking about processes and outcomes. This is obvious.

Process upon processes with a changing target, there can be no positive outcomes that patients and providers have and are facing. There are plenty of deviants in the political process to keep changing an undefined target. (Deviants are simply individuals who differ in many aspects from the larger flock of society...Urban Dictionary)

As I mentioned in my December col-umn, in the book Systems Thinking Basics, Virginia Anderson and Lauren Johnson define systems thinking as a “holistic and big picture view of the whole. It is recog-nizing the interconnections between parts of a system and synthesizing them into a unified view.” Are we ready to accept unified/united to make the new paradigm work?

This is what I am thinking: HHS/CMS will come under more scrutiny concerning the way they do business. Ripping out and tearing down silos that add layers of

processes with no definitive outcomes. Hopefully, with the change in leadership in the Veteran Administration we may have a business model to emulate.

Hold HHS / CMS accountable. There is discussion now to give CMS more authority to fine providers without having to go through, as HHS/CMS says, “the expensive and time consuming due process audit.” I guess with the results of the different Medicare/RAC audits through both internal employees and contractors, which have been dismissed, thrown out, etc, I would be looking for a non-transparent way to have my cake and eat it too.

In a 2014 article, “CMS Hasn’t Got a Clue!” Medical Economics, West Tennessee Medical News, I quoted Melvin Kranzberg, who said, “This year is expected to be a watershed year in the area of information technology (HIT). Technology is neither good nor bad, nor is it neutral.”

Alongside challenging HIT reporting programs such as Meaningful Use II, ICD-10 implementation, are significant administrative simplification (for who?) opportunities with new standards and operating rules.”

I recently spoke to a friend and colleague, Robert Tennant, senior policy advisor for MGMA Government Affairs who had just returned from a panel discussion on interoperability. He said for all practical purposes it looked as though Meaningful Use II had ground to a halt. In Stage I Meaningful Use, 90 percent of hospitals and 75-80 percent of physicians were prepared for Stage I. Less than two percent of both hospitals and physicians

were prepared for Meaningful Use II.”Much of this is due to changes made

in Stage II which impacted Stage I which still has not been meaningfully defined. This most likely will cause another delay in Meaningful Use II and the implementation of ICD-10.

Tennant said, “Even if providers were prepared for Meaningful Use I and II, there would still be interoperability issues. The data required has more than 500 data points and would overwhelm us with all the information. He refers to a new concept, Targeted Interoperability, which means useful, actionable, reliable and standardized. In my simple mind, I compare that to all of the useless, time-consuming emails that I have to decide whether to read, save, or delete.

Members of the House Energy and Commerce Committee issued a report last year, saying health information technology would be “unable to truly transform our health system unless they can easily locate and exchange health information.” Spearheaded by Rep. Michael Burgess, R-Texas, House members said, “More must be done to bolster interoperability nationwide. Adopting these standards by 2018 is reasonable and should be the highest priority for the Office of the National Coordinator for Health Information Technology (ONC). The office of ONC seemed to agree, with its new chief, Karen DeSalvo, MD, calling interoperability the “Top priority for 2014” earlier this year.

HHS Secretary Sylvia Mathews Burwell, in October appointed DeSalvo to serve as acting Assistant of Health, effective immediately. She will serve as acting Assistant of Health, while maintaining her leadership of ONC and continuing to work on high-level issues at ONC and will follow the policy direction that she has set. She will continue leading the development of the interoperability road map and remain involved in meaningful use policy making.

I am not sure what type of medical degree she has, but I hope Dr. DeSalvo’s medicine bag is full of medicine. I think Dr. Joseph Schneider, chief medical information officer at Baylor Scott & White Health in Dallas, was more articulate with his concern. “DeSalvo is trying to handle two demanding jobs at the same time, which seldom has positive outcomes for anyone. If you give people too many things to do, they don’t get it done terribly well.”

Just like Ollie said to Stan: “Well, here’s another nice mess you’ve gotten us into.”

FROCKET and Other Common MisconceptionsBY BILL APPLING

MedicalEconomics

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

At Five-Year Mark, continued from page 1As reported previously in West Ten-

nessee Medical News, this and other aspects of the law have led to a wave of consoli-dations between physicians’ groups and hospital systems, allowing them to insulate themselves, at least to an extent. It also has helped them “gain more clout” when nego-tiating contracts with payers, Becker said.

However, the transition has been less than smooth, according to McPeak’s recent remarks.

“Unfortunately, ACA implementa-tion has also complicated the business of insurance for our carrier community,” she said in a statement. “The stepped rollout of the legislation, coupled with reliance on Department of Health and Human Ser-vices discretion, has often led to providers searching for answers and last-minute revi-sions to business operations.”

This was particularly evident when physicians received notice from Blue Cross Blue Shield of Tennessee (BCBS-TN) in November 2013 that the insurance company would be amending its contract so doctors would receive a 48 percent reduction in the

reimbursement cost, set by 2013 Medicare payments standards, for all services deemed “in-office physician lab services.”

The amendment went into effect on Jan. 1, 2014. At the time of the notice, doctors were given until Dec. 20, 2013, to decide whether they would accept the amendment. Ultimately, they did; it was either that or opt out altogether. And the situation is not unique.

Becker said it is something that, ulti-mately, could result in some kind of single payer, state-run system such as Medicare for all. In that case, healthcare would be financed by a public- or quasi-public entity, but care delivery would remain in private hands, according to Physicians for a Na-tional Health Program.

“We don’t know what it’s going to morph into,” Becker said. “I don’t know if this was intended (by the law) or (might be) a consequence of it.”

Unless or until such a thing occurs, larger physicians’ and hospital groups are here to stay, he said, and smaller, more rural providers aren’t likely to survive. “I

think we’re going to see a lot more of that.”As it is, about 60 percent of physicians

are being hired under some type of agree-ment with hospital systems, what Becker calls “an enormous jump” that likely will not slow.

Meanwhile, insurance premiums have increased for patients in Tennessee, while Medicaid coverage has not been expanded – yet.

“At least from a hospital standpoint, access to care might be getting worse,” Becker said.

However, the care itself might just have improved.

“Frankly, I think care’s gotten better because of what we’ve been able to do with safety and quality of care,” he said, mean-ing more attention for patients and fewer details missed as primary care doctors, spe-cialists and hospital systems are forced to coordinate more closely.

That, he said, is where the ACA’s in-tent – and the reality of it, admittedly a “mixed bag” – are most marked. “In the end, it’s all about the patient,” he said.


By JULIE PARKER

Missed family gatherings and soccer games, frustration with bureaucracy, dwindling self-worth and utter exhaustion often overshadow the initial call to heal others.

In the environment of protracted work days, countless rounds, scarce breaks, and pagers ring-ing incessantly have led many physicians to opt for early retirement, sec-ond-guess their chosen profession, and/or suffer professional burnout.

Alarmingly, more than 400 doctors commit suicide annually; the suicide rate is four times higher for women physicians than women in other professions.

According to a recent Medical Econom-ics survey, more than one-third of physi-cians reported that if they could go back in time, they would choose a different specialty – or a different career alto-gether.

With an estimated 90,000 too few physi-cians practicing by 2020, America’s doctors will continue to work over-time to meet the demand.

“Most of us followed a calling to serve others through practicing medicine,” said Starla Fitch, MD, author of Remedy for Burnout: 7 Prescriptions Doctors Use to Find Meaning in Medicine (Langdon Street Press, 2014). “We’ve dedicated our time, talent and treasure to healing others, but as we (did), many of us forgot how to heal our-selves.”

Encountering burnout led to an ex-perience for Fitch, a board-certifi ed oph-thalmologist specializing in oculoplastic surgery, which renewed her spirit. One result: she established the popular love-medicineagain.com, an online community to help medical professionals reconnect with their passion for the practice after surviving life-altering burnout. A featured blogger for Huffi ngton Post, certifi ed life coach and CBS contributor, Fitch wrote Remedy for Burnout to benefi t colleagues and doctors-in-training.

“The level of burnout among physi-cians is at an all-time high,” said Fitch. “A great many of my burned-out colleagues are frustrated with the changes in the re-lationships within medicine.”

One such dysfunctional relation-ship: the tie between doctors and insur-ance companies. Case in point: a large managed-care network recently removed Fitch’s practice from its list of preferred providers.

“Had we not taken good care of our patients?

Weren’t we avail-able for those patients

24/7? Did patients complain that my part-

ners and I didn’t deliver quality care? No. No.

And no. The managed-care network decided to

provide the types of ser-vices we provide,” Fitch

explained. “It opted to move the services in-house to save

money, regardless of the con-sequences to its patients.”

The impact of that decision? One af-fected patient had been diagnosed with eyelid cancer. Surgery had been sched-uled to remove the growth, followed by another surgery for reconstruction, Fitch said.

“The loss of continuity that has emerged in our healthcare system hasn’t only disrupted our patients’ health,” she said, “it’s disrupted physicians’ quality of care.”

Fitch’s personal prescriptions call for doctors to:

Develop resilience.Practice faith, which Fitch describes

as “front and center faith … the kind we doctors have when we make that fi rst inci-sion and trust we’ll be able to later close the wound.”

Cultivate self-worth. “Too often, we see ourselves incorrectly,” explained Fitch. “Instead of looking in the mirror and see-ing the specialness we possess, we allow what we think other people think about us to enter the equation.”

Promote creativity. “Your staff has more creative tips up their sleeves than you can imagine,” said Fitch. “Brainstorm with them on ways to improve patient fl ow, appointment time congestion, or any number of things that will allow for hap-pier employees and healthier patients.”

Fitch also included a section on inter-personal prescriptions, encouraging physi-cians to:

Foster support. “’Grinning and bear-ing it’ isn’t a successful coping mecha-nism,” said Fitch. “The stigma around doctors asking for help lingers, unfortu-nately.”

Embrace compassion. When Fitch asked a colleague advice he would give his 29-year-old self, the doctor said: “Try to be more empathetic. That’s more impor-tant than anything else. Having some idea of a patient’s situation really changes the way you treat people.”

Encourage connection, “the spark that ignites when you have a conversation

The Secret Suffering of DoctorsOphthalmologist pens book about the looming crisis in medicine, a remedy for burnout

Dr. Starla Fitch

Missed family gatherings and soccer games, frustration with bureaucracy, dwindling self-worth and utter exhaustion often overshadow the initial

ond-guess their chosen profession, and/or suffer professional burnout.

able for those patients 24/7? Did patients

complain that my part-ners and I didn’t deliver

quality care? No. No. And no. The managed-

care network decided to provide the types of ser-

vices we provide,” Fitch explained. “It opted to move

the services in-house to save money, regardless of the con-

By Denise Burke, Angela Youngberg, John Arnold and Cory Brown

The historical transformation of the healthcare delivery system continues, and 2015 promises to bring to the forefront a number of key issues affecting providers. Chief among these issues are how will providers be reimbursed and how can they prepare for new models of care delivery and reimbursement while government scrutiny continues to increase. Naturally, integration will continue, and provider focuses in 2015 will be in areas that include:

Payor Contracting. Bundled payments and shared savings programs will materially expand in scope and scale with third party payors. Providers should be pre-pared for enhanced efforts by payors to increase cost efficiency. Providers should be aggressive in attempt-ing to reach contracts with payors that incorporate these inevitable concepts. On the ACO front, CMS is-sued a proposed rule on December 1, 2014 that would change the structure of the Medicare ACO program to make it more attractive to providers. Providers who have previously considered and rejected the idea of Medicare ACO participation should take a fresh look at the matter in light of the proposed changes.

Telemedicine. One of the fastest-growing trends among providers is the delivery of patient care through telemedicine. Both payors and providers view telemedicine as a meaningful way to reduce costs, increase efficiency in care delivery and improve patient access to care. As evidence of how payors are embracing telemedicine, starting on January 1, 2015, Medicare will cover wellness, behavioral health, and care for chronic disease management in certain expanded circumstances for visits that are not face-to-face visits.

Investments in Healthcare Information Technol-ogy. As more providers have invested in electronic health record systems and other emerging technolo-gies, the discussion about interoperability will be more pervasive. Coordinating care for patients with complex health conditions who see multiple physicians can be supported by better IT interoperability. There will also be more likelihood for data breaches, however, which can result in material liability for providers and troublesome audits by enforcement agencies.

Changes in Models of Care. Urgent care centers, retail medical clinics, federally qualified health centers (FQHCs) and rural health clinics (RHCs) will continue to proliferate in 2015. As emergency department costs increase, the Affordable Care Act begins to take effect and the primary care physician shortage wors-ens, urgent care centers are playing an increasingly important role. Urgent care provides cost-effective, convenient medical services for low- to mid-acuity illness or injury, is significantly less expensive than the cost of care at emergency departments, and urgent care centers may be owned by physicians, hospitals or private investors. Urgent care centers located in non-urban areas may also qualify for RHC status, which may dramatically increase Medicaid reimbursement. Similarly, FQHCs are qualified to receive enhanced reimbursement under Medicare and Medicaid.

Changing Strategies for Alignment. The eco-nomic feasibility of independent medical practices and smaller hospitals will face continuing challenges in 2015. In addition to the continued growth in the number of hospital-employed physicians and the number of smaller facilities being acquired by larger hospital systems, changing strategies for alignment will emerge. Not only will clinical integration continue, entities such as Shared Services Organiza-tions (SSOs) will continue to be an attractive option for providers seeking to form collaborations without losing independence or control while obtaining some of the benefits of consolidation, such as increased purchasing power, reduced costs of care and shared best practices.

Continued Enforcement. The $5.7 billion generated by False Claims Act litigation and settlements in 2014 is alarming and seemingly counter-productive to focusing on the above important initiatives, but relief for providers is not likely in 2015.

THE YEAR AHEAD FOR PROVIDERS

Denise Burke

Angela Youngberg

John Arnold

Cory Brown

www.wallerlaw.com(CONTINUED ON PAGE 10)


By CINDy SANDERS, ELISABETH BELMONT & JOEL HAMME

Already one of the most highly regu-lated industries in America, 2015 looks to be another active year across healthcare’s legal landscape. Two past presidents of the American Health Lawyers Associa-tion, Elisabeth Belmont and Joel Hamme, took time to share insights and predictions for the coming year.

Subsidies in the Health Insurance Exchanges

Under the Affordable Care Act, in-dividuals with incomes between 100 and 400 percent of the federal poverty level are eligible to receive federal tax credit subsidies for purchasing health insurance on the exchanges. Hamme noted that in King v. Burwell, the Fourth Circuit court ruled the IRS acted lawfully in interpret-ing such subsidies were permissible not only for state exchanges but also for fed-erally run exchanges and those that are a federal-state partnership. However, the Supreme Court has agreed to review this decision.

Hamme explained, “Of the 50 states and the District of Columbia, only 17 have state established exchanges; 7 have partnership exchanges and the remaining 27 are federally operated. Thus, if the Su-preme Court were to overturn the Fourth Circuit’s decision, individuals in two-thirds of the 51 jurisdictions would be ineligible for subsidies for purchasing health insur-ance on the exchanges.” He added that while there was some debate as to how det-rimental such a decision would prove to be to the ACA, certainly it would be a major setback. “The King case essentially rep-resents the last major legal hurdle for the ACA. If the subsidies challenge fails, ACA opponents will be relegated to trying to repeal or signifi cantly modify the ACA by legislative and executive branch actions.”

Medicaid Eligibility ExpansionSince the Supreme Court ruling that

mandatory Medicaid expansion wasn’t permissible, 29 states voluntarily have au-thorized Medicaid eligibility expansion or obtained federal approval of an alternate expansion plan to take advantage of gen-erous federal fi nancial support tied to the program. However, Hamme pointed out,

the 2014 election results impacting gov-ernorships and state legislatures seem to have strengthened the numbers of those opposing such expansion in several states that were still weighing the options. “In at least one state, it is conceivable that Medicaid eligibility expansion will be re-scinded after having been implemented,” he said.

Hamme continued, “For 2015, the key Medicaid eligibility expansion devel-opment will be whether the slow erosion of state opposition to expansion continues as states decide that they do not want to forego the fi nancial advantages of expan-sion or whether this erosion is abated by those fi ercely opposed to the ACA.” He added it will be interesting to see how fl ex-ible the federal government might be with respect to work and work search require-ments and benefi ciary cost-sharing obli-gations for states that are seeking waivers for alternate expansion models.

ACA Going ForwardAs Hamme pointed out, the ACA has

already generated several legal decisions and navigated a number of political and operational obstacles in its relatively short life. However, a number of hurdles … including the decision on exchange sub-sidies and the law’s unpopularity among large swaths of the public … remain.

“During 2015, interested observers should look to various barometers to as-sess whether the ACA is working … and equally important … whether it is gain-ing the public acceptance needed to as-sure its political survival,” Hamme said. He added some of those measures would include the administration of the ex-changes, whether offerings to consumers were deemed acceptable in terms of plan choices and affordability, a continued decline in the number of uninsured, and whether or not the ACA could continue

to withstand legal and political assaults.“Like 2013 and 2014, the coming

year will witness numerous developments that will lead either to the ACA’s long-term viability or its premature demise,” Hamme concluded.

Fraud and AbuseOn Oct. 31, 2014, the U.S. Depart-

ment of Health and Human Services Of-fi ce of Inspector General (OIG) released the FY-2015 Work Plan. Always eagerly anticipated, the document gives insight into the OIG’s planned reviews and ac-tivities with respect to HHS programs and operations. Belmont noted, “In the intro-duction to the Work Plan, OIG stated that, in the coming year, the agency plans to continue to focus on issues such as emerg-ing payment, eligibility, management, IT security vulnerabilities, care quality and access in Medicare and Medicaid, public health and human services programs, and appropriateness of Medicare and Medic-aid payments.”

Belmont highlighted a few areas of interest for this year:

Hospitals: With 22 substantive areas under review, the OIG is deeply engaged with hospital reviews both on the billing and payment side, and quality of care is-sues, which are a particular priority for current Department of Justice (DOJ) and OIG enforcement efforts. OIG continues to scrutinize CMS contractors’ implemen-tation of outlier reconciliation (of which the OIG has been critical for many years) and remains intensely interested in inpa-tient versus outpatient payments, the “two midnight” rule for inpatient admissions, and cardiac catheterizations.

Hospice: Hospice billings for general inpatient care, a focus of relators and the DOJ, is under close review by the OIG.

Freestanding Clinic Providers: OIG con-tinues to examine certain payment sys-

tems such as provider-based services and freestanding clinic payments, with an eye toward reducing disparity of payments based on site of service.

Laboratories: OIG added a review of independent clinical laboratory billing requirements, without further specifying the billing requirements at issue. This may coincide with increased local cover-age determinations by contactors, OIG enforcement against clinical laboratories under its Civil Monetary Penalties Law authority, and OIG’s general heightened scrutiny of technical billing and payment compliance by clinical laboratories, espe-cially specialty laboratories.

Accountable Care Organizations: OIG intends to conduct a risk assessment of CMS’ administration of the Pioneer ACO Model.

Medicaid Managed Care: OIG added a review of state collection of rebates for drugs dispensed to Medicaid managed care enrollees.

Medicare Part D: This is an area where there will be continuing scrutiny of the quality of Part D data submitted to CMS. The OIG also plans to follow up on the steps CMS has taken to improve its over-sight of Part D sponsors’ Pharmacy and Therapeutics Committee confl ict-of-in-terest procedure in the wake of the OIG’s critical 2013 report.

Health Information & Technology

“Data now is recognized as one of a healthcare organization’s most valuable assets, especially as a result of the transi-tion to a more analytically driven indus-try,” Belmont said. “Given the increasing importance of data to a healthcare organi-zation, it is advisable for the organization to implement appropriate data gover-nance best practices.”

With the accumulation of data also comes an obligation to make sure pro-tected health information (PHI) stays protected. “In 2015, healthcare privacy and security compliance will continue to expand with respect to the scope, number of enforcement bodies and increased en-forcement activity, and overlapping sets of requirements,” Belmont said. “In ad-dition to the requirements of the HIPAA Privacy and Security Rules, healthcare providers also will need to navigate re-quirements promulgated by the Federal Trade Commission, Centers for Medi-care and Medicaid Services, Offi ce of the National Coordinator, and state attorney generals. Additionally,” she continued, “increasing exposure for privacy and se-curity breaches may occur as the result of state common or statutory law, despite there being no private right of action with regard to HIPAA violations. As a con-sequence, healthcare organizations and practitioners need to manage the com-plex daily operational processes required to maintain appropriate privacy and se-curity of protected health information and devote necessary resources to ensure regu-latory compliance.”

Hot Button Legal Issues to Watch in 2015About the Experts

Elisabeth Belmont, Esq. serves as corporate counsel for MaineHealth, ranked among the nation’s top 100 integrated healthcare delivery networks. She is a member of the Board on Health Care Services for the Institute of Medicine and its Committee on Diagnostic Error in Health Care. Belmont is also a member of the National Quality Forum’s Health IT Patient Safety Measures Standing Committee. In addition to serving as a past president of the American Health Lawyers Association, she is also the former chair of

the organization’s HIT Practice Group and the current chair of the Inhouse Counsel Program. In 2007, Modern Healthcare named her to their list of “Top 25 Most Powerful Women in Healthcare.”

Joel Hamme, Esq. is a principal with Powers, Pyles, Sutter & Verville in Washington, D.C. He joined the fi rm in 1998 and focuses his practice on long term care, Medicare and Medicaid reimbursement issues, provider licensure and certifi cation matters, and litigation in his areas of expertise. He is a member of the District of Columbia and Pennsylvania bars, as well as the bars of the Supreme Court of the United States and numerous federal appeals courts. A past president of AHLA, Hamme is a frequent speaker and lecturer on healthcare issues and has authored

numerous articles and book chapters relating to healthcare law.

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tals first broached the subject of funding the state’s portion so Tennessee wouldn’t ultimately lose out on $900 million in fed-eral funding support. “Hospitals have taken that on for the last five years,” Becker said. “The dollars used to come from the gen-eral fund.” Becker added he is hopeful the general fund might again pick up some of state’s portion of Medicaid funding down the line as the economy continues to stabilize.

Another ongoing priority, Becker said, is ensuring the state’s Certif-icate of Need program stays in tact. “There is no looming threat right now, but it’s al-ways a concern,” Becker noted, adding the CON process levels the playing field for facilities across the state.

Russ Miller, CEO of the Tennessee Medical Association, is also eager to see more Tennesseans be able to access the healthcare system through a commonsense Medicaid expansion plan. Additionally, the TMA has a full slate of activities pertaining to professional development, membership resources, and advocacy planned for 2015.

Among some of their key priorities for the year are preparing members for ICD-10, finishing the work on payer ac-countability, looking at issues pertaining to graduate medical education and physician sustainability, and helping TMA members, in partnership with other healthcare pro-fessionals, navigate new payment models and collaborative care arrangements.

A major push for the TMA over the next 18 months is becoming recertified as a CME provider. Miller said the orga-nization served as the state accreditor for continuing medical education until around 2005 but dropped that function for various reasons. “We thought it was time to bring it back,” he said.

The TMA already has a strong edu-cational component within the staff and offers online CME courses alongside lead-ership development and training on the latest issues. However, going through the recertification process will allow the state association to provide more clinical content to physicians and other providers. “It will give us the ability to create more original content to meet the needs of the market and to get it to them faster without having to use a third party,” Miller explained.

Staying on an education theme, Miller said another issue is graduate medical edu-cation. “The Medicare program funds resi-dency programs in every state,” he pointed out. Looking at concerns over physician sustainability and shortages in a number of areas, Miller continued, “You can get more doctors through medical school, but if resi-dency positions don’t exist, you can’t finish training them.”

A cap of $50 million for GME has been in place in the TennCare waiver with-out any increase since the 1990s. “We’re asking the state to seek out more funding for graduate medical education,” he said of a hope the cap could be raised by $25 mil-

By CINDy SANDERS

For Craig Becker, president and CEO of the Tennessee Hospital Association, the top priority for 2015 is securing Medicaid expansion in Tennessee … now, it looks like that could happen this year.

On Dec. 15, 2014, Gov. Bill Haslam intro-duced his Insure Ten-nessee voucher plan to provide an alternative coverage option to low-income Tennesseans who don’t qualify for either TennCare or fed-eral subsidies. It’s estimated nearly 200,000 employed Tennesseans at or below 138 percent of the federal poverty level would be impacted by the pilot program designed to help them participate in employer-offered plans.

In responding to the plan’s announce-ment, Becker stated, “For the past two years, THA’s number one priority has been securing Medicaid expansion in our state, and today marks the beginning of this goal becoming a reality. I applaud the governor’s thoughtful approach to this vi-tally important issue and am grateful for his hard work with the Department of Health and Human Services in recent months.”

Becker added the Insure Tennessee plan is a meaningful alternative to tradi-tional expansion. He continued, “I also believe Insure Tennessee helps provide a solution to the financial challenges hospi-tals across Tennessee have faced for the last several years as a result of extreme cuts in healthcare reimbursement.”

However, he recognizes there is still more work to do on behalf of the THA membership. Getting the plan through the Tennessee Legislature is the next chal-lenge. “It’s most needed,” Becker said. “We’ve lost several hospitals in the last year. It’s going to be much tougher, es-pecially for our small and rural hospitals to survive … and for our urban safety net hospitals to provide the level of services they do … if we don’t get expansion.”

Still, having the Insure Tennessee plan approved by HHS is clearly an im-portant first step.

Other priorities for 2015 include pas-sage of the hospital assessment, which al-lows Tennessee hospitals to put up $452 million to help fund the TennCare pro-gram and draw down federal match dol-lars at a 2:1 rate. Although passage has been fairly routine the last few years, there was initially some skepticism when hospi-

THA, TMA Outline 2015 Priorities

THA’s New LeadershipDuring the annual meeting this past November, the Tennessee Hospital

Association membership elected and installed the 2015 board of directors.

Mark Medley, senior vice president and president of hospital operations for Franklin-based Capella Healthcare, was installed as chairman. A Fellow of the American College of Healthcare Executives, Medley is responsible for the operations of 14 acute care and affiliated Capella entities throughout the United States. Previously, he served as a hospital CEO and division CFO for LifePoint Hospitals and began his career with

HCA. Prior to his current THA role, Medley served as chairman of the state association’s Council on Government Affairs and received the THA Small or Rural Hospital Leadership Award in 2013. He has also served on the boards of the THA Solutions Group and the Tennessee Rural Partnership.

Keith Goodwin, president and CEO of East Tennessee Children’s Hospital in Knoxville, was installed as chairman-elect and will step into the chairman’s role at the 2015 annual meeting in Nashville this coming November. Goodwin has served in his current position with ETCH since 2007. Prior to that, he spent more than 28 years at the Nationwide Children’s Hospital in Columbus, Ohio and also served as CEO at the

Children’s Hospital of Austin for three years. In addition to being a member of the boards of THA, Children’s Hospital Alliance of Tennessee and Hospital Alliance of Tennessee, Goodwin serves on the boards of the East Tennessee Foundation, Metropolitan Drug Commission and Knox County Imagination Library.

Reginald Coopwood, MD, president and CEO of Regional One Health in Memphis, handed the gavel over to Medley and stepped into his new role as immediate past chair. He also will serve as speaker of the THA House of Delegates in 2015. Coopwood received his medical degree from Meharry in Nashville and previously served as CMO for Nashville General Hospital and later as CEO of the Metropolitan Nashville Hospital

Authority before accepting his current position in March 2010. Coopwood serves on the boards of March of Dimes, QSource and Mid-South e-Health Alliance, among others.

Craig BeckerRuss Miller

lion. Miller was quick to add that doesn’t mean $75 million would be automatically funded, but at least there would be room for growth that doesn’t currently exist.

“Taking the long view, doctors often stay where they do residency. We want to keep doctors in Tennessee so we don’t have access issues for our citizenry.”

On the advocacy side, Miller said, “First and foremost is the continuation of the work we started last year on payer ac-countability.”

He expects legislation to be introduced in 2015 that addresses an issue he said has been an ongoing problem regarding com-mercial insurers making changes, often to fee schedules, mid-term in a contract cycle rather than waiting until the end of the con-tract and re-negotiating with all parties at the table.

“What we heard from our doctors is they just needed more predictability,” Miller said. He added it’s difficult to plan for the year when contracts could be uni-laterally changed with little notice. “We spent almost every week with the insurers

this (past) summer to tweak (the proposed legislation) it to make sure we don’t have unintended consequences,” Miller noted of working earnestly to get insurer’s input.

The TMA has also played a part in addressing some of the larger societal issues facing Tennesseans, including prescription drug abuse. Noting limited resources make it difficult for any one organization to make a big impact, Miller said this has led to more statewide collaboration. “It takes a lot of or-ganizations working together to move the needle a little bit,” he pointed out. In addi-tion to creating classes on the subject to help providers appropriately diagnose and treat patients with powerful opioids, TMA has also joined colleagues in educating the public and Tennessee Legislature about the issue.

Miller said much of the coming year’s work is an investment in the future to en-sure Tennessee continues to have realistic rules and regulations, a good practice en-vironment, fairness in reimbursement, and improved population health. “We want to make our state a great place to be a doc-tor,” he said of TMA’s ongoing mission.

Online Event Calendar


Hot Button Legal Issues to Watch in 2015


By JULIE PARKER

Telemedicine is the key to reforming healthcare, say Telehealth Resource Cen-ters (TRCs) leaders, who are promoting telehealth activity – especially to under-served populations – via 14 regional and national offices, funded by the U.S. De-partment of Health and Human Services’ Health Resources and Services Admin-istration (HRSA) Office of Rural Health Policy.

“Access to care is becoming more of a problem and telemedicine is the answer, especially because fewer primary doctors are coming out of residency … and more new physicians are moving into special-ties,” said Paula Guy, CEO of Global Partner-ship for TeleHealth and the Florida Partnership for TeleHealth. “Tech-nology is allowing the physician to go to the patient instead of vice versa, and in telemedi-cine, there are truly no limits.”

Early last month, the Southeastern Telehealth Resource Center (SETRC)

hosted the first-of-its-kind Florida Tele-Health Summit – Transforming the Deliv-ery of Healthcare – in Orlando, along with the Florida Partnership for TeleHealth and Florida State University College of Medicine, to connect state lawmakers and healthcare leaders in preparation for the Florida 2015 legislative session, starting March 3.

“Florida’s one of the states that isn’t yet in full swing with telehealth initia-tives, which is a direct result of the lack of support from some legislators in the state government,” said at-tendee Nick Hernandez, CEO of ABISA LLC, a practice management firm based in Florida. “Legislators need to be involved to take it to the next level. Telemedicine isn’t the future … it’s now.”

Where’s the Money?Telemedicine advocates have lob-

bied state lawmakers to pass telehealth legislation that includes, among other provisions, reimbursement for telehealth at the same rate as an in-clinic visit. Only

21 states mandate telemedicine compen-sation at the same rate as in-person care.

“The key to shaping telemedicine pol-icy is to show insurance companies how telemedicine saves lives,” said Hernandez, who also attended the Florida TaxWatch-hosted Telehealth Cornerstone Confer-ence a month earlier in Tallahassee, Fla. “Countless studies across the nation easily prove this.”

According to a survey from Foley & Lardner LLP, a national law firm spe-cializing in telemedicine, reimbursement remains one of the biggest obstacles to im-mediate adoption of telemedicine. Forty-one percent of physician respondents said they’re not reimbursed for telemedicine services; 21 percent reported receiving lower rates from managed care companies for telemedicine than in-person care.

“The reimbursement landscape is already changing, and there are many viable options for getting compensated for practicing telemedicine,” said Larry Vernaglia, chair of Foley’s Health Care Practice.

Telemedicine already plays an impor-tant role in lowering hospital readmission rates, which also allays financial penalties for reimbursement, Guy pointed out.

“Heart failure is a great example,” she said. “Telemedicine allows the nec-essary follow-up and patient education opportunities for those who have been re-cently discharged. Patients can use simple technology to record heart rhythms and submit other patient biometrics.”

Before telemedicine can truly be em-braced, provider licensing and connec-tivity in rural areas must be addressed, Hernandez pointed out.

“It’s a significant barrier (that) a phy-sician must be licensed in each state where he’s practicing,” he said.

Only 10 states extend a conditional or telemedicine license to out-of-state physi-cians: Alabama, Louisiana, and Tennessee in Medical News’ coverage area, and Min-nesota, Montana, Nevada, New Mexico, Ohio, Oregon and Texas.

“Florida’s been chewing on it for a couple of years at the capitol,” said SETRC director Rena Brewer. “We’re hopeful 2015 is the year for meaningful telehealth policy for Florida.”

Problems with broadband connectiv-ity have also hindered telemedicine ad-vancement.

“Many believe the proliferation of 4G may be the answer,” noted Hernandez.

The Global PictureAfter an industry conference in Rome

Oct. 7-8, 2014, The Economist reported that telemedicine on an international level was “stuck in the waiting room.”

“Even smartphones and tablets have failed to usher in the telemedicine revo-lution,” it said, pointing out that one of the first documented telemedicine prac-tices occurred in 1924, when a recovering patient at home consulted with his doctor via a television link. Telemedicine had been touted as healthcare’s future since NASA began monitoring astronauts in space in the 1960s. “Governments have been slow to embrace an approach that could improve coverage and outcomes … but are under increasing pressure from aging populations and a surge in chronic diseases, just as public budgets are being squeezed.”

The situation in the European Union is simpler than in the United States, said The Economist. “Countries may not pass laws that would stop doctors practicing telemedicine, and doctors need only be licensed in one country to practice at all. But member states don’t agree on whether to pay for care that’s administered re-motely; some, including Germany, rarely pay for it at all.”

In Israel, whose healthcare system is completely digitized, the health ministry saw a spike in telemedicine in 2010; infor-mal guidelines were introduced in 2012.

For American physicians, telemedicine offers opportunities to assist in underserved areas of the world. For example, African countries such as Rwanda often consult with U.S. oncologists on difficult cases.

“The smartest thing (U.S.) organiza-tions can do now,” said Vernaglia, “is to continue developing programs, and be ready for the law to catch up – because it will.”

Remedy: TelemedicineIn the New Health Economy, telemedicine eases physician shortage, improves patient satisfaction and promotes competition

Paula Guy

Nick Hernandez

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in the doctors’ lounge and you laugh at the same jokes, commiserate over the same wins or losses of sports teams, or offer con-gratulations or condolences for the highs and lows we all experience,” she said. “These relationships have a profound im-pact on doctors’ lives and are, therefore, the ones that need fostering.”

Going forward, Fitch hopes physi-cians find their own personal remedy to overcome burnout. She uses “entrain-ment,” a word from the biomusicology world that means “the synchronization of organisms to an external rhythm, often produced by other organisms with which they interact socially.”

“Sometimes when I’m in the OR, I ask the anesthesiologist to slightly turn down the volume of the patient’s pulse ox-imeter,” she said, “as I can feel my own pulse trying to keep time with the patient’s rhythm.”

Fitch encourages physicians to “be brave and reach out to others in the com-munity.”

“Together,” she said, “we can all find meaning in medicine.”

Secret Suffering, continued from page 7


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GrandRounds

THA Recognizes West Tennessee Healthcare Board Member

West Tennessee Healthcare Board of Trustees Member Curtis Mansfield was recognized by the Tennessee Hospital Association at its annual meet-ing in Nashville. Mansfield was among 21 people from across the state who received honors at the 76th annual meeting at the Gaylord Opryland Re-sort and Convention Center. The Meritorious Ser-vice Award was given to Mansfield for his contribu-tions while serving for the past 17 years on the West Tennessee Healthcare Board of Trustees.

In addition to his role as a member of the West Tennessee Healthcare Board of Trustees, he is also a past board chairman. He has also served as a direc-tor of local organizations including Jackson Rotary Club, Jackson Arts Council, and Jackson-Madison County Area Chamber of Commerce.

Greg Milam, current West Tennessee Health-care board chairman, said Mansfield has been an excellent role model.

Curtis is currently President and Board of Direc-tors member of FIRSTBANK in Jackson. He and his wife, Joan, have four children and six grandchildren all living in the Jackson area.

Tennessee Hospital Association Chair-Elect Mark Medley presents award to West Tennessee Health-care board member Curtis Mansfield during annual meeting in Nashville.

Jackson-Madison County General Hospital ED Debuts Improved Entrance AreaJackson-Madison County General Hospital officials held a formal ribbon-cutting for its remodeled and expanded Emergency

Department entrance area in December.Jackson-Madison County General Hospital has remained committed to meeting the emergency needs of the residents of Jackson

and West Tennessee since 1950, according to James Ross, Jackson-Madison County General Hospital Chief Operating Officer. He said the new patient entrance area is an example of the kinds of ongoing improvements that are made to provide the best possible patient care and respond effectively to the wide range of emergencies that are seen every day.

The newly remodeled area will allow visitors more immediate access to Emergency Department registration and intake staff. The area also includes expand-ed patient triage space, 4 new triage rooms and ded-icated areas for electrocar-diogram (EKG) testing and laboratory specimen col-lection.

The 4 new triage rooms will offer Emergen-cy Department patients greater privacy, and allow greater use of mid level practitioners and other qualified medical provid-ers in initial patient as-sessments and ordering of diagnostic tests. These changes are intended to help speed the initial pa-tient evaluation process and reduce the length of time required for Emergen-cy Department visits. The new triage rooms also al-low the staff to isolate more quickly patients who enter the Emergency Depart-ment with a potentially infectious disease.

The remodeled area also includes a second waiting area to better accommodate patients during peak times such as the flu sea-son, a waiting room for laboratory and x-ray patients, and a waiting room for general patients.

The improvements further support other key features of the ED that allow for effective response to the most serious emergencies. Features such as a dedicated ED radiology team and equipment to provide x-rays and diagnostic testing, and having ED specific labo-ratory and phlebotomy collection services, all for the fastest possible diagnostic testing when seconds count the most; separate EMS entrances for patients arriving for emergency care and for patients who need EMS transport when they are discharged. There is also an EMS bay specially designed to accommodate heavy EMS traffic without delaying patient care.

The Jackson-Madison County General Hospital Emergency Department is staffed by up to 10 physicians and mid level provid-ers, as well as a nursing staff of 43. All Emergency Department staff members are certified in Basic Life Support and the RN’s must be certified in Advanced Cardiac Life Support and Pediatric Advanced Life Support as well. A full range of physician specialists are on call 24/7. The Emergency Department includes 60 examination and treatment rooms, as well as a Fast Track unit for the treatment of minor emergencies.

Jackson-Madison County General Hospital officials celebrated newly remodeled and expanded Emergency Department entrance area with formal ribbon cutting.

Documents

West TN Medical News January 2015