Bulletin A C M

Allegheny County Medical Society
Bulletin
November 2014
The MOC debate
Veterans and PTSD
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Allegheny County Medical Society
Bulletin
November 2014 / Vol. 104 No. 11
Articles
Articles
Departments
Financial Health .................. 442 Legal Summary ................... 463 Letter to the Editor ............. 434
Inflation and your wealth: Keep it ‘real’
Gary S. Weinstein, MD, FACS
Court rejects contempt application
Michael A. Cassidy, Esq.
Special Report .................... 445 Special Report .................... 464
New ACMS Foundation focus: Healthy
Children, Healthy Communities,
Healthy Future
Diane C. Wuycheck
Special Report .................... 449
HPV-related cancers preventable
Alan Finkelstein, MD
Materia Medica .................... 452
Cannabis considered
Lucas G. Hill, PharmD
Gregory B. Castelli, PharmD, BCPS
2014 Annual Meeting Recap:
Helping Physicians Adapt to Change
Pennsylvania Medical Society
Society News ...................... 439
• Med students attend HOD meeting
• Pittsburgh Ophthalmology Society
• Medical Student Career Night
ACMS Alliance News .......... 441
Reportable Diseases .......... 466
Perspectives
Editorial ............................... 430
Thanksgiving
Deval (Reshma) Paranjpe, MD, FACS
Legal Report ....................... 457 Perspective ......................... 432
Personal cybersecurity – a HIPAA ‘lite’
approach
Beth Anne Jackson, Esq.
A view from the trenches: The IOM
and the treatment of PTSD in the VA
and DOD
Barry Fisher, MD
Special Report .................... 460
Accessing VA care for transitioning
veterans
Amy Boyles, LCSW
Special Report .................... 462
The MOC debate hits home
Leslie Howell, PAMED
On the cover
2014 Photo Contest
Winners announced
on page 436.
Sore Throat Protection
by Terrence W. Starz, MD
Dr. Starz specializes in
rheumatology and internal medicine.
Bulletin
Affiliated with Pennsylvania Medical Society and American Medical Association
2014
Executive Committee
and Board of Directors
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DIRECTORS
2014
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Brahma N. Sharma
2015
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Karl R. Olsen
2016
Robert W. Bragdon
Thomas B. Campbell
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PEER REVIEW BOARD
2014
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2015
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2016
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Editorial
H
Thanksgiving
ave you ever noticed that bad news
dominates nearly every media
outlet, so much so that a good news or
human interest story seems like balm
on your wounds?
I have more than a few patients
who tell me that they have given up
on watching the news. “But … don’t
you want to know what’s going on in
the world?” I ask. “Sure I do,” is the
invariable reply. “But the news makes
me depressed and anxious. So I stop
watching, and I feel better.”
Well, that makes grand sense in the
tradition of the old joke:
“Doctor, it hurts when I do this.”
“Well, then don’t do that.”
But for the rest of us, who might
love to follow this approach but can’t
afford to, what options remain? The unofficial motto of local and national news
stations is “If it bleeds, it leads.” And
lately, there has been a lot of bleeding
taking place all over the world. And
yes, all bleeding stops eventually, but
in the case of our world, new bleeding springs from old wounds as time
passes. From the atrocities of ISIS to
school shootings in the United States
to the daily acts of violence and other
crime that take place in every viewing
area, the carnage seems never-ending.
It’s easy to become discouraged, until
you realize that conflicts like war and
disease have existed in every era of
human history, albeit with less news
coverage.
The concept of gratefulness as an
antidote to unhappiness, fear and terror
also has existed in every era in human
430
Deval
(Reshma)
Paranjpe,
MD, FACS
history, with more or less news coverage. Most religions stress gratefulness
to the supreme being(s) involved
therein as a central tenet; gratefulness
for being alive, for being chosen, for
being saved, or for being part of the
community. Humans always have been
grateful for being spared from death,
disease or debilitation. Ancient and
modern religions alike have traditions of thanking the divine for spring
renewal, fair weather, full harvest and
mild winters. We are understandably
grateful for escaping natural disasters
– earthquakes, tornadoes, lava flows.
Something about the act of communal
gratitude bonds us to each other and
makes us forget our differences in the
face of terror.
The original Thanksgiving story told
to schoolchildren all over our fair land
involves the Pilgrims and the Native
Americans giving thanks for a good
harvest and for each other’s friendship,
which would help them endure the
harsh winter. If you forget for a minute
that the Europeans’ arrival to North
America would cause disease, war
and oppression for Native Americans
in the centuries to come, and just take
yourself back to the childhood narrative as perhaps it was for that moment
in time, Thanksgiving is about giving
This holiday season, find
someone with whom you
don’t always agree, and
find something for which
you are both undeniably
grateful. This common
ground of gratitude can
bridge the gap between two
people ...
thanks and joining together to do it –
and feeling less alone.
Our political parties are more
polarized now than they have been in
decades. The concepts of reaching
across the aisle to compromise or
going out for a friendly dinner after a
fierce and lively debate have all but
disappeared. Instead, we unfriend
each other on Facebook, and perpetrate uncomfortable silences at holiday
gatherings. Why? Why can’t we agree
to disagree, agree to work together,
and agree and give thanks that we live
in a wonderful country that allows us to
do just that?
Ebola threatens our shores. I’m
grateful that we have access to knowledge and equipment to prevent its
spread. Terrorism always lurks. I am
grateful for a government, whatever its
problems, that is committed to preventing it. And I am grateful for fellow
countrymen and countrywomen who
refuse to cow down to it.
Intolerance, intemperance and
injustice exist. I am grateful for the kind
Bulletin / November 2014
Editorial
people in the world who stand up and
fight against all of these.
Gratefulness also can be more
mundane. I’m grateful that the Pirates
have been doing so well in the past
two years after a decades-long losing
streak. I’m grateful that Pittsburgh
is thriving. I’m grateful that Pumpkin-Spice-flavored everything exists.
I’m grateful that no airline has seen fit
to install the patented “standing seating
plan” in a plane. I’m grateful that TLC
has taken “Honey Boo Boo” off the
air. I am grateful for chocolate, and
for pie, and for brined turkey, and for
those little crispy onions on the green
bean casserole. You know the ones
I mean. I’m grateful that scientists at
Harvard have figured out how to store
700 terabytes of data in a gram of DNA
using base pairs A-T and G-C as a
binary code. I’m grateful that we live
in a world where beauty and wonders
happen every day for us to see.
I am grateful for the unwavering
love of family and the support of
friends. I am grateful for our profession.
And I am grateful for you, dear reader.
Thank you.
This holiday season, find someone
with whom you don’t always agree,
and find something for which you are
both undeniably grateful. This common
ground of gratitude can bridge the gap
between two people, and perhaps go
on to unite communities for good. And
only then will the bad news cease, and
good news rise to take its place.
Dr. Paranjpe is an ophthalmologist
and medical editor of the ACMS Bulletin. She can be reached at reshma_
[email protected]
The opinion expressed in this column
is that of the writer and does not
necessarily reflect the opinion of the
Editorial Board, the Bulletin, or the
Allegheny County Medical Society.
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Bulletin / November 2014
431
Executive
Perspective
Committee
A view from the trenches
The IOM and the treatment of PTSD in the VA and DOD
“Out beyond ideas of
wrongdoing and rightdoing
there is a field. I’ll meet you
there.” Jalal-Ad-Din Rumi
The Institute of Medicine’s (IOM)
report on the state of PTSD treatment
in the DOD and VA is now fresh off
the presses. Their exhaustive report,
entitled “Treatment of Posttraumatic
Stress Disorder in Military and Veteran
Populations: Final Assessment,” lists
a series of critical findings and broad
recommendations. Their criticisms of
VA/DOD care for patients with PTSD
include: poor transition and coordination of care between the DOD and VA;
inconsistent implementation of recommended evidence-based treatments;
inadequate workforce to meet the
growing needs for treating soldiers returning from the current conflicts in the
Middle East; inadequate assessment of
the efficacy of treatments offered; lack
of family involvement in the recovery
of these soldiers and veterans; and
a dearth of research dedicated to the
study of treatments for PTSD.
In Whitney McKnight’s front-page
article on the IOM study in Clinical
Psychiatry News (July 2014), we find
the following summary of the IOM
review: … the DOD approach to PTSD
treatment is “local, ad hoc, incremental,
and crisis driven, with little planning.” In
the IOM report the committee opines,
432
Barry
Fisher, MD
“While VA programs benefit from better
organization and consistency, the lack
of data on either department’s delivery
methods and outcomes means there is
“no way of knowing whether the care
they are providing is effective or whether the DOD and VA’s expenditures are
resulting in high-value health care.”
McKnight adds in her article that,
“the report is based on 4 years of
combing through data provided by the
DOD and VA, peer-reviewed literature,
government documents, research databases, and testimonies from a variety
of DOD and VA experts and providers
at military bases and treatment facilities across the country, including six VA
medical centers.”
Committee member Dr. Elspeth
Cameron Ritchie was quoted as
saying, “What we found over and
over again were really hardworking,
well-intentioned people who wanted to
do the best they could, but they either
didn’t have an administrative structure
to support them, or enough staff, or
they had an overwhelming number of
patients.”
Its predecessor report, entitled
“Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence,”
an exhaustive review of more than
3,000 treatment studies of psychotherapy and pharmacotherapy, concluded
that the evidence base for treatments
was lacking (save for exposure based
psychotherapy). At that time, high dropout rates and problems with handling
missing data complicated the ability of
the committee to adequately assess
and endorse other treatments for
PTSD. While both of these IOM studies
are scholarly, well researched and
carefully reviewed, they do not comport
well with the limitations of clinical practice. Implicit, though not directly stated,
is the conclusion that the VA and DOD
fail to provide well-researched treatments. What also is evident in these
reports, in my opinion, is a lack of
appreciation for the complexity and difficulty in treating a less than “research
perfect” population.
With regard to the first criticism,
namely, lack of coordination of care
between VA and DOD, the committee
members do not take into account the
differences in culture between the two
systems. Active-duty patients often are
reluctant to seek treatment for PTSD
when seeking treatment may negatively impact their promotion and retention
in the service. In addition, there may be
subtle biases against treatment communicated from superiors, and confidentiality issues are less clear than
in a civilian health care system such
as the VA system. In point of fact, the
DOD and VA may find themselves in
adversarial positions when it comes to
Bulletin / November 2014
Executive
Perspective
Committee
fitness-for-duty assessments and other
important issues facing the soldier/veteran. In addition to the cultural impediments to coordinated care between
the VA and DOD, the lack of a single
computerized record system for VA and
DOD also impedes seamless transition
of care between DOD and VA.
Another criticism in this study was
the failure of clinicians practicing evidence-based psychotherapies to see
veterans with PTSD for the prescribed
number of sessions required. These
veterans are primarily outpatients and
are not “captured audiences” but busy
individuals with jobs, families, legal
problems and other distractions making
adherence to therapy requirements difficult. In addition, patients are not single-diagnosis individuals, and failure to
adhere to treatment recommendations
could reflect problems of comorbidity.
The problem of comorbidity also is
relevant to criticisms about failure to
provide evidence-based pharmacotherapies. For example, the strongly
discouraged use of benzodiazepines
in PTSD treatment has an evidence
base in studies in which comorbidity is
an exclusion for inclusion in the study.
This prohibition may not translate well
when comorbid panic disorder, obsessive compulsive disorder, psychoses
and bipolar disorder exist in patients
with PTSD and may confound the IOM
conclusions regarding treatment.
Even when the psychotherapists
and prescribers adhere to treatment
guidelines, one does not necessarily
see improvement in symptoms. One
clue to this observation may rest in
the findings of a recent study entitled
Disparities in Adverse Childhood
Experiences Among Individuals With
a History of Military Service (Blosnich,
et al, 2014). This study showed that
current soldiers had a higher prevalence of adverse childhood experiences and had twice the odds of having
a forced sexual experience before
the age of 18 relative to age matched
non-military controls. Early childhood
experiences are not the focus of most
evidence-based treatments for combat PTSD, and an important variable
affecting response to treatment could
be getting missed. While not the intent
of this study, these findings may point
to the advantage of applying long-term,
insight-oriented/transference-focused
psychotherapies in patients treated for
combat-related PTSD. At this point in
time, these therapies are not encouraged nor generally practiced at the VA
or DOD.
While having the above criticisms of
the IOM study of PTSD treatments, it’s
hard to argue with their recommenda-
References
1. Blosnich, et al, Diaparities in Adverse Childhood Experiences Among Individuals With
A History of Military Service, JAMA Psychiatry, 7/23/14(APA, online).
2. Institute of Medicine (IOM). 2007. Treatment of Posttraumatic Stress Disorder: An
Assessment of the Evidence. Washington, DC: The National Academies Press.
3. Institute of Medicine (IOM). 2014. Treatment for posttraumatic stress disorder in military and veteran populations: Final Assessment. Washington DC: The National Academies
Press.
4. McKnight, W. IOM: Targeted research needed for PTSD care, Clinical Psychiatry
News, July 2014, vol. 42, # 7, Parsippany, NJ, Frontline Medical Communications.
Bulletin / November 2014
tion to increase family involvement in
care. There are years of hard evidence
supporting the fact that recovery from
PTSD is more likely when families are
supportive of their loved ones with
PTSD. Likewise, it’s hard to argue with
their recommendation to increase workforce given that the numbers of veterans seeking treatment for PTSD has
more than doubled during these recent
conflicts. If the above cautionary observations regarding DOD/VA culture,
patient complexity and co-morbidity are
taken into account, the IOM’s recommendations are more likely to be useful
to administrators and clinicians who are
looking to improve care for individuals
with PTSD at the VA and DOD.
Dr. Fisher is section chief for
Outpatient Services Behavioral Health
Service Line VAMC Pittsburgh and is
medical director of the Combat Recovery Clinic. He is a general adult psychiatrist with special interest in trauma
and co-occurring disorders. He can be
reached at [email protected]
The opinion expressed in this column
is that of the writer and does not
necessarily reflect the opinion of the
Editorial Board, the Bulletin, or the
Allegheny County Medical Society.
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433
Letter to the Editor
*This letter was written in response
to Dr. Timothy Lesaca’s editorial in the
September Bulletin, “Something rotten
in Denmark?” (p. 384).
Dr. Lesaca,
Thank you for your thought-provoking editorial. I suspect you already
know the answers to many of the
questions it asks, but I’d like to share a
few thoughts nonetheless. Let me say
at the outset that I’ve done very well
on the various standardized tests I’ve
had to take. While this has much to
do with God’s grace, and while I don’t
believe it makes me a better person or
a better doctor, I do think it qualifies me
to comment on the standardized-test
industry without it coming across as
sour grapes. Like you, I’ve known both
intelligent, deserving students who did
not do well on standardized tests for
one reason or another, and students
who were academically marginal but
who were absolutely gifted test-takers.
A few thoughts, in no particular
order.
1. We’re conditioned to accept this
test bureaucracy from early in medical school. We’re also conditioned
to accept rampant hypocrisy by the
USMLE. How so? Consider the “passfail” nature of the Step 1. USMLE treats
Step 1 as a pass/fail test, and thus
states that:
If you pass a Step or Step Component, you are not allowed to retake it.
Well, that makes sense: if a test is
pass/fail and you pass it, there would
be no reason to take it again. However,
we all know what is stated elsewhere
on the USMLE website:
With the exception of Step 2 CS
(which is reported as Pass/Fail), USMLE
results are reported on a 3-digit scale.
434
Clearly, a test can’t be both truly
pass/fail and come with a detailed
grade. So why not simply make it pass/
fail? Or, if numerical grades are to be
the plan, why not abandon the notion
of pass/fail? On the one hand, NBME
seems to want the Step 1 to be just a
licensing test; on the other, it seems
also to want it to serve as the MCAT of
residency applications. In other words,
NBME wants to have its cake and eat it
too. And so, by the time we are halfway
through medical school, we learn that
the standardized-test industry has its
own best interests at heart. We see its
casual disregard for what happens to
those luckless souls who get the worst
of all possible Step 1 grades, a very
low pass – this being the worst possible since, as we’ve seen, it can never
be changed. (By comparison, a student
who fails may at least theoretically be
able to do much better on a second try,
and convince a sympathetic admissions committee that he had a good
reason for his first low score.)
2. I’m not an internist; I’m an anesthesiologist. This means that ABIM’s
decisions don’t directly affect me, but
the American Board of Anesthesiology
is following ABIM’s example pretty
closely. Board certification, once a oneand-done thing, suddenly now entails
MOC – but only for those who passed
their boards after a certain date. To
prevent a mutiny, MOC is initially made
relatively straightforward, involving
very limited activities and an easy test.
As time passes, the test gets harder
and other requirements grow. Look at
how the ABA’s requirements (available
online) have changed: Those who
passed the boards in 2007 or earlier do
not need to do a simulation, whereas
those who passed in 2008 or later do.
The simulation costs $1500 or more
for eight hours, not counting travel
expenses and missed work, and is only
offered at certain academic centers.
Clearly the goal is an incremental
approach towards an ever-expanding
MOC bureaucracy, with physicians always divided between the already-certified older docs and the younger docs
who want to be able to compete with
them for jobs.
3. The CMS “incentive” of 0.5 percent affects one two-hundredth of the
already pathetic Medicare reimbursements – so, depending on the case,
we may be talking about an “incentive”
of under a dollar. As Mom used to say:
Don’t spend it all in one place. But by
comparison, the costs of MOCA have
skyrocketed. These changes mainly (as
we saw in #2) affect recent graduates,
which in light of loan repayment schedules probably includes docs in their
first several years of attending practice.
These docs are often drowning in debt;
meanwhile, they are getting into their
thirties, and the 48 percent (as of 2012,
according to AAMC’s published data)
who are women will be acutely aware
of the statistics about fertility and age.
If they desire children, now is the time
– debt or no. Meanwhile, the price of
these essentially mandatory MOC activities is breathtakingly high. Again, the
simulation runs a cool $1500. CME can
be done for free, but ASA would like to
sell me CME with automatic reporting to
its own (mandatory, of course) electronic system for hundreds more. The
exam itself – currently every 10 years,
but I’m sure it will expand, just as the
USMLE continues to expand - costs
$2100 in my field. ABA has commented,
in response to complaints about the
cost of the various exercises, that it is
“exploring ways to increase the value of
Continued on Page 436
Bulletin / November 2014
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435
Letter to the Editor
From Page 434
these costs.” In English, this appears to
mean, “The price isn’t coming down, but
we’ll keep telling you what a great deal
you’re getting.” (Speaking of expanding
tests, the USMLE introduced “Step 2
CS” the year after I would have had
to take it. Simply being born one year
earlier spared me from a mandatory
exam costing a cool $1355, plus travel
expenses. Am I a worse doctor for not
having to undergo this test? If yes, why
am I still allowed to practice? If no, why
do the younger guys need it?)
4. Noam Chomsky once used the
term “manufacturing consent” for
herding people to a predetermined
decision. While he used it to argue
for left-wing politics, the term can be
applied to any organization trying to
give the illusion of people choosing
whether or not to support something
that government or management
has already decided it would do. The
strategy is simple: Offer two wildly
undesirable choices, one clearly worse
than the other, then announce that the
people in question have “asked for” the
one you’d intended them to choose.
Clearly MOC’s backers are doing
something similar here: We are given
a choice not of whether we will participate in MOC, but of which expensive,
onerous, and unnecessary activities
we will use to pad their bottom line.
You can safely assume that this will
be reported as doctors agreeing that
MOC is a valuable and important thing
to do – especially since most, if not all,
of these activities include a mandatory,
maybe-anonymous-maybe-not, survey
about whether they were worthwhile.
5. I say in #4 that we are not given
a choice of whether we will participate.
This is not, in the strictest sense, true:
I can physically refuse to participate in
the activities. But when refusal to participate comes with consequences, participation is not really voluntary; rather,
it is coerced. You mention credentialing
and CMS “incentives,” and one could
name other concerns – from patients
who search online and discover that
their doctor is “not meeting requirements,” to inquiries about credentials at
a legal deposition. Some combination
of these is presumably meant to compel those with non-time-limited certificates to do MOC, despite the promise
that they wouldn’t have to. But for the
anesthesiologists who passed their
boards anytime in the past 14 years,
the biggest threat is the simplest: The
certificate will expire. If I am to say that
I am board-certified after the expiration
date on my certificate, I have no choice
but to participate in MOCA.
6. And, finally, the inevitable consequence of adding endless layers of
bureaucracy, each with its own requirements to satisfy and busy-work to do:
More and more of us are simply leaving clinical medicine. The older docs
retire early; the younger ones curtail
their hours or retrain. PQRS? QCDR?
MOCA? As a teenage texter might
write, I am SMH (shaking my head).
Thanks, once more, for daring to
speak up. I doubt it will make much
difference, but perhaps if enough
people speak out, it will. AAPS, the Association of American Physicians and
Surgeons, is leading the fight against
MOC and currently pursuing a lawsuit
against ABMS to resist mandatory
MOC – perhaps common sense may
yet prevail!
Charles Horton, MD
For more on the MOC, please see
page 462.
2014 Photo Contest Winners
1st Place - Bruce A. Wright, MD “The Point”
2nd Place - Alan H. Klein, MD “Falling Water Revisited”
3rd Place - Kimberly Hennon, MD “Jenny Lake and the Grand Tetons”
Additional winners: Frederick Doerfler Jr., MD; Anthony Spinola, MD;
Charles F. Sturm, MD; Elias Hilal, MD
*Winning photos will be featured on the 2015 covers of the Bulletin.
436
Bulletin / November 2014
Letter to the Editor
Dear Editor:
Thank you for publishing Greg Patrick, MD’s editorial “Tell Me a Story” in
the September edition of the Allegheny County Medical Society Bulletin.
His comments regarding his recent
frustrations from his Electronic Health
Record “EHR” echo my own experience with EHRs. Re-emphasizing his
comments that the EHR interferes
with patient care and it is difficult for a
physician to determine when reading a
treatment plan, the sequence leading
up to that plan, or even who ordered
it. With my paper charts, my problem
list clearly not only lists the patient’s
diseases and problems, but it is
sequenced by date, often important information in delivering care. EHRs list
the problems at the time of the visit,
but not those problems in chronological sequence.
And it gets worse. At a recent
symposium held at the Duquesne Club
by the Business Times, “The Future
of Health Care,” one of the panelists
was Dr. Andrew R. Watson, medical
director of telemedicine at UPMC. His
comments regarding patient care are
quite disturbing: “There’s going to be
huge requirements of people to get
engaged in a different way: On the one
hand, patients are increasingly turning
to computers to communicate with
doctors via telemedicine, which is help-
ing to save costs by cutting down on
face-to-face visits and the time it takes
to drive to them, and is enabling home
health care through remote monitoring.
Face-to-face visits are outdated.” (My
emphasis.)
Is he really serious? Face-to-face
visits are outdated? The invasion of our
offices by the information technology
industry has thrust itself between our
patients and our delivery of care. If
telemedicine has its way by disrupting
the hands on delivery of medical care,
we as physicians, and our patients, are
in serious trouble.
Sincerely,
Marc J. Schneiderman, MD
Squash
your fears of
surprise costs
with our
New Life
Home Building
Process.
412.384.8170
Bulletin / November 2014
437
Is it a swim lesson? Or an example of our deep
experience in spinal cord injury rehabilitation?
A lot of science goes into our world-class therapies. There is a lot of splashing, too. That’s
because we are the region’s only facility with two therapeutic pools, plus a sensory room and
healing therapeutic garden. They’re part of our unique pediatric rehabilitation programs that
combine elements of recreation with cutting-edge techniques to help your patients recover
from a host of spinal cord injuries and complications. After all, who ever said therapy has to
be all work and no play? For referral information, call 412.420.2400 or visit amazingkids.org.
438
Bulletin / November 2014
Society News
Pittsburgh Ophthalmology
Society
H. Kaz Soong, MD,
professor of Ophthalmology and Visual Sciences
at the University of Michigan Kellogg Eye Center, Dr. Soong
will speak to the members
of the Pittsburgh Ophthalmology
Society Thursday, Dec. 4, at the ACMS
building.
Dr. Soong will provide lectures on
1) Acanthamoeba keratitis; 2) what
makes DSEK stick; 3) the versatile
femtosecond laser; and 4) Spreading
our wings into the global scene. Dr. Shilpa Kodati, resident of the
UPMC Eye Institute, also will present a
case for discussion.
Contact Dianne Meister at (412)
321-5030 to attend the meeting.
Medical Student Career Night
held at O’Hara Student Center
James Ireland / ACMS Assistant Executive Director
Med students attend HOD meeting
Medical student members of the ACMS Delegation attended the House of
Delegates meeting in Hershey Oct. 25-26. For more on the HOD meeting,
see page 460. From left are Samuel Lindner, Claire Paduano, John Demko,
Vladimir Lamm, Benjamin Ware, Akash Goyal and Ryan Williamson.
On Oct. 30, the University of Pittsburgh Medical Student AMA Chapter
and the Allegheny County Medical Society (ACMS) hosted the AMA Career
& Shadow Fair at the O’Hara Student
Center. The session was attended by
100 students and 25 physicians.
Students were able to meet and
speak with physicians regarding specific specialties. Specialties represented
included Anesthesiology; Emergency
Medicine; Family Practice; Internal
Medicine; Nephrology; Obstetrics/Gynecology; Ophthalmology; Pathology;
Pediatric Surgery; Radiology; Surgical
Oncology; Urology; Vascular Surgery;
and Hematology.
From left are medical
student Krshan Thadikonda,
Lawrence John, MD, and
medical student Ryan Williamson.
Bulletin / November 2014
James Ireland / ACMS Assistant Executive Director
439
In every home there’s a story
you’re a part of.
2014 National Home Care and Hospice Month
At Interim HealthCare, we’ve been writing the story of home care for nearly 50 years. We’re proud of our heritage and
the dedicated professionals who have played such an important role in meeting the needs of patients at every stage
of their lives — in the comfort of their own homes.
View our Stories From Home
at InterimHealthCare.com/Stories
(800) 447-2030
440
Bulletin / November 2014
Alliance News
Welcome new members
We are delighted to welcome new
members into our organization. Yvette
Lawson is a woman of distinction in
her lifetime career in the world and
business of printed publications. Geraldine Orr, sister of Donald Orr, MD,
has found time for us, away from her
profession in the field of accounting.
Both women have expressed interest
in serving in leadership roles and on
committees for General Meetings,
namely the Holiday Brunch on Dec. 7,
2014, and the Annual Meeting May 19,
2015. Along with individual dynamism,
both women bring experience and
enthusiasm to us. It will be our pleasure to mentor them into the work and
social side of the Allegheny County
Medical Society Alliance (ACMSA)!
In Memoriam
Lee R. Oehrle, our friend, colleague
and long-time member of ACMSA, died
recently. Lee was a pianist, classically
trained at Eastman School of Music,
and a graduate of Carnegie Mellon
University. A fervent volunteer, Lee
devoted decades in time, effort and
support of adult literacy programs,
music and choir programs at Southminster and Fox Chapel Presbyterian
ACMS Alliance
Church(es). She was a reader for the
blind with Pittsburgh’s Radio Information Service on WDUQ. Lee enhanced
the ACMSA with her commitment to our
own projects and events. Lee is survived by her husband, John S. Oehrle,
MD, a son and daughter and grandchildren. The full obituary is available
in the Pittsburgh Post-Gazette Aug.
12-14, 2014.
Wrap-Up September
General Meeting
The first of three General Meetings
of ACMSA for Alliance year 2014-15
took place Sept 23 at South Hills Country Club. The event planning was masterfully managed by Chairman Barbara
Wible, with Committee members Patti
Hetrick, Liz Blume, Lois Levy, William
Hetrick, MD, and Joseph Roarty, PhD.
The Business Meeting was conducted
by Chairman of the ACMSA Governing
Board, KJ Reshmi. ACMSA Past Presidents in attendance were recognized
for their service and commitment to the
Alliance.
Donna Nardine, Executive Director
of The Watchful Shepherd, USA and
Claudine Femiani, wife and spokesperson for the organization’s founder,
Dr. Joe Femiani, presented a riveting
program, very relevant in today’s world.
Now in its 20th year, The Watchful
Shepherd is a national organization
with programs for addressing prevention of child abuse through intervention in troubled family situations. The
Watchful Shepherd works with law
enforcement, court systems, hospitals
and community resources.
The Watchful Shepherd is benefiting individuals and society in general
through methods of keeping families
together, and connected to agencies
and organizations able and willing to
help. The speakers provided various
printed materials of interest to all in
attendance. Contact information: The
Watchful Shepherd, 1061 Waterdam
Plaza Drive, Suite 204, McMurray, PA
15317; (724) 941-3339; [email protected]
watchful.org.
The program was followed by a
luscious luncheon. Proceeds from the
Autumn General Meeting will benefit
ACMS Foundation for philanthropic
efforts in the community. Thanks to
all for your wonderful arrangements,
attendance and generous support in
giving us an awesome autumnal start
to a promising new Alliance year!
Content and text by
Kathleen Jennings Reshmi
Congratulations
PAMED Alliance on
its 90th Anniversary!
1925-2014
Bulletin / November 2014
441
Financial Health
Inflation and your wealth:
Keep it ‘real’
I
nflation increases the cost of goods
and services and reduces purchasing
power over time. It is measured by the
Consumer Price Index (CPI), which
calculates the monthly cost of a basket
of goods and services likely to be
purchased by urban consumers. The
CPI increased by 1.5 percent in 2013
and ranged from -10.8 percent to +20.4
percent annually over the past century.
Most retirees experience above-average inflation because health care
expenses grow faster than the CPI.
Most economists believe that low
inflation is positive for economic growth
but higher levels are deleterious.
Weimer Germany provides the best
example of what happens during rampant inflation. From 1914-23, the cost
of living increased by a factor of 218
million due to war debt, reparations
payments, central bank mismanagement and inadequate taxation. Higher
prices were initially attributed to war
shortages and strengthening of the
U.S. dollar against the Deutschmark
(DM). As currency values continued to
fall, consumers cashed paychecks to
buy tangible goods for consumption,
accumulation or barter. They endured
long lines, limited store hours, empty
shelves, thick wads of currency and
complex calculations to complete
transactions.
The government responded to
currency shortages by printing DM
24 hours a day, 7 days a week. De-
442
Gary S.
Weinstein,
MD, FACS
spite using fast-drying ink and printing
on one side only, paper costs exceeded the value of the debased currency!
When demand outstripped supply, local
governments and large companies
were licensed to print their own legal
tender, further fueling the inflation.
The press published daily prices with
“multipliers” for standard goods and
services, often by factors of millions. As
the crisis worsened, hoarding of food
and fuel, public and personal theft,
counterfeiting, bribery of governmental
officials, political unrest and public
health (starvation, rickets, tuberculosis)
worsened. The government regularly
assured the public that inflation was
over, but it accelerated for 10 years.
As paper money became worthless,
material assets, precious metals, gold,
jewelry, collectables and farm crops
became valuable. Small businessmen,
tradesmen and professionals demanded payment in goods or bartered
services rather than DM. Families
gradually sold furniture, artwork and
musical instruments to obtain basic life
necessities. Hyperinflation relentlessly
destroyed the value of fixed income investments such as government bonds,
certificates of deposit, savings bonds,
annuities and insurance policies. In
contrast, the German stock market rallied but not enough to match inflation.
The real (post inflation) value of stocks
declined 97 percent and the dividend
yield dropped to 0.25 percent. Although
the German stock market recovered a
decade later, most investors had liquidated their portfolios during the inflationary period to fund living expenses.
Portfolios are difficult to protect from
hyperinflation but can be structured
to minimize low to moderate inflation.
Common stocks usually outpace
inflation over time but experience
significant short-term volatility. Holding
30 to 40 percent equity allows most
portfolios to generate positive real
returns. As inflation increases, stocks
initially fall then rebound as companies
raise prices to offset higher costs. A
substantial (30 to 50 percent) equity
allocation to international stock indexes
further reduces inflation risk because it
is often country specific. The Weimer
hyperinflation was limited to the
Austro-Hungarian Empire and spared
western democracies.
Bond portfolios are more vulnerable
than stocks to inflation because prices
fall as rates rise and interest is paid
with devalued currency. The potential
loss of principal is best gauged by
bond portfolio “duration,” which measures the number of years it takes for
the principal to be repaid by interest
Bulletin / November 2014
Financial Health
payments. A 5-year duration bond
portfolio loses 5 percent in value if real
interest rates rise 1 percent (5 X 1)
and 10 percent if they rise 2 percent
(5 X 2). Limiting portfolio durations to
less than 5 years provides reasonable
downside protection from rising rates.
Bond principal can be preserved in
tax-deferred accounts with Treasury
Inflation-Protected Securities (TIPS).
The principal is adjusted semiannually
(based on the CPI), but interest payments are taxed as ordinary income.
Precious metals funds, gold funds,
hard bullion, real estate and commod-
ities also maintain value in inflationary times. Most experts recommend
allocating up to 10 percent of the equity
portfolio to real estate investment trusts
(REITS) and 5 percent to precious metals or gold funds. These are best held
in tax-deferred accounts because REIT
income is taxed as ordinary income
and precious metal and gold funds
need to be rebalanced, which generates capital gains taxes. Life, disability
and annuity insurance products can be
protected with inflation riders.
Measure your portfolio returns
and insurance payments in real (post
inflation) terms. It is far better to have
small real returns than large nominal
ones. When it comes to managing your
wealth, strive to keep it “real!”
Dr. Weinstein practiced oculoplastic
surgery for 25 years and taught investing at Carnegie Mellon University’s Osher program and the American Academy of Ophthalmology. He co-authored
a Retirement Planning chapter in J.K.
Lasser’s Expert Financial Planning and
lectures to physician groups on investing and financial planning.
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Bulletin / November 2014
443
Allegheny Health Network welcomes
Suzanne Schiffman, MD
Surgical Oncology
Dr. Schiffman is a board-certified general surgeon and surgical oncologist who
specializes in treating patients with complex abdominal malignancies including
cancerous conditions of the liver, bile duct, pancreas, stomach, small bowel, colon
and peritoneum. Her practice includes the use of minimally invasive surgical
techniques in benign and malignant gastrointestinal disease.
She is specialty-trained in liver, bile duct, and pancreatic surgery. In addition, she
performs cytoreductive surgery in combination with hyperthermic intraperitoneal
chemotherapy (HIPEC) when indicated for peritoneal metastases. She advocates
a team-oriented approach to healthcare with an emphasis on education and clear
communication with her patients.
Dr. Schiffman earned her medical degree from Jefferson Medical College. She
completed her general surgical residency at the University of Louisville where
she served as administrative chief resident. Following residency, Dr. Schiffman
completed fellowships in both surgical oncology and hepatobiliary surgery at
the University of Pittsburgh Medical Center.
For an appointment, please call:
Allegheny General Hospital
320 North Avenue
Pittsburgh, PA 15212
412.359.3115
West Penn Hospital
Medical Pavilion
4727 Friendship Avenue
Pittsburgh, PA 15224
412.359.3115
Wexford Health +
Wellness Pavilion
12311 Perry Highway
Wexford, PA 15090
412.362. DOCTORS
(412.362.8677)
Dr. Schiffman is on staff at Allegheny General Hospital and West Penn Hospital.
As always, new patients are welcome. Most major insurances are accepted.
444
Bulletin / November 2014
Special Report
New ACMS Foundation focus:
Healthy Children, Healthy Communities, Healthy Future
Diane C. Wuycheck
I
nstituted in 1960, ACMS started the
Allegheny County Medical Society
Foundation with donations from the
polio immunization program. The
immunization effort was undertaken
by ACMS and the Allegheny County
Health Department, and sparked a
public outpouring of donations collected in jars on the streets of Pittsburgh.
The Foundation has since given $2.26
million back to the community.
While so much has changed since
that early start, so much remains the
same for those the ACMS Foundation
seeks to serve. To zero in on core
issues the Foundation could potentially
impact, the ACMS Foundation, not
surprisingly, found that an increasing
number of health issues affecting families and their communities arise from
their home environments.
A new mission statement captures
that focus: ACMS Foundation grants
will support home and community
environments that nurture and develop healthy children and families
for a healthy Allegheny County.
The ACMS Foundation’s vision
makes that ideal clearer still:
• We will help people help themselves through the practical application
of knowledge and resources to improve
their physical and behavioral health,
their quality of life and that of future
generations.
• We recognize that many medical
Bulletin / November 2014
illnesses can be traced to unhealthy
circumstances in our community that
occur during the formative years, and
can be successfully remediated or
prevented.
• We will support organization-based activities that engage
individuals and families in the planning,
development, evaluation and implementation of programs at the community level that assist individuals in
creating supportive and healthy home
environments.
• We believe that all people have
the inherent capacity to effect change
in their lives and in their communities.
We will support programs that respect
and value individuals and their collaborative work to improve health care in
our community.
Physicians and other donors who
support the ACMS Foundation through
the annual Gala and direct contributions may not realize how those dollars
directly impact children and families for
a healthy Allegheny County. To put a
human face on the work made possible
through an ACMS Foundation grant,
recent grant recipients shared stories of
families they serve. A common denominator was support in a variety of forms.
There is something powerful
about support groups – those
gathered together united by a common
bond. Without the funding of the ACMS
Foundation, parents and caregivers of
children with spina bifida might never
have known just how powerful!
The monthly groups offered by the
Spina Bifida Association of Western
Pennsylvania not only provide crucial
respite for parents but also include a
group for children to meet and share,
too. Sometimes there’s a speaker (e.g.,
explaining warning signs); sometimes
there is a training component (like how
to prevent sepsis) to help caregivers
manage daily activities and challenges.
However, caregivers say, being together is what matters.
At the same time, kids ages 1-7
generally, can just play with their peers
without fear of feeling “different” or getting hurt! They build their social skills
and independence, too. Currently, 12
families from around the region breathe
easier for a few hours. Their simple,
common wish – that they could have
more sessions!
Low-income single parents face
an array of challenges. Angel’s
Place offers hope and possibilities.
That comes in the form of child care
and education support – keys to their
wellbeing and independence. Because
education is such a critical need, celebrating exceptional students – those
who excel not only in school but as
parents – is the goal of the Showcase
of Scholars.
Randi’s experience conveys why
she was one of the awardees: “I had
always dreamed of becoming a nurse.
Divorced in 2011, I moved in with my
grandmother. I couldn’t afford daycare
but needed to earn an income. I found
AmeriCorps, committing to 10 months
Continued on Page 446
445
Special Report
Child Care Associate Brittany claps along with Child’s Way attendees Ava and Maddie during a morning sing along
as part of the program’s daily academic programming.
From Page 445
of service to earn a “living stipend,” an
additional education award and subsidized childcare! After that commitment, I
had no daycare options and didn’t qualify for government assistance. Online I
found Angel’s Place! I honestly thought
it was too good to be true. Angel’s Place
took me in. I was finally going to get an
education and start down a career path.
I still want to be a nurse!”
When the whir of sirens subsides
and parents are assured a loved one
is in good hands, where do they turn?
A long drive home after a tiring ordeal
gives way to the convenience, com446
fort and cost-effectiveness of Family
House. Since 1983, Family House has
provided a home away from home for
a few days or an extended stay, in the
company of others who understand
their needs – a warm bed, a hug.
The ACMS Foundation’s support
of Family House helps to reduce the
already modest rates for families to
share time with others who can empathize. In fact, families cite that it’s not
just the room but the “community support” they experience from staff, more
than 150 volunteers, and the other
families that makes all the difference.
The four Family House sites comprise
the largest hospital hospitality house
in the nation, so the ACMS Foundation
grant “goes a long way,” says Ron
Guca, director of development. Family
House needs between $140,000 and
$240,000 every year to support 15,000
patients and their families who need
financial assistance. In addition to
transplant, cancer and trauma patients,
Family House welcomes families of
patients participating in clinical trials
and those experiencing complex
neurologic and orthopedic surgeries,
among others.
Child’s Way® is a Pediatric Extended Care Center (PECC) for medically fragile children age birth to 21,
offering an alternative or supplement to
Bulletin / November 2014
Special Report
Child’s Way
Clinical Director
Erin Colvin sits
with Child’s Way
attendee Catelin.
Photos courtesy of
Child’s Way and the
Spina Bifida Association
of Western Pennsylvania
in-home nursing and therapy care for
children with complex medical needs.
Licensed as the first PECC in the
Commonwealth of Pennsylvania, this
program was established in 1998 to fill
an identified need in the community.
Weekdays from 6:30 a.m. until 6 p.m.,
Child’s Way’s registered nurses and
child care associates meet a child’s
medical needs – including monitoring
vitals and medication administration –
while children participate in activities in
a typical classroom environment.
This combination is not only a hit
with children but also provides parents
peace of mind, perhaps best described
by Amee, whose son comes to Child’s
Way: “My main concern was finding
someone who could care for all of his
medical needs and that he was safe,
but I also wanted him in an environment where he could play with his
Bulletin / November 2014
peers. [Then one day] I walked into
Child’s Way and they said, ‘Why don’t
you show mommy what you did today?’
He turned around and he let go of the
table and he walked over to me. I’ve
never been so proud or happy or emotional about something in my entire life.
It felt like the day he was born.”
This ACMS Foundation grant
supports critical program needs and
funding gaps for some of the area’s
most vulnerable families – including
child care fee scholarships, foregone
charges from medical insurance, and
medical care for children with shortterm insurance denials. The grant
provided the equivalent of child care
fee scholarships for seven children for
one month.
As these stories show, the impact of
the ACMS Foundation extends beyond
the dollars. It lives on in a legacy of lo-
cal institutions, services and resources
grown from Foundation seed money, in
healthy families and communities, and
medical and social service professionals making a difference in the region
and beyond.
Tax-deductible contributions to
the ACMS Foundation can be made
online at www.acmsfoundation.org or
by returning the envelope inserted in
this issue. A complete list of all ACMS
Foundation grants is available on the
website.
Diane Wuycheck is a former ACMS
director of communications and media
relations manager for several local
corporations. She established a private
practice in marketing communications
in downtown Pittsburgh in 2002. Contact her at [email protected]
447
448
Bulletin / November 2014
Special Report
HPV-related cancers preventable
2
014 marks the 100th birthday of
Jonas Salk, whose polio vaccine
has virtually eliminated a nervous
system-destroying disease that once
confined scores of children and young
adults to iron lungs and wheelchairs.
Salk’s vaccine, developed at the University of Pittsburgh, quickly became a
cornerstone of preventive health care
for adolescents across the globe.
As we celebrate the man behind
one of medicine’s greatest achievements, we also must confront a public
health paradox that Salk himself would
have found unacceptable. There is
a safe, proven vaccine available to
protect children against certain types
of human papillomavirus (HPV), which
causes an estimated 33,000 cases of
cervical, vaginal, vulvar, oropharyngeal,
penile and anal cancers in the United
States each year. Yet few kids receive
this cancer-preventing gift: Just 38 percent of girls between the ages of 13-17
and 14 percent of boys completed the
three-dose HPV vaccine regimen in
2013, according to the Centers for Disease Control and Prevention (CDC).
We have a shot to fight cancer – the
scourge of our lifetime – and we’re not
using it.
But, as with polio in the 1940s and
1950s, Pittsburgh is stepping forward
to keep our community healthy. The
Jewish Healthcare Foundation (JHF)
– with additional funding support from
The Grable Foundation, the Eye &
Ear Foundation of Pittsburgh, and
a Mobilization for Health: National
Prevention Partnership Award from the
U.S. Department of Health and Human
Services – has launched a campaign
Bulletin / November 2014
Alan Finkelstein, MD
to increase HPV vaccination rates by
activating individuals and organizations
from across our region.
The campaign kicked off in February, when JHF convened an advisory
committee featuring more than 40 clinicians, researchers, community activists,
educators, health plan representatives
and Allegheny County Health Department leaders. Sub-committees of the
advisory are tailoring culturally competent messages about the vaccine’s
benefits to parents, teens and young
adults (for “catch up”); collaborating
with health care providers to encourage
them to talk about HPV; and working
with regulators and others to advocate
for policy changes that could one day
boost HPV vaccination rates past the
80 percent goal established by the
CDC. JHF also has launched a Pittsburgh chapter of Grandmother Power,
providing activist grandmothers with
the education and resources needed
to take the cancer prevention message
back to their families and communities.
Along with Fred Rogers Company CEO William Isler, I co-chair the
HPV campaign advisory working with
parents and providers in the Pittsburgh
region. And we need your help. We
have found that parents who do not
vaccinate their children against HPV
often say they lack information about
the vaccine, or they’re concerned
about its side effects. It’s the job of the
clinician – a family’s trusted partner in
making informed health care decisions
– to ensure that parents understand
the cancer-preventing potential
of the vaccine.
The HPV
vaccine is recommended for
girls and boys
aged 11-12 (before exposure to HPV).
The vaccine also is recommended for
girls 13-26 and boys 13-21 who did not
get it when they were younger, as they
may not have been exposed to any or
all of the HPV types prevented by the
vaccine. Licensure trials have shown
the HPV vaccine to be 100 percent
effective against incident infection,
with protective immunity for at least a
decade.
More than 57 million doses of the
HPV vaccine have been safely administered since 2006, with the most
serious common side effect being
dizziness (which is why doctors have
those who are vaccinated wait 15 minutes before standing up). Given those
results, a procession of leading health
care organizations including the CDC,
American Academy of Family Physicians, American Academy of Pediatrics,
and the Society for Adolescent Health
and Medicine recommend the vaccine
for boys and girls. For these health
care professionals, discussing the HPV
vaccine with parents and young adults
is no different than explaining how the
Tdap and Meningococcal vaccines can
stave off myriad health problems in the
future.
Research shows that a strong
provider recommendation is the single
largest motivating factor for parents to
Continued on Page 450
449
Special Report
From Page 449
vaccinate their children and for young
adults who missed getting vaccinated when they were younger to get
vaccinated. But despite the strong
evidence supporting the HPV vaccine’s
efficacy and safety, the CDC says
that physicians do not recommend
the HPV vaccine to about one-third of
age-appropriate girls, and more than
half of age-appropriate boys. Each day,
children in our region visit their doctor
and miss an opportunity to receive
one of the few vaccines in the world
proven to prevent certain cancers. The
CDC estimates that if providers had
given the HPV vaccine during health
care visits when another vaccine was
administered, about 91 percent of girls
born in 2000 would have received at
least one dose of the HPV vaccine by
age 13.
When Salk’s polio work earned him
the Congressional Medal for Distinguished Civilian Achievement, he said
that “the greatest reward for doing is
the opportunity to do more.” We, as
a community, simply must do more to
ensure that our children are given the
opportunity to carry out their ambitions. When I talk to parents, many of
whom have been touched by cancer,
I tell them that there’s a shot available
to prevent their kids from potentially
having to endure similar health struggles. On behalf of JHF and the band
of health care and community leaders mobilizing to protect our children
against the consequences of the HPV
virus, I welcome you to join us. Will
you, like Salk, do more for our region’s
children?
Dr. Finkelstein is a family physician in Pittsburgh and has been on
the faculty of the UPMC-Shadyside
Family Medicine Residency Program
since 2001. He serves on the Advisory
Committee of the Jewish Healthcare
Foundation’s HPV immunization campaign, and is the Board Chair of Adagio
Health, a local nonprofit providing care
for underserved women and families in
23 counties in western Pennsylvania.
P HYSIC I A N S ,
W E TH A N K YOU.
H PV VACC IN AT ION IS CA NC E R P RE VE N T I O N .
To the physicians who take care of our children and grandchildren and
help to ensure they are protected against HPV-related cancers — thank
you for recommending and providing the vaccine to your patients.
450
Bulletin / November 2014
Care is Your Business, Change is Ours
The healthcare environment is changing. Physicians must focus on providing the highest quality care with intense
competition for their time. Medical practices face increased challenges tied to changes to regulation, insurance protocols,
cost-management and revenue management.
Houston Harbaugh has over 30 years of experience in helping physicians and medical practices manage change through
contract negotiations with hospitals and payors; contract management; advocacy and new practice start-up counsel.
We have provided critical support in practice mergers and acquisitions. And we have provided sound advocacy on issues
ranging from HIPAA compliance to medical staff and peer review matters.
Every challenge a medical practice can face, we have seen. We have helped practices of all size and structure meet
these challenges. And we know what is ahead. Houston Harbaugh: Your voice in medical practice management.
YOUR VOICE l hh-law.com
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Bulletin / November 2014
451
Materia Medica
Cannabis considered
Lucas G. Hill, PharmD
Gregory B. Castelli,
PharmD, BCPS
W
hen determining whether to
recommend any medication to a
patient, there are at least three factors
a medical provider must assess. While
safety and efficacy are the most commonly cited factors, another important
consideration is regulatory status. Is
the medication available without a
prescription? Are its ingredients and
manufacturing processes monitored by
the United States Food and Drug Administration (FDA)? Is the medication
a controlled substance and if so, how
is its prescribing logistically limited?
A variety of regulatory limitations may
preclude prescribing in certain circumstances and such may be the case for
cannabis.
While the FDA classifies cannabis,
commonly referred to as marijuana, a
schedule I narcotic with no legitimate
medical purpose, 21 states have provisions for its medicinal use. Additionally,
18 states have reduced or eliminated
criminal penalties for recreational use
and possession of cannabis.1 Pennsylvania law does not yet differ from
federal policy, but legislation to allow
medicinal use is being considered in
the state legislature.2 Currently, possession of less than 30 grams (one
ounce) of cannabis in Pennsylvania
is considered a misdemeanor with a
maximum penalty of 30 days in prison
and a $500 fine. Possession of more
452
than 30 grams could result in imprisonment for up to one year accompanied
by a $5,000 fine.3 Though legal liability
for prescribing cannabis is difficult to
estimate, it would be prudent not to
recommend it until current state laws
are amended.
The endocannabinoid system is
comprised of cannabinoid (CB) receptors in the human body that can
be agonized by both endogenous and
exogenous ligands. The CB1 receptor
is prevalent in the basal ganglia, hippocampus, cerebellum and visual cortex.
The CB2 receptor is located primarily in
the spleen, tonsils, bone marrow and
leukocytes. Anandamide and 2-arachidonyl glycerol, arachidonic acid
derivatives, are endogenous ligands for
these receptors. While the normal daily
activity of these ligands and receptors
has not been fully elucidated, some
clues are provided by the failed CB1
antagonist rimonabant (Acomplia®).
Rimonabant was shown to be an effective smoking cessation aid and also
induced weight loss in obese patients.
However, it was withdrawn from the
European market and never approved
in the United States due to increased
depression and thoughts of suicide,
as well as other neurologic adverse
effects.4
The efficacy of synthetic cannabinoid agonists has been established
for multiple medical indications. The
most referenced cannabinoid, tetrahydrocannabinol (THC), is believed to
be primarily responsible for the psychoactive effects of cannabis. Another
cannabinoid of interest, cannabidiol
(CBD), is believed to be less psychoactive than THC while exhibiting similar
therapeutic effects. For this reason,
strains of cannabis that contain little or
no THC but have high concentrations
of CBD are gaining popularity among
patients who use cannabis medicinally.
A THC-analog called dronabinol (Marinol®), approved by the FDA in 1985, is
indicated for use in acquired immunodeficiency syndrome (AIDS) associated
anorexia and chemotherapy-induced
nausea and vomiting. A mixture of
dronabinol and CBD called nabiximols
(Sativex®) is approved in Europe for
the treatment of neuropathic pain and
spasticity related to multiple sclerosis
(MS) as well as opioid-refractory cancer pain.6 Data regarding the efficacy
of inhaled cannabis is extremely limited
due to legal restrictions and a lack of
dose standardization. However, available evidence suggests it has similar
efficacy in AIDS-associated anorexia5,
MS-related spasticity6 and neuropathic
pain7.
There is currently increased interest
in the use of cannabis and synthetic
cannabinoids as an active treatment for
glioblastomas and other cancers. Guzman et al. report that when intratumoral
THC is used in patients with advanced
glioblastomas who have failed standard
therapy, the median survival rate is 24
weeks. Additionally, their in-vitro results
showed a possible decrease in tumor
cells.8 Cannabis also is being used by
some patients with refractory seizures,
though a systematic review published
in Neurology, the official journal of
the American Academy of Neurology,
Bulletin / November 2014
Materia Medica
concluded there is insufficient evidence
to support this practice.9
The most common adverse effects
associated with cannabis inhalation are
those that recreational users find appealing. These may include a distorted
perception of time, increased hunger,
somnolence and euphoria. While few
patients seek treatment for cannabis
addiction and withdrawal symptoms
are rarely observed, a mild withdrawal
syndrome consisting of irritability and
self-limiting sleep disturbance can
occur. Study populations who were administered very large doses of cannabis for various periods of time followed
by rapid cessation have experienced
restlessness, irritability, insomnia,
nausea and cramping. Severe adverse
reactions to cannabis use such as
anxiety and hallucinations are typically
only associated with oral ingestions of
high doses. Early use of cannabis is
associated with an increased risk of
developing schizophrenia later in life,
though there is no compelling evidence
of a causal relationship. Cannabis use
may trigger acute episodes of psychosis in patients with severe mental
illness and should be avoided in this
population.4
Tetrault et al. conducted a systematic review to investigate the association
between cannabis inhalation and impaired respiratory function. Thirty-four
studies that evaluated pulmonary
function or respiratory complications
were included in the final analysis.
Based on 14 studies evaluating the effect of cannabis inhalation on long-term
respiratory complications, the authors
concluded use of inhaled cannabis
was not associated with decreased
respiratory function. However, long-
term cannabis inhalation was associated with an increased risk of cough,
phlegm and wheeze.10 This effect was
largely demonstrated by Moore et al.
in a cross-sectional analysis of 6,728
patients that demonstrated those who
had smoked cannabis at least 100
times were more likely than those who
had never smoked cannabis to develop
cough (OR 2, 95 percent CI 1.323.01), phlegm (OR 1.89, 95 percent CI
1.35-2.66), and wheeze (OR 2.98, 95
percent CI 2.05-4.34).11
Members of the health care community remain unsure of how to approach
cannabinoid use for medicinal purposes. A clinician’s ability to recommend
inhaled cannabis depends on state
regulations; however, cannabis and its
derivatives have clearly demonstrated
efficacy in several medical conditions.
Continued on Page 454
Moving?
Be sure to let us know ....
We can update our system to better serve you!
When your patients call, we will know where to send
them. Call (412) 321-5030 to update your information.
Bulletin / November 2014
453
Materia Medica
From Page 453
This efficacy, coupled with a self-limiting, mild side-effect profile, may prove
to be beneficial for some patients.
Further study regarding the optimal
concentrations of THC, CBD and
other cannabis constituents for various
indications may shed more light on the
issue and allow patients who cannot
References
1. State laws. National Organization
for the Reform of Marijuana Laws Website.
http://norml.org/laws/. Accessed February 14,
2014.
2. Medical marijuana may be coming to
Pittsburgh. Marijuana Policy Project Website.
http://www.mpp.org/states/pennsylvania/.
Accessed January 8, 2014.
3. Pennsylvania laws and penalties.
National Organization for the Reform of Marijuana Laws Website. http://norml.org/laws/
item/pennsylvania-penalties-2. Accessed
February 14, 2014.
4. Brunton L, Chabner B, Knollman B,
eds. Goodman & Gilman’s: The Pharmacological Basis of Therapeutics. 12th ed. New
454
tolerate the psychoactive effects of THC
to utilize inhaled cannabis or related
extracts.
Lucas G. Hill, PharmD, is a PGY2
ambulatory care pharmacy resident
at UPMC St. Margaret and can be
reached at [email protected] Gregory
B. Castelli, PharmD, BCPS, is a clinical
assistant professor at the West Virginia
York, NY: McGraw-Hill; 2011:388, 663-4.
5. Haney M, Rabkin J, Gunderson E,
Foltin RW. Dronabinol and marijuana in
HIV(+) marijuana smokers: acute effects on
caloric intake and mood. Psychopharmacology (Berl). 2005;181(1):170-8.
6. Corey-Bloom J, Wolfson T, Gamst A, et
al. Smoked cannabis for spasticity in multiple
sclerosis: a randomized, placebo-controlled
trial. CMAJ. 2012;184(1):1143-50.
7. Wilsey B, Marcotte T, Tsodikov A, et al.
A randomized, placebo-controlled, crossover
trial of cannabis cigarettes in neuropathic
pain. J Pain. 2008;9(6):506-21.
8. Guzmán M, Duarte MJ, Blázquez C,
et al. A pilot clinical study of Delta9-tetrahydrocannabinol in patients with recurrent
University School of Pharmacy and
can be reached at [email protected]
com.
Heather Sakely, PharmD, BCPS,
is director of Geriatric Pharmacotherapy and director of PGY2 Geriatric
Pharmacy Residency at UPMC St.
Margaret. She served as an editor for
this publication and can be reached at
[email protected]
glioblastoma multiforme. Br J Cancer.
2006;95(2):197-203.
9. Moore BA, Augustson EM, Moser RP,
Budney AJ. Respiratory effects of marijuana
and tobacco use in a US sample. J Gen
Intern Med. 2005;20:33-7.
10. Tetrault J, Crothers K, Moore B, et al.
Effects of marijuana smoking on pulmonary
function and respiratory complications. Arch
Intern Med. 2007;167:221-8.
11. Koppel BS, Brust JC, Fife T, et al.
Systematic review: efficacy and safety of
medical marijuana in selected neurologic disorders: report of the Guideline Development
Subcommittee of the American Academy of
Neurology. Neurology. 2014;82(17):1556-63.
Bulletin / November 2014
q
Allegheny County
MediCAl SoCiety
Leadership and Advocacy for Patients and Physicians
ACMS selects vendors for quality and
value. Contact our Endorsed Vendors
for special pricing.
Banking and
Financial Services
Practice Financing,
Revenue Cycle Management
Physician Only Mortgage
Program
Private Banking
Fifth Third Bank
Robert Foley, 412.291.5401
[email protected]
Banking, Financial
and Leasing
Services
Medical Banking,
Office VISA/MC Service
PNC Bank
Brian Wozniak, 412.779.1692
[email protected]
What does ACMS
membership
do for me?
Bulletin / November 2014
Group Insurance
Programs
Medical, Disability, Property
and Casualty
USI Affinity
Bob Cagna, 412.851-5202
[email protected]
Printing Services
and Professional
Announcements
Service for New Associates,
Offices and Address Changes
Allegheny County Medical
Society
Professional Liability Susan Brown, 412.321.5030
[email protected]
Insurance
PMSLIC
Laurie Bush, 800-445-1212,
ext. 5558; [email protected]
Medical and Surgical
Supplies
Allegheny Medcare
Michael Gomber, 412.580.7900
[email protected]
com
Auto and Home
Insurance
Liberty Mutual
Kathy Smith, 412.859.6605,
ext. 51911;
[email protected]
Member Resources
BMI Charts, Healthy Lifestyle
Posters, Where-to-Turn cards
Allegheny County Medical
Life Insurance
Society
Malachy Whalen & Co.
412.321.5030
Malachy Whalen, 412.281.4050 [email protected]
[email protected]
455
Allegheny
County
Medical
Society
Foundation
713 Ridge Avenue
Pittsburgh, PA 15212-6098
(412) 321-5030
FAX (412) 321-5323
www.acms.org
Created, funded and
administered by physicians
since 1960, the Allegheny
County Medical Society
Foundation has given
more than $2.6 million to
various community
programs.
Over the past year, the
foundation contributed to
or sponsored the
organizations and
activities listed here:
The annual ACMS
Foundation Community
Awards Gala raises funds
for the foundation’s medical
student and CCAC’s health
career scholarships. Plan
to attend the 2015 Gala on
March 7!
456
Please include the
ACMS Foundation
in your year-end giving:
• Angels’ Place – Showcase of Scholars Program
• Carnegie Institute, Pittsburgh Regional Science and Engineering Fair
for two student awards in the field of medicine and biology
• Children’s Home of Pittsburgh – Child’s Way Program
• Community College of Allegheny County Education Foundation for ACMS
Foundation Endowed Scholarship Fund for health care career scholarships
• Family House, Inc. – Family Assistance Program
• Providence Connections, Inc. – Bridging the Gap:
Preparing at-risk students for success in school & life program
• Spina Bifida Association of W. PA – Community Outreach and Support
Group for Caretakers Program
• The Foundation of the Pennsylvania Medical Society for ACMS
Foundation Medical Student Scholarship Fund
• United Way – Community-Based Chronic Care Self Management Program
• University of Pittsburgh School of Medicine – Medical Student Career
Night
Allegheny County Medical Society Foundation
Name
Address
Phone
Please send your tax-deductible contribution to ACMS Foundation,
713 Ridge Avenue, Pittsburgh, PA 15212-6098. Checks should be made
out to ACMS Foundation. For more information, please call (412) 321-5030.
Bulletin / November 2014
Legal Report
Personal cybersecurity –
a HIPAA ‘lite’ approach
P
hishing emails. Viruses that affected the security of your online
transactions by exploiting weaknesses
in encryption technology (Heartbleed)
and now one that could potentially allow a hacker to control your “smart” appliances (Shellshock). Twelve-character passwords, different ones for each
website that you log into. Cybersecurity
may be handled by the HIPAA Security
Officer and IT team at work, but what
about at home? How do you protect
your sensitive information – details
about your bank accounts, retirement
funds, taxes, credit card statements,
photographs, email and other personal
correspondence?
Type in “personal cybersecurity”
on Google, and you will get 43 million
results. Some of the links will even
take you to scam websites. The sheer
volume of advice is overwhelming,
but using a familiar approach – HIPAA – can yield a practical blueprint
for protecting yourself and your family
from cybercriminals. Yes, HIPAA is just
about the last thing you want to think
about at home, but consider this: The
goals of the HIPAA security rules are
to protect the confidentiality, integrity
and availability of electronic Protected
Health Information (PHI).
Your goal with respect to your own
sensitive information is the same: You
want it to remain private, unaltered and
available to you when you need it. To
accomplish that goal, you can folBulletin / November 2014
Beth Anne
Jackson,
Esq.
low the same methods that were used
at your workplace to become compliant
with the HIPAA security rules: Conduct a risk assessment, and based on
what you find, implement appropriate
administrative, physical and technical
safeguards. Personal cybersecurity is a
process, and the HIPAA “lite” approach
can make it a manageable one.
Create your game plan: risk
assessment. The first step of a risk
assessment is to list every device that
you use to access, create or maintain
your sensitive personal information
(PI). Don’t limit your thought process to
your personal computer or laptop – include smartphones, iPads, tablet computers, thumb drives, game consoles,
external hard drives and your printer/
scanner/copier, even if they belong to
or are used primarily by other members
of your household. Next, answer the
following questions about the steps you
take to manage the risk to your PI. As
you answer each one, rank the level
of risk that each issue poses using a
numeric scale or narrative descriptions
(low, medium, high).
• Access: Do you limit access to
each device by password, house rules
or otherwise? Can your children, other
household members or guests get onto
the computer that contains your most
sensitive PI? Have you enabled the
automatic log-off procedure on your
computer so that it locks when the
machine is idle for a specified period of
time?
• Data segregation: Do you segregate your data, or is the .pdf of last
year’s tax return in the same documents folder as your daughter’s book
report? Do you limit access to folders
or programs containing PI?
• Training: Do all household members know the rules about computer
use and what can happen if they aren’t
followed? Do they understand the risks
of clicking on links in emails1 and in
pop-up ads and of continuing on to
visit a website after the warning that
the website does not have a security
certificate issued by a trusted certificate authority? Do they understand
when it’s safe to download a program,
document or video from the internet?
• Password management: Do you
use strong passwords or pass phrases
(at least 12 characters, including upper
and lower case letters, a number and a
symbol)? Do you use the same password multiple times? Do you allow your
browser to save your passwords so
that you can automatically log-in? Do
you use a secure password management program?2
Continued on Page 458
457
Legal Report
From Page 457
• Protection from malware: Have
you installed anti-virus and anti-malware software? Do you regularly review
the scan reports to determine if an
issue needs to be addressed? Do you
have this software set to automatically
update or does it only update when you
log on? If the latter, do you sometimes
skip the update so that you can use the
computer for other things first?
• Data backup plan: Do you regularly back up your data? How often?
Online or to a physical device? If you
back up manually to an external hard
drive, is that stored off-premises in
case of theft or fire?
• Disaster recovery plan: If your
devices were destroyed, lost or stolen, do you know how to access your
backed-up data to restore it to a new
computer?
• Loss or theft: What steps do you
and your family take to ensure the
physical security of your devices? Is
your home security system sufficient?
Do you lock your car and stow devices
out of sight or in the trunk when you
leave them in the car?
• Disposal: Do you destroy data
on devices before they are discarded,
traded in or donated? If so, how? Are
they physically destroyed or overwritten by special software?3
• Encryption: Are your devices encrypted? Do they contain enough PI to
warrant total disk encryption? Could PI
be maintained in special files or folders
that could be encrypted?4 If you use
an external hard drive to back up your
computer, is it also encrypted?
• Settings: Are the settings on
your smartphone and other portable
devices appropriate? For example, is
your smartphone Wi-Fi setting “on” all
the time so that your phone automatically accesses a public Wi-Fi hotspot
instead of your more secure 4g data
plan, leaving you open to others who,
with a simple device, can log every
keystroke you take? Have you reviewed the security settings on your
device, including those on your email
and other apps?
Implementing a risk management plan. Review your answers to
the questions above and the risk level
each item poses. Start with those items
that pose the greatest risk. Research
solutions one by one as needed5 or
consult a qualified computer professional if you do not have the time to do
so. Document the steps you take so
that the process can be updated and
repeated the next time you acquire
a new device. Also create and write
down “house rules,” then educate the
entire family about what they are and
why they are important.
People are typically the weakest link
in a security management program.
Therefore, in crafting your solutions,
control what you have the power to
control (through technical controls –
software and settings) and mitigate
the other risks in pragmatic ways. For
example, making certain computers
or devices off-limits to your children
or limiting certain activities to specific
devices (like an iPad) can make good
sense, especially if they download a lot
(e.g., mods to use in playing Minecraft)
or indiscriminately click on links on
YouTube and other sites.
Remember that securing sensitive
information from cybercriminals is a
process. As such, it must be re-evaluated and updated to respond to new
threats, new devices and changes in
Serving the legal needs of health
care practitioners and facilities
BETH
ANNE
JACKSON
Esq. LLC
4050 Washington Road
Suite 3N
McMurray, PA 15317
724 941-1902
[email protected]
www.jacksonhealthlaw.com
• Regulatory - Stark, AntiKickback, HIPAA, EMTALA
• Compliance training and policies
• Physician-hospital contracts
• Employment contracts
• Joint ventures and other
business transactions
• Operational issues and policies
458
Bulletin / November 2014
Legal Report
the information that you want to protect. Establishing first
what types of sensitive information that you have and the
various risks and benefits of how, when and where you create, access or maintain that data is key to creating a viable
framework to protect it.
Author’s Note: Like many attorneys, I find myself attending to client matters outside of regular office hours from
home. As a result of business associates becoming directly subject to HIPAA through the HITECH Act, I had to go
through the entire security risk assessment process and create and implement security policies and procedures so that
I could begin to accept electronic PHI. (I had previously only
accepted PHI on paper.) As a solo practitioner, I didn’t have
References
1. For descriptions of phishing emails,
see Microsoft’s Safety & Security Center,
“How to recognize phishing email messages,
links, or phone calls,” available online at:
http://www.microsoft.com/security/online-privacy/phishing-symptoms.aspx.
2. For a recent review of password
manager programs, see Rubenking, Neil
J., “The Best Password Managers,” available online at http://www.pcmag.com/article2/0,2817,2407168,00.asp.
3. Deleting files does not erase them!
the option to simply log-on to my employer’s systems and
not worry about security implications. The computer and the
procedures I used at home for work had to be as secure as
the one in my office to ensure the confidentiality of my clients’
data, including but not limited to PHI. In the process, I found
HIPAA “lite” to be a viable approach to cybersecurity for my
entire family, including devices that I did not use for work.
Ms. Jackson is the sole member of Beth Anne Jackson,
Esq. LLC, a law firm that serves the legal needs of health
care practitioners and facilities in southwestern and central
Pennsylvania. She may be reached at (724) 941-1902 or
[email protected] Her website is: www.jacksonhealthlaw.com.
Avast, an antivirus software maker, was
able to recover deleted personal information
from 20 Android phones that it purchased on
eBay. From these phones it was able to gain
access to 40,000 stored photos (some compromising), 750 emails and texts, 4 previous
owners’ identities and more. This mimics the
results of an MIT study in which researchers
were able to recover “erased” information
from 2/3 of the computers that it purchased
on eBay. Consumer Reports, “Erasing data
isn’t enough to prevent identity theft when
recycling gadgets,” available online at: http://
www.consumerreports.org/cro/news/2014/08/
erasing-data-is-not-enough-to-prevent-identity-theft/index.htm.
4. Microsoft and Adobe files can be
individually encrypted with a password if you
have the proper versions of that software.
5. Consumer Reports.com has an
excellent series of articles on personal cyber-security that can be accessed without a
subscription in its “Guide to Internet security,”
available online at: http://www.consumerreports.org/cro/electronics-computers/
guide-to-internet-security/index.htm
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12/18/13 10:47 AM
459
Special Report
N
Accessing VA care
for transitioning veterans
ew Veterans, separating from the
service after deployment in support of Operations Enduring Freedom,
Iraqi Freedom and New Dawn (OEF/
OIF/OND), have a five-year window of
opportunity to access copay-free care
related to their service at VA medical
centers because of their status as
combat veterans.
The five years of co-pay free health
care related to service begins on
the separation date from the military
deployment. During this time, all medical care related to service, including
routine primary care visits is free of
charge.
At VA Pittsburgh, returning combat
veterans can access a comprehensive
post-deployment clinic at the Heinz
campus. This clinic consists of medical
doctors, physician assistants, RNs,
social workers, LPNs, and various
specialty clinics including polytrauma,
physical therapy, speech and more.
Combat veterans typically enroll in
the VA through two different avenues.
1) Injured and seriously injured
veterans who are being treated in
Amy Boyles, LCSW
Department of Defense (DOD) receive
appointments at VA medical centers
and are contacted before they leave
the service, with the goal of providing
a seamless transition of care and ensuring that all medications and appointments are arranged before the veteran
returns home.
2) Veterans who are not injured can
access VA care by directly enrolling in
a local VA medical center or Community-Based Outpatient Clinic (CBOC).
Veterans complete an enrollment
form online or in person and need to
submit it with a copy of their discharge
paperwork. Any veteran who needs
assistance enrolling can contact or visit
VA enrollment specialists in person for
assistance.
Some of the VA Pittsburgh clinics
that provide valuable specialty services
to veterans include:
• Case Management Services
• Healthcare for Homeless Veterans
• Veterans Justice Outreach
• Combat Stress Recovery Clinic
• Individual and/or Group Counseling
• Center for Treatment of Addictive
Disorders
• Military Sexual Trauma Services
• Dental Exam (to be completed
within 180 days of date of separation)
• Physical and Occupational Therapy
• Employment Counseling and
Vocational Rehabilitation
Any veteran wishing to learn more
about obtaining services in the OEF/
OIF/OND clinic should contact the program manager, Amy Boyles, at (412)
822-2363.
Amy Boyles serves as the program
manager and clinical social worker for
the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New
Dawn (OEF/OIF/OND) clinic at the VA
Pittsburgh Health Care System. She
also is a counselor in the University of
Pittsburgh Counseling Center.
Allegheny County Medical Society
Leadership and Advocacy
for Patients and Physicians
460
Bulletin / November 2014
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Ruby Marcocelli
461
Special Report
The MOC debate hits home
Leslie Howell, PAMED
R
arely does an issue simultaneously
instill great passion and considerable angst for physicians at the level
that we are seeing for the American
Board of Medical Specialties’ (ABMS’)
Maintenance of Certification™ (MOC).
Most physicians will concede that
the expressed intent of MOC is appropriate: to ensure the patient community that physicians are continuing to
assess and improve their knowledge
and capabilities after graduate medical education (GME) training. It goes
without saying that physicians are
committed to lifelong learning and
continuous improvement. However, this
same group also contends that the current processes and practices in place
across the various specialty boards are
cumbersome, costly, and significantly
cutting into their time with patients.
Of the four components of MOC –
(I) licensure and professional standing,
(II) lifelong learning and assessment,
(III) cognitive exam, and (IV) practice
performance assessment – the exam
and the practice performance assessment appear to be the areas of greatest concern. The exam component,
in particular, has been under a great
deal of scrutiny. Input we’ve received
from Pennsylvania Medical Society
(PAMED) members thus far indicates
that it is viewed as an uncertain measure of a physician’s actual skill in his
or her specialty and is punitive. Consequently, many fear that failing the exam
will result in a loss of privileges at
462
hospitals, insurance reimbursements,
network participation, and possibly
even employment.
PAMED has formed a Task Force
on Continuous Professional Education
to examine MOC in its current form and
the concerns circulating throughout the
state and to seek input from Pennsylvania’s physicians. The goal: reshape
MOC, in whatever future form it might
take, into a process of continuous
learning and improvement based on
evidence-based guidelines, national
standards, and best practices that is
relevant to what a physician actually
does within his or her practice of medicine and one that enhances, rather
than impedes, the care of patients.
Delegates at the 2014 House of
Delegates meeting, held October
17-19 in Hershey, debated the merits
of the task force’s initial recommendations, as well as other resolutions and
reports related to MOC. One of the
documents developed by the task force
and adopted by the PAMED Board is a
Maintenance of Certification Statement
of Principles which outlines PAMED’s
position on what MOC should be:
• PAMED is committed to lifelong
learning, cognitive expertise, practice
quality improvement, and adherence
to the highest standards of medical
practice.
• PAMED supports a process of
continuous learning and improvement
based on evidence-based guidelines,
national standards, and best practices,
in combination with customized continuing education.
• The MOC process should be
designed to identify performance gaps
and unmet needs, providing direction
and guidance for improvement in
physician performance and delivery of
care.
• The MOC process should be evaluated periodically to measure physician
satisfaction, knowledge uptake, and
intent to maintain or change practice.
• Board certificates should have
lifetime status, with MOC used as a
tool for continuous improvement.
• The MOC program should not be
associated with hospital privileges,
insurance reimbursements, or network
participation.
• The MOC program should not be
required for Maintenance of Licensure
(MOL).
• Specialty boards, which develop
MOC standards, may approve curriculum, but should be independent from
entities designing and delivering that
curriculum, and should have no financial interest in the process.
• A majority of specialty board members who are involved with the MOC
program should be actively practicing
physicians directly engaged in patient
care.
• MOC activities and measurement
should be relevant to real world clinical
practice.
• MOC process should not be cost
prohibitive or present barriers to patient
care.
The delegates also asked that several items be referred to the AMA:
• Work with the ABMS to eliminate
practice performance assessment
modules as currently written from the
Bulletin / November 2014
Special Report
requirements of MOC.
• Develop and disseminate a public
statement, with simultaneous direct
notification to the American Board of
Internal Medicine (ABIM) and other
ABMS-sponsoring boards that their
current MOC program appears to be
focused too heavily on enhancing
ABIM revenues and fails to provide a
meaningful, evidence-based, and accurate assessment of clinical skills.
• Investigate and/or establish alternative pathways for MOC.
• Report back to the House of
Delegates at the Annual AMA Meeting
in June 2015.
The delegates also recommended
that PAMED ask the AMA to revoke
its support for MOC if no action is
taken by the ABMS in working with the
AMA to make MOC requirements less
onerous.
PAMED will continue to support
efforts to create a reasonable and
economical assessment process that
provides physicians with the information necessary to improve the quality
and efficiency of their practices.
Meanwhile, to get more input
from PA’s physicians, PAMED will be
emailing physicians a brief survey the
week of November 10. Please watch
for this email. It will take no more than
two minutes to complete so please add
your voice to the conversation!
For more information on PAMED’s
Task Force on Continuous Professional Education or next steps on MOC,
please email Scot Chadwick at [email protected] or call Scot at
(717) 909-7814.
Leslie Howell is director of CME,
training and physician leadership programs at PAMED.
Legal Summary
Court rejects contempt application
Michael A. Cassidy, Esq.
Commonwealth Court has rejected the application
by the Pennsylvania Attorney General to hold Highmark
in contempt of the Consent Decrees approved by the
Court involving the Commonwealth of Pennsylvania,
Highmark and UPMC on July 1, 2014.
By way of background, Highmark and UPMC
entered into identical but separate reciprocal Consent
Decrees in July arising out of UPMC’s termination of its
participation agreements with Highmark. The purpose
of the Consent Decrees was to clarify ongoing access
to UPMC hospitals, physicians and services for beneficiaries covered by Highmark insurance products.
One of the issues included in the Consent Decrees
was continued access to UPMC hospitals, physicians
and services by “vulnerable populations”, which was
defined to include eligible Medicare beneficiaries.
Pursuant to the Consent Decrees, the vulnerable
populations which were covered by Highmark Medicare
products, such as Medicare Advantage, were granted
continued access at in-network rates to UPMC hospiBulletin / November 2014
tals, physicians and services.
As has already been reported in the news, in September Highmark began offering the Community Blue
program which does not provide Medicare beneficiaries
access to UPMC facilities, physicians and services,
although Highmark also offers Medicare products with
UPMC access but at a different premium structure.
UPMC and the Pennsylvania Attorney General
asserted that Highmark’s actions violated the Consent
Decrees and the Attorney General applied to Commonwealth Court for a holding that Highmark was in
contempt of the Consent Decrees. The Commonwealth
Court denied the application, holding that the Consent
Decrees do not require that UPMC be included in all
Highmark Medicare products.
Mr. Cassidy is a shareholder with Tucker
Arensburg and chair of the firm’s Healthcare
Practice Group; he also serves as legal counsel to ACMS. He can be reached at (412)
594-5515 or [email protected]
463
Special Report
2014 Annual Meeting Recap:
Helping Physicians Adapt to Change
A
s the rate of change in our health
care system – and our medical
practices – continues to accelerate,
more doctors are feeling the weight of
blame for costs, outcomes, and quality,
says Karen Rizzo, MD, FACS, newly
installed president of the Pennsylvania
Medical Society (PAMED).
Dr. Rizzo, an otolaryngologist/ENT
from Lancaster, was sworn in as the
165th president of PAMED on Oct. 18
during the annual statewide meeting
in Hershey. Several other Pennsylvania physicians also were elected to
PAMED’s Board during the meeting.
“The cost of health care rests
squarely on their [physicians’] backs as
their burden,” she said, along with the
blame for poor outcomes, ordering too
many tests, and not spending enough
time with patients.
Dr. Rizzo told the more than 300
delegates attending the PAMED House
of Delegates and Annual Education
Conference that instead of carrying that
blame, they must adopt physician-led
solutions to address the changes happening all around us. While continuing to support
PAMED’s strong advocacy agenda,
she will advocate for three strategic
directions during her year in office:
• Promote PAMED programs that
help physicians learn about and
respond to all the changes taking place
around them;
• Develop and then implement
an intentional, thoughtful strategy to
engage with insurance companies to
464
understand how they measure our performance, how they measure quality,
and how they measure the costs we
generate to their covered lives;
• Develop our vibrant and enthusiastic young physician community by
creating a Leadership Academy for
Young Physicians.
2014 House of Delegates
Actions
As a result of deliberations at the
2014 House of Delegates, PAMED’s
already robust agenda for the coming
year will add important issues such as:
• Maintenance of Certification
(MOC) – Ask the American Medical
Association (AMA) to:
• Work with the American Board of
Medical Specialties (ABMS) to eliminate practice performance assessment
modules as currently written from the
requirements of MOC.
• Develop and disseminate a public
statement, with simultaneous direct
notification to the American Board of
Internal Medicine (ABIM) and other
ABMS sponsoring boards, that their
current MOC program appears to be
focused too heavily on enhancing
ABIM revenues and fails to provide a
meaningful, evidence-based, and accurate assessment of clinical skills.
• Investigate and/or establish alternative pathways for MOC.
• Report back to the House of
Delegates at the Annual AMA Meeting
in June 2015.
The PAMED Board was asked to
study a recommendation to then ask
the AMA to revoke its support for MOC
if no action is taken by the ABMS in
working with the AMA to make MOC
requirements less onerous.
PAMED will continue to support
efforts to create a reasonable and
economical assessment process that
provides physicians with the information necessary to improve the quality
and efficiency of their practices.
• E-Cigarette advertising/endorsement – Ask the AMA to work through
an appropriate federal process to
prohibit e-cigarette companies from
paying for product placement in films
and hiring celebrity spokespersons,
and to prohibit e-cigarette advertising
on television.
• Ebola preparedness – Continue to
provide Pennsylvania physicians with
important information, such as local
and state guidelines, how to put on and
remove personal protective equipment,
identification of containment facilities,
and access to sensitive and specific
surveillance tools. PAMED will continue to work with the Pennsylvania
Department of Health and other state
preparedness partners to ensure that
health care facilities are prepared in
the event that Pennsylvania faces an
Ebola outbreak.
• Medicare coverage of vaccines
– Aggressively petition the Centers
for Medicare and Medicaid Services
(CMS) to include tetanus and Tdap at
both the “Welcome to Medicare” and
Annual Medicare Wellness visits, and
Bulletin / November 2014
Special Report
John G. Krah / ACMS Executive Director
Members of the ACMS Delegation attend the House of Delegates meeting in Hershey Oct. 25.
other clinically appropriate encounters,
that allows for coverage and payment
of these vaccines to Medicare recipients who have not been vaccinated
within the past 10 years.
• Barriers to getting health care –
Work with insurers to provide payments
to physicians and physician-supervised
designees for medications, vaccines,
and their administration, without the
burden of prior-authorization or any
other administrative barriers.
• Telemedicine – Work with stakeholders to evaluate the different applications and uses of electronic technology to adopt standard definitions of
what constitutes telemedicine, identify
standards for coverage and payment
for the use of telemedicine, and work to
establish policy in Pennsylvania for the
licensure of providers and payment for
services.
• Urgent care clinics – Work to
educate urgent and retail clinics on the
Bulletin / November 2014
importance of transmission of point
of service patient medical records to
primary care physicians and specialists, and investigate any complaints of
non-disclosure of medical records by
a facility due to alleged financial and
network associations.
• Single national narcotic provider
number – Ask the AMA to continue
to work with the Drug Enforcement
Administration (DEA) and Congress
to move toward a system in which
individual physician DEA registration
numbers are person-specific rather
than site-specific within a state.
• Unification of GME accreditation
standards – Seek legislation to: 1) drop
the licensure requirement for DOs to
do at least one AOA approved year;
and 2) make the number of required
GME years the same, whether for
DOs or MDs, to get a full, unrestricted
license.
• Independent practice access to
facilities and insurance program participation – Seek legislation to provide
access to participation in insurance
networks and hospital facilities for
independent physicians that meet the
accepted quality measures.
• Hospital privileges for private
practice physicians – Pursue legislation
concerning the enforcement of the
Community Benefit Standard in Pennsylvania; research ways to provide
legal support to aid PAMED member
physicians who are impacted by hospitals’ exclusionary tactics; and work to
maintain private physician health care
network relationships.
• Contracts with insurers – Pursue
fairer insurer contracts and consider
support of legislation to provide for contracts between insurers and networks
to assure access to care with a level of
insurance coverage for patients.
• Universal Patient Transfer Form –
Work with state government agencies
465
Special Report
and hospitals to develop a Universal Patient Transfer
Form (UPTF) and an understanding of how it will work in
Pennsylvania.
• Membership dues – The PAMED Board, working with
the Membership Task Force, will be studying alternative
dues models. At the annual meeting, members provided
a lot of good feedback and ideas that will be incorporated
into the task force’s discussion.
*Reprinted with permission from the Pennsylvania
Medical Society.
The ACMS Delegation was led by Amelia A. Paré, MD,
FACS, ACMS Delegation chair; and Christopher Daly,
MD, ACMS Delegation vice chair.
ACMS Delegation
Taiwen Chen, MD
Douglas F. Clough, MD
Patricia L. Dalby, MD
Christopher J. Daly, MD,
Vice Chair
M. Sabina Daroski, MD
David J. Deitrick, MD
H. Jordan Garber, MD
Kevin O. Garrett, MD,
FACS
Sharon L. Goldstein, MD
Mark A. Goodman, MD
Mindy B. Hutchinson, MD
Lawrence R. John, MD
Ronald A. Landay, MD
Phillip R. Levine, MD
Jan W. Madison, MD
Deval M. Paranjpe, MD,
FACS
Amelia A. Pare, MD,
FACS, Chair
Gerald W. Pifer, MD
John P. Williams, MD
William F. Coppula, MD
Lora A. Cox-Vance, MD
Todd M. Hertzberg, MD
Bruce L. Wilder, MD, JD
*Prabir K. Mullick, MD
*William Simmons, MD
*Carl A. Sirio, MD
*Rajiv R. Varma, MD
*John F. Delaney Jr, MD
*Bruce A. MacLeod, MD
Medical students:
Ryan Williamson
Ben Ware
Alexis Chidi
Reportable Diseases
2014: Q3
Allegheny County Health Department
Selected Reportable Diseases
Jan.–Sept.
Disease/Condition
2014
2013
Campylobacteriosis
Cryptosporidiosis
Shiga-toxin producing Ecoli
Giardiasis
Guillain-Barre Syndrome
Hepatitis A
Hepatitis B (acute)
Hepatitis C (confirmed)
Legionellosis
Listeriosis
Malaria
Meningitis, Viral
Haemophilus influenza
Invasive Disease
S. pneumoniae Invasive
Disease, drug resistant
Meningococcal Invasive Disease
Pertussis
Salmonellosis
Shigellosis
West Nile Virus Infection
Tuberculosis
AIDS*
HIV*
Gonorrhea
Chlamydia
Syphilis, Primary & Secondary
Carbon Monoxide Poisoning
2012
78 129118
2122 21
4
34
13
5596 62
9
10
4
4
4
8
11
8
1
848
734
701
5294 55
23 3
34 6
25
35
56
8
19
20
0
3
0
0
2
2
9946 209
77 105127
79 10
0
0
2
1615 17
5290 87
116147 137
1,5862,171 2,392
4,2906,095 6,442
44
24
55
9
13
26
*Subject to adjustment due to lag in case reporting.
Disease reports may be filed weekdays during regular business
hours from 8:30 a.m. to 4:30 p.m. by calling 412-578-8060.
At all other times, please call the Health Department’s 24-hour
telephone line, 412-687-2243.
For display or classified advertising information,
call Bulletin Managing Editor Meagan Welling
at (412) 321-5030, ext. 105; email [email protected];
or visit www.acms.org.
466
Bulletin / November 2014
Proud to be endorsed by the Allegheny County Medical Society
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