June 2009 Bulletin - Allegheny County Medical Society

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June 2009 Bulletin - Allegheny County Medical Society

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BULLETIN

of the Allegheny County Medical Society

June 2009

ARTICLES PERSPECTIVES DEPARTMENTS

Materia Medica........................258

The JUPITER Trial: Implications for Practice

Thomas M. Barus, PharmD

Thomas L. Rihn, PharmD

Legal Report ............................262

Burger v. Blair Medical Associates: Who’s

Handling Your Medical Records Releases

Beth Anne Jackson, ESQ

Editorial................................... 246

Acute Myocardial Infarction: Comparing

Door-to-Balloon Times

Stuart G. Tauberg, MD, FACC, FACP

President’s Message ..................249

Get Involved in Meaningful Health

Care Reform

Douglas F. Clough, MD, FACP

Society News ........................... 250

♦ ACMS Medical Student Award

♦ Photos: senior health fair

♦ ACMS awards nominations

♦ Ophthalmology society

♦ Student intern

♦ Annual meeting of surgeons

Activities & Accolades .............252

Financial Health ......................266

Income-Based Loan Repayment: the Good,

the Bad and the Unintended

Michael Chapman, MD

Practice Management ..............270

The Patient-Centered Medical Home—

Is Your Practice Ready

Sherry Migliore, MPA, FACHE

Technology & Medicine ..........274

Is It Time for a Technology Checkup

Ed Strode

Special Report..........................277

Crisis Help Available to Residents in

Allegheny County

Profile ......................................278

A Prodigious Pair of Physician Musicians

Linda L. Smith

Perspective ...............................282

Reforms Needed to Alleviate Current

Health Care Crisis

Krishnan Gopal, MD, FACS


Make sure you

have finished

speaking before

your audience

has finished

listening.


—Dorothy Sarnoff

Cover Art:

The “Bean” at

Millennium Park,

Chicago

by Y. Erica Mak, MD

ACMS Alliance Update............253

From the Mailbag ....................255

Continuing Education .............256

Calendar ..................................257

HIPAA Q&A ........................... 281

Insurance FAQs .......................281

Editorial Index: Jan-June ‘09 ... 284

Ad Index: Jan-June ‘09 .............289

Classifieds ................................290

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Dr. Mak recently graduated in medicine from

the University of Pittsburgh.


2009

Executive Committee and

Board of Directors

President

Douglas F. Clough

President-elect

John F. Delaney Jr.

Vice President

Leo R. McCafferty

Secretary

Rajiv R. Varma

Treasurer

Amelia A. Paré

Board Chair

Adam J. Gordon

DIRECTORS

2009

Doris K. Cope

Lawrence R. John

Brian Miller

Anthony Spinola

James E. Wilberger Jr.

John P. Williams

2010

Parvis Baghai

Christopher J. Daly

David J. Deitrick

Steven Evans

Jon A. Levy

2011

Melinda M. Campopiano

Kevin O. Garrett

Donald B. Middleton

Adriana M. Selvaggio

G. Alan Yeasted

PEER REVIEW BOARD

2009

Leo R. McCafferty

Mark A. Goodman

Russell J. Sacco

2010

Alan A. Axelson

Terence W. Starz

2011

Krishnan A. Gopal

William M. Swartz

Affiliated with Pennsylvania Medical Society and American Medical Association

PMS DISTRICT TRUSTEE

Paul W. Dishart

COMMITTEES

Bylaws

Leo R. McCafferty

Communications

Amelia A. Paré

Finance

G. Alan Yeasted

Membership

John F. Delaney Jr.

Nominating

John F. Delaney Jr.

Occupational Medicine

Joseph J. Schwerha

ACMS ALLIANCE

President

Patty Barnett

First Vice President

Lois Levy

Second Vice President

Ruhie Radfar

Recording Secretary

Sandie Colatrella

Corresponding Secretary

Doris Delserone

Treasurer

Josephine Martinez

Assistant Treasurer

Sandra Da Costa

ADMINISTRATIVE STAFF

Executive Director

John G. Krah

(jkrah@acms.org)

Assistant to the Director

Dorothy S. Hostovich

(dhostovich@acms.org)

Bookkeeper

Susan L. Brown

(sbrown@acms.org)

Communications

Assistant

Elizabeth L. Fulton

(efulton@acms.org)

Bulletin

Medical Editor

Scott Miller

(millers8@upmc.edu)

Associate Editors

Melinda M. Campopiano

(campopianomm@gmail.com)

Michael P. Chapman

(chapmanmp@upmc.edu)

Fredric Jarrett

(jarrettf@upmc.edu)

Deval Paranjpe

(reshma_paranjpe@hotmail.com)

Stuart G. Tauberg

(tlindsey@nb.net)

Adam Z. Tobias

(tobiasa@upmc.edu)

Frank Vertosick

(vertosick@acms.org)

Gary S. Weinstein

(garyweinsteinmd@aol.com)

Managing Editor

Linda L. Smith

(lsmith@acms.org)

Contributing Editors

(bulletin@acms.org)

Ryan Greytak

Gregory B. Patrick

Heather A. Sakely

Carey T. Vinson

www.acms.org.

Assistant Executive Director,

Membership/Information

Services

James D. Ireland

(jireland@acms.org)

Manager

Dianne K. Meister

(dmeister@acms.org)

Assistant

Nadine M. Popovich

(npopovich@acms.org)

Leadership and Advocacy for Patients and Physicians

EDITORIAL/ADVERTISING

OFFICES: Bulletin of the Allegheny

County Medical Society, 713

Ridge Avenue, Pittsburgh, PA

15212; (412) 321-5030; fax (412)

321-5323. USPS #072920. PUB-

LISHER: Allegheny County Medical

Society at above address.

The Bulletin of the Allegheny County

Medical Society welcomes contributions

from readers, physicians, medical

students, members of allied professions,

spouses, etc. Items may

be letters, informal clinical reports,

editorials, or articles. Contributions

are received with the understanding

that they are not under simultaneous

consideration by another publication.

Issued the third Saturday of each

month. Deadline for submission of

copy is the SECOND Wednesday

preceding publication date. Periodical

postage paid at Pittsburgh, PA.

Bulletin of the Allegheny County

Medical Society reserves the right to

edit reader contributions for brevity,

clarity, and length as well as to reject

any subject material submitted.

The opinions expressed in the Editorials

and other opinion pieces

are those of the writer and do not

necessarily reflect the official

policy of the Allegheny County

Medical Society, the institution

with which the author is affiliated,

or the opinion of the Editorial

Board. Advertisements do not imply

sponsorship by or endorsement

of the ACMS, except where

noted.

Publisher reserves the right to exclude

any advertisement which in its opinion

does not conform to the standards of

the publication. The acceptance of

advertising in this publication in no

way constitutes approval or endorsement

of products or services by the

Allegheny County Medical Society of

any company or its products.

Subscriptions: $30 nonprofit organizations;

$40 ACMS advertisers, and

$50 others. Single copy $5. Advertising

rates and information sent upon

request by calling (412) 321-5030. Visit

www.acms.org.

COPYRIGHT 2009:

ALLEGHENY COUNTY MEDICAL

SOCIETY

POSTMASTER—Send address

changes to: Bulletin of the

Allegheny County Medical

Society, 713 Ridge Avenue,

Pittsburgh, PA 15212.

ISSN: 0098-3772


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EDITORIAL

Acute Myocardial Infarction:

Comparing Door-to-Balloon Times

STUART G. TAUBERG, MD, FACC, FACP

Much ado has been made lately tion is with a complex statistical for all of the routine STAT lab work

in minimizing door-toballoon

analysis in which multiple factors for to get back before making the

times in acute myocardial each organization and individual are determination whether or not the

infarction. This is the time it takes presented and undergo complex patient should go to the cath lab. In

for the patient to present to the scrutiny. It would be very difficult to fact, hospitals and physicians are

emergency room door until he or simplify this for the lay public, the currently being pushed to make the

she has an open coronary vessel in emergency response system and cath lab decision earlier and earlier,

the cath lab after presenting with ST insurers.

without any labs being drawn at all.

elevation myocardial infarction. For instance, it is obvious that It appears to be the standard of

The national benchmark of 90 there will be an occasional outlier. care for medic units in the Pittsburgh

minutes or less is the “gold standard” This is the patient who takes quite a

region now to make a diagno-

for ideal patient care.

long time to get from door to sis in the field with an EKG and to

However, when used as a measuring

balloon. The reasons for the delay call the emergency room doctor who

stick for hospital and physi-

could be many and could quite will then notify a cardiologist and

cian response times, it is not universally

possibly be well justified medically, the cath lab staff that a patient is

agreed upon as the best way to such as the need to rule out intracra-

coming in with an acute myocardial

calculate this measurement. nial event before going to the cath infarction. The cath lab staff and

It is easy to determine what the lab, or the need to resuscitate a cardiologist are often expected to act

door-to-balloon time is in a given patient from the field before going immediately without the diagnosis

case. However, for quality assurance to the cath lab, or the need to of acute myocardial infarction being

purposes, do we want to review consult GI or neurology or hematology

confirmed by an emergency depart-

hospitals’ and physicians’ mean

for clearance for anticoagulation ment electrocardiogram or brief

door-to-balloon time, or their before going to the cath lab. Already, emergency physician intake evaluation.

median door-to-balloon time, or cardiologists are pushed not to wait

their mode door-toballoon

Sometimes when this

time, or do we

happens, the patient

want to look at some other

arrives at the hospital with

sort of measurements

an equivocal EKG or

involving standard deviation

without an acute myocar-

that involve complex

dial infarction. Often the

statistics

patient arrives in the

Obviously, the fairest

emergency room with an

way to evaluate the situa-

acute myocardial infarc-

246

:

Bulletin June 2009


EDITORIAL

Before big business

and the media drive

medical standard of

care, a very complex

scientific evaluation

has to be performed.

tion. Occasionally the patient arrives

with an acute myocardial infarction,

and the physician who has been

called in from home to do the case

has to bow out for another cardiologist

whom the family or primary

care doctor prefers (when the patient

presents to a hospital that offers

freedom of choice).

Many of these delays are incorrectly

being laid at the doorstep of

the hospital or physician.

The push to perform cardiac

catheterization on individuals with

chest pain and possible myocardial

infarction will lead to an increased

number of patients going to catheterization

without acute myocardial

infarction and, in fact, without acute

coronary syndrome or coronary

artery disease altogether.

Based on historical statistics that

we are all taught in medical/osteopathic

school, you cannot change

the sensitivity without effecting the

specificity of a situation and vice

versa. If we wish to make sure that

every patient possible is taken to the

cath lab within 90 minutes of

presenting to the door, it is quite

possible that we will take patients to

the cath lab who do not actually

need to be there.

When there is an outlier whose

time to the cath lab is extraordinarily

long, whether it is for appropriate or

inappropriate reasons, should this

June 2009 : Bulletin

outlier be averaged into the physician

and hospital statistics as it

would be if the average were calculated

as a mean rather than a median

or mode or standard deviation

Since it is quite possible to have a

door-to-balloon time that is hours

and hours greater than 90 minutes,

but impossible to have a door-toballoon

time that is hours and hours

less than 90 minutes, there is some

statistical bias toward door-toballoon

times being calculated in a

misleadingly long manner if they are

calculated as a pure mean.

It is important to note whether

the receiving referral center calculates

the door-to-balloon time from

the time that the helicopter lands on

the roof until the artery is opened

(when a patient is coming from an

outlying hospital), or does this high

level referral center begin the clock

when the patient reaches the emergency

room at the outlying hospital

and include the time of the helicopter

and/or ground transportation to

the referral center It is important to

compare apples to apples in this

arena.

Before big business and the

media drive medical standard of

care, a very complex scientific

evaluation has to be performed. It is

important that emergency in-thefield

response teams and organizations

do not get caught up in the

public relations mania nor allow

pseudo-facts to dictate their referral

pattern. It would be ideal if a standardized,

unbiased and unaligned

group of local physicians were

consulted to help overview the data

that large insurers and medical

organizations are imparting to the

public. Let’s treat the patient, not

the door-to-balloon times.

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Dr. Tauberg specializes in cardiovascular

disease and serves as associate editor of the

ACMS Bulletin. He can be reached through

his medical assistant Tracie Lindsey at (412)

469-0600 or tlindsey@nb.net.

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.

STAY CONNECTED

New Phone or FAX Number

New address or e-mail

Be sure to let the medical society know.

That way you won’t miss out on any of the

great benefits you’re entitled to as a member!

E-mail acms@acms.org or

call (412) 321-5030 and ask for

Nadine Popovich (ext. 110) or Jim Ireland (ext. 101)

247


APPLICATION FOR MEMBERSHIP

Full Name(please print):

Office:

Home:

acms@acms.org www.acms.org M.E. #:

(Office Use Only)

Last First Middle

E-Mail: Office Fax:

Preferred Mailing Address: Office Address Home Address

Sex: Spouse’s Name:

Area Code & Phone Number

Area Code & Phone Number

Area Code & Phone Number

Birth Place: Date of Birth:

Education

Dates

Institution Location Degree/Specialty Begin End

Med School

Residency

Fellowship

Primary

Specialty:

Board

Certification:

Secondary

Specialty

Date

Certified:

License: PA No.: Date Issued:

Present Type of Practice:

Solo Two Physician Hospital (Non-Government)

Industry Medical School Government/Military

Group-

Name:

Other (Specify) ______________________

Present Hospital Appointments: Dates:

Dates:

Dates:

Within the last 5 years, have you been convicted of a felony crime Yes No. If yes, please provide full information.

Within the last 5 years, has your license to practice medicine in any Yes

No. If yes, please provide full information.

jurisdiction been limited, suspended or revoked

Within the last 5 years, have you been the subject of any disciplinary

action by any medical society or hospital staff

Yes

No. If yes, please provide full information.

If elected to membership, I agree to conduct myself professionally and personally according to the principles of medical ethics and to be governed by the Constitution and Bylaws

of the Allegheny County Medical Society and the Pennsylvania Medical Society.

I hereby release, and hold harmless from any liability or loss, the Allegheny County Medical Society, the Pennsylvania Medical Society, their officers, agents, employees, and

members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications and hereby release from any

liability any and all individuals and organizations, who, in good faith and without malice, provide information to the above named organizations, or to their authorized

representatives, concerning my professional competence, ethical conduct, character and other qualifications for membership.

I also authorize the above named organizations, in the consideration of my application, to make inquiry of any of my references and institutions by which I have been employed or

extended privileges, as to my qualifications. I further authorize any of the above persons or institutions to forward any and all information their records may contain and agree to

hold them harmless for any actions by me for their acts.

Date:

Signature:

11/24/08 jdi

TO INSURE PROMPT PROCESSING PLEASE COMPLETE ENTIRE APPLICATION.

:

248 Bulletin June 2009


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PRESIDENT’S MESSAGE

Get Involved in Meaningful Health

Care Reform

DOUGLAS F. CLOUGH, MD, FACP

Physicians and other health care

professionals provide the best

patient care possible using available

resources. The current debate

regarding health care reform seems

more focused on how to pay for

health care. The reimbursement

system seems to emphasize technology

over direct hands-on patient

care, but technology does not

provide health care. Medical professionals

who use technology provide

care.

To often, the culture of large

organizations and institutions seems

to indicate that it is the job of

medical professionals to support

them. For meaningful health care

reform to take place, this must

change. It should be the mission of

hospitals, health care systems and

insurance companies to support the

efforts of medical professionals in

delivering health care. Health care is

delivered at a grass roots level on a

one-to-one basis for individual

patients.

For health care reform to truly

work, medical professionals who

actually provide direct patient care

need to become more involved in

the process of change. Without

meaningful involvement of these

June 2009 : Bulletin

medical professionals, it is my fear

that reform of our current health

care system—which is so desperately

needed—will fail.

The Allegheny County Medical

Society, to the best of its abilities,

will represent all practicing physicians

and their patients in the health

care reform process. To do this, the

medical society needs ongoing

support and input from our physician

members.

I urge you to call (412) 321-

5030, e-mail the medical society at

acms@acms.org or speak to any

physician on the medical society’s

ALLEGHENY

COUNTY

MEDICAL

SOCIETY

Member Benefit

Insurance Programs

Auto

Homeowner’s

Disability

Long Term Care

Health

Dental

executive committee, board of

directors, peer review board or

committees about your concerns and

ideas on reforming our health care

system. See page 244 of this issue of

the Bulletin for a complete listing of

these individuals.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○


Dr. Clough is a specialist in general internal

medicine and 2009 ACMS president; he can

be reached at clough@acms.org.

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.

Contact the plan administrator for details.

USI Insurance Services 724-873-8150

249


SOCIETY NEWS

Medical Student Award (l. to r.): ACMS President-elect John

Delaney Jr., MD, award recipient Alik Widge, MD, and ACMS

board member John Williams, MD. See article below.

More than 1,100 senior city residents attend April’s Senior

Healthy Living Expo at the IBEW Circuit Center on the South

Side; Pittsburgh Mayor Luke Ravenstahl and Citiparks co-hosted

the event. In May nearly 8,000 attended State Senator Jane Orie’s

13 th annual Senior Expo at CCAC North in McCandless.

ACMS Medical Student Award

The medical society recently recognized

three medical school graduates

with its Medical Student Award.

ACMS board member John Williams,

MD, presented the award to

Alik Widge, MD, at the University

of Pittsburgh School of Medicine

senior awards ceremony. ACMS

President-elect John Delaney Jr.,

MD, also attended the event.

Drs. Kathryn Hickle, Temple

University School of Medicine, and

Vanessa Papalazaros, Drexel University

College of Medicine, accepted

their awards in Philadelphia.

The award recognizes fourthyear

medical students attending

school in Allegheny County who

have demonstrated good academic

performance, extraordinary interpersonal

traits and extracurricular

service, and active involvement in

organized medicine.

These prestigious awards recognize

member physicians who have made

extraordinary contributions to

medicine and humanity, as well as to

the medical society.

ACMS also is accepting nominations

for the Benjamin Rush awards

that recognize lay individuals and

organizations for outstanding contributions

to the health and welfare of

citizens of Allegheny County on

behalf of the medical profession.

For more information and a

nomination form, visit www.acms.

org or call Elizabeth Fulton at (412)

321-5030. Nominations for 2009

are due at the society office by

October 2.

Ophthalmology society

Members of the Pittsburgh Ophthalmology

Society and their families

are invited to attend the Pittsburgh

Vintage Grand Prix, July 19,

at Schenley Park. Mark your calendars

now and contact Dianne

Meister at (412) 321-5030 or

dmeister@acms.org to register or for

more details on this second annual

Student intern

Ann E. Miller is

serving a student

internship at the

medical society

office this summer.

She is working on

a variety of

projects, including

following national health care

Ms. Miller

reform proposals, writing a Bulletin

article on the electronic health

record pilot in Pittsburgh and

compiling a resident director database.

Ms. Miller is an undergraduate

honors student at The Pennsylvania

State University, where she is majoring

in health policy and administration.

Last year she was a select

member of the Women’s Leadership

Initiative, a leadership building

program in the College of Health

and Human Development. She has

participated in the Penn State Dance

MaraTHON for three years and

spent last summer studying abroad

in Rome, Italy.

ACMS Awards nominations

Nominations are accepted yearround

for the Frederick M. Jacob,

Nathaniel Bedford, Ralph C. Wilde

and Physician Volunteer awards. social event.

:

250 Bulletin June 2009


SOCIETY NEWS

Area residents presented at annual meeting of surgeons in May

(l. to r.): Sohail Shah, UPMC Presbyterian Hospital; Julie Ann

Corcoran, DO, Conemaugh Medical Center, Johnstown; Geoffrey

B. Pelz, MD, Allegheny General Hospital; and Tracee Short, MD,

UPMC Mercy.

Annual meeting of surgeons

The annual meeting of the Southwestern

PA Chapter of the American

College of Surgeons and the Pittsburgh

Surgical Society was held May

8-9 at Nemacolin Woodlands

Resort. The weekend opened with a

reception in the Malachite Room at

Falling Rock and presentations by

four outstanding residents from

local surgical programs (see photo,

above left), including Sohail Shah,

MD, UPMC Presbyterian, for

Embryonic blood flow regulates

pancreatic differentiation; Julie Ann

Corcoran, DO, Conemaugh Medical

Center, Johnstown, for The

accuracy of self-reported vs. witnessed

loss of consciousness in DX Grade III

Concussion; Geoffrey B. Pelz, MD,

Allegheny General Hospital, for

Drive line infections in patients

undergoing placement of left ventricular

assist devices (LVADs) using two

different techniques; Tracee Short, MD,

UPMC Mercy, for Are high volume

surgeon’s skills transferrable between

quality institutions

Saturday’s program included

Complication of colon & rectal

June 2009 : Bulletin

surgery, James Celebrezze, MD;

Preventable trauma events, Juan

Puyana, MD; What Price Quality

David Lerberg, MD; Identifying and

preventing retained post-operative

foreign bodies, Kurt Stahlfeld, MD;

Can surgeons really learn about patient

safety from pilots James M.

McGreevy, MD (formerly of Pittsburgh,

now at the University of Utah

Medical Center, Salt Lake City);

CMS “Never Events,” Medicare

payment system and Model Home

programs, Andrew W. Gurman, MD

(vice speaker of the AMA House of

Delegates, PA); College of Surgeons,

Board of Governor’s Report, Kevin

Garrett, MD (chapter governor);

American PA Commission on Cancer

Report, T. Clark Gamblin, MD

(COC state liaison); and Report from

the PA State Committee on Trauma,

Juan Puyana, MD (member, Pennsylvania

State Committee on

Trauma).

Saturday afternoon’s family

outdoor activities included the grand

opening of Nemacolin WOOFlands,

visiting the wild animals at the

Wildlife Academy, Kidz Club events,

ACS Chapter President Kathleen Erb, MD, announced that a

$500 grant would be available for Sohail Shah, MD, to attend the

College’s Clinical Congress in the fall for his presentation on

embryonic blood flow. Pictured (l. to r.) are Kevin Garrett, MD

(chapter governor), and Drs. Shah and Erb.

Drs. Stahlfeld and Erb (see below)

the spa and shooting range. At

dinner, Dr. McGreevy discussed his

love of flying and time spent in

active military service in Iraq. Dr.

Kathleen Erb presented a plaque to

Kurt Stahlfeld, MD, immediate past

president, in recognition of his

service to the chapter.

Highmark Blue Cross Blue

Shield sponsored Saturday’s dinner.

Watch for an announcement of

an open council meeting to be held

in September, when all members will

be invited to attend to discuss

chapter activities and provide input

for future meetings.

251


ACTIVITIES & ACCOLADES

Headshots

Needed

ACMS Treasurer Amelia Paré, MD (third from right), represented the medical society on

April 30 in a panel discussion at Consumer Health Coalition’s Catalysts for Better Care:

Engaging Patients to Improve Health Outcomes. The panel discussed ways patients can

become more actively involved in their health care.

ACMS members! Please send a

recent headshot photo of yourself for

the medical society’s files for use in

Bulletin articles

Files in jpeg or tiff format can be sent

via e-mail to lsmith@acms.org. Send

prints to Elizabeth Fulton at ACMS,

713 Ridge Avenue, Pittsburgh, PA

15212. Please indicate whether or not

you would like them returned.

The American

Society for Aesthetic

Plastic Surgery

(ASAPS) recently

elected Leo R.

McCafferty, MD,

Dr. McCafferty

plastic surgery, as its

secretary. Dr. McCafferty also serves

as chair of the Administrative

Commission for ASAPS and vice

president of the ACMS.

The American

Society for Investigative

Pathology

(ASIP) recently

honored George K.

Michalopoulos,

MD, medical Dr. Michalopoulos

oncology, with its Rous-Whipple

Award. The award is presented

annually to a scientist who has a

distinguished career in research and

continues to advance the understanding

of disease. Dr.

Michalopoulos’ research on the

pathways of growth factors that lead

the liver to regenerate led ASIP to

honor him with this award.

The East Liberty

Family Health Center

honored Donald B.

Middleton, MD,

internal medicine,

and Jeanette South-

Paul, MD, family

medicine, at its

Fanfare for the

Common Man event

in May as two of its

25 Common People

who Advance our

Mission Uncommonly

Well!

Dr. Middleton

Dr. South-Paul

Cyril H. Wecht, MD,

JD, legal medicine, is

editor of Preparing

and Winning

Professional Negligence

Cases. The book

highlights areas of Dr. Wecht

practical concern and special interest

for physicians and plaintiff and

defense trial attorneys who deal with

medical malpractice litigation.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○


Send your Activities & Accolades items to

Elizabeth Fulton at ACMS, 713 Ridge Ave.,

Pittsburgh, PA 15212 or e-mail efulton@

acms.org. We also encourage you to send a

recent photograph indicating whether it needs

to be returned.

:

252 Bulletin June 2009


ACMS ALLIANCE UPDATE

ACMS Alliance

Membership Application

First Name/middle init. ________________

Last Name __________________________

Address ____________________________

City/State/Zip _______________________

Phone (area code) ____________________

Fax (area code) ______________________

Email ______________________________

Please Indicate:

___new member

___resident spouse

___reinstated

___child

Make checks payable to ACMS Alliance

Mail to: ACMS Alliance

713 Ridge Avenue

Pittsburgh, PA 15212

(l. to r.) Patty Barnett, Joyce Orr, Dr. Arthur Levine, Tina Purpura and Sandra Da Costa.

Check presentation

Represented by Patty Barnett, Joyce

Orr, Tina Purpura and Sandra Da

Costa, the ACMS Alliance presented

a check for $2,200 to Dr. Arthur

Levine at the University of Pittsburgh

for the AMA Foundation,

with proceeds to benefit the University

of Pittsburgh Medical Scholarship

Fund. The funds came from the

alliance’s Fall Fiesta Fashion Show,

held last October. Ms. Orr was

allliance president at the time and

Ms. Barnett, Purpura and Da Costa

co-chaired the event.

2009-2010 ACMS Alliance officers

The alliance installed its new officers

on May 9 at its International

Brunch and Doctor’s Recognition,

held at the South Hills Country

Club. The names of the new officers

appear in the box, above right. The

group kicked off its new year at a

June 9 luncheon.

June 2009 : Bulletin

ACMS Alliance Officers

Patty Barnett, President

Joyce Orr, Immediate Past-president

Lois Levy, First Vice-president

Ruhie Radfar, MD, Second Vice-president

Josephine Martinez, Treasurer

Sandra Da Costa, Assistant Treasurer

Sandie Colatrella, Recording Secretary

Doris Delserone, Corresponding Secretary

Grace Ghoshhajra, Director

Rose Kunkel-Roarty, Director

Tina Purpura, Director

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○


The ACMS Alliance is an organization of

spouses and supporters of the Allegheny County

Medical Society membership. Information is

gleaned from the alliance’s newsletter, ACMSA

News Update. For information on becoming

a member of the ACMS Alliance, contact

Sandra Da Costa at (412) 343-2914 or Mary

Kay Schaner at (724) 941-5147 or visit

www.acms.org.

Dues:

County ..... $25 ($12.50/resident)

State......... $40 ($20/resident)

National ... $25 ($12.50/resident)

Total ........ $90 ($45/resident)

ACMS Medical Student

Scholarship...

$2,000 will be awarded

annually to each of two

qualified medical students.

For information on how to

apply for the ACMS Student

Scholarship or how to

contribute to the scholarship

fund, e-mail

studentservicesfoundation@

pamedsoc.org or call

(717) 558-7854.

(Note: The PMS

Foundation is

administering the

scholarship.)

253


Doctors and Patients. Preserve the Relationship. ®

Free. Members-Only Information

From the Pennsylvania Medical Society

Of the thousands of calls and e-mails we receive from Members every year, many concern the

same issues and questions. So, we’ve developed a series of brief publications that address

these common Concerns. They’re free and available only to Members.

Regulations

Practice Guidelines for Physician Assistants

and Certified Registered Nurse Practitioners

A resource for physician practices to understand licensure,

scope of practice, and reimbursement rules and

guidelines for these positions.

Setting the Record Straight: What You Need to Know

About Medical Records

From Ownership rights to copying fees, “Setting the

Record Straight” will help you make sure you’re handling

these vital documents appropriately and legally.

Disease Reporting

Includes lists of reportable diseases, how and where to

report, confidentiality rules and penalties for failing to

report.

Reimbursement

Act 6: A Crash Course in Auto Accident

Reimbursement

A concise run-down of the steps you need to take to get

appropriately reimbursed for care of patients injured in a

motor vehicle accident.

Your Right to Timely Payment Under Act 68

Provides details of physician’s rights under the Quality and

Health Care Accountability & Protection Act, including

provisions for prompt payment of clean claims within 45

days.

Collection Protocols for the Medical Practice

Manage your accounts receivable and prevent them from

becoming delinquent. “Collection Protocols” includes tips

on managing accounts and also useful collection techniques.

Workers’ Compensation:

The Application for Fee Review Process

FAQs and sample forms for when you have trouble getting

paid for workers’ compensation health care services or

when an insurer is making you wait for payment.

Practice Management

Policy and Procedural Manuals/Employee

Handbooks for Medical Practices

Use this brief publication to find out the basic information

that should be included in a comprehensive

employee handbook for your practice.

Selecting Computer Hardware

and Software for Your Medical Practice

Use this short paper to help you with the process of

selecting a practice management system for your

medical practice.

Setting Up a Practice—Areas to Consider

For physicians who are considering starting a practice.

With all there is to consider, you’ll probably miss

something without a checklist like this.

Medical Liability

Arbitration of Medical Liability Claims

Focuses on private arbitration outside the judicial

system that takes place if the physician and patient

have a voluntary agreement to engage in arbitration.

Medical Professional Liability Insurance Options

Basic information and definitions for physicians considering

new as well as traditional medical liability insurance

options.

Lawsuit Protection Strategies

Designed to be an instructional tool for physicians so

that they can have a more informed discussion with

their legal and financial advisors.

Order any of these publications

by calling (800) 228-7823

or on the Pennsylvania Medical Society

Web site store, www.pamedsoc.org/store.

:

254 Bulletin June 2009


FROM THE MAILBAG

May 21, 2009

It is indeed a gift to possess artistic

ability, as well as to have a mind for

science. Dr. Marryshow is one of

those enviable individuals. Once

again, he has shown us his artistic

side with his latest poetic accomplishment,

“Apologies To Mother

Earth” (Bulletin, May 2009, p. 222).

In it, he seeks forgiveness for all of

us—for our abusive treatment of the

earth and its creatures. The message

is very sobering and highly emotional,

presented in an expressive,

lyrical style. He draws the reader in.

He compels one to take heed. Bravo,

Dr. Marryshow!

Joseph Mazzei, MD

Diagnostic radiology

May 7, 2009

Hi Dr. Miller,

I had to write to tell you that your

article, “In Sickness and in Health,”

moved me to tears (Bulletin, April

2009, p. 146). We just lost our last

parent on Friday, March 13. All four

of our parents died at home on

hospice, and I am very proud of the

fact that we were able to grant their

wishes. But as the nurse in the

family, I can’t tell you how many

times I would cry myself to sleep

and just pray to have one more

moment as their “daughter” instead

of their “caregiver.”

My dad was the first one to go,

and he was only 60 years old. His

hospital bed was in my living room,

and I can still see it there even

though we have changed furniture

twice since then. My sister died very

suddenly two years ago, also at the

age of 60. While I still prefer having

the opportunity and blessing of

caring for the people we love, I was

June 2009 : Bulletin

very moved by your insight into

what happens to those of us who

care for the people we love and lose.

Thanks for the inspiration and

understanding.

Diane L. Karcz, RN

Gallagher Home Health Services

Dr. Miller’s response:

Hi Diane,

Thank you for your nice comments

concerning the editorial I wrote.

There are so many things about

providing health care in the home

setting that only those of us who

experience it regularly can relate to.

You certainly have my sympathy

concerning the recent deaths in your

family.

Scott Miller, MD, MA

Internal medicine and palliative care

May 19, 2009

Dear ACMS staff and

members of the

Board of Directors:

Today the movers are

coming, and tomorrow,

Jennifer and I

Dr. Widge

will set out on a

journey across the continent to

Seattle, where I’ll begin residency

training in psychiatry. While I’m

excited about the prospects for the

future, I’m leaving with a slightly

heavy heart, as I have to leave

behind so many excellent friends

and colleagues such as yourselves.

ACMS has been a bright spot in my

medical education since the very first

year, and I have always appreciated

the opportunity to learn from my

colleagues what it truly means to

serve our patients. Beyond that, I am

deeply grateful that you chose to

honor me with this year’s medical

student award. I treasure that recognition

far more than any of the

departmental or academic awards on

offer, because I know the quality of

the men and women who work to

select it each year.

Thank you for everything. Good

luck in the many battles to come as

America faces a health system

overhaul; and I hope to see at least

some of you again at future meetings.

Best wishes,

Alik Widge, MD, PhD

May 19, 2009

In response to Dr. Levine’s retort

(Bulletin, May 2009, p. 212), he did

not address the salaries of the administration

and board of directors

that add to the cost of tuition. He

did not address the cost of national

exams that add to medical student

debt. Additionally, medical schools

can use their endowment funds to

help pay for tuition. According to

the National Association of College

and University Business Officers

(www.nacubo.org/documents/

research/NES2008PublicTable-

AllInstitutionsByFY08MarketValue.

pdf), Harvard and the University of

Pittsburgh have over $30 billion and

$2 billion in endowment funds,

respectively. Yet, their tuition/fees

are over $45,000 (http://hms.

harvard.edu/admissions/default.

asppage=costs) and $30,000,

respectively. It sounds like medical

students could easily go to school for

free, medical schools could easily

balance their budget and no government

funds are needed.

Sundeep Ram, DO

255


Allegheny Medcare

Trust, quality and personal

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you expect anything less from

your medical supply company

CONTINUING EDUCATION

EIGHTH INTERNATIONAL CONFERENCE ON BIPOLAR DISORDER—

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Western Psychiatric Institute and Clinic & University of

Pittsburgh School of Medicine. E-mail bipolarconference@

upmc.edu or call (412) 802-6917. Visit www.8thbipolar.org.

23RD COMBINED SKIN PATHOLOGY COURSE—July 24-29, Hyatt

Regency International Airport Hotel. Sponsor: Medical Education

Resources. E-mail Tami Good at tami@mer.org. Or contact

Course Director Alan Silverman, MD, at 412-682-3083 or

asilverman@ameripath.com.

REGIONAL MENTAL HEALTH TRAINING SERIES—April-June 2009.

Sponsor: Western Psychiatric Institute and Clinic. Call Nancy

Mundy at (412) 802-6900 or visit www.wpic.pitt.edu/oerp for

more information.

HIV/AIDS TRAININGS—many available. Sponsor: Pennsylvania/

MidAtlantic AIDS Education and Training Center, various

locations. For information, visit www.pamaaetc.org.

Savings, Service and Solutions!

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○


This listing includes local events that are coming up soon; a more

complete list is available on the medical society’s website at

www.acms.org or by calling (412) 321-5030.

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supplies and costs quickly and easily.

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:

256 Bulletin June 2009


JUNE/JULY CALENDAR

June is the month for the following national awareness

programs: scleroderma, aphasia, scoliosis and

home safety. June 1-July 4 is Fireworks Safety

Month and June 27-July 5 is Eye Safety Awareness

Week. (Source: U.S. Dept. of Health and Human

Services, www.healthfinder.gov/library/nho/).

June 23, 5:30 pm ........... ACMS Foundation Board

July 3 .............................. ACMS office closed for holiday

July 8, 8-9:30 am ............ Committee for Quality at End of Life

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Many hands make light work.

...Too many cooks spoil the broth.

Clothes make the man.

...Don’t judge a book by its cover.

Nothing ventured, nothing gained.

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Absence makes the heart grow fonder.

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June 2009 : Bulletin

257


○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

MATERIA MEDICA

The JUPITER Trial:

Implications for Practice

THOMAS M. BARUS, PharmD

THOMAS L. RIHN, PharmD

Coronary heart disease (CHD) remains the

number one killer of American males and

females. 1 Dyslipidemia is a critically important,

major independent risk factor for CHD. The prevalence

of total cholesterol (in adults age 20 and older) at or

above 200 mg/dL exceeds 105 million in the U.S

(50,800,000 males; 55,900,000 females). This represents

about 48 percent of the adult population. 2

The Justification for the Use of Statins in Primary

Prevention: An Intervention Trial Evaluating

Rosuvastatin (JUPITER) trial is beginning to impact

clinical practice today. Health care practitioners are

attempting to define the “right way to practice,” considering

the results of this study. Is there a clear answer

JUPITER trial design

The JUPITER trial was a randomized, double-blind,

placebo-controlled, multi-center trial conducted at

1,315 sites in 26 countries.

The trial randomly assigned

17,802 apparently

healthy men and

women with

lowdensity

lipoprotein (LDL) cholesterol levels of less than

130 mg/dl and high-sensitivity C-reactive protein (hs-

CRP) levels of 2.0 mg/L or higher to rosuvastatin

(Crestor), 20 mg daily, or placebo. Patients were followed

and assessed for the occurrence of the combined

primary end point of myocardial infarction, stroke,

arterial revascularization, hospitalization for unstable

angina, or death from cardiovascular causes. 3

Potential impact of JUPITER

The results of the JUPITER trial indicated that

rosuvastatin was associated with a significant reduction

(~50% reduction) in major cardiovascular events,

defined as nonfatal MI, nonfatal stroke, unstable angina,

arterial revascularization, or cardiovascular death in

apparently “healthy individuals” with an LDL-cholesterol

(LDL-C) 2mg/

dL. The study was terminated early after a median of 1.9

years of follow-up (planned

maximum follow-up was five

years).

:

258 Bulletin June 2009


MATERIA MEDICA

Low Risk ... High Risk

Considering the findings of the trial, Dr. Erica Spatz

(Yale University School of Medicine) and colleagues

estimate that an additional 19.2% of adults with elevated

high-sensitivity C-reactive protein (hs-CRP) and

normal LDL-cholesterol levels are candidates for primary

prevention with statin therapy. 4 In middle-aged

and older populations, there are already a huge number

of individuals—58%, or 33 million Americans—who

meet the current recommendations for statin therapy. “If

we adopt the findings of the JUPITER trial in clinical

practice, this would add 11 million individuals, or

another 20% of the population,” Dr. Spatz says.

Contemporary practice

The New England Journal of Medicine created a poll

for practitioners to assess whether they will change their

practice on the therapeutic use of statins or laboratory

practices based on the study results. The results (disclosed

November 10, 2008) showed 26% said the trial

will likely significantly impact their prescribing; 22%

appeared indeterminate; and 52% say the study will not

likely effect prescribing.

“This trial is very thought provoking and could lead

to more general use of statins as a whole,” says Dr.

George Sokos, Allegheny General Hospital’s associate

program director of cardiovascular disease fellowships

and assistant professor at Drexel University College of

Medicine. Dr. Sokos agrees that JUPITER provides

enough evidence to change practice. “I have ordered

CRP in all patients with a strong family history of CHD

and in some patients with no other risk factors,” he says.

Patients currently eligible for statin therapy are

June 2009 : Bulletin

Figure 1. LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes

and Drug Therapy in Different Risk Categories

Risk Category LDL-C Goal (mg/dL) LDL-C level at which to

initiate therapeutic

lifestyle changes

CHD or other

vascular disease

(peripheral, carotid

disease)

Risk equivalents

such as DM

(10 yr risk >20%)

2+ risk factors

(10 yr risk 190

(160-189; LDL lowering

drug optional)

designated by the Third

Report of the Expert Panel on

Detection, Evaluation, and

Treatment of High Blood

Cholesterol in Adults (Adult

Treatment Panel III). Updates

from 2004 by the American

College of Cardiology

Foundation are included and

summarized in Figure 1. 5,6

Economic considerations

The cost of statin

therapy to the patient is a

concern surrounding the

JUPITER results. If

rosuvastatin, available only as a brand name (Crestor), is

prescribed more frequently, many patients will find

themselves paying higher co-payments. Medicare patients

may reach the “donut-hole,” a period of 100

percent patient-incurred, out-of-pocket cost, more

quickly with the average yearly cost of Crestor at

~$1,200.

“Based on a cost of $116 per month for Crestor,

treatment of the sub-population represented by JUPI-

TER participants would total approximately $557,000

to save a life each year, according to an estimate. Generic

statin therapy (at ~$5 per month) would cost ~$24,000

to save a life each year. The cost figures reflect only

patient expenses for drugs and do not include the cost of

physician visits or testing.” 7

For example, payers such as Caremark, a leading

pharmacy benefits manager (PBM), have shown that

compliance to a medication significantly declines as copayments

exceed $10 per drug monthly. Crestor currently

hovers between a “Tier 2” and “Prior Authorization

Only” medication reimbursement. The co-pays at

these levels are almost always greater than $10.

Current hs-CRP lab tests cost an average of $50,

according to Quest Diagnostics. Alternative testing is

available as a screening mechanism using a CholesTech

LDX machine, where one cartridge is priced at approximately

$10, but does not include staff salaries or other

supplies. “Perhaps the greatest value of the CRP will be

in further stratifying patients determined to be at an

immediate risk for more aggressive therapy.” 7

continued on page 260

259


MATERIA MEDICA (from page 259)

A marketing ploy

The JUPITER trial was financially supported by

AstraZeneca, the manufacturers of rosuvastatin

(Crestor). The sponsor had no role in the conduct of

analysis or drafting of manuscript, and it had no access

to unblinded trial data until after submission. 3 The

advantage for AstraZeneca’s sponsorship is obvious; they

will be first-to-market with respect to the evidence-based

reduced LDL and CRP outcomes. Since statins, as a

class, lower levels of high sensitivity C-reactive protein as

well as cholesterol, does rosuvastatin do this more

effectively than others The makers of atorvastatin

(Lipitor) have said that their ASCOT and CARDS

studies are not “dissimiliar,” based on the enrolled

patient’s baseline LDL levels. AstraZeneca may find itself

with a short-lived clinical advantage if other statins are

proven to have similiar results or are perceived to have

similar results.

Team-based approach

Clinical pharmacists have recently focused on the

results and implications of the JUPITER trial. Currently,

dyslipidemia treatment is an opportunity for reimbursable

medication therapy management (MTM) services.

Should pharmacists begin to identify statin eligible

patients A shift of this nature would likely enhance the

identification of disease, increase physician visits, increase

disease awareness and decrease overall health care

costs. Pharmacists are not diagnosticians; however, by

implementing a diagnostic algorithm including certain

risk factors, the pharmacist may be in a good position to

identify patients needing treatment, considering that

they practice in the most accessible of health care settings.

By combining the skills of both the physician and

the pharmacist, future screening mechanisms should

enhance patient outcomes. This team-based approach to

dyslipidemias can only produce favorable outcomes.

Unanswered questions

A primary concern about the JUPITER trial results

seems to be the absence of long-term data, especially

since the potential expanded use would be for such a

:

260 Bulletin June 2009


MATERIA MEDICA

large population for chronic use. 7 Another major concern

may be the finding of increased physician-reported

diabetes. However, similar cases have been reported in

studies of pravastatin, simvastatin and atorvastatin.

Analysis of the follow-up period of JUPITER showed no

differences between study groups. An additional area

where more research is necessary is determining whether

the benefit seen in JUPITER was due to the reduction

in LDL levels or because of the lowered CRP levels. At

the 12-month point, the rosuvastatin group showed a 50

percent lower median LDL level and a 37 percent lower

CRP level. 3

The rosuvastatin arm in the JUPITER trial showed a

median LDL range of 53-55 during the 12 to 48 month

follow-ups, while the placebo groups had an LDL

median range of 106-110. In healthy individuals, will

this difference affect other physiologic systems such as

steroid synthesis Have the long-term effects of lowered

LDL levels to ~50 mg/dl been studied and proven safe in

otherwise normally healthy individuals

Pleiotropic effects of statins include improvement of

endothelial dysfunction, increased nitric oxide

bioavailability, antioxidant properties, inhibition of

inflammatory responses and stabilization of atherosclerotic

plaques. 8 Does rosuvastatin effectively lower CRP

more than other statins Practitioners currently prescribe

statins interchangeably after dose adjustments. Can this

recent data be extrapolated across the statin class to

atorvastatin, simvastatin, pravastatin, lovastatin and

fluvastatin Utilizing statins in asymptomatic, apparently

healthy patients may not be free of potential conse-

quences. Further studies are necessary to prove that the

cost and safety of such an approach outweigh any risks.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○


Mr. Barus is a recent PharmD graduate from Duquesne University

School of Pharmacy. Dr. Rihn is associate professor of clinical practice,

Duquesne University School of Pharmacy. They can be reached at

(412) 396-1295.

REFERENCES

1

Center for Disease Control. Compressed mortality file: underlying

cause of death, 1979 to 2004; http:// wonder.cdc.gov/

mortSQL.html)

2

American Heart Association. Heart Disease and Stroke Statistics—2008

Update.

3

Ridker PM, Danielson E, Fonseca FA et al. Rosuvastatin to

prevent vascular events in men and women with elevated

C-reactive protein. New Engl J Med 2008; DOI: 10.1056/

NEJMoa0807646. Available at: www.nejm.org.

4

O’Riordan M. One in five middle-aged adults newly eligible for

statins based on JUPITER. January 14, 2009. www.theheart.org

5

JAMA MAY 16, 2001;285:2486-97, www.nhlbi.nih.gov JACC

2004;44:720-732

6

Expert Panel on Detection, Evaluation and Treatment of High

Blood Cholesterol in Adults. Executive summary of the Third

Report of the National Cholesterol Education Program (NCEP)

Expert Panel on Detection, Evaluation, and Treatment of High

Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA.

2001; 285: 2486–2497.

7

Olsen C, Diller W. AstraZenecas JUPITER Study Brings

Challenges for Crestor Marketing. The Pink Sheet. November

17,2008.

8

Davignon J. Atherosclerosis: Evolving Vascular Biology and

Clinical Implications, Beneficial Cardiovascular Pleiotropic Effects

of Statins. American Heart Association. Circulation. 2004;109:III-

39–III-43.

Where-to-Turn cards give important information and phone

numbers for victims of domestic violence. The cards are the

size of a business card and are discreet enough to carry in a

Quantities of cards are available at no cost by contacting

Allegheny County Medical Society at 412-321-5030.

June 2009 : Bulletin

261


○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

LEGAL REPORT

Burger v. Blair Medical

Associates: Who’s

Handling Your Medical

Records Releases

BETH ANNE JACKSON, ESQ

Diana Burger (Plaintiff) was treated by a Blair $60,000. The physician was not held personally liable.

Medical Associates (BMA) physician from BMA appealed, arguing that the gravamen of Plaintiff’s

1996 until 2001. 1 In October 1999, Plaintiff claim was an “invasion of privacy,” subject to a one-year

signed an authorization that permitted BMA to release statute of limitations, not a “breach of physician-patient

medical records to her employer’s workers’ compensation

confidentiality,” subject to the general two-year statute

consultant for the purpose of calculating medical of limitations. Ultimately, the matter went to the Penn-

expenses incurred as a result of the Plaintiff’s workrelated

sylvania Supreme Court, which decided in February

injury. BMA, which had a new electronic medi-

2009 that the two-year statute of limitations applied.

cal records system, released the medical record to the

workers’ compensation consultant, including the Import

patient’s social history that stated that the Plaintiff

Attorneys reviewing this case note to themselves that

smoked marijuana daily and took non-prescribed, a breach of physician-patient confidentiality claim is

prescription pain medications. How the information potentially viable for two years. Physicians, however,

reached the employer was not established at trial. Plaintiff

was subsequently fired based on her drug use and First, physicians have always been required to comply

should take several other valuable lessons from this case.

sued BMA and her physician nearly

with the parameters of a release under

two years later for breach of physician-patient

confidentiality, seek-

privacy rules—issued after this case

the common law. The HIPAA

ing approximately $500,000 in

was tried—only made it a regulatory

requirement. The privacy

damages.

At trial, Plaintiff argued

rules require that “when a

that the release of this information

was not related to the

a valid authorization for its use

covered entity obtains or receives

medical expenses occasioned by

or disclosure of protected health

her work-related injury; the

information, such use or disclosure

must be consistent with

jury agreed, awarding damages

from BMA to the Plaintiff in

such authorization.”

the amount of approximately

Second, because of the

262

:

Bulletin June 2009


LEGAL REPORT

damages demanded and awarded, and the nearly eight

years of litigation that followed, treating physicians

should consider personally reviewing the content of

records being released pursuant to an authorization, 2

especially in litigation-oriented treatment situations

(e.g., personal injury caused by third party, workers’

compensation). When this is not practicable, this

function may be delegated to a privacy officer with a

clinical background; however, all questions regarding

medical relatedness must be referred to and decided

upon by the treating physician.

Third, when using electronic medical records, be

aware of sections that automatically fill in from prior

entries. The information in such sections may have no

relevance to the purpose of the disclosure and, therefore,

may need to be redacted.

Finally, physicians may want to give some thought as

to whether, how and where sensitive information should

be included in the treatment notes for work-related and

other injury situations in which the records are likely to

be disclosed to third parties.

Although a patient’s use of illicit drugs will certainly

affect a physician’s treatment regimen and must be

documented, if the drug use is not related to the

patient’s work-related injury or condition, such references

will either need to be redacted prior to release of

the records or documented separately and not disclosed.

This approach should also be used with respect to

information specially protected under Pennsylvania and

federal law (HIV, records of mental health treatment,

substance abuse records), as well as other sensitive

information that could compromise a patient’s reputation.

As noted above, the use of electronic medical

records complicates this process as the software templates

essentially dictate where information may be

recorded, potentially raising the risk of inadvertent

unauthorized disclosure if users of the system are not

careful.

Policy and procedure recommendations

Each practice should already have in place a records

disclosure procedure that designates who reviews the

continued on page 265

M edicine is like a labyrinth –

a maze of pathways, each beckoning

exploration to uncover new information

that could benefit our health. Yet in spite

of this complexity, medicine’s greatest

achievements have been the simplest –

the products of intense focus.

At West Penn Allegheny Health System,

we choose to place all of our resources –

indeed our entire focus – exactly where

they belong: at home, in western

Pennsylvania, on improving the health

of our patients.

The West Penn Allegheny Health System –

one purpose, one mission.

One Purpose. One Mission.

www.wpahs.org

June 2009 : Bulletin

263


:

264 Bulletin June 2009


LEGAL REPORT (from page 263)

authorization, pulls the chart and copies or prints

relevant information, as well as the time frames within

which such tasks are to be accomplished. Typically, the

privacy officer reviews and approves the records before

they are released. However, because it is ultimately the

physician’s legal responsibility to maintain physician–

patient confidentiality, physician practices should

consider amending such policies to require the treating

physician to personally review records before their

release, at least in cases in which litigation over the

causation of the condition treated is a possibility. (Note

that, while the treating physician was not held personally

liable in the BMA case, she was named in the initial

lawsuit and was a party in the trial phase.) The checklist

below may be utilized by the privacy officer and/or

treating physician to facilitate this process.

Medical records release checklist

Ensure that the authorization is valid.

• Is it filled out completely

• Is it signed and dated (Compare signatures.)

• Does it describe the information to be released

• Does it specify the purpose of the disclosure

• Has it expired or been revoked (Check the chart.)

• Is any of the information false that you know of

Review the substantive content of the records to be released.

• Does it contain specially protected information such

as HIV-related information, mental health treatment

or substance abuse

• If so, was that information specifically authorized to

be released

• Is all information to be disclosed related to the

purpose and limited to the scope of information

stated in the authorization (Pay attention to date or

event parameters.)

• If not, should the copies of the record be redacted

Address doubts or concerns.

• Are there any doubts or concerns about the authenticity

of the release (If so, contact the patient

directly to confirm its authenticity.)

• Is there information in the record that is related to

the purpose of the release and that the patient may

not be aware of and may not want to be released (If

so, review the information with the patient prior to

disclosing. This gives the patient the opportunity to

revoke the release and prepare a new one with a

more limited purpose or scope of information.)

• Is there a dispute between you and a patient or a

June 2009 : Bulletin

patient’s attorney regarding what can and cannot be

released (If so, contact your attorney prior to

releasing any records.)

Conclusion

The BMA case made it clear that, under Pennsylvania

common law, a breach of physician-patient confidentiality

need not be pursued solely under an “invasion

of privacy” theory. Depending on the facts and the

gravamen of the claim, a patient may be able to sue

directly on a breach of physician-patient confidentiality

theory, which gives them two years to file a lawsuit.

These two types of claims may overlap, but—to paraphrase

the court—an invasion of privacy claim does not

necessarily subsume the breach of physician-patient

confidentiality claim. Direct treating physician involvement

in the disclosure of medical records is important to

prevent unauthorized disclosures, particularly in cases

involving third parties such as workers’ compensation

and some personal injury cases. In determining his or

her level of involvement in medical records releases, the

treating physician must balance complying with the

authorization with protecting the patient’s confidentiality

and guarding his or her own valuable time. However,

the investment of adequate time to review a medical

record for information potentially unrelated to an

authorization’s purpose is a wise one that can avert

lawsuits and their sequellae: payment of damages and

attorneys’ fees and the wasteful expenditure of time and

energy on a lawsuit.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○


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 can be reached at (724)

941-1902 or bjackson-law@verizon.net.

REFERENCES

1

Burger v. Blair Medical Associates, 2009 Pa. LEXIS 300 (Pa.,

Feb. 20, 2009).

2

It should be noted that an authorization is not required if the

workers’ compensation insurer is entitled to the information under

Pennsylvania law. Nevertheless, information disclosed to the

workers’ compensation insurer pursuant to this exception is

subject to the “minimum necessary” HIPAA standard, which

requires that a covered entity disclose the minimum information

necessary to accomplish the purpose of the disclosure. This

results in essentially the same level of disclosure as a properly

drafted authorization and requires the same level of review

recommended for authorizations.

265


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FINANCIAL HEALTH

Income-Based Loan

Repayment: the Good,

the Bad and the

Unintended

MICHAEL CHAPMAN, MD

Disclaimer: This is not a gloom and doom

article. It does start off with a healthy dose of

ugly reality, but those are just the facts needed

to set the scene. I promise, if you read on, I will lead

you, Vergil-like, through the student debt Inferno into

Paradise—well, perhaps not—but at least the acceptable

Purgatory of the Income-Based Repayment (IBR)

system and your options for surviving within it as a

resident and young physician.

Debt and income: where we really stand

Saying that attending medical school is a costly

enterprise is a bit like saying that Rod Blagojevich was a

trifle eccentric in his style of governance. The word

that you are looking for in both cases is “ruinous.”

Attending a private medical school

these days is ruinously expensive for folks

of normal means. Our own beloved

University of Pittsburgh School of

Medicine projects a $58,076 cost of

attendance for an in-state student in

the first year alone. This is $62,096

if you happen to be out of state,

and it jumps even higher in the

third year. Moreover, it does not

include thousands of dollars in fees

for the USMLE, study materials

and travel to testing centers and residency interviews.

In short, a survey of a very large chunk of students

by the AMA Medical Student Section at schools similar

to ours projects medical students graduating with

$250,000 to $300,000 of debt, often in addition to

undergraduate debt. The American Association of

Medical Colleges (AAMC) reports a median debt of

$180,000 for 2008 graduates of private schools, but this

median is misleadingly low as it falls between two modes

and includes numerous outliers at the low end, such as

Caribbean schools and private schools in the South that

receive substantial subsidy for their nearly 100 percent

in-state population. Nor does this figure

include undergraduate and consumer

credit card debt, which the average

med student carries to the combined

total of $25,500.

More worrying still are the

sweeping trends. Over the last eight

years, aggregate physician incomes

rose roughly 1.45 percent per

annum. (Residents fared a bit

better at around 1.9 percent.) Bear

in mind, these modest income

“gains” are actually losses. The

Consumer Price Index—basically

“how much stuff costs”—is one of

:

266 Bulletin June 2009


FINANCIAL

the better metrics of real inflation for average wage

earners. It has risen roughly 4 percent per year for the

past two decades, so effective physician wages are actually

decreasing by 2.5 percent per year.

Here’s the rub: In that same time period, tuition was

rising at a 6.9 percent annual rate and Federal Stafford

Loan interest rates have jumped from less than 2 percent

to 6.8 percent. Worse yet, over half of medical student

debt is from other types of federal loan programs (FFEL

or PLUS) or private loans being serviced at 8.5 percent

or even higher. Aggregate medical student debt itself is

climbing at the astounding rate of 11 percent per year.

Welcome to residency: Get used to Ramen, right

OK, let’s sum up all those numbers. Your ability to

buy stuff shrinks at 2.5 percent per year. Your debt

increases at 11 percent with each passing graduation

year. You start your residency making an average of

$45,659 pre-tax with an extremely optimistic $180,000

in debt. We’ll assume a 30-year repayment schedule that

gives you a monthly payment of $1,173. After federal

taxes, this leaves you at around $2,169 in monthly

income. That’s for everything: rent, food, state and local

taxes, utilities, insurance, you name it. Good luck.

Most banks, when they examine what makes for a

qualified borrower, consider a debt-income ratio of 1:9

as “hardship” and are leery about lending under those

terms. That equates to 15 percent of your monthly gross

income, meaning that you need to be making roughly

$94,000 to make those payments while still experiencing

some level of financial distress. You’re making half of

that, so that won’t fly. What are your options

The way things used to be: the 20/220 rule

Until now, 67 percent of residents have been able to

defer their payments entirely until they have finished

residency by claiming financial hardship under the socalled

20/220 rule. This rule simply stated that federal

loan payments could be deferred without interest accruing

on subsidized loans if: (a) the debt was over 20

percent of their income or (b) their income minus debt

burden was less than 220 percent of the federal poverty

level. It was simple and consistently applicable to most

residents, no matter the length of their residency.

However, in September 2007, all that changed when

President Bush signed the College Cost Reduction and

Access Act (CCRAA) into law. This ironically-named

bill eliminates the 20/220 deferment pathway, starting

in July 2009. If you are in your residency now, pay

attention, because your financial options are about to

change dramatically.

Forbearance

The other option was always forbearance, and still is.

As with deferment, you make no payments, but there

are major associated negatives. Forbearance must be

applied for every 12 months, in accordance with the

specific requirements of the lender (not the government),

and it is expensive, as interest still accrues and

capitalizes (i.e., churns back into the principal, thus

increasing total debt exponentially). Depending on your

debt level and the length of your residency, this can get

ugly. For a three- or four-year residency at the low end

of the debt spectrum ($155k), 6.8 percent interest and

continued on page 268

June 2009 : Bulletin

ACMS Physician

Career Center

www.acms.org

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An integrated network of dozens of the

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267


FEATURE (from page 267)

10 years of repayment, the total interest penalty is

approximately $14k. Not too bad, but for most of us,

this is a pipe dream.

For a surgeon with $180,000 in med school debt, a

seven-year residency and a 30-year payoff at 6.8 percent,

forbearance will cost him or her more than $117,000 in

additional interest payments over the lifetime of the

loan. Personally, forbearance would cost me roughly

$140,000 in extra interest.

The Income-Based Repayment Program

So, depending on your circumstances, forbearance

can be a fairly painful option. Thus, even though it was

defeated on the 20/220 rule, the AMA lobbied hard

during the negotiated rule-making session with the

Department of Education and succeeded in achieving

some very positive repayment rules updates (based on

some older and little-used repayment pathways known as

income sensitive or income contingent systems).

The new pathway is the Income-Based Repayment

Program or IBR. Available this July—just as 20/220

shuts down—the IBR simply caps total payments for

most federal loans at 15 percent of your current adjusted

gross income (AGI) above 150 percent of the federal

poverty line. That is right at the margin of what banks

consider acceptable. It’s fairly doable (if not pleasant),

assuming you are not servicing other major debt (e.g.,

a house, car or private student loans).

This actually starts looking pretty good. Now I’m

starting my residency with a $376 per month payment,

no matter how much debt I carry, and any accruing

interest that doesn’t cover is paid by the government,

including the interest on unsubsidized loans.

The really sweet part of the program is that you pay

15 percent of your AGI (minus the poverty line adjustment)

for the lifetime of the loan, period. If you are

flush one year, you pay more; if you are unemployed or

volunteering your skills abroad for free, well, you pay

nothing. If your spouse makes tons of coin, no worries:

It doesn’t count toward calculating your payments.

Better still, after 25 years of payments at this rate, you’re

done. The remainder of your federal loans are forgiven

after 25 years of IBR repayment, and this includes your

residency.

Cash flow, net worth and decisions

Consciously or not, most of us have chosen to lead a

cash flow driven financial existence. We chose that path

the moment we chose to go into debt for several hundred

thousand dollars in order to invest in a medical

education that won’t start yielding appreciable return

for at least 10 years. This is a perfectly reasonable

option, one that numerous corporations live by, content

to eat huge paper losses as long as more cash comes in

than goes out. Forbearance is the logical extreme of

choosing cash flow over net worth.

Not that there is anything wrong with a net worth

driven strategy. An old friend of mine (who is a very

well compensated MBA) and I just did a little back-ofthe-envelope

calculation and figured that I would catch

up to her in net worth at roughly the age of 42. That’s

really not bad and, for traditional medical students,

that’d be more like age 35. However, I don’t much care

for the notion of living in effective poverty for 10 to 15

years simply to get my paper worth to some magic

number that I’m happy with.

Based on a logic driven by net worth, you should,

in fact, eat Ramen all through your residency. You

should take on a 10-year repayment starting the moment

you graduate medical school and try to pay as

much of it as possible each month. Further, you rent a

one-room apartment and drive a lousy car for your first

six years as an attending. In my opinion, that is more

pain than need be endured with the current options.

The truth is, most folks can’t afford 10-year repayment.

This “standard” repayment schedule of 10 years

for federal student loans saves you an astonishing

$174,000 in interest over the lifetime of the loan,

compared to a 30-year loan, but increases your loan

payments by an equally staggering $800-$1,200 per

month. It gets worse. Remember, half of all doctors are

above those median debt numbers of $160-$180k—

many well above. More than half of all student loans are

serviced at a much higher rate than 6.8 percent. Most

doctors train far longer than three or four years, and

most who train for shorter periods don’t start making

“good money” fresh out of their residency. In any event,

our debt is widening the gap with our out-of-residency

starting salary at a combined rate of nearly 15 percent

per year, so you start losing fast on the net worth

calculation.

The conventional wisdom is that the IBR program

makes more sense for those of us who will make less

money and have more debt. Others should go ahead

and try to pay down their debt fast. That is basically

true except for the facts that (a) prolonged training

:

268 Bulletin June 2009


FEATURE

equates to much higher salaries; and (b) inflation

whittles away at the value of both debt and savings, so

cash today always has more value than cash tomorrow,

whether it is coming in or going out. In the final analysis,

net worth accumulation per se (in terms of paying

down debt) is going to be a luxury of sorts for many of

us, something that is really only going to happen later in

our careers.

To this way of thinking, either the pediatrics resident

with low debt or the neurosurgeon with high debt

benefits from forbearance all the more, because of the

existence of the IBR. The IBR suppresses the future cash

flow effect of whatever interest penalty you incur from

taking forbearance. It allows you to utilize forbearance to

begin saving and investing, and then allows you the

liquidity to capitalize on future market conditions while

stretching your repayment away into a future, while

inflation removes the real value of your debt, and interest

payouts are capped proportional to your income.

Unintended consequences

Under a specific provision of the CCRAA, the

outlook is even better for any student going into some

kind of public service (read: “low paying”) job. Under

the new Public Service Loan Forgiveness program, they

will have their remaining loans forgiven after 10 years of

any combination of types of public service and simultaneous

IBR. This is great news for physicians committed

to public or military service in the U.S. It is even better

news for people who might be not quite as committed.

You can try public service and then leave penaltyfree

if you change your mind before your 10 years are

up. This has the potential repercussion, however, of

gutting the incentives to join military, federal civilian

and state or locality-based loan repayment or scholarship

programs that lock you in for a decade or more. These

older programs have you in “golden handcuffs,” as you

will owe them full and (immediate) repayment if you

leave.

Thus, I would predict a mass migration away from

these programs over the next few years, particularly the

more restrictive military ones. However, I would also

hope the IBR as a whole removes the golden handcuffs

from even more of the general population of doctors,

allowing more to “dabble” in public and charitable service

for a few years, without injuring themselves financially.

A final plea to those in charge

In a nutshell, although the AMA fought and lost on

20/220, IBR is not so bad, and it offers some intriguing

options; most of us will benefit the most by taking

forbearance through residency, then entering the IBR.

But I remain troubled, not so much by the “stopped

clock, right twice a day” floundering of the government,

but with our own inability as the medical profession to

deal with raising our own “children.”

Our Hippocratic Oath binds the medical student

and professor of medicine together as child and parent,

just as it binds all physicians together as brother and

sister. Yet, sadly, we are raising our “children” on welfare,

at the mercy of the federal government. It is the clear

responsibility of the medical profession to figure out

how to provide affordable medical education. However,

to be frank, those in power in medical schools have little

incentive to do so, as long as their students can merely

be sent to suckle more from the federal teat.

Over the past year-and-a-half of fighting over and

analyzing the fallout of the change to the IBR, I have

been appalled to learn how little most medical school

faculty across this country know about the actual cost of

medical education and the mechanisms of financing it.

Even financial aid administrators took little to no

interest when the AMA approached them for collaboration

and advice on this issue.

Medical schools and medical students had better

stop looking to the sky for aid and instead start working

together in the spirit of our professional family to solve

this themselves. If we fail in this, to quote the American

Association of Medical Colleges, “The outlook for

medical education looks bleak.”

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○


Dr. Chapman recently graduated in medicine from the University of

Pittsburgh, and he serves as associate editor of the ACMS Bulletin. He

can be reached at chapmanmp@upmc.edu.

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.

June 2009 : Bulletin

269


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PRACTICE MANAGEMENT

The Patient-Centered

Medical Home—Is

Your Practice Ready

SHERRY MIGLIORE, MPA, FACHE

In January 2008, the National Commission on

Quality Assurance (NCQA) released certification

standards for physician practices to be recognized for

providing care that “seeks to strengthen the physicianpatient

relationship by replacing episodic care based on

illness and patient complaints with coordinated care and

a long-term healing relationship.” By achieving this

certification, physicians can demonstrate to their peers,

payors and the general public that they provide quality

patient care.

The American Academy of Pediatrics (AAP) introduced

the medical home concept in 1967, initially

referring to a central location for

housing a child’s medical record. In

2002, AAP expanded the concept to

include other operational characteristics

such as accessible, comprehensive,

family-centered and culturally

effective care. The American Academy

of Family Physicians (AAFP)

and the American College of Physicians

(ACP) have since developed

their own models for improving

patient care called the “medical

home” or “advanced medical home.”

The above three organizations and the American

Osteopathic Association have jointly defined a medical

home as a model of care in which the following principles

are followed:

Personal physician. Each patient has on ongoing

relationship with a personal physician trained to provide

first contact, continuous and comprehensive care.

Physician-directed medical practice. The personal

physician leads a team that takes collective responsibility

for the patient’s ongoing care.

Whole-person orientation. The personal physician is

responsible for providing all of the patient’s health care

needs and, when needed, arranges

for appropriate care with other

qualified professionals. This includes

care for all stages of life,

acute and chronic care, preventative

services and end-of-life care.

Care is coordinated or integrated

across all elements of the complex

health care system and the patient’s

community. Care is facilitated by

registries, information technology,

health information exchange and

other means to assure that patients

:

270 Bulletin June 2009


PRACTICE MANAGEMENT

The personal physician is

responsible for providing all of

the patient’s health care needs

and, when needed, arranges for

appropriate care with other

qualified professionals.

receive the indicated care when and where they need and

want it in a culturally and linguistically appropriate

manner.

Enhanced access to care is available through systems

such as open scheduling, expanded hours and new

options for communication between the patient and the

practice.

Payment for services appropriately recognizes the

added value provided to patients who have a patientcentered

medical home.

Quality and safety are hallmarks in which:

• evidence-based medicine and clinical decision/support

tools guide decision-making;

• physicians accept accountability for continuous quality

improvement through voluntary engagement in

performance measurement and improvement;

• patients actively participate in decision-making, and

feedback is sought to ensure patients’ expectations are

being met;

• information technology is utilized to support optimal

patient care, performance measurement, patient

education and enhanced communication; and

• patients and families participate in quality improvement

activities.

Patient-centered medical home

The patient-centered medical home has nine standards

with one overall score. Each standard consists of

several specific elements. The nine standards and the

intent of each standard are:

1. Access and communication. The intent of this standard

is to ensure that the practice provides patient

access during and after regular business hours and

that it communicates effectively with patients.

2. Patient tracking and registry functions. The practice

must have readily accessible, clinically useful information

about patients that enables it to treat them

comprehensively and systematically.

June 2009 : Bulletin

3. Care management. The practice maintains continuous

relationships with patients by implementing

evidence-based guidelines and applying them to the

identified needs of individual patients over time and

with the intensity needed by the patients.

4. Patient self-management support. The practice collaborates

with patients and families to pursue their

goals for optimal achievable health.

5. Electronic prescribing. The practice seeks to reduce

medical errors and improve efficiency by eliminating

handwritten prescriptions and by using drug safety

checks and cost information when prescribing.

6. Test tracking. The practice works to improve effectiveness

of care, patient safety and efficiency by

using timely information on all tests and results.

7. Referral tracking. The practice seeks to improve

effectiveness, timeliness and coordination of care by

following through on consultations with other

practitioners.

8. Performance reporting and improvement. The practice

seeks to improve effectiveness, efficiency, timeliness

and other aspects of quality by measuring and

reporting performance, comparing itself to national

benchmarks, giving physicians regular feedback and

taking actions to improve.

9. Advanced electronic communications. The practice

maximizes use of electronic communication to

improve timeliness, effectiveness, efficiency and

coordination of care.

To be recognized as a medical home by NCQA, the

practice conducts a self-scoring readiness assessment

using the NCQA web-based survey tool to submit its

data for evaluation. NCQA scores the practice by

evaluating all data and documents submitted. On-site

audits are conducted by NCQA for at least five percent

of practices to review source data to validate documentation

provided in the evaluation mentioned above.

NCQA provides final information to the practice and

places information regarding level of performance to the

NCQA website and to data users such as health plans

and physician directory publishers. NCQA does not

report information on practices that do not pass at any

level.

The cost to purchase the survey tool license is $80

for all practice sizes. Application fees for NCQA review

and recognition depend on the size of the practice.

These range from $450 for a one-physician practice to

continued on page 273

271


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272 Bulletin June 2009


PRACTICE MANAGEMENT (from page 271)

$2,700 for practices of six to 100 physicians. Practices

with more than 100 physicians pay $2,700, plus $10 for

each additional physician. NCQA offers a 20 percent

discount for applicants sponsored by health plans,

employers and other programs.

Some payors, such as Highmark, provide financial

rewards to eligible practices that have met the NCQA

performance criteria. It is expected that more payors will

follow suit in the future. For more on Highmark’s

current initiatives, go to www.highmark.com.

To learn more about the NCQA medical home, visit

www.ncqa.org. The standards and guidelines can be

accessed at this website, as well as the scoring for each

element within the nine standards. Interested practices

should also contact the payors with which they participate

to determine whether financial rewards are available

for those that achieve the NCQA recognition.

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Ms. Migliore is director of consulting at PMSCO Healthcare Consulting,

a subsidiary of the Pennsylvania Medical Society. She can be

reached at smigliore@consultPMSCO.com. For more information, visit

www.consultPMSCO.com.












Are your medical records being audited

by Medicare or an insurance company

YOU DON’T HAVE TO GO INTO AN AUDIT “BLINDLY.”

If you would like your medical records audited by an

outside expert before a payor audits them, or if you

need a second opinion regarding the results of a

recent audit, contact PMSCO Health Consulting

(PMSCO).

PMSCO’s experienced coders are certified through

the American Academy of Professional Coders, and

have performed hundreds of medical practice coding

audits.

June 2009 : Bulletin

PMSCO will work with you, or your legal counsel

through attorney-client privilege, to ensure the best

outcome possible in an audit situation.

Let PMSCO’s certified coders guide you by providing

expert advice, confirmatory audit service, and documentation

and coding education.

Contact PMSCO by calling 1-888-294-4336, or by

visiting our website at www.consultPMSCO.com.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

○ ○ ○ ○ ○ ○ ○ ○

Ms. Migliore is director of consulting for PMSCO Healthcare Consulting.

Contact Information: www.consultPMSCO.com 888.294.4336

PMSCO is a


subsidiary

experts@consultPMSCO.com

of Pennsylvania Medical Society. She can

be reached at smigliore@consultPMSCO.com.

273


TECHNOLOGY & MEDICINE

Is It Time for a Technology

Checkup

Review the security, availability and performance of your

office computer network

ED STRODE

reprinted with permission from the St. Louis Metropolitan Medicine, the journal of the St. Louis Metropolitan Medical Society

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When is the last time your office had a technology

checkup Information on your patient

medical history, your patient insurance and

your accounting records are essential to running your

practice. Most, if not all, of that information is stored

and accessed from your computer network.

A regular checkup will give you the feedback you

need to have confidence in the security, availability and

performance of your computer network. Below are some

functions to review with your information technology

professional.

Security doesn’t only apply to people on the outside

trying to get in. The majority of security breaches

initiate from inside your operation. Strong technology

controls like strict password requirements and password

expirations help to mitigate the risk of compromised

data. Strong passwords are effective in keeping people

from guessing or even advanced computer programs

from determining your password to access information

on your computer network. The expiration of passwords

forces users to periodically change their password again

to reduce the risk of security breaches.

The physical security of your computer network

seems like it would be more obvious, but it is often

overlooked. If an employee remains logged in while

leaving for lunch or even for the day, this provides an

open invitation for an unauthorized person to peruse

confidential data on your network. Other things as

simple as privacy screens for monitors are often overlooked

or deemed unnecessary, but you would be

surprised what a nosey neighbor can glean from a

computer screen during a 10-15 second

stare. The costs to eliminate some of

those risks are negligible or even free as a

configuration option. Don’t forget that a

convenient USB port can pose a security

risk due to its easy access.

Security and privacy

Start with HIPAA. While your software vendor may

boast about their system’s compliance, it is ultimately

your responsibility to ensure that the information you

have in your possession is cared for and shared within

those HIPAA standards. A technology checkup will help

to identify strengths as well as any weaknesses in security

or lack of security you currently have in place.

Another concern is unauthorized access from the

outside world through an Internet connection.

Not only can this cause havoc as

a security breach, it also has the potential

to jeopardize the integrity of your server

as it co-exists with others on the Internet.

A reliable firewall device that is configured

properly can go a long way to cover

Information availability and reliability

any exposure to outside threats infiltrating

your system through the connection

wonders here, too. Whether you have

Regular technology checkups can do

to the Internet.

adopted the use of EMR or not, access to

:

274 Bulletin June 2009


TECHNOLOGY

A regular checkup will give you

the feedback you need to have

confidence in the security,

availability and performance of

your computer network.

patient information on the system at the time you need

it is critical to the way your practice operates. Maximizing

your time for better service to your patient is important.

Maximizing the time of the practice staff needed to

bill, receive and file claims is equally as important. The

information on your system needs to be readily available

to meet those demands.

Regular technology checkups can ensure that you

have the tools in place to avoid costly downtime from

viruses, botnets, spyware, etc., that often infiltrate

computer networks. Those checkups can also help to

make sure the hardware and software running your

practice management system is kept up to date with

patches and fixes that are released regularly by the

manufacturers. When applied correctly, those patches

and fixes can help to avoid untimely crashes and fix

known security flaws within the existing configurations.

These proactive actions ultimately increase the availability

of information when you need it.

Access to information when you want it is important

enough, but how important is it for you to access

information from where you want it Your other office,

your home, a hospital, a hotel room on vacation or even

your phone can all be possibilities to access your patient

and practice information. Are all of those connection

options available to you now, and how reliable are they

Regular technology checkups can be used to discuss

information access and make sure your access capabilities

stay up with your demand for information.

Disaster recovery

System disasters can make accessing your data

impossible; larger disasters can wipe out an entire office

or city blocks. How prepared are you to recover A

discussion of tolerance level for being without your

information is a crucial one to have with your trusted

technology partner. They would be able to help you

with both scenarios and to understand what is involved

June 2009 : Bulletin

in recovering from each extreme. The reality of disaster

possibilities and the preparation for recovery are important

pieces of your overall practice planning and are not

limited to your computer network.

Data storage

Data storage is an area that should be monitored

regularly as well. Regular technology checkups will also

let you know how much data you are using now and

how much room you have left for additional storage.

This will be helpful in planning for system upgrades and

enhancements as well as avoiding immediate problems

by unexpectedly running out of space. EMR brings

storage concerns to a whole new level as everything is

maintained in digital form to be readily accessible.

Memory utilization and processor utilization are a

couple of other areas that help a technology professional

determine the performance and taxation of a computer

network server. Identifying problems or taxation trends

can help prevent slow or sluggish behavior from your

network. Most technology professionals will also offer an

automated monitoring and alerting service. A managed

service like that will notify them when certain performance

thresholds are exceeded so potential disaster or

performance degradation can be avoided. Such a service

is money well spent with a monthly or yearly fee that

will allow for the 24-hour monitoring of critical components

of your computer network. The early diagnosis of

any problems discovered by the monitoring allows for a

higher success rate in treatment and many times will

avoid problems from developing all together.

Regular checkups are as good for your practice and

your computer network as they are for your patients.

The lifeblood of your practice is in the information

stored and accessed on your computer network. The

proactive approach to maintenance and upkeep can save

hours of lost production, gigabytes of lost data and

thousands of lost dollars in recovery from disaster or

litigation over a breach of security. Regular checkups will

give you the feedback you need to have confidence in

the security, availability and performance of your information

systems. Your trusted technology partner can

assist in creating a maintenance and wellness check that

fits your unique needs. Remember, an ounce of prevention

is worth a pound of cure.

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Ed Strode is director of AMD Technology Solutions in St. Louis, Mo.

He can be reached at (314) 655-5565 or estrode@amdts.com.

275


:

276 Bulletin June 2009


SPECIAL REPORT

Crisis Help Available

to Residents in

Allegheny County

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Western Psychiatric Institute & Clinic of UPMC

and Allegheny County have teamed up to provide

behavioral health crisis services to all county residents.

Nearly one in five Americans is affected by a mental

health concern in a given year. In many instances,

people hesitate to seek support for their mental health

due to stigma, shame or fear. A crisis can be anything

from feeling lonely and needing to talk, to feeling

overwhelmed with life. Our lives are full of stressors

both large and small, but no matter the complexity, it

helps to talk with someone and it is important to seek

help before a crisis becomes a crisis.

To address these issues, Western Psychiatric Institute

and Clinic of UPMC and Allegheny County have

established the “re:solve Crisis Network,” a confidential

service available 24-hours-a-day, 365 days a year.

People who live in Allegheny County may call when

they are feeling exceptionally lonely or stressed, are

experiencing an emotional crisis or just need to talk. Or,

they may call for someone they know who seems ready

to shatter.

By dialing toll-free at 1-888-7-YOU CAN (1-888-

796-8226), callers can talk one-on-one with a highly

trained crisis counselor, or they can choose to meet faceto-face

at the 333 Braddock Avenue location. No appointment

is necessary. Mobile crisis counselors also will

travel to where a person is located—anywhere in Allegheny

County. Overnight services are available for people

whose crisis extends over a period of time.

The services of re:solve Crisis Network are designed

to help county residents, regardless of age, ability to pay

or whether or not they have used behavioral health or

other supportive services previously. The first step to

feeling relief starts with picking up the phone and

making the call—any day, any time, for any reason.

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Information for this Special Report was provided by the re:Solve Crisis

Network. For more, visit www.upmc.com/Services/resolvecrisisnetwork.

June 2009 : Bulletin

HumanServices.net

Physicians often want to provide information for their patients that

helps meet personal or family needs beyond medical concerns. The

Allegheny County Department of Human Services provides a vast

array of useful information at www.alleghenycounty.us/dhs.

A drop-down menu on the website’s main page makes it easy to

search on a wide range of topics, including but not limited to:

Basic Needs: food assistance, housing & homelessness, utility

assistance, home needs & repair, family & parent support, employment,

transportation and child care.

Children: child protective services, permanency for children,

children 0-6, and youth development.

Young Adults: employment training for youth, teen parent support,

partnerships in youth transition and CYF independent living.

Older Adults: protection from abuse & neglect, services in the

home, nursing home alternatives, adult foster care, nursing home

transition, advocacy for long-term care, caregiver support, health

insurance counseling, and senior training & employment.

Disabilities: physical disabilities, accessable housing, developmental

disabilities, mental retardation and personal care.

Individual & Community Health: mental health services & support,

substance abuse management, wellness & recovery, health

insurance coverage, pregnancy, autism, and violence prevention

reduction & intervention.

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277


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PROFILE

A Prodigious Pair of

Physician Musicians

LINDA L. SMITH

There’s a body of scientific research in leisure

studies that examines the concept of “flow,” that

lost-in-time feeling you experience when you’re

doing what you love the most, whether it’s skiing down

a snowy slope of white powder, hiking in the wilderness

or losing yourself in a Mozart sonata. “Peak flow” is

most likely to happen when that leisurely pursuit is

active in nature, not passive. In other words, the benefit

is maximal when you smack that tennis ball behind your

opponent as opposed to watching the match from the

bleachers, or when you play your favorite instrument or

sing your favorite song rather than just listening to

music. That’s what music does for at least two area

physicians profiled here (and likely many, many more).

Paul Caplan retired as the PSO travel physician in 1990.

“Since the orchestra’s trips coincide with my vacation

time, my children have enjoyed traveling with me

over the years. My daughter Alissa, who is now 21,

recently traveled with me to China in May; our first

international trip together happened when she was just

four years old. My 24-year-old son Jim has vivid memories

of being in Hong Kong and Tokyo when he was

seven,” he says.

According to Dr. Osial, his travels around the world

with the orchestra exposed him to many experiences,

including the privilege of meeting and getting to know

interesting people, such as Andre Previn, Mariss Jansons

and Sarah Chang, 1 as well as the PSO musicians. “Many

of my best friends are PSO people,” he says.

Dr. Osial says Vienna’s Musikverein 2 is his favorite

concert venue. “It is truly the mecca of the music

world,” he says. His “favorite venue” list is large, but

others would include Salzburg and Prince Albert Hall in

London; in London it’s not just the music but the total

experience of the Proms Concerts. Dr. Osial says people

should know that the Pittsburgh Symphony Orchestra is

well-known and much appreciated by audiences around

the world.

On last year’s trip there was an outbreak of food

poisoning, and many of the musicians became ill (not an

uncommon event on tour). When the PSO is on the

road, Dr. Osial attends all the performances and keeps

office hours, as well as being on call. He treats the usual

complaints such as gastrointestinal illness, chest pain,

problems with diabetes and injuries. Musicians often

take advantage of “down time” on tour to seek advice

Dr. Osial and the Pittsburgh Symphony Orchestra

Thaddeus A. Osial Jr., MD, rheumatology, began

taking music lessons in eighth grade and played clarinet

at both Pittsburgh’s Central Catholic High School in the

1960s and with the University of Michigan Marching

Band in the 1970s (including a trip to the 1970 Rose

Bowl). He says he chose the clarinet because his father

played the clarinet. “We’re Polish; it’s the Clarinet Polka

thing,” he says. He also has played saxophone.

Dr. Osial’s involvement with the Pittsburgh Symphony

Orchestra (PSO) goes beyond simply sitting in

the audience, although you’ll likely find him there at

most of the group’s performances. He has served as the

PSO’s travel physician for the past 19 years, having

made more than 20 overseas trips with them—most of

them two to three weeks in length—to places like

Austria, most of Europe and the Vatican. He recently

returned from concerts in China and Taiwan, and will

visit Bonn and Lucerne with the group in September.

1

Andre Previn is an Academy Award and Grammy Award winning

Dr. Osial’s involvement with the orchestra began as a pianist, conductor and composer; Sarah Chang is a Korean-American

violin virtuoso; and Mariss Jansons formerly conducted the PSO and

subscriber when he was a medical student at University now conducts the Royal Concertgebouw Orchestra of Amsterdam.

of Pittsburgh School of Medicine in the 1970s. He says 2

Musikverein (music club) is famous for its acoustics and is one of the

he was “in the right place at the right time” when Dr. three finest concert halls in the world.

:

278 Bulletin June 2009


PROFILE

Pittsburgh Symphony Orchestra

For more than 100 years, the Pittsburgh Symphony Orchestra

(PSO) has been an essential part of Pittsburgh’s cultural

landscape. The PSO prides itself in artistic excellence, a rich

history of the world’s finest conductors and musicians, a strong

commitment to the Pittsburgh region and the cultivation of its

family of constituents and households. This tradition was

furthered with great enthusiasm in the fall of 2008 when Austrian

conductor Manfred Honeck assumed the position of music

director with the orchestra. With a long and distinguished history

of touring, both domestically and overseas, the PSO has earned

critical acclaim. The orchestra has also achieved a

long and illustrious reputation for its recordings

and radio concerts. Whether touring or at home

in historic Heinz Hall, the Pittsburgh Symphony

Orchestra remains among the world’s top

orchestras, and has even been named by some

as the “Greatest American Orchestra.”

See: www.pittsburghsymphony.org

Dr. Osial began taking music lessons in eighth grade.

about general medical problems, ask about issues in the

family or simply talk about personal concerns and

problems. Here in Pittsburgh, Dr. Osial makes himself

available for urgent issues that sometimes crop up for

visiting conductors and performers. He says he also

serves as primary care provider for many of the PSO

members and staff.

Dr. Osial says music is a major form of relaxation

and stress relief. “I had let my own clarinet playing lapse,

but recently have begun to play again and I’m taking

lessons, mainly just for the fun of it. I do hope to play at

least with my friends, especially a very dear friend who is

a wonderful pianist. We’ve kiddingly talked about

sneaking me into a PSO rehearsal, but never have,” he

says.

Dr. Salama and the Mendelssohn Choir

MaryBeth P. Salama, MD, family medicine and

palliative medicine, first became involved with music at

the tender age of seven when she began taking piano

lessons. As a young school girl she took an interest in

vocal music, singing in various choirs and musical

productions. As an undergraduate at Bates College,

where she minored in music, Dr. Salama enjoyed performing

the Faure Requiem with the college choir and

June 2009 : Bulletin

The Mendelssohn Choir of Pittsburgh

The Mendelssohn Choir of Pittsburgh, a largely volunteer choir of

115 voices, including a 20-voice professional core, is renowned

for its versatility, performing oratorio, opera, Broadway, folk and

symphonic repertoire. Founded in 1908 and having the distinction

of being Pittsburgh’s oldest continuing performing art organization,

the choir is in its 100 th season, the third under the direction of

Music Director Betsy Burleigh. A leader and collaborator in the

regional arts community and the Pittsburgh Symphony’s chorus of

choice, the Mendelssohn’s artistic partners have included

Pittsburgh Opera, River City Brass Band, International Poetry

Forum, Duquesne University Tamburitzans and Pittsburgh Ballet

Theatre. Members of the choir share a remarkable commitment to

the art of making great choral music and collectively contribute an

estimated 30,000 hours of service per season.

See: www.themendelssohn.org

regularly sang and performed on period instruments

with a renaissance group known as The Red House

Circus.

In 1982 when she settled in Pittsburgh, a friend who

was trying out for the Mendelssohn Choir convinced

Dr. Salama to do the same and the rest is history. “If I

had known it was semi-pro, I don’t know if I would have

had the courage to do it,” she says. Today she not only

continues to sing in the choir, but also sits on its board

continued on page 280

279


PROFILE (from page 279)

of directors. An avid

gardener and talented

cook, she recently helped

coordinate the

Mendelssohn Choir Cookbook.

Dr. Salama has many

great musical memories of

her time with the

Mendelssohn Choir, but

her favorites include

performing as the “choir of

choice” with the PSO on

such works as the Verdi

Dr. Salama

Requiem and Mahler’s

Resurrection Symphony. She also has enjoyed traveling

with the choir to perform at New York’s Carnegie Hall

and Chautauqua Institute and singing Haydn’s The

Creation with her daughter and The Robert Page Festival

Singers in Budapest and Vienna last summer. “I thoroughly

enjoy any time the music takes you out of your

own life and joins you in this bigger event that impacts

and joins other’s lives,” she says.

Dr. Salama says that music “grounds” her and renews

her, allowing her to continue the hard work that she

does as a hospice physician. “The fact that we sing in

many languages and expressions of faith means a lot to

me. I love the ability not only to enjoy but participate in

music that expresses this spirituality for many. When I

am feeling low or out of energy, music picks me up and

helps me to look at the bigger picture,” she says.

Dr. Salama spends at least three hours a week in

rehearsal and another two hours reviewing and preparing

for rehearsal. She says she plays music in her car whenever

she is traveling, often listening to versions of what

the chorus will sing, particularly if it is in another

language, such as the upcoming Rachmaninoff Vespers.

A Pittsburgh Symphony devotee herself, Dr. Salama

attends symphony performances whenever possible and

supports both the symphony and the Mendelssohn

Choir as a donor as well. She says that many individuals

think they are donating to the choir when they give to

the symphony because they often perform together; in

fact, the choir is a separate, not-for-profit organization.

“In our current tough economical environment, all

the musical organizations we know and love need our

help more than ever. Ticket prices cover less than half

the expenses these organizations face. If you really love

music and want these organizations to succeed, support

them not only with your attendance but with your

donations so they will be healthy for the future and for

our children,” she says.

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Ms. Smith is the Bulletin managing editor for the Allegheny County

Medical Society. She can be reached at lsmith@acms.org.

Medicine is not immune to

economic trends.

Physician Referrals

Did you know we get calls daily asking for

referrals to physicians Be sure your

membership information is up to date so

that you get connected, including:

√ Hospital Affiliations

√ E-mail address

√ Correct phone/fax/address/e-mail

E-mail acms@acms.org or

call (412) 321-5030 and ask for

Nadine Popovich (ext. 110) or

Jim Ireland (ext. 101)

ALLEGHENY COUNTY

MEDICAL SOCIETY

But knowing the forecast helps weather the storms of

shifting revenue in your medical practice.

With the Kell Group's forecasts on up or down revenue

trends, you'll have the information you need when deciding

to make an expenditure —or hold on an expansion plan.

Get on the Kell Group’s radar today and call

412-381-5160.

www.kellgroup.com

:

280 Bulletin June 2009


HIPAA Q&A

Q

: I have read that HIPAA complaint violations

are on the increase. How can I protect my

practice

A

: In order for a covered entity to protect itself

from complaints, it is best to be proactive.

First and foremost have a culture of HIPAA compliance.

Be sure that all employees are familiar with the

privacy and security officer and his or her duties.

Make sure that this person (or people) is up to date

on the policies. To have someone on the role by

name is not meeting the standard. Second, have all

of the policies for the six Rules of HIPAA and, by

February 17, 2010, for HITECH as well. Third,

make sure that the policies are enforced. This is done

by mandatory training and awareness. If there was a

violation, and it was shown that the employee

trained for 5-10 minutes, that would not be acceptable.

Good training prevents errors. Last, manage the

violation and the complaint in a timely and effective

manner. Violations will simply not go away.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○


Information for this column was provided by Joan M. Kiel, PhD,

CHPS, who serves as HIPAA compliance officer at Duquesne

University and is certified in health care privacy and security. She

can be reached at (412) 396-4419. Submit your questions to

HIPAA@acms.org. The column will publish answers to the most

frequently asked questions; individual questions will not be

answered. Log on to the ACMS website (www.acms.org) for

HIPAA events.

Insurance FAQs*

Q

: If my child graduates from high school, then

goes to college, is she covered What about

after graduation from college

A

: The ACMS-sponsored Highmark program

provides coverage for full-time students up

to age 25. Once your child graduates, she would

need to obtain her own insurance on the first of

the month after graduation. Call the number

below to ask about short-term medical policies

and review individual medical plans for your

child.

Q

: Do I have to use Medicare as my primary

insurance

A

: If you are eligible for Medicare, but are still

working, and your employer has 20 or

more employees, then your ACMS group coverage

will remain primary over Medicare. If your

employer has fewer than 20 employees, you may

decide whether Medicare or the group plan is to

be your primary insurer. Call the number below

to review your specific situation.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○


*Frequently asked questions (FAQs) about ACMS-sponsored

Highmark medical insurance plans are provided by USI

Affinity Insurance. For additional information, contact your

program administrator at USI Affinity at (800) 327-1550.

The Gloria Carroll Team

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Pittsburgh, PA 15237

(412) 367-8000 Ext. 242

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This 4 bedroom, 2.5 bath home offers

a move-in ready location! Sunroom

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the deck area and large fenced in

backyard. The kitchen offers plenty of

counter space and stainless appliances!

June 2009 : Bulletin

281


○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

PERSPECTIVE

Reforms Needed to Alleviate Current

Health Care Crisis

KRISHNAN GOPAL, MD, FACS

There is no denying that a health

Still, Medicare does not cover all

care crisis exists in this country

expenses; the elderly are responsible

right now. The money that is being My sincere hope is that for paying 20 percent of the bill that

spent on health care is skyrocketing the reforms, however Medicare does not cover. Often the

at a rate comparable to no other meaningful, are not elderly must buy personal insurance

country. The amount spent on caught in the quagmire to cover the gap. The premiums for

health care is bursting out of all

this insurance are gradually creeping

seams. There are various reasons for

of political bickering

up, which many elderly cannot

the rising costs of health care. along the party line. afford. Additionally, Medicare

The number of uninsured is

patients have to buy supplemental

rising and, with a faltering economy

insurance for their medications. All

and high unemployment, it is bound conditions like obesity, hypertension,

of this adds up to quite an expense if

to exceed one’s imagination. Job

diabetes and smoking-related these seniors have to solely survive

losses deprive individuals of their lung diseases. Today it is estimated on their social security payments.

health insurance, making it hard for that about 60 percent to 70 percent Life expectancy has increased, and

them to buy individual coverage. of health care expenditures are for the elderly live longer and get sicker.

The affordability of health insurance the management of the complications

They tend to incur heavy medical

for average Americans, whether

related to these chronic condi-

expenses when they are sicker. One

employed, unemployed or retired, is tions, all of which could have been crude assessment estimates that

of great concern. Without health prevented. No one cared about elderly sick patients incur about 80

insurance, people can ignore preventive

taking personal responsibility for his percent of medical care expenses,

measures and get deathly sick, or her health care as long as someone mostly from nursing homes and

sometimes requiring more intense paid for it. They continued to personal care centers, to have their

medical care and further increasing smoke, neglected exercise and did lives prolonged by only a few

health care costs.

not control their blood pressure or months.

Decades ago, medical care was diabetes. It is only now that we are To augment their income, many

inexpensive. For a long time there realizing that we should concentrate physicians and group associations are

were only a few players in the health on this aspect of health care to save adding laboratory and radiology

care arena: providers and patients. money.

facilities at their practice locations.

The providers were physicians, When Medicare was initiated in This helps them to self refer their

insurers and hospitals. All of them 1967, elderly people were assured of patients and to seek even more

operated low scale. Little emphasis health care coverage for life. Now, if referrals. This practice can be

was placed on preventive measures; you look at the demographics of the abused, however, with needless tests

in fact, preventive measures often aging population of this country, it ordered to generate income. Overutilization

were ignored and not paid. Gradually

is conceivable that Medicare (along

of some invasive proce-

chronic conditions took a heavy with Social Security) could eventudures

is also blamed for rising health

toll on providing health care for ally bankrupt the federal government.

care costs. Innovations in the health

complications related to chronic

field are exploding each day, and the

282

:

Bulletin June 2009


PERSPECTIVE

newer options often cost much

more. As patients demand the latest

available options, the cost of care

escalates.

Pharmaceutical companies

inflate the prices of new drugs to

recover the amount spent on their

research and development. The costs

of such drugs become highly prohibitive.

Some of the newer medications,

both for cancer treatment and

immunomodulators (which is

supposed to change one’s immunity)

cost a ton of money and are being

offered to everyone without assessing

who needs them most.

Insurance premiums have been

outpacing the rate of inflation. Even

though insurance companies are

considered non-profit entities, they

can still amass and hide large

amounts of profit as surplus, at the

same time increasing premiums for

the insured. The establishment of

insurance companies and more

hospitals to cope with all the regulatory

requirements increases the

number of supportive administrative

staff with large monthly compensations.

Increasing numbers of private

practice physicians unable to cope

with the administrative demands are

giving up their private practice and

joining institutions or hospitals in

droves as salaried employees. This

move not only denies the autonomy

of these physicians, but also provides

no incentive to cut health care costs,

as they are now salaried employees.

So far, all the stakeholders in

health care—government, insurance

companies, physicians, hospitals,

employers, patients, attorneys,

medical societies and all accreditation

agencies—are finger pointing

and blaming others for rising health

care costs. This finger pointing has

gone on too long and serves no

useful purpose.

Before the health crisis becomes

just like the present financial crisis, it

is time for all to wade through the

options, come to a consensus,

initiate a plan and take action. This

process cannot be ignored or put off.

Unlike prior attempts by the

government, the present administration

seems to have started earnestly,

in good faith, with all the stakeholders

at the table. Discussions on

reforms are aimed at the following

guiding principles:

• improving the insurance market,

• making health care affordable,

• protecting families’ financial

health,

• investing in prevention and

wellness,

• guaranteeing universal health care

to cover all Americans,

• assisting low-income individuals

through premium subsidies,

• providing information and insurance

portability,

• reducing system fragmentation,

• reforming antitrust rules for

groups to contract jointly,

• easing the liability pressure on the

practice,

Got Something to Say

If you’re an ACMS

member and would like

to write a Perspective,

e-mail Linda Smith at

lsmith@acms.org. or call

(412) 321-5030, x105.

• improving patient safety and

quality care, and

• maintaining long-term fiscal

sustainability.

Let us hope that these stakeholders

will see clearly through the crisis

and offer some meaningful, cogent

and workable health care reform. My

sincere hope is that the reforms,

however meaningful, are not caught

in the quagmire of political bickering

along the party line.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○


Dr. Gopal is a colon and rectal surgeon and

past president of the Allegheny County Medcal

Society. He can be reached at gopal @acms.org.

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.

Help your patients talk to

you about their BMI

Allegheny County Medical Society

is offering free posters explaining

body mass index (BMI) and

showing a colorful, easy-to-read

BMI chart. The posters can be used

in your office to help you talk

about weight loss and management

with your patients.

To order a quantity of posters, call

the society office at 412-321-5030.

You can view or download a

smaller version online at

www.acms.org.

Allegheny County Medical Society

June 2009 : Bulletin

283


2009 BULLETIN EDITORIAL INDEX: JANUARY-JUNE

Volume 98 No. 1 ................ January 2009 ........................Pages 1-52

Volume 98 No. 2 ................ February 2009 ....................Pages 53-96

Volume 98 No. 3 ................ March 2009 ......................Pages 97-140

Volume 98 No. 4 ................ April 2009 ......................Pages 141-192

Volume 98 No. 5 ................ May 2009 .......................Pages 193-240

Volume 98 No. 6 ................ June 2009 .......................Pages 241-292

A

Above & Beyond ....................................................... 81

Academic Perspective:

Confronting the Albatross of Medical

Student Debt ....................................................... 134

Arthur S. Levine, MD

ACMS Alliance Update ................................... 109, 253

ACMS Calendar .................. 21, 71, 115, 161, 215, 257

Activities and Accolades ...... 19, 66, 110, 155, 211, 252

ALCOSAN agreement ............................................. 187

B

Board of Directors ........................................... 136, 236

Bulletin correction.............................................. 69, 230

C

Cancer Support Groups ............................................... 7

Classified Advertising .......... 50, 94, 138, 190, 238, 290

Community Notes ...................... 17, 64, 111, 157, 212

Community Partnerships ......................................... 202

Continuing Education......... 19, 70, 114, 160, 214, 256

D

Dear Doctor ............................................................ 159

E

Editorials:

Acute Myocardial Infarction: Comparing

Door-to-Balloon Times ........................................ 246

Stuart G. Tauberg, MD, FACC, FACP

I Am Not a “Health Care Provider” ......................... 8

Melinda M. Campopiano, MD

Random Thoughts for a Random Time ............... 198

Frank Vertosick, MD

A Reading List: Medical and Non-Medical ............ 58

Fredric Jarrett, MD, FACS, FACSC

The “Uninsured”: A dangerously glib label

on a much more complicated package.................. 102

Michael P. Chapman

You’re Doing What ............................................. 148

Adam Z. Tobias, MD

Ethical Responsibilities in Change in Affiliation

of Medical Practices or Separation of Employment .. 237

Executive Committee:

Here We Go Again!................................................ 60

John F. Delaney Jr., MD, DrPH

What Can Your Medical Societies Do to

Help You With Your Professional and

Personal Life ............................................... 150, 201

Amelia A. Paré, MD

F

Features:

2008 ACMS Award Winners ................................. 42

Elizabeth L. Fulton

2008—Year-in-Review ........................................... 30

2009 ACMS President and Officers ....................... 38

Medical Tourism Explained.................................. 174

Elizabeth L. Fulton

Specialty Society Update: 2009 .............................. 79

Financial Health:

Code Blue: Resuscitate Your Financial Plan.......... 224

Gary S. Weinstein, MD, FACS

The Good, the Bad and the Ugly–Not all 401(k)

Investment Options are Created Equal ................ 170

Neil H. Alexander, JD, CPF, AIFA

Donald M. Belt, MBA, CFA, AIFA

Income-Based Loan Repayment: The Good, the

Bad and the Unintended ...................................... 266

Michael Chapman, MD

Your Home Is Your Castle, But Not Really

an Investment ........................................................ 82

Gary S. Weinstein, MD, FACS

:

284 Bulletin June 2009


2009 EDITORIAL INDEX

From the Mailbox ............................... 18, 69, 212, 255

G

H

HIPAA Q&A .............................. 29, 87, 129, 160, 281

I

Improving Colorectal Cancer Screening Rates ......... 155

In Memoriam .............................. 16, 65, 113, 159, 210

Insurance FAQs ................................................. 19, 281

J

K

L

Legal Report:

Burger v. Blair Medical Associates: Who’s

Handling Your Medical Records Releases............ 262

Beth Anne Jackson, Esq.

Compliance with Red Flag Rules: Identity Theft

Protection Program Requirement......................... 220

Paul J. Welk, PT, Esq.

Considerations in Hiring a Physician Assistant:

Making an Educated Decision ............................... 76

Beth Anne Jackson, Esq.

Locked Out .......................................................... 26

William H. Maruca, Esq.

Medicare’s Recovery Audit Contractor Program ... 166

Michael G. Wiethorn, Esq.

What Accommodations Must You Provide for

Disabled Patients ................................................ 122

Nawshin Ali, Esq.

M

Materia Medica:

Excedrin Products in the Elderly .......................... 216

Heather Sakely, PharmD, BCPS

Mansoor Alam, MD

The JUPITER Trial: Implications for Practice...... 258

Thomas M. Barus, PharmD

Thamas L. Rihn, PharmD

Medication Safety Updates: Evidence-based

Recommendations ................................................. 22

Stephanie Ballard, PharmD

Rachelle Busby, PharmD

Lisa Harinstein, PharmD

Romiplostim (Nplate) for the Management of

Chronic ITP .......................................................... 72

June 2009 : Bulletin

Rachael DeGol, PharmD Candidate

Thomas L. Rihn, PharmD

Pamela Koerner, PharmD

Stress Ulcer Prophylaxis: When is it Necessary .... 162

Molly McGraw, PharmD

Medical Reserve Corps Application.......................... 156

Medical Student Musings:

Four Weeks on the Navajo Nation ......................... 12

Erica Mak

Happy to be Back at the Hospital ........................ 204

Ryan Greytak

The Match Game ................................................ 106

Ramin Saghafi

Scope & Scalpel 2009 Preview ............................. 153

Yaron Fridman

Membership Applications ................................. 92, 189

Miller Time: Scott Miller, MD, MA

The Power of Presence ............................................. 6

In Sickness and in Health .................................... 146

N

O

P

Perspective:

Reforms Needed to Alleviate Current Health

Care Crisis ........................................................... 282

Krishnan Gopal, MD, FACS

To Flush or Not to Flush ..................................... 186

Timothy Lesaca, MD

Photo Feature:

2009 ACMS Gala–A Celebration of Caring in Our

Community ............................................................. 116

Poetry:

Apologies to Mother Earth................................... 222

Basil Albert Marryshow, MD

Poison Pen: Edward P. Krenzelok, PharmD, FAACT,

DABAT

Acetaminophen Overdosage: the most common

poisoning ............................................................... 45

continued on page 286

285


2009 EDITORIAL INDEX (from page 285)

Plant and mushroom exposures—Should we

be concerned ...................................................... 231

Poison Prevention Month .................................... 126

Practice Management:

Collecting Self-Pay Balances: Top 10 Tips from

the Front Line...................................................... 176

Donna J. Kell

Good Reasons to Post-op Your Accounts

Receivable ............................................................ 127

Brad Runyeon

Liability Risks Associated with Adding Ancillary

Services ................................................................ 228

Karen K. Davis, MA, CPHRM

The Patient-Centered Medical Home—Is Your

Practice Ready .................................................... 270

Sherry Migliore, MPA, FACHE

Risk Management and Retail-based Health

Clinics ................................................................... 86

Karen K. Davis, MA, CPHRM

President’s Message: Douglas F. Clough, MD

ACMS: Your Physician Organization ..................... 11

Get Involved in Meaningful Health Care

Reform ................................................................ 249

My Goal: Leadership and Advocacy for

Patients and Physicians ........................................ 105

Profiles:

Dr. Solano—Dedicated Physician .......................... 48

Elizabeth L. Fulton

Meet Your President: Douglas F. Clough,

MD, FACP .......................................................... 104

Elizabeth L. Fulton

A Prodigious Pair of Physician Musicians ............. 278

Linda L. Smith

Q

R

Reportable Diseases:

2008: Q4 ............................................................... 75

2009: Q1 ............................................................. 223

S

Society News:

2010 Nomination Response Form ....................... 209

ACMS awards nominations ................................. 250

ACMS call for nominations ................................. 209

ACMS Medical Student Award ...................... 63, 250

Annual meeting of surgeons ................................. 251

Game-day parking permits................................... 155

Geriatric clinical update ................................. 62, 206

Geriatrics society’s Martin Award ........................... 15

New PMS website .................................................. 64

Ob/gyn society ...................................... 15, 108, 154

Obstetrics/gynecology society .............................. 209

Ophthalmology society .......................... 15, 108, 154

Photo: Executive Committee meeting.................... 15

Photo: Medical Student Award ............................ 250

Photo: Obstetrical gynecological society .............. 108

Photo: OSHA update 2009 ................................. 207

Photos: Ophthalmology society ................... 108, 154

Photos: Science and engineering fair .................... 206

Photos: Senior health fairs ................................... 250

Surgeons and ob/gyns ............................................ 15

Surgeons’ joint meeting ....................................... 108

Surgeons’ meeting ................................................ 207

Surgical society ...................................................... 15

Surgical society joint meeting................................. 62

Special Reports:

Health Department Waives Exclusion for School

Vaccinations......................................................... 121

Online CME/CEU Program: Physician Orders

for Life-Sustaining Treatment (POLST) ............... 131

The Need for Regional Demonstrations in

Containing Costs and Improving Quality ............ 226

Karen Wolk Feinstein, PhD

The Physicians’ Health Programs: A Resource

for All of Us ........................................................... 84

Elizabeth Massella, MD

Pitt Receives $8.4 million to Improve Disaster

Preparedness ........................................................ 173

Professional Internships for Practice Managers:

Partnerships for the Future..................................... 17

Psychiatrists on Call ............................................. 172

Medical Records Reproduction Fees ...................... 41

National Healthcare Decisions Day ..................... 130

Operation Walk Pittsburgh .................................. 233

Tony DiGioia, MD

Janice Harmon

Tom Maidens

:

286 Bulletin June 2009


2009 EDITORIAL INDEX

A Report from Haiti ............................................ 232

Daniel R. Lattanzi, MD

Update: Work Continues for Primary Care

Working Group ................................................... 184

Linda Smith

Voices of Our Region........................................... 128

Kathleen Burk

T

Technology and Medicine:

Choosing the Right EHR System .......................... 46

Danielle Taimuty, MA, CPC, CPC-EMS

The Electronic Health Record (EHR) and

the Doctor ........................................................... 180

Bruce L. Wilder, MD, MPH, JD

Is It Time for a Technology Checkup .................. 274

Ed Strode

On Your Mark, Get Ready, Get Set–

Go Paperless!.......................................................... 90

Danielle Taimuty, MA, CPC, CPC-EMS

U

V

W

X

Y

Z

ACMS Members

New Partner

New Address

Retiring

Congratulatory Message

Announce it here...

Professional announcement advertisements in

the Bulletin are available to ACMS members

at our lowest prices.

Contact Linda Smith at 412-321-5030

for more information.

June 2009 : Bulletin

287


What Does ACMS Membership Do For Me

ACMS members have exclusive access to vendors of physician

supplies and services at special rates. We screen all vendors for

quality and value, so you don’t have to.

Membership Group Insurance

Programs

Blue Cross/Blue Shield, Disability,

Property and Casualty

USI Affinity

Bob Cagna, 724.873.8150

Banking, Financial and

Leasing Services

Medical Banking, Office VISA/MC

Service

PNC Bank

Frank Van Horn, 724.853.0238

Medical Liability Insurance

PMSLIC

Marketing Department

Lisa Klinger, 717.802.9236

Medical Supplies

Allegheny Medcare

Michael Gomber, 412.580.7900

Medical Waste Removal

Medical Waste Recovery Inc.

Mike Musiak, 724.309.9261

Printing Services and

Professional Announcements

Service for New Associates, Offices

and Address Changes

Allegheny County Medical

Society

Susan Brown, 412.321.5030

Records Management

Business Records Management

Inc. (BRM)

David Phillips, 412.321.0600

Auto and Home Insurance

Liberty Mutual

Angelo DiNardo, 412-859-6605,

ext. 51902

Collection Service

I.C. System Inc.

Matthew Buffalini, 800.279.6711,

ext. 1212

Member Resources

BMI Charts, Where-to-Turn cards

Allegheny County Medical

Society

Life, HIV Coverage

Malachy Whalen & Co.

Malachy Whalen, 412.281.4050

Elizabeth Fulton, 412.321.5030

:

288 Bulletin June 2009


2009 BULLETIN ADVERTISING INDEX: JANUARY-JUNE

Accounting

Kline Keppel and Koryak ...................... (412) 281-1901

Billing/claims/collections

AccuMed Billing Services ...................... (800) 290-2528

Fenner Consulting ................................ (412) 788-8007

I.C. System ........................................... (800) 279-3511

Kell Group............................................ (412) 381-5160

Medical Billing Solutions ...................... (412) 823-9030

Clinical

Inspiris .................................................. (310) 903-3460

Pittsburgh Vein Center ........................ (412) 373-9580/

(724) 542-4142

The Surgery Center at Cranberry .......... (724) 772-1766

UPMC/DCI (412) 647-3700

Diagnostic

Med Health Services ....................(412) 373-7900 ext. 3

Financial

Hefren-Tillotson ................................... (412) 258-1069

National City/PNC .............................. (866) 874-3675

Hospice/Assisted Living

Heartland ............................................. (800) 497-0575

Schenley Gardens.................................. (412) 621-4200

Insurance

Malachy Whalen & Co. ........................ (412) 281-4050

PMSLIC ............................................... (800) 217-8080

USI Affinity .......................................... (724) 873-8150

Legal

HoustonHarbaugh ................................ (412) 281-5060

Tucker Arensberg ........ (412) 594-3945/(412) 594-5642

Medical Record Storage

Business Records Management Inc. ...... (412) 321-0600

Medical Supplies/Equipment

Allegheny Medcare ............................... (412) 580-7900

Organizations/institutions

Act One Theatre School........................ (412) 487-5613

Tobacco Free Allegheny ........................ (412) 322-8321

West Penn Allegheny Health System

Practice Management Services

Allscripts ............................................... (919) 854-3931

Alpern Rosenthal .................................. (412) 281-1018

PMSCO ............................................... (888) 294-4336

Virtual OfficeWare Inc. ........................ (888) 950-0688

Real estate/development

Kossman Development Company......... (412) 921-6100

Medical Office Time Share (SCA)......... (724) 772-5640

Prudential Preferred Realty .................(800) 860-SOLD

Prudential Preferred Realty–Gloria Carroll ... (412) 367-

8000 ext. 242

ReMax Select Realty ................(724) 933-6300 ext. 662

Staffing

ACMS Physician Career Center ............ (888) 884-8242

Transcription

Davis Transcription ............................... (412) 788-5300

Free classified ad on the world wide web!

www.

acms.

org

Place a classified advertisement in the Bulletin and your ad will

also appear on the Allegheny County Medical Society’s website

for the duration of the advertisement at NO ADDITIONAL COST.

Check out your ad at http://www.acms.org. For more

information, call Elizabeth Fulton at (412) 321-5030.

June 2009 : Bulletin

289


CLASSIFIEDS

Help Wanted

PHYSICIAN–A traditional family

practice located in Cranberry,

PA, is seeking a full-time or parttime

BC/BE Physician. Office

and hospital only and call will be

at least 1:4. Very competitive salary,

productivity-based incentive,

and outstanding benefits. H1-B

sponsorship is available. Interested

candidates may apply in

confidence by faxing a CV to Kim

at 412-647-8929. EOE

PHYSICIAN WITH ACTIVE/

or can activate PA license, any

specialty, for two half days per

month. Malpractice insurance

provided. Ideal for retired physician.

412-734-1100.

PART-TIME PHYSICIAN

NEEDED–Ideal for retired,

semi-retired or those looking for

extra income. Malpractice coverage

included, any specialty may

apply. Office setting. Call 724-

272-6104.

The medical society appreciates

and depends on its advertisers.

Please remember to tell them

you saw their ad in the Bulletin.

Flamingos

—a 2008 photo contest entry

by Dr. John M. Mikulla, whose

specialty is ophthalmology.

Do you have unpaid

receivables

Stamp Out Unpaid Bills!

The Allegheny County Medical Society

has partnered with I.C. System to

provide members with intelligent

collection solutions.

For more information on our endorsed debt

recovery services, CALL:

1-800-279-3511

:

290 Bulletin June 2009


June 2009 : Bulletin

291


Malachy Whalen & Co., Inc.

Visit www.malachy.com

(412) 281-4050

(800) 343-5382

FAX (412) 261-5955

Why should you call us for insurance

LOW PRICES & NO HASSLE!

♦ Low Cost: NO HASSLE!

We have low-cost term insurance that are the same

as the internet firms. Check our low rates at

www.malachy.com.

Malachy Whalen

mw@malachy.com

Clark Whalen

clarkw@malachy.com

Peggy McNamee

peggymc@malachy.com

♦ Easy Application Process: NO HASSLE!

Just complete and e-mail a simple request form and

we’ll go shopping for you!

♦ Health Issues: NO HASSLE!

We specialize in helping physicians with health

problems.

♦ Great Service: NO HASSLE!

We offer personal consultations and we make house

calls at your request—with NO pressure.

www.malachy.com

Your ACMS

“No Hassle”

Insurance Source

endorsed by

Allegheny County

Medical Society

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