Bulletin A C M
Allegheny County Medical Society Bulletin November 2014 The MOC debate Veterans and PTSD New ACMS Foundation Mission Statement ! W E N FREE BL OD PRESSURE MEDICINE * Lisinopril & Lisinopril HCTZ UP TO 90 TABLETS WITH PRESCRIPTION s u l P INTRODUCING OUR NEW MOBILE APP! No smartphone? Sign up for text message alerts at the Pharmacy instead! PICKUP ALERTS MY IPTIONS PRESCR * EASY REFILLS S& SERVICEGS SAVIN L NOW REFIL LY SALE WEEK RX SFER TRAN MACY PHAR TOR LOCA PILL REMINDERS *Prescription required. Giant Eagle reserves the right to modify or discontinue offer at any time. Restrictions may apply. See Pharmacy or GiantEagle.com/Pharmacy for details. 23821_Allegheny_Bulletin.indd 1 7/18/14 3:25 PM Allegheny County Medical Society Bulletin November 2014 / Vol. 104 No. 11 Articles Articles Departments Financial Health .................. 442 Legal Summary ................... 463 Letter to the Editor ............. 434 Inflation and your wealth: Keep it ‘real’ Gary S. Weinstein, MD, FACS Court rejects contempt application Michael A. Cassidy, Esq. Special Report .................... 445 Special Report .................... 464 New ACMS Foundation focus: Healthy Children, Healthy Communities, Healthy Future Diane C. Wuycheck Special Report .................... 449 HPV-related cancers preventable Alan Finkelstein, MD Materia Medica .................... 452 Cannabis considered Lucas G. Hill, PharmD Gregory B. Castelli, PharmD, BCPS 2014 Annual Meeting Recap: Helping Physicians Adapt to Change Pennsylvania Medical Society Society News ...................... 439 • Med students attend HOD meeting • Pittsburgh Ophthalmology Society • Medical Student Career Night ACMS Alliance News .......... 441 Reportable Diseases .......... 466 Perspectives Editorial ............................... 430 Thanksgiving Deval (Reshma) Paranjpe, MD, FACS Legal Report ....................... 457 Perspective ......................... 432 Personal cybersecurity – a HIPAA ‘lite’ approach Beth Anne Jackson, Esq. A view from the trenches: The IOM and the treatment of PTSD in the VA and DOD Barry Fisher, MD Special Report .................... 460 Accessing VA care for transitioning veterans Amy Boyles, LCSW Special Report .................... 462 The MOC debate hits home Leslie Howell, PAMED On the cover 2014 Photo Contest Winners announced on page 436. Sore Throat Protection by Terrence W. Starz, MD Dr. Starz specializes in rheumatology and internal medicine. Bulletin Affiliated with Pennsylvania Medical Society and American Medical Association 2014 Executive Committee and Board of Directors President Kevin O. Garrett President-elect John P. Williams Vice President Lawrence R. John Secretary David J. Deitrick Treasurer Robert C. Cicco Board Chair Amelia A. Paré DIRECTORS 2014 Kenneth P. Cheng William K. Johnjulio Jan W. Madison Donald B. Middleton Brahma N. Sharma 2015 Vijay K. Bahl Patricia L. Bononi M. Sabina Daroski Sharon L. Goldstein Karl R. Olsen 2016 Robert W. Bragdon Thomas B. Campbell Douglas F. Clough Jason J. Lamb Adele L. Towers PEER REVIEW BOARD 2014 Albert W. Biglan Edward Teeple Jr. 2015 Paul W. Dishart G. Alan Yeasted 2016 John G. Guehl Rajiv R. Varma PAMED DISTRICT TRUSTEE John F. Delaney Jr. COMMITTEES Awards Donald B. Middleton Bylaws Lawrence R. John Communications Amelia A. Paré Finance Karl R. Olsen Nominating Rajiv R. Varma Occupational Medicine Teresa Silvaggio Primary Care Lawrence R. John 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 Bulletin Managing Editor Meagan Welling (mwelling@acms.org) Assistant Executive Director, Membership/Information Services James D. Ireland (jireland@acms.org) Manager Dianne K. Meister (dmeister@acms.org) Field Representative Nadine M. Popovich (npopovich@acms.org) Medical Editor Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com) Associate Editors Michael Best (bestmw@upmc.edu) Robert H. Howland (howlandrh@upmc.edu)) Timothy Lesaca (tlesaca@hotmail.com) Scott Miller (millers8@upmc.edu) Gregory B. Patrick (gpatrick@hvhs.org) Brahma N. Sharma (bsharma763@aol.com) Frank Vertosick (vertosick@acms.org) Michael W. Weiss (mww@tririversortho.com) Managing Editor Meagan K. Welling (mwelling@acms.org) Contributing Writer Heather A. Sakely (bulletin@acms.org) ACMS ALLIANCE President Kathleen Reshmi First Vice President Patty Barnett Second Vice President Joyce Orr Recording Secretary Justina Purpura Corresponding Secretary Doris Delserone Treasurer Josephine Martinez Assistant Treasurer Sandra Da Costa www.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. PUBLISHER: 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 Monday preceding publication date. Periodical postage paid at Pittsburgh, PA. Bulletin of the Allegheny County Medical Society reserves the right to edit all 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; $50 others. Single copy, $5. Advertising rates and information sent upon request by calling (412) 321-5030 or online at www.acms.org. COPYRIGHT 2013: 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 Defining Tri Rivers Surgical Associates Quality Tri Rivers Surgical Associates celebrating At a time when healthcare reform is changing rapidly, Tri Rivers Surgical continues to focus on building a strong, cooperative physician-specialist relationship, recognizing it as the cornerstone for mutual success. For more than 40 years, Tri Rivers has defined quality care. Beginning in 2015, we will provide that same quality care under our new name, Tri Rivers Musculoskeletal Centers. 1-866-874-7483 www.TriRiversOrtho.com Editorial H Thanksgiving ave you ever noticed that bad news dominates nearly every media outlet, so much so that a good news or human interest story seems like balm on your wounds? I have more than a few patients who tell me that they have given up on watching the news. “But … don’t you want to know what’s going on in the world?” I ask. “Sure I do,” is the invariable reply. “But the news makes me depressed and anxious. So I stop watching, and I feel better.” Well, that makes grand sense in the tradition of the old joke: “Doctor, it hurts when I do this.” “Well, then don’t do that.” But for the rest of us, who might love to follow this approach but can’t afford to, what options remain? The unofficial motto of local and national news stations is “If it bleeds, it leads.” And lately, there has been a lot of bleeding taking place all over the world. And yes, all bleeding stops eventually, but in the case of our world, new bleeding springs from old wounds as time passes. From the atrocities of ISIS to school shootings in the United States to the daily acts of violence and other crime that take place in every viewing area, the carnage seems never-ending. It’s easy to become discouraged, until you realize that conflicts like war and disease have existed in every era of human history, albeit with less news coverage. The concept of gratefulness as an antidote to unhappiness, fear and terror also has existed in every era in human 430 Deval (Reshma) Paranjpe, MD, FACS history, with more or less news coverage. Most religions stress gratefulness to the supreme being(s) involved therein as a central tenet; gratefulness for being alive, for being chosen, for being saved, or for being part of the community. Humans always have been grateful for being spared from death, disease or debilitation. Ancient and modern religions alike have traditions of thanking the divine for spring renewal, fair weather, full harvest and mild winters. We are understandably grateful for escaping natural disasters – earthquakes, tornadoes, lava flows. Something about the act of communal gratitude bonds us to each other and makes us forget our differences in the face of terror. The original Thanksgiving story told to schoolchildren all over our fair land involves the Pilgrims and the Native Americans giving thanks for a good harvest and for each other’s friendship, which would help them endure the harsh winter. If you forget for a minute that the Europeans’ arrival to North America would cause disease, war and oppression for Native Americans in the centuries to come, and just take yourself back to the childhood narrative as perhaps it was for that moment in time, Thanksgiving is about giving This holiday season, find someone with whom you don’t always agree, and find something for which you are both undeniably grateful. This common ground of gratitude can bridge the gap between two people ... thanks and joining together to do it – and feeling less alone. Our political parties are more polarized now than they have been in decades. The concepts of reaching across the aisle to compromise or going out for a friendly dinner after a fierce and lively debate have all but disappeared. Instead, we unfriend each other on Facebook, and perpetrate uncomfortable silences at holiday gatherings. Why? Why can’t we agree to disagree, agree to work together, and agree and give thanks that we live in a wonderful country that allows us to do just that? Ebola threatens our shores. I’m grateful that we have access to knowledge and equipment to prevent its spread. Terrorism always lurks. I am grateful for a government, whatever its problems, that is committed to preventing it. And I am grateful for fellow countrymen and countrywomen who refuse to cow down to it. Intolerance, intemperance and injustice exist. I am grateful for the kind Bulletin / November 2014 Editorial people in the world who stand up and fight against all of these. Gratefulness also can be more mundane. I’m grateful that the Pirates have been doing so well in the past two years after a decades-long losing streak. I’m grateful that Pittsburgh is thriving. I’m grateful that Pumpkin-Spice-flavored everything exists. I’m grateful that no airline has seen fit to install the patented “standing seating plan” in a plane. I’m grateful that TLC has taken “Honey Boo Boo” off the air. I am grateful for chocolate, and for pie, and for brined turkey, and for those little crispy onions on the green bean casserole. You know the ones I mean. I’m grateful that scientists at Harvard have figured out how to store 700 terabytes of data in a gram of DNA using base pairs A-T and G-C as a binary code. I’m grateful that we live in a world where beauty and wonders happen every day for us to see. I am grateful for the unwavering love of family and the support of friends. I am grateful for our profession. And I am grateful for you, dear reader. Thank you. This holiday season, find someone with whom you don’t always agree, and find something for which you are both undeniably grateful. This common ground of gratitude can bridge the gap between two people, and perhaps go on to unite communities for good. And only then will the bad news cease, and good news rise to take its place. Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at reshma_ paranjpe@hotmail.com. 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. FOX CHAPEL - $1,350,000 SHADY SIDE $399,000 ASPINWALL - $317,000 SQUIRREL HILL $369,000 Bulletin / November 2014 431 Executive Perspective Committee A view from the trenches The IOM and the treatment of PTSD in the VA and DOD “Out beyond ideas of wrongdoing and rightdoing there is a field. I’ll meet you there.” Jalal-Ad-Din Rumi The Institute of Medicine’s (IOM) report on the state of PTSD treatment in the DOD and VA is now fresh off the presses. Their exhaustive report, entitled “Treatment of Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment,” lists a series of critical findings and broad recommendations. Their criticisms of VA/DOD care for patients with PTSD include: poor transition and coordination of care between the DOD and VA; inconsistent implementation of recommended evidence-based treatments; inadequate workforce to meet the growing needs for treating soldiers returning from the current conflicts in the Middle East; inadequate assessment of the efficacy of treatments offered; lack of family involvement in the recovery of these soldiers and veterans; and a dearth of research dedicated to the study of treatments for PTSD. In Whitney McKnight’s front-page article on the IOM study in Clinical Psychiatry News (July 2014), we find the following summary of the IOM review: … the DOD approach to PTSD treatment is “local, ad hoc, incremental, and crisis driven, with little planning.” In the IOM report the committee opines, 432 Barry Fisher, MD “While VA programs benefit from better organization and consistency, the lack of data on either department’s delivery methods and outcomes means there is “no way of knowing whether the care they are providing is effective or whether the DOD and VA’s expenditures are resulting in high-value health care.” McKnight adds in her article that, “the report is based on 4 years of combing through data provided by the DOD and VA, peer-reviewed literature, government documents, research databases, and testimonies from a variety of DOD and VA experts and providers at military bases and treatment facilities across the country, including six VA medical centers.” Committee member Dr. Elspeth Cameron Ritchie was quoted as saying, “What we found over and over again were really hardworking, well-intentioned people who wanted to do the best they could, but they either didn’t have an administrative structure to support them, or enough staff, or they had an overwhelming number of patients.” Its predecessor report, entitled “Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence,” an exhaustive review of more than 3,000 treatment studies of psychotherapy and pharmacotherapy, concluded that the evidence base for treatments was lacking (save for exposure based psychotherapy). At that time, high dropout rates and problems with handling missing data complicated the ability of the committee to adequately assess and endorse other treatments for PTSD. While both of these IOM studies are scholarly, well researched and carefully reviewed, they do not comport well with the limitations of clinical practice. Implicit, though not directly stated, is the conclusion that the VA and DOD fail to provide well-researched treatments. What also is evident in these reports, in my opinion, is a lack of appreciation for the complexity and difficulty in treating a less than “research perfect” population. With regard to the first criticism, namely, lack of coordination of care between VA and DOD, the committee members do not take into account the differences in culture between the two systems. Active-duty patients often are reluctant to seek treatment for PTSD when seeking treatment may negatively impact their promotion and retention in the service. In addition, there may be subtle biases against treatment communicated from superiors, and confidentiality issues are less clear than in a civilian health care system such as the VA system. In point of fact, the DOD and VA may find themselves in adversarial positions when it comes to Bulletin / November 2014 Executive Perspective Committee fitness-for-duty assessments and other important issues facing the soldier/veteran. In addition to the cultural impediments to coordinated care between the VA and DOD, the lack of a single computerized record system for VA and DOD also impedes seamless transition of care between DOD and VA. Another criticism in this study was the failure of clinicians practicing evidence-based psychotherapies to see veterans with PTSD for the prescribed number of sessions required. These veterans are primarily outpatients and are not “captured audiences” but busy individuals with jobs, families, legal problems and other distractions making adherence to therapy requirements difficult. In addition, patients are not single-diagnosis individuals, and failure to adhere to treatment recommendations could reflect problems of comorbidity. The problem of comorbidity also is relevant to criticisms about failure to provide evidence-based pharmacotherapies. For example, the strongly discouraged use of benzodiazepines in PTSD treatment has an evidence base in studies in which comorbidity is an exclusion for inclusion in the study. This prohibition may not translate well when comorbid panic disorder, obsessive compulsive disorder, psychoses and bipolar disorder exist in patients with PTSD and may confound the IOM conclusions regarding treatment. Even when the psychotherapists and prescribers adhere to treatment guidelines, one does not necessarily see improvement in symptoms. One clue to this observation may rest in the findings of a recent study entitled Disparities in Adverse Childhood Experiences Among Individuals With a History of Military Service (Blosnich, et al, 2014). This study showed that current soldiers had a higher prevalence of adverse childhood experiences and had twice the odds of having a forced sexual experience before the age of 18 relative to age matched non-military controls. Early childhood experiences are not the focus of most evidence-based treatments for combat PTSD, and an important variable affecting response to treatment could be getting missed. While not the intent of this study, these findings may point to the advantage of applying long-term, insight-oriented/transference-focused psychotherapies in patients treated for combat-related PTSD. At this point in time, these therapies are not encouraged nor generally practiced at the VA or DOD. While having the above criticisms of the IOM study of PTSD treatments, it’s hard to argue with their recommenda- References 1. Blosnich, et al, Diaparities in Adverse Childhood Experiences Among Individuals With A History of Military Service, JAMA Psychiatry, 7/23/14(APA, online). 2. Institute of Medicine (IOM). 2007. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. 3. Institute of Medicine (IOM). 2014. Treatment for posttraumatic stress disorder in military and veteran populations: Final Assessment. Washington DC: The National Academies Press. 4. McKnight, W. IOM: Targeted research needed for PTSD care, Clinical Psychiatry News, July 2014, vol. 42, # 7, Parsippany, NJ, Frontline Medical Communications. Bulletin / November 2014 tion to increase family involvement in care. There are years of hard evidence supporting the fact that recovery from PTSD is more likely when families are supportive of their loved ones with PTSD. Likewise, it’s hard to argue with their recommendation to increase workforce given that the numbers of veterans seeking treatment for PTSD has more than doubled during these recent conflicts. If the above cautionary observations regarding DOD/VA culture, patient complexity and co-morbidity are taken into account, the IOM’s recommendations are more likely to be useful to administrators and clinicians who are looking to improve care for individuals with PTSD at the VA and DOD. Dr. Fisher is section chief for Outpatient Services Behavioral Health Service Line VAMC Pittsburgh and is medical director of the Combat Recovery Clinic. He is a general adult psychiatrist with special interest in trauma and co-occurring disorders. He can be reached at Barry.Fisher@va.gov. 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. Looking for answers about government benefits and services? USA.gov has you covered. USA.gov 1 (800) FED-INFO 433 Letter to the Editor *This letter was written in response to Dr. Timothy Lesaca’s editorial in the September Bulletin, “Something rotten in Denmark?” (p. 384). Dr. Lesaca, Thank you for your thought-provoking editorial. I suspect you already know the answers to many of the questions it asks, but I’d like to share a few thoughts nonetheless. Let me say at the outset that I’ve done very well on the various standardized tests I’ve had to take. While this has much to do with God’s grace, and while I don’t believe it makes me a better person or a better doctor, I do think it qualifies me to comment on the standardized-test industry without it coming across as sour grapes. Like you, I’ve known both intelligent, deserving students who did not do well on standardized tests for one reason or another, and students who were academically marginal but who were absolutely gifted test-takers. A few thoughts, in no particular order. 1. We’re conditioned to accept this test bureaucracy from early in medical school. We’re also conditioned to accept rampant hypocrisy by the USMLE. How so? Consider the “passfail” nature of the Step 1. USMLE treats Step 1 as a pass/fail test, and thus states that: If you pass a Step or Step Component, you are not allowed to retake it. Well, that makes sense: if a test is pass/fail and you pass it, there would be no reason to take it again. However, we all know what is stated elsewhere on the USMLE website: With the exception of Step 2 CS (which is reported as Pass/Fail), USMLE results are reported on a 3-digit scale. 434 Clearly, a test can’t be both truly pass/fail and come with a detailed grade. So why not simply make it pass/ fail? Or, if numerical grades are to be the plan, why not abandon the notion of pass/fail? On the one hand, NBME seems to want the Step 1 to be just a licensing test; on the other, it seems also to want it to serve as the MCAT of residency applications. In other words, NBME wants to have its cake and eat it too. And so, by the time we are halfway through medical school, we learn that the standardized-test industry has its own best interests at heart. We see its casual disregard for what happens to those luckless souls who get the worst of all possible Step 1 grades, a very low pass – this being the worst possible since, as we’ve seen, it can never be changed. (By comparison, a student who fails may at least theoretically be able to do much better on a second try, and convince a sympathetic admissions committee that he had a good reason for his first low score.) 2. I’m not an internist; I’m an anesthesiologist. This means that ABIM’s decisions don’t directly affect me, but the American Board of Anesthesiology is following ABIM’s example pretty closely. Board certification, once a oneand-done thing, suddenly now entails MOC – but only for those who passed their boards after a certain date. To prevent a mutiny, MOC is initially made relatively straightforward, involving very limited activities and an easy test. As time passes, the test gets harder and other requirements grow. Look at how the ABA’s requirements (available online) have changed: Those who passed the boards in 2007 or earlier do not need to do a simulation, whereas those who passed in 2008 or later do. The simulation costs $1500 or more for eight hours, not counting travel expenses and missed work, and is only offered at certain academic centers. Clearly the goal is an incremental approach towards an ever-expanding MOC bureaucracy, with physicians always divided between the already-certified older docs and the younger docs who want to be able to compete with them for jobs. 3. The CMS “incentive” of 0.5 percent affects one two-hundredth of the already pathetic Medicare reimbursements – so, depending on the case, we may be talking about an “incentive” of under a dollar. As Mom used to say: Don’t spend it all in one place. But by comparison, the costs of MOCA have skyrocketed. These changes mainly (as we saw in #2) affect recent graduates, which in light of loan repayment schedules probably includes docs in their first several years of attending practice. These docs are often drowning in debt; meanwhile, they are getting into their thirties, and the 48 percent (as of 2012, according to AAMC’s published data) who are women will be acutely aware of the statistics about fertility and age. If they desire children, now is the time – debt or no. Meanwhile, the price of these essentially mandatory MOC activities is breathtakingly high. Again, the simulation runs a cool $1500. CME can be done for free, but ASA would like to sell me CME with automatic reporting to its own (mandatory, of course) electronic system for hundreds more. The exam itself – currently every 10 years, but I’m sure it will expand, just as the USMLE continues to expand - costs $2100 in my field. ABA has commented, in response to complaints about the cost of the various exercises, that it is “exploring ways to increase the value of Continued on Page 436 Bulletin / November 2014 PER MONTH WITH SCHEDULED SERVICES WWW.SECUREDMEDWASTE.COM 1-877-861-8970 We Guarantee 30% savings and have saved customers as much as 50% No Long Term Contract ‘‘we don’t trick customers into signing ridiculous contracts for services like the larger provider’’. Easy “No Hassle” Transition. We have helped thousands of customers make the switch. Flexible Service Options... weekly, bi-weekly, monthly, quarterly “YOU PICK” Per box “Flat-Rate” Pricing - no additional or hidden fees! HAVE YOU REVIEWED YOUR INVOICE FOR SERVICES LATELY? It’s as easy as 1 2 3…. Contact us, Select Service, Schedule Pickup Multi Box Discounts Local and Family owned “you’re talking to the owners when you call” Courteous and Professional Service - we’ll even assist in the packaging of your box if not ready Why Pay More? Call us now!!! Thank You, Jim Hitt, President Call Paula for a “No Obligation” Quote 877.861.8970 Bulletin / November 2014 435 Letter to the Editor From Page 434 these costs.” In English, this appears to mean, “The price isn’t coming down, but we’ll keep telling you what a great deal you’re getting.” (Speaking of expanding tests, the USMLE introduced “Step 2 CS” the year after I would have had to take it. Simply being born one year earlier spared me from a mandatory exam costing a cool $1355, plus travel expenses. Am I a worse doctor for not having to undergo this test? If yes, why am I still allowed to practice? If no, why do the younger guys need it?) 4. Noam Chomsky once used the term “manufacturing consent” for herding people to a predetermined decision. While he used it to argue for left-wing politics, the term can be applied to any organization trying to give the illusion of people choosing whether or not to support something that government or management has already decided it would do. The strategy is simple: Offer two wildly undesirable choices, one clearly worse than the other, then announce that the people in question have “asked for” the one you’d intended them to choose. Clearly MOC’s backers are doing something similar here: We are given a choice not of whether we will participate in MOC, but of which expensive, onerous, and unnecessary activities we will use to pad their bottom line. You can safely assume that this will be reported as doctors agreeing that MOC is a valuable and important thing to do – especially since most, if not all, of these activities include a mandatory, maybe-anonymous-maybe-not, survey about whether they were worthwhile. 5. I say in #4 that we are not given a choice of whether we will participate. This is not, in the strictest sense, true: I can physically refuse to participate in the activities. But when refusal to participate comes with consequences, participation is not really voluntary; rather, it is coerced. You mention credentialing and CMS “incentives,” and one could name other concerns – from patients who search online and discover that their doctor is “not meeting requirements,” to inquiries about credentials at a legal deposition. Some combination of these is presumably meant to compel those with non-time-limited certificates to do MOC, despite the promise that they wouldn’t have to. But for the anesthesiologists who passed their boards anytime in the past 14 years, the biggest threat is the simplest: The certificate will expire. If I am to say that I am board-certified after the expiration date on my certificate, I have no choice but to participate in MOCA. 6. And, finally, the inevitable consequence of adding endless layers of bureaucracy, each with its own requirements to satisfy and busy-work to do: More and more of us are simply leaving clinical medicine. The older docs retire early; the younger ones curtail their hours or retrain. PQRS? QCDR? MOCA? As a teenage texter might write, I am SMH (shaking my head). Thanks, once more, for daring to speak up. I doubt it will make much difference, but perhaps if enough people speak out, it will. AAPS, the Association of American Physicians and Surgeons, is leading the fight against MOC and currently pursuing a lawsuit against ABMS to resist mandatory MOC – perhaps common sense may yet prevail! Charles Horton, MD For more on the MOC, please see page 462. 2014 Photo Contest Winners 1st Place - Bruce A. Wright, MD “The Point” 2nd Place - Alan H. Klein, MD “Falling Water Revisited” 3rd Place - Kimberly Hennon, MD “Jenny Lake and the Grand Tetons” Additional winners: Frederick Doerfler Jr., MD; Anthony Spinola, MD; Charles F. Sturm, MD; Elias Hilal, MD *Winning photos will be featured on the 2015 covers of the Bulletin. 436 Bulletin / November 2014 Letter to the Editor Dear Editor: Thank you for publishing Greg Patrick, MD’s editorial “Tell Me a Story” in the September edition of the Allegheny County Medical Society Bulletin. His comments regarding his recent frustrations from his Electronic Health Record “EHR” echo my own experience with EHRs. Re-emphasizing his comments that the EHR interferes with patient care and it is difficult for a physician to determine when reading a treatment plan, the sequence leading up to that plan, or even who ordered it. With my paper charts, my problem list clearly not only lists the patient’s diseases and problems, but it is sequenced by date, often important information in delivering care. EHRs list the problems at the time of the visit, but not those problems in chronological sequence. And it gets worse. At a recent symposium held at the Duquesne Club by the Business Times, “The Future of Health Care,” one of the panelists was Dr. Andrew R. Watson, medical director of telemedicine at UPMC. His comments regarding patient care are quite disturbing: “There’s going to be huge requirements of people to get engaged in a different way: On the one hand, patients are increasingly turning to computers to communicate with doctors via telemedicine, which is help- ing to save costs by cutting down on face-to-face visits and the time it takes to drive to them, and is enabling home health care through remote monitoring. Face-to-face visits are outdated.” (My emphasis.) Is he really serious? Face-to-face visits are outdated? The invasion of our offices by the information technology industry has thrust itself between our patients and our delivery of care. If telemedicine has its way by disrupting the hands on delivery of medical care, we as physicians, and our patients, are in serious trouble. Sincerely, Marc J. Schneiderman, MD Squash your fears of surprise costs with our New Life Home Building Process. 412.384.8170 Bulletin / November 2014 437 Is it a swim lesson? Or an example of our deep experience in spinal cord injury rehabilitation? A lot of science goes into our world-class therapies. There is a lot of splashing, too. That’s because we are the region’s only facility with two therapeutic pools, plus a sensory room and healing therapeutic garden. They’re part of our unique pediatric rehabilitation programs that combine elements of recreation with cutting-edge techniques to help your patients recover from a host of spinal cord injuries and complications. After all, who ever said therapy has to be all work and no play? For referral information, call 412.420.2400 or visit amazingkids.org. 438 Bulletin / November 2014 Society News Pittsburgh Ophthalmology Society H. Kaz Soong, MD, professor of Ophthalmology and Visual Sciences at the University of Michigan Kellogg Eye Center, Dr. Soong will speak to the members of the Pittsburgh Ophthalmology Society Thursday, Dec. 4, at the ACMS building. Dr. Soong will provide lectures on 1) Acanthamoeba keratitis; 2) what makes DSEK stick; 3) the versatile femtosecond laser; and 4) Spreading our wings into the global scene. Dr. Shilpa Kodati, resident of the UPMC Eye Institute, also will present a case for discussion. Contact Dianne Meister at (412) 321-5030 to attend the meeting. Medical Student Career Night held at O’Hara Student Center James Ireland / ACMS Assistant Executive Director Med students attend HOD meeting Medical student members of the ACMS Delegation attended the House of Delegates meeting in Hershey Oct. 25-26. For more on the HOD meeting, see page 460. From left are Samuel Lindner, Claire Paduano, John Demko, Vladimir Lamm, Benjamin Ware, Akash Goyal and Ryan Williamson. On Oct. 30, the University of Pittsburgh Medical Student AMA Chapter and the Allegheny County Medical Society (ACMS) hosted the AMA Career & Shadow Fair at the O’Hara Student Center. The session was attended by 100 students and 25 physicians. Students were able to meet and speak with physicians regarding specific specialties. Specialties represented included Anesthesiology; Emergency Medicine; Family Practice; Internal Medicine; Nephrology; Obstetrics/Gynecology; Ophthalmology; Pathology; Pediatric Surgery; Radiology; Surgical Oncology; Urology; Vascular Surgery; and Hematology. From left are medical student Krshan Thadikonda, Lawrence John, MD, and medical student Ryan Williamson. Bulletin / November 2014 James Ireland / ACMS Assistant Executive Director 439 In every home there’s a story you’re a part of. 2014 National Home Care and Hospice Month At Interim HealthCare, we’ve been writing the story of home care for nearly 50 years. We’re proud of our heritage and the dedicated professionals who have played such an important role in meeting the needs of patients at every stage of their lives — in the comfort of their own homes. View our Stories From Home at InterimHealthCare.com/Stories (800) 447-2030 440 Bulletin / November 2014 Alliance News Welcome new members We are delighted to welcome new members into our organization. Yvette Lawson is a woman of distinction in her lifetime career in the world and business of printed publications. Geraldine Orr, sister of Donald Orr, MD, has found time for us, away from her profession in the field of accounting. Both women have expressed interest in serving in leadership roles and on committees for General Meetings, namely the Holiday Brunch on Dec. 7, 2014, and the Annual Meeting May 19, 2015. Along with individual dynamism, both women bring experience and enthusiasm to us. It will be our pleasure to mentor them into the work and social side of the Allegheny County Medical Society Alliance (ACMSA)! In Memoriam Lee R. Oehrle, our friend, colleague and long-time member of ACMSA, died recently. Lee was a pianist, classically trained at Eastman School of Music, and a graduate of Carnegie Mellon University. A fervent volunteer, Lee devoted decades in time, effort and support of adult literacy programs, music and choir programs at Southminster and Fox Chapel Presbyterian ACMS Alliance Church(es). She was a reader for the blind with Pittsburgh’s Radio Information Service on WDUQ. Lee enhanced the ACMSA with her commitment to our own projects and events. Lee is survived by her husband, John S. Oehrle, MD, a son and daughter and grandchildren. The full obituary is available in the Pittsburgh Post-Gazette Aug. 12-14, 2014. Wrap-Up September General Meeting The first of three General Meetings of ACMSA for Alliance year 2014-15 took place Sept 23 at South Hills Country Club. The event planning was masterfully managed by Chairman Barbara Wible, with Committee members Patti Hetrick, Liz Blume, Lois Levy, William Hetrick, MD, and Joseph Roarty, PhD. The Business Meeting was conducted by Chairman of the ACMSA Governing Board, KJ Reshmi. ACMSA Past Presidents in attendance were recognized for their service and commitment to the Alliance. Donna Nardine, Executive Director of The Watchful Shepherd, USA and Claudine Femiani, wife and spokesperson for the organization’s founder, Dr. Joe Femiani, presented a riveting program, very relevant in today’s world. Now in its 20th year, The Watchful Shepherd is a national organization with programs for addressing prevention of child abuse through intervention in troubled family situations. The Watchful Shepherd works with law enforcement, court systems, hospitals and community resources. The Watchful Shepherd is benefiting individuals and society in general through methods of keeping families together, and connected to agencies and organizations able and willing to help. The speakers provided various printed materials of interest to all in attendance. Contact information: The Watchful Shepherd, 1061 Waterdam Plaza Drive, Suite 204, McMurray, PA 15317; (724) 941-3339; shepherd@ watchful.org. The program was followed by a luscious luncheon. Proceeds from the Autumn General Meeting will benefit ACMS Foundation for philanthropic efforts in the community. Thanks to all for your wonderful arrangements, attendance and generous support in giving us an awesome autumnal start to a promising new Alliance year! Content and text by Kathleen Jennings Reshmi Congratulations PAMED Alliance on its 90th Anniversary! 1925-2014 Bulletin / November 2014 441 Financial Health Inflation and your wealth: Keep it ‘real’ I nflation increases the cost of goods and services and reduces purchasing power over time. It is measured by the Consumer Price Index (CPI), which calculates the monthly cost of a basket of goods and services likely to be purchased by urban consumers. The CPI increased by 1.5 percent in 2013 and ranged from -10.8 percent to +20.4 percent annually over the past century. Most retirees experience above-average inflation because health care expenses grow faster than the CPI. Most economists believe that low inflation is positive for economic growth but higher levels are deleterious. Weimer Germany provides the best example of what happens during rampant inflation. From 1914-23, the cost of living increased by a factor of 218 million due to war debt, reparations payments, central bank mismanagement and inadequate taxation. Higher prices were initially attributed to war shortages and strengthening of the U.S. dollar against the Deutschmark (DM). As currency values continued to fall, consumers cashed paychecks to buy tangible goods for consumption, accumulation or barter. They endured long lines, limited store hours, empty shelves, thick wads of currency and complex calculations to complete transactions. The government responded to currency shortages by printing DM 24 hours a day, 7 days a week. De- 442 Gary S. Weinstein, MD, FACS spite using fast-drying ink and printing on one side only, paper costs exceeded the value of the debased currency! When demand outstripped supply, local governments and large companies were licensed to print their own legal tender, further fueling the inflation. The press published daily prices with “multipliers” for standard goods and services, often by factors of millions. As the crisis worsened, hoarding of food and fuel, public and personal theft, counterfeiting, bribery of governmental officials, political unrest and public health (starvation, rickets, tuberculosis) worsened. The government regularly assured the public that inflation was over, but it accelerated for 10 years. As paper money became worthless, material assets, precious metals, gold, jewelry, collectables and farm crops became valuable. Small businessmen, tradesmen and professionals demanded payment in goods or bartered services rather than DM. Families gradually sold furniture, artwork and musical instruments to obtain basic life necessities. Hyperinflation relentlessly destroyed the value of fixed income investments such as government bonds, certificates of deposit, savings bonds, annuities and insurance policies. In contrast, the German stock market rallied but not enough to match inflation. The real (post inflation) value of stocks declined 97 percent and the dividend yield dropped to 0.25 percent. Although the German stock market recovered a decade later, most investors had liquidated their portfolios during the inflationary period to fund living expenses. Portfolios are difficult to protect from hyperinflation but can be structured to minimize low to moderate inflation. Common stocks usually outpace inflation over time but experience significant short-term volatility. Holding 30 to 40 percent equity allows most portfolios to generate positive real returns. As inflation increases, stocks initially fall then rebound as companies raise prices to offset higher costs. A substantial (30 to 50 percent) equity allocation to international stock indexes further reduces inflation risk because it is often country specific. The Weimer hyperinflation was limited to the Austro-Hungarian Empire and spared western democracies. Bond portfolios are more vulnerable than stocks to inflation because prices fall as rates rise and interest is paid with devalued currency. The potential loss of principal is best gauged by bond portfolio “duration,” which measures the number of years it takes for the principal to be repaid by interest Bulletin / November 2014 Financial Health payments. A 5-year duration bond portfolio loses 5 percent in value if real interest rates rise 1 percent (5 X 1) and 10 percent if they rise 2 percent (5 X 2). Limiting portfolio durations to less than 5 years provides reasonable downside protection from rising rates. Bond principal can be preserved in tax-deferred accounts with Treasury Inflation-Protected Securities (TIPS). The principal is adjusted semiannually (based on the CPI), but interest payments are taxed as ordinary income. Precious metals funds, gold funds, hard bullion, real estate and commod- ities also maintain value in inflationary times. Most experts recommend allocating up to 10 percent of the equity portfolio to real estate investment trusts (REITS) and 5 percent to precious metals or gold funds. These are best held in tax-deferred accounts because REIT income is taxed as ordinary income and precious metal and gold funds need to be rebalanced, which generates capital gains taxes. Life, disability and annuity insurance products can be protected with inflation riders. Measure your portfolio returns and insurance payments in real (post inflation) terms. It is far better to have small real returns than large nominal ones. When it comes to managing your wealth, strive to keep it “real!” Dr. Weinstein practiced oculoplastic surgery for 25 years and taught investing at Carnegie Mellon University’s Osher program and the American Academy of Ophthalmology. He co-authored a Retirement Planning chapter in J.K. Lasser’s Expert Financial Planning and lectures to physician groups on investing and financial planning. 18541 Medical Society Color Ad v1_Layout 1 4/29/14 10:22 AM Page 1 Leading the practice in complex divorce, support and custody matters since 1978 Wilder Mahood McKinley & Oglesby James E. Mahood Brian E. McKinley Darren K. Oglesby Bruce Lord Wilder, Of Counsel 10th Floor Koppers Building, Pittsburgh, PA 15219 • 412-261-4040 www.wildermahood.com Bulletin / November 2014 443 Allegheny Health Network welcomes Suzanne Schiffman, MD Surgical Oncology Dr. Schiffman is a board-certified general surgeon and surgical oncologist who specializes in treating patients with complex abdominal malignancies including cancerous conditions of the liver, bile duct, pancreas, stomach, small bowel, colon and peritoneum. Her practice includes the use of minimally invasive surgical techniques in benign and malignant gastrointestinal disease. She is specialty-trained in liver, bile duct, and pancreatic surgery. In addition, she performs cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) when indicated for peritoneal metastases. She advocates a team-oriented approach to healthcare with an emphasis on education and clear communication with her patients. Dr. Schiffman earned her medical degree from Jefferson Medical College. She completed her general surgical residency at the University of Louisville where she served as administrative chief resident. Following residency, Dr. Schiffman completed fellowships in both surgical oncology and hepatobiliary surgery at the University of Pittsburgh Medical Center. For an appointment, please call: Allegheny General Hospital 320 North Avenue Pittsburgh, PA 15212 412.359.3115 West Penn Hospital Medical Pavilion 4727 Friendship Avenue Pittsburgh, PA 15224 412.359.3115 Wexford Health + Wellness Pavilion 12311 Perry Highway Wexford, PA 15090 412.362. DOCTORS (412.362.8677) Dr. Schiffman is on staff at Allegheny General Hospital and West Penn Hospital. As always, new patients are welcome. Most major insurances are accepted. 444 Bulletin / November 2014 Special Report New ACMS Foundation focus: Healthy Children, Healthy Communities, Healthy Future Diane C. Wuycheck I nstituted in 1960, ACMS started the Allegheny County Medical Society Foundation with donations from the polio immunization program. The immunization effort was undertaken by ACMS and the Allegheny County Health Department, and sparked a public outpouring of donations collected in jars on the streets of Pittsburgh. The Foundation has since given $2.26 million back to the community. While so much has changed since that early start, so much remains the same for those the ACMS Foundation seeks to serve. To zero in on core issues the Foundation could potentially impact, the ACMS Foundation, not surprisingly, found that an increasing number of health issues affecting families and their communities arise from their home environments. A new mission statement captures that focus: ACMS Foundation grants will support home and community environments that nurture and develop healthy children and families for a healthy Allegheny County. The ACMS Foundation’s vision makes that ideal clearer still: • We will help people help themselves through the practical application of knowledge and resources to improve their physical and behavioral health, their quality of life and that of future generations. • We recognize that many medical Bulletin / November 2014 illnesses can be traced to unhealthy circumstances in our community that occur during the formative years, and can be successfully remediated or prevented. • We will support organization-based activities that engage individuals and families in the planning, development, evaluation and implementation of programs at the community level that assist individuals in creating supportive and healthy home environments. • We believe that all people have the inherent capacity to effect change in their lives and in their communities. We will support programs that respect and value individuals and their collaborative work to improve health care in our community. Physicians and other donors who support the ACMS Foundation through the annual Gala and direct contributions may not realize how those dollars directly impact children and families for a healthy Allegheny County. To put a human face on the work made possible through an ACMS Foundation grant, recent grant recipients shared stories of families they serve. A common denominator was support in a variety of forms. There is something powerful about support groups – those gathered together united by a common bond. Without the funding of the ACMS Foundation, parents and caregivers of children with spina bifida might never have known just how powerful! The monthly groups offered by the Spina Bifida Association of Western Pennsylvania not only provide crucial respite for parents but also include a group for children to meet and share, too. Sometimes there’s a speaker (e.g., explaining warning signs); sometimes there is a training component (like how to prevent sepsis) to help caregivers manage daily activities and challenges. However, caregivers say, being together is what matters. At the same time, kids ages 1-7 generally, can just play with their peers without fear of feeling “different” or getting hurt! They build their social skills and independence, too. Currently, 12 families from around the region breathe easier for a few hours. Their simple, common wish – that they could have more sessions! Low-income single parents face an array of challenges. Angel’s Place offers hope and possibilities. That comes in the form of child care and education support – keys to their wellbeing and independence. Because education is such a critical need, celebrating exceptional students – those who excel not only in school but as parents – is the goal of the Showcase of Scholars. Randi’s experience conveys why she was one of the awardees: “I had always dreamed of becoming a nurse. Divorced in 2011, I moved in with my grandmother. I couldn’t afford daycare but needed to earn an income. I found AmeriCorps, committing to 10 months Continued on Page 446 445 Special Report Child Care Associate Brittany claps along with Child’s Way attendees Ava and Maddie during a morning sing along as part of the program’s daily academic programming. From Page 445 of service to earn a “living stipend,” an additional education award and subsidized childcare! After that commitment, I had no daycare options and didn’t qualify for government assistance. Online I found Angel’s Place! I honestly thought it was too good to be true. Angel’s Place took me in. I was finally going to get an education and start down a career path. I still want to be a nurse!” When the whir of sirens subsides and parents are assured a loved one is in good hands, where do they turn? A long drive home after a tiring ordeal gives way to the convenience, com446 fort and cost-effectiveness of Family House. Since 1983, Family House has provided a home away from home for a few days or an extended stay, in the company of others who understand their needs – a warm bed, a hug. The ACMS Foundation’s support of Family House helps to reduce the already modest rates for families to share time with others who can empathize. In fact, families cite that it’s not just the room but the “community support” they experience from staff, more than 150 volunteers, and the other families that makes all the difference. The four Family House sites comprise the largest hospital hospitality house in the nation, so the ACMS Foundation grant “goes a long way,” says Ron Guca, director of development. Family House needs between $140,000 and $240,000 every year to support 15,000 patients and their families who need financial assistance. In addition to transplant, cancer and trauma patients, Family House welcomes families of patients participating in clinical trials and those experiencing complex neurologic and orthopedic surgeries, among others. Child’s Way® is a Pediatric Extended Care Center (PECC) for medically fragile children age birth to 21, offering an alternative or supplement to Bulletin / November 2014 Special Report Child’s Way Clinical Director Erin Colvin sits with Child’s Way attendee Catelin. Photos courtesy of Child’s Way and the Spina Bifida Association of Western Pennsylvania in-home nursing and therapy care for children with complex medical needs. Licensed as the first PECC in the Commonwealth of Pennsylvania, this program was established in 1998 to fill an identified need in the community. Weekdays from 6:30 a.m. until 6 p.m., Child’s Way’s registered nurses and child care associates meet a child’s medical needs – including monitoring vitals and medication administration – while children participate in activities in a typical classroom environment. This combination is not only a hit with children but also provides parents peace of mind, perhaps best described by Amee, whose son comes to Child’s Way: “My main concern was finding someone who could care for all of his medical needs and that he was safe, but I also wanted him in an environment where he could play with his Bulletin / November 2014 peers. [Then one day] I walked into Child’s Way and they said, ‘Why don’t you show mommy what you did today?’ He turned around and he let go of the table and he walked over to me. I’ve never been so proud or happy or emotional about something in my entire life. It felt like the day he was born.” This ACMS Foundation grant supports critical program needs and funding gaps for some of the area’s most vulnerable families – including child care fee scholarships, foregone charges from medical insurance, and medical care for children with shortterm insurance denials. The grant provided the equivalent of child care fee scholarships for seven children for one month. As these stories show, the impact of the ACMS Foundation extends beyond the dollars. It lives on in a legacy of lo- cal institutions, services and resources grown from Foundation seed money, in healthy families and communities, and medical and social service professionals making a difference in the region and beyond. Tax-deductible contributions to the ACMS Foundation can be made online at www.acmsfoundation.org or by returning the envelope inserted in this issue. A complete list of all ACMS Foundation grants is available on the website. Diane Wuycheck is a former ACMS director of communications and media relations manager for several local corporations. She established a private practice in marketing communications in downtown Pittsburgh in 2002. Contact her at wuycheck@wuycheck.com. 447 448 Bulletin / November 2014 Special Report HPV-related cancers preventable 2 014 marks the 100th birthday of Jonas Salk, whose polio vaccine has virtually eliminated a nervous system-destroying disease that once confined scores of children and young adults to iron lungs and wheelchairs. Salk’s vaccine, developed at the University of Pittsburgh, quickly became a cornerstone of preventive health care for adolescents across the globe. As we celebrate the man behind one of medicine’s greatest achievements, we also must confront a public health paradox that Salk himself would have found unacceptable. There is a safe, proven vaccine available to protect children against certain types of human papillomavirus (HPV), which causes an estimated 33,000 cases of cervical, vaginal, vulvar, oropharyngeal, penile and anal cancers in the United States each year. Yet few kids receive this cancer-preventing gift: Just 38 percent of girls between the ages of 13-17 and 14 percent of boys completed the three-dose HPV vaccine regimen in 2013, according to the Centers for Disease Control and Prevention (CDC). We have a shot to fight cancer – the scourge of our lifetime – and we’re not using it. But, as with polio in the 1940s and 1950s, Pittsburgh is stepping forward to keep our community healthy. The Jewish Healthcare Foundation (JHF) – with additional funding support from The Grable Foundation, the Eye & Ear Foundation of Pittsburgh, and a Mobilization for Health: National Prevention Partnership Award from the U.S. Department of Health and Human Services – has launched a campaign Bulletin / November 2014 Alan Finkelstein, MD to increase HPV vaccination rates by activating individuals and organizations from across our region. The campaign kicked off in February, when JHF convened an advisory committee featuring more than 40 clinicians, researchers, community activists, educators, health plan representatives and Allegheny County Health Department leaders. Sub-committees of the advisory are tailoring culturally competent messages about the vaccine’s benefits to parents, teens and young adults (for “catch up”); collaborating with health care providers to encourage them to talk about HPV; and working with regulators and others to advocate for policy changes that could one day boost HPV vaccination rates past the 80 percent goal established by the CDC. JHF also has launched a Pittsburgh chapter of Grandmother Power, providing activist grandmothers with the education and resources needed to take the cancer prevention message back to their families and communities. Along with Fred Rogers Company CEO William Isler, I co-chair the HPV campaign advisory working with parents and providers in the Pittsburgh region. And we need your help. We have found that parents who do not vaccinate their children against HPV often say they lack information about the vaccine, or they’re concerned about its side effects. It’s the job of the clinician – a family’s trusted partner in making informed health care decisions – to ensure that parents understand the cancer-preventing potential of the vaccine. The HPV vaccine is recommended for girls and boys aged 11-12 (before exposure to HPV). The vaccine also is recommended for girls 13-26 and boys 13-21 who did not get it when they were younger, as they may not have been exposed to any or all of the HPV types prevented by the vaccine. Licensure trials have shown the HPV vaccine to be 100 percent effective against incident infection, with protective immunity for at least a decade. More than 57 million doses of the HPV vaccine have been safely administered since 2006, with the most serious common side effect being dizziness (which is why doctors have those who are vaccinated wait 15 minutes before standing up). Given those results, a procession of leading health care organizations including the CDC, American Academy of Family Physicians, American Academy of Pediatrics, and the Society for Adolescent Health and Medicine recommend the vaccine for boys and girls. For these health care professionals, discussing the HPV vaccine with parents and young adults is no different than explaining how the Tdap and Meningococcal vaccines can stave off myriad health problems in the future. Research shows that a strong provider recommendation is the single largest motivating factor for parents to Continued on Page 450 449 Special Report From Page 449 vaccinate their children and for young adults who missed getting vaccinated when they were younger to get vaccinated. But despite the strong evidence supporting the HPV vaccine’s efficacy and safety, the CDC says that physicians do not recommend the HPV vaccine to about one-third of age-appropriate girls, and more than half of age-appropriate boys. Each day, children in our region visit their doctor and miss an opportunity to receive one of the few vaccines in the world proven to prevent certain cancers. The CDC estimates that if providers had given the HPV vaccine during health care visits when another vaccine was administered, about 91 percent of girls born in 2000 would have received at least one dose of the HPV vaccine by age 13. When Salk’s polio work earned him the Congressional Medal for Distinguished Civilian Achievement, he said that “the greatest reward for doing is the opportunity to do more.” We, as a community, simply must do more to ensure that our children are given the opportunity to carry out their ambitions. When I talk to parents, many of whom have been touched by cancer, I tell them that there’s a shot available to prevent their kids from potentially having to endure similar health struggles. On behalf of JHF and the band of health care and community leaders mobilizing to protect our children against the consequences of the HPV virus, I welcome you to join us. Will you, like Salk, do more for our region’s children? Dr. Finkelstein is a family physician in Pittsburgh and has been on the faculty of the UPMC-Shadyside Family Medicine Residency Program since 2001. He serves on the Advisory Committee of the Jewish Healthcare Foundation’s HPV immunization campaign, and is the Board Chair of Adagio Health, a local nonprofit providing care for underserved women and families in 23 counties in western Pennsylvania. P HYSIC I A N S , W E TH A N K YOU. H PV VACC IN AT ION IS CA NC E R P RE VE N T I O N . To the physicians who take care of our children and grandchildren and help to ensure they are protected against HPV-related cancers — thank you for recommending and providing the vaccine to your patients. 450 Bulletin / November 2014 Care is Your Business, Change is Ours The healthcare environment is changing. Physicians must focus on providing the highest quality care with intense competition for their time. Medical practices face increased challenges tied to changes to regulation, insurance protocols, cost-management and revenue management. Houston Harbaugh has over 30 years of experience in helping physicians and medical practices manage change through contract negotiations with hospitals and payors; contract management; advocacy and new practice start-up counsel. We have provided critical support in practice mergers and acquisitions. And we have provided sound advocacy on issues ranging from HIPAA compliance to medical staff and peer review matters. Every challenge a medical practice can face, we have seen. We have helped practices of all size and structure meet these challenges. And we know what is ahead. Houston Harbaugh: Your voice in medical practice management. YOUR VOICE l hh-law.com Business • Employment • Estates and Trusts • Health Care Litigation • Oil and Gas • Public Finance • Real Estate Bulletin / November 2014 451 Materia Medica Cannabis considered Lucas G. Hill, PharmD Gregory B. Castelli, PharmD, BCPS W hen determining whether to recommend any medication to a patient, there are at least three factors a medical provider must assess. While safety and efficacy are the most commonly cited factors, another important consideration is regulatory status. Is the medication available without a prescription? Are its ingredients and manufacturing processes monitored by the United States Food and Drug Administration (FDA)? Is the medication a controlled substance and if so, how is its prescribing logistically limited? A variety of regulatory limitations may preclude prescribing in certain circumstances and such may be the case for cannabis. While the FDA classifies cannabis, commonly referred to as marijuana, a schedule I narcotic with no legitimate medical purpose, 21 states have provisions for its medicinal use. Additionally, 18 states have reduced or eliminated criminal penalties for recreational use and possession of cannabis.1 Pennsylvania law does not yet differ from federal policy, but legislation to allow medicinal use is being considered in the state legislature.2 Currently, possession of less than 30 grams (one ounce) of cannabis in Pennsylvania is considered a misdemeanor with a maximum penalty of 30 days in prison and a $500 fine. Possession of more 452 than 30 grams could result in imprisonment for up to one year accompanied by a $5,000 fine.3 Though legal liability for prescribing cannabis is difficult to estimate, it would be prudent not to recommend it until current state laws are amended. The endocannabinoid system is comprised of cannabinoid (CB) receptors in the human body that can be agonized by both endogenous and exogenous ligands. The CB1 receptor is prevalent in the basal ganglia, hippocampus, cerebellum and visual cortex. The CB2 receptor is located primarily in the spleen, tonsils, bone marrow and leukocytes. Anandamide and 2-arachidonyl glycerol, arachidonic acid derivatives, are endogenous ligands for these receptors. While the normal daily activity of these ligands and receptors has not been fully elucidated, some clues are provided by the failed CB1 antagonist rimonabant (Acomplia®). Rimonabant was shown to be an effective smoking cessation aid and also induced weight loss in obese patients. However, it was withdrawn from the European market and never approved in the United States due to increased depression and thoughts of suicide, as well as other neurologic adverse effects.4 The efficacy of synthetic cannabinoid agonists has been established for multiple medical indications. The most referenced cannabinoid, tetrahydrocannabinol (THC), is believed to be primarily responsible for the psychoactive effects of cannabis. Another cannabinoid of interest, cannabidiol (CBD), is believed to be less psychoactive than THC while exhibiting similar therapeutic effects. For this reason, strains of cannabis that contain little or no THC but have high concentrations of CBD are gaining popularity among patients who use cannabis medicinally. A THC-analog called dronabinol (Marinol®), approved by the FDA in 1985, is indicated for use in acquired immunodeficiency syndrome (AIDS) associated anorexia and chemotherapy-induced nausea and vomiting. A mixture of dronabinol and CBD called nabiximols (Sativex®) is approved in Europe for the treatment of neuropathic pain and spasticity related to multiple sclerosis (MS) as well as opioid-refractory cancer pain.6 Data regarding the efficacy of inhaled cannabis is extremely limited due to legal restrictions and a lack of dose standardization. However, available evidence suggests it has similar efficacy in AIDS-associated anorexia5, MS-related spasticity6 and neuropathic pain7. There is currently increased interest in the use of cannabis and synthetic cannabinoids as an active treatment for glioblastomas and other cancers. Guzman et al. report that when intratumoral THC is used in patients with advanced glioblastomas who have failed standard therapy, the median survival rate is 24 weeks. Additionally, their in-vitro results showed a possible decrease in tumor cells.8 Cannabis also is being used by some patients with refractory seizures, though a systematic review published in Neurology, the official journal of the American Academy of Neurology, Bulletin / November 2014 Materia Medica concluded there is insufficient evidence to support this practice.9 The most common adverse effects associated with cannabis inhalation are those that recreational users find appealing. These may include a distorted perception of time, increased hunger, somnolence and euphoria. While few patients seek treatment for cannabis addiction and withdrawal symptoms are rarely observed, a mild withdrawal syndrome consisting of irritability and self-limiting sleep disturbance can occur. Study populations who were administered very large doses of cannabis for various periods of time followed by rapid cessation have experienced restlessness, irritability, insomnia, nausea and cramping. Severe adverse reactions to cannabis use such as anxiety and hallucinations are typically only associated with oral ingestions of high doses. Early use of cannabis is associated with an increased risk of developing schizophrenia later in life, though there is no compelling evidence of a causal relationship. Cannabis use may trigger acute episodes of psychosis in patients with severe mental illness and should be avoided in this population.4 Tetrault et al. conducted a systematic review to investigate the association between cannabis inhalation and impaired respiratory function. Thirty-four studies that evaluated pulmonary function or respiratory complications were included in the final analysis. Based on 14 studies evaluating the effect of cannabis inhalation on long-term respiratory complications, the authors concluded use of inhaled cannabis was not associated with decreased respiratory function. However, long- term cannabis inhalation was associated with an increased risk of cough, phlegm and wheeze.10 This effect was largely demonstrated by Moore et al. in a cross-sectional analysis of 6,728 patients that demonstrated those who had smoked cannabis at least 100 times were more likely than those who had never smoked cannabis to develop cough (OR 2, 95 percent CI 1.323.01), phlegm (OR 1.89, 95 percent CI 1.35-2.66), and wheeze (OR 2.98, 95 percent CI 2.05-4.34).11 Members of the health care community remain unsure of how to approach cannabinoid use for medicinal purposes. A clinician’s ability to recommend inhaled cannabis depends on state regulations; however, cannabis and its derivatives have clearly demonstrated efficacy in several medical conditions. Continued on Page 454 Moving? Be sure to let us know .... We can update our system to better serve you! When your patients call, we will know where to send them. Call (412) 321-5030 to update your information. Bulletin / November 2014 453 Materia Medica From Page 453 This efficacy, coupled with a self-limiting, mild side-effect profile, may prove to be beneficial for some patients. Further study regarding the optimal concentrations of THC, CBD and other cannabis constituents for various indications may shed more light on the issue and allow patients who cannot References 1. State laws. National Organization for the Reform of Marijuana Laws Website. http://norml.org/laws/. Accessed February 14, 2014. 2. Medical marijuana may be coming to Pittsburgh. Marijuana Policy Project Website. http://www.mpp.org/states/pennsylvania/. Accessed January 8, 2014. 3. Pennsylvania laws and penalties. National Organization for the Reform of Marijuana Laws Website. http://norml.org/laws/ item/pennsylvania-penalties-2. Accessed February 14, 2014. 4. Brunton L, Chabner B, Knollman B, eds. Goodman & Gilman’s: The Pharmacological Basis of Therapeutics. 12th ed. New 454 tolerate the psychoactive effects of THC to utilize inhaled cannabis or related extracts. Lucas G. Hill, PharmD, is a PGY2 ambulatory care pharmacy resident at UPMC St. Margaret and can be reached at hilllg@upmc.edu. Gregory B. Castelli, PharmD, BCPS, is a clinical assistant professor at the West Virginia York, NY: McGraw-Hill; 2011:388, 663-4. 5. Haney M, Rabkin J, Gunderson E, Foltin RW. Dronabinol and marijuana in HIV(+) marijuana smokers: acute effects on caloric intake and mood. Psychopharmacology (Berl). 2005;181(1):170-8. 6. Corey-Bloom J, Wolfson T, Gamst A, et al. Smoked cannabis for spasticity in multiple sclerosis: a randomized, placebo-controlled trial. CMAJ. 2012;184(1):1143-50. 7. Wilsey B, Marcotte T, Tsodikov A, et al. A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain. J Pain. 2008;9(6):506-21. 8. Guzmán M, Duarte MJ, Blázquez C, et al. A pilot clinical study of Delta9-tetrahydrocannabinol in patients with recurrent University School of Pharmacy and can be reached at greg.castelli@gmail. com. Heather Sakely, PharmD, BCPS, is director of Geriatric Pharmacotherapy and director of PGY2 Geriatric Pharmacy Residency at UPMC St. Margaret. She served as an editor for this publication and can be reached at sakelyh@upmc.edu. glioblastoma multiforme. Br J Cancer. 2006;95(2):197-203. 9. Moore BA, Augustson EM, Moser RP, Budney AJ. Respiratory effects of marijuana and tobacco use in a US sample. J Gen Intern Med. 2005;20:33-7. 10. Tetrault J, Crothers K, Moore B, et al. Effects of marijuana smoking on pulmonary function and respiratory complications. Arch Intern Med. 2007;167:221-8. 11. Koppel BS, Brust JC, Fife T, et al. Systematic review: efficacy and safety of medical marijuana in selected neurologic disorders: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2014;82(17):1556-63. Bulletin / November 2014 q Allegheny County MediCAl SoCiety Leadership and Advocacy for Patients and Physicians ACMS selects vendors for quality and value. Contact our Endorsed Vendors for special pricing. Banking and Financial Services Practice Financing, Revenue Cycle Management Physician Only Mortgage Program Private Banking Fifth Third Bank Robert Foley, 412.291.5401 robert.foley@53.com Banking, Financial and Leasing Services Medical Banking, Office VISA/MC Service PNC Bank Brian Wozniak, 412.779.1692 brian.wozniak@pnc.com What does ACMS membership do for me? Bulletin / November 2014 Group Insurance Programs Medical, Disability, Property and Casualty USI Affinity Bob Cagna, 412.851-5202 bob.cagna@usiaffinity.com Printing Services and Professional Announcements Service for New Associates, Offices and Address Changes Allegheny County Medical Society Professional Liability Susan Brown, 412.321.5030 sbrown@acms.org Insurance PMSLIC Laurie Bush, 800-445-1212, ext. 5558; lbush@pmslic.com Medical and Surgical Supplies Allegheny Medcare Michael Gomber, 412.580.7900 michael.gomber@henryschein. com Auto and Home Insurance Liberty Mutual Kathy Smith, 412.859.6605, ext. 51911; kathy.smith@libertymutual.com Member Resources BMI Charts, Healthy Lifestyle Posters, Where-to-Turn cards Allegheny County Medical Life Insurance Society Malachy Whalen & Co. 412.321.5030 Malachy Whalen, 412.281.4050 acms@acms.org mw@malachy.com 455 Allegheny County Medical Society Foundation 713 Ridge Avenue Pittsburgh, PA 15212-6098 (412) 321-5030 FAX (412) 321-5323 www.acms.org Created, funded and administered by physicians since 1960, the Allegheny County Medical Society Foundation has given more than $2.6 million to various community programs. Over the past year, the foundation contributed to or sponsored the organizations and activities listed here: The annual ACMS Foundation Community Awards Gala raises funds for the foundation’s medical student and CCAC’s health career scholarships. Plan to attend the 2015 Gala on March 7! 456 Please include the ACMS Foundation in your year-end giving: • Angels’ Place – Showcase of Scholars Program • Carnegie Institute, Pittsburgh Regional Science and Engineering Fair for two student awards in the field of medicine and biology • Children’s Home of Pittsburgh – Child’s Way Program • Community College of Allegheny County Education Foundation for ACMS Foundation Endowed Scholarship Fund for health care career scholarships • Family House, Inc. – Family Assistance Program • Providence Connections, Inc. – Bridging the Gap: Preparing at-risk students for success in school & life program • Spina Bifida Association of W. PA – Community Outreach and Support Group for Caretakers Program • The Foundation of the Pennsylvania Medical Society for ACMS Foundation Medical Student Scholarship Fund • United Way – Community-Based Chronic Care Self Management Program • University of Pittsburgh School of Medicine – Medical Student Career Night Allegheny County Medical Society Foundation Name Address Phone Please send your tax-deductible contribution to ACMS Foundation, 713 Ridge Avenue, Pittsburgh, PA 15212-6098. Checks should be made out to ACMS Foundation. For more information, please call (412) 321-5030. Bulletin / November 2014 Legal Report Personal cybersecurity – a HIPAA ‘lite’ approach P hishing emails. Viruses that affected the security of your online transactions by exploiting weaknesses in encryption technology (Heartbleed) and now one that could potentially allow a hacker to control your “smart” appliances (Shellshock). Twelve-character passwords, different ones for each website that you log into. Cybersecurity may be handled by the HIPAA Security Officer and IT team at work, but what about at home? How do you protect your sensitive information – details about your bank accounts, retirement funds, taxes, credit card statements, photographs, email and other personal correspondence? Type in “personal cybersecurity” on Google, and you will get 43 million results. Some of the links will even take you to scam websites. The sheer volume of advice is overwhelming, but using a familiar approach – HIPAA – can yield a practical blueprint for protecting yourself and your family from cybercriminals. Yes, HIPAA is just about the last thing you want to think about at home, but consider this: The goals of the HIPAA security rules are to protect the confidentiality, integrity and availability of electronic Protected Health Information (PHI). Your goal with respect to your own sensitive information is the same: You want it to remain private, unaltered and available to you when you need it. To accomplish that goal, you can folBulletin / November 2014 Beth Anne Jackson, Esq. low the same methods that were used at your workplace to become compliant with the HIPAA security rules: Conduct a risk assessment, and based on what you find, implement appropriate administrative, physical and technical safeguards. Personal cybersecurity is a process, and the HIPAA “lite” approach can make it a manageable one. Create your game plan: risk assessment. The first step of a risk assessment is to list every device that you use to access, create or maintain your sensitive personal information (PI). Don’t limit your thought process to your personal computer or laptop – include smartphones, iPads, tablet computers, thumb drives, game consoles, external hard drives and your printer/ scanner/copier, even if they belong to or are used primarily by other members of your household. Next, answer the following questions about the steps you take to manage the risk to your PI. As you answer each one, rank the level of risk that each issue poses using a numeric scale or narrative descriptions (low, medium, high). • Access: Do you limit access to each device by password, house rules or otherwise? Can your children, other household members or guests get onto the computer that contains your most sensitive PI? Have you enabled the automatic log-off procedure on your computer so that it locks when the machine is idle for a specified period of time? • Data segregation: Do you segregate your data, or is the .pdf of last year’s tax return in the same documents folder as your daughter’s book report? Do you limit access to folders or programs containing PI? • Training: Do all household members know the rules about computer use and what can happen if they aren’t followed? Do they understand the risks of clicking on links in emails1 and in pop-up ads and of continuing on to visit a website after the warning that the website does not have a security certificate issued by a trusted certificate authority? Do they understand when it’s safe to download a program, document or video from the internet? • Password management: Do you use strong passwords or pass phrases (at least 12 characters, including upper and lower case letters, a number and a symbol)? Do you use the same password multiple times? Do you allow your browser to save your passwords so that you can automatically log-in? Do you use a secure password management program?2 Continued on Page 458 457 Legal Report From Page 457 • Protection from malware: Have you installed anti-virus and anti-malware software? Do you regularly review the scan reports to determine if an issue needs to be addressed? Do you have this software set to automatically update or does it only update when you log on? If the latter, do you sometimes skip the update so that you can use the computer for other things first? • Data backup plan: Do you regularly back up your data? How often? Online or to a physical device? If you back up manually to an external hard drive, is that stored off-premises in case of theft or fire? • Disaster recovery plan: If your devices were destroyed, lost or stolen, do you know how to access your backed-up data to restore it to a new computer? • Loss or theft: What steps do you and your family take to ensure the physical security of your devices? Is your home security system sufficient? Do you lock your car and stow devices out of sight or in the trunk when you leave them in the car? • Disposal: Do you destroy data on devices before they are discarded, traded in or donated? If so, how? Are they physically destroyed or overwritten by special software?3 • Encryption: Are your devices encrypted? Do they contain enough PI to warrant total disk encryption? Could PI be maintained in special files or folders that could be encrypted?4 If you use an external hard drive to back up your computer, is it also encrypted? • Settings: Are the settings on your smartphone and other portable devices appropriate? For example, is your smartphone Wi-Fi setting “on” all the time so that your phone automatically accesses a public Wi-Fi hotspot instead of your more secure 4g data plan, leaving you open to others who, with a simple device, can log every keystroke you take? Have you reviewed the security settings on your device, including those on your email and other apps? Implementing a risk management plan. Review your answers to the questions above and the risk level each item poses. Start with those items that pose the greatest risk. Research solutions one by one as needed5 or consult a qualified computer professional if you do not have the time to do so. Document the steps you take so that the process can be updated and repeated the next time you acquire a new device. Also create and write down “house rules,” then educate the entire family about what they are and why they are important. People are typically the weakest link in a security management program. Therefore, in crafting your solutions, control what you have the power to control (through technical controls – software and settings) and mitigate the other risks in pragmatic ways. For example, making certain computers or devices off-limits to your children or limiting certain activities to specific devices (like an iPad) can make good sense, especially if they download a lot (e.g., mods to use in playing Minecraft) or indiscriminately click on links on YouTube and other sites. Remember that securing sensitive information from cybercriminals is a process. As such, it must be re-evaluated and updated to respond to new threats, new devices and changes in Serving the legal needs of health care practitioners and facilities BETH ANNE JACKSON Esq. LLC 4050 Washington Road Suite 3N McMurray, PA 15317 724 941-1902 bjackson-law@verizon.net www.jacksonhealthlaw.com • Regulatory - Stark, AntiKickback, HIPAA, EMTALA • Compliance training and policies • Physician-hospital contracts • Employment contracts • Joint ventures and other business transactions • Operational issues and policies 458 Bulletin / November 2014 Legal Report the information that you want to protect. Establishing first what types of sensitive information that you have and the various risks and benefits of how, when and where you create, access or maintain that data is key to creating a viable framework to protect it. Author’s Note: Like many attorneys, I find myself attending to client matters outside of regular office hours from home. As a result of business associates becoming directly subject to HIPAA through the HITECH Act, I had to go through the entire security risk assessment process and create and implement security policies and procedures so that I could begin to accept electronic PHI. (I had previously only accepted PHI on paper.) As a solo practitioner, I didn’t have References 1. For descriptions of phishing emails, see Microsoft’s Safety & Security Center, “How to recognize phishing email messages, links, or phone calls,” available online at: http://www.microsoft.com/security/online-privacy/phishing-symptoms.aspx. 2. For a recent review of password manager programs, see Rubenking, Neil J., “The Best Password Managers,” available online at http://www.pcmag.com/article2/0,2817,2407168,00.asp. 3. Deleting files does not erase them! the option to simply log-on to my employer’s systems and not worry about security implications. The computer and the procedures I used at home for work had to be as secure as the one in my office to ensure the confidentiality of my clients’ data, including but not limited to PHI. In the process, I found HIPAA “lite” to be a viable approach to cybersecurity for my entire family, including devices that I did not use for work. Ms. Jackson is the sole member of Beth Anne Jackson, Esq. LLC, a law firm that serves the legal needs of health care practitioners and facilities in southwestern and central Pennsylvania. She may be reached at (724) 941-1902 or bjackson-law@verizon.net. Her website is: www.jacksonhealthlaw.com. Avast, an antivirus software maker, was able to recover deleted personal information from 20 Android phones that it purchased on eBay. From these phones it was able to gain access to 40,000 stored photos (some compromising), 750 emails and texts, 4 previous owners’ identities and more. This mimics the results of an MIT study in which researchers were able to recover “erased” information from 2/3 of the computers that it purchased on eBay. Consumer Reports, “Erasing data isn’t enough to prevent identity theft when recycling gadgets,” available online at: http:// www.consumerreports.org/cro/news/2014/08/ erasing-data-is-not-enough-to-prevent-identity-theft/index.htm. 4. Microsoft and Adobe files can be individually encrypted with a password if you have the proper versions of that software. 5. Consumer Reports.com has an excellent series of articles on personal cyber-security that can be accessed without a subscription in its “Guide to Internet security,” available online at: http://www.consumerreports.org/cro/electronics-computers/ guide-to-internet-security/index.htm Get the Most $$ for the Care You Give 32131-KellAd-ACMSB-QtrBbw.indd 1 Bulletin / November 2014 Physicians can’t afford to lose time...or money. At the Kell Group, we understand the increasing demands placed on physicians. That’s why our focus is to make sure your billing processes bring you maximum reimbursement. The Kell Group increases medical practice collection rates an average of 12 percent. That’s roughly $12,000 for every $100,000 of billing. We increase revenue through sound, thorough and consistent billing practices and processes. We help new practices establish robust billing systems, and we help established practices get the most out of their billing systems to achieve maximum revenues. Above all, we provide support to our clients with integrity, and with high levels of personalized service, acting as an extension of the medical practice team. 56 South 21st Street Pittsburgh, PA 15203-1930 (412) 381-5160 Fax: (412) 381-5162 We can help. Call us. www.kellgroup.com 12/18/13 10:47 AM 459 Special Report N Accessing VA care for transitioning veterans ew Veterans, separating from the service after deployment in support of Operations Enduring Freedom, Iraqi Freedom and New Dawn (OEF/ OIF/OND), have a five-year window of opportunity to access copay-free care related to their service at VA medical centers because of their status as combat veterans. The five years of co-pay free health care related to service begins on the separation date from the military deployment. During this time, all medical care related to service, including routine primary care visits is free of charge. At VA Pittsburgh, returning combat veterans can access a comprehensive post-deployment clinic at the Heinz campus. This clinic consists of medical doctors, physician assistants, RNs, social workers, LPNs, and various specialty clinics including polytrauma, physical therapy, speech and more. Combat veterans typically enroll in the VA through two different avenues. 1) Injured and seriously injured veterans who are being treated in Amy Boyles, LCSW Department of Defense (DOD) receive appointments at VA medical centers and are contacted before they leave the service, with the goal of providing a seamless transition of care and ensuring that all medications and appointments are arranged before the veteran returns home. 2) Veterans who are not injured can access VA care by directly enrolling in a local VA medical center or Community-Based Outpatient Clinic (CBOC). Veterans complete an enrollment form online or in person and need to submit it with a copy of their discharge paperwork. Any veteran who needs assistance enrolling can contact or visit VA enrollment specialists in person for assistance. Some of the VA Pittsburgh clinics that provide valuable specialty services to veterans include: • Case Management Services • Healthcare for Homeless Veterans • Veterans Justice Outreach • Combat Stress Recovery Clinic • Individual and/or Group Counseling • Center for Treatment of Addictive Disorders • Military Sexual Trauma Services • Dental Exam (to be completed within 180 days of date of separation) • Physical and Occupational Therapy • Employment Counseling and Vocational Rehabilitation Any veteran wishing to learn more about obtaining services in the OEF/ OIF/OND clinic should contact the program manager, Amy Boyles, at (412) 822-2363. Amy Boyles serves as the program manager and clinical social worker for the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) clinic at the VA Pittsburgh Health Care System. She also is a counselor in the University of Pittsburgh Counseling Center. Allegheny County Medical Society Leadership and Advocacy for Patients and Physicians 460 Bulletin / November 2014 We will reduce your medical office and supply costs. Allegheny 3 reasons Medcare to consult We will reduce your medical office and supply costs. Mike Gomber for your medical supply needs 3 reasons Mike 1 Mike isn’t just a “sales rep.” to consult is a professional consultant with an MBA and 30 yearsMike experience Gomber serving physicians. Savings, Service forand yourSolutions! medical supply needs 2 Mike will find the best solution to isn’t just 1 Mike your medical supply needs, not a “sales rep.” Mike a professional consultant with just the “product ofisthe month” an MBA and 30 years experience that others are pushing. serving physicians. Allegheny Medicare is endorsed Mike will find the best solution to 2 County by the Allegheny Medical medical supply needs, not Society—the only your medical supply company that is! just the “product of the month” that others are pushing. “The best solution to your 3 medical supply needs.” Michael L. Gomber, MBA Medicare is endorsed 3 Allegheny More than 30 years meeting by the Allegheny County Medical physicians’ needs Savings, Service and Solutions! Society—the only medical supply (412) 580-7900 company that is! Michael L. Gomber, MBA Fax (724) 223-0959 More than 30 years meeting physicians’ needs Email: michael.gomber 412.580.7900 Fax: 724.223.0959 E-mail: michael.gomber@henryschein.com @henryshein.com A Allegheny Medcare endorsed by LLEGHENY COUNTY MEDICAL SOCIETY Allegheny Medcare Savings, Service and Solutions! Allegheny Medcare Henry Schein, a Fortune 500 Company Michael L. Gomber, MBA Together to serve to provide a one-stop More than 30 years meeting physicians’ needs solution for all your needs 412.580.7900 Fax: 724.223.0959 endorsed by ALLEGHENY COUNTY MEDICAL SOCIETY Bulletin / November 2014 E-mail: michael.gomber@henryschein.com Allegheny Medcare Henry Schein, a Fortune 500 Company Together to serve to provide a one-stop solution for all your needs Ruby Marcocelli 461 Special Report The MOC debate hits home Leslie Howell, PAMED R arely does an issue simultaneously instill great passion and considerable angst for physicians at the level that we are seeing for the American Board of Medical Specialties’ (ABMS’) Maintenance of Certification™ (MOC). Most physicians will concede that the expressed intent of MOC is appropriate: to ensure the patient community that physicians are continuing to assess and improve their knowledge and capabilities after graduate medical education (GME) training. It goes without saying that physicians are committed to lifelong learning and continuous improvement. However, this same group also contends that the current processes and practices in place across the various specialty boards are cumbersome, costly, and significantly cutting into their time with patients. Of the four components of MOC – (I) licensure and professional standing, (II) lifelong learning and assessment, (III) cognitive exam, and (IV) practice performance assessment – the exam and the practice performance assessment appear to be the areas of greatest concern. The exam component, in particular, has been under a great deal of scrutiny. Input we’ve received from Pennsylvania Medical Society (PAMED) members thus far indicates that it is viewed as an uncertain measure of a physician’s actual skill in his or her specialty and is punitive. Consequently, many fear that failing the exam will result in a loss of privileges at 462 hospitals, insurance reimbursements, network participation, and possibly even employment. PAMED has formed a Task Force on Continuous Professional Education to examine MOC in its current form and the concerns circulating throughout the state and to seek input from Pennsylvania’s physicians. The goal: reshape MOC, in whatever future form it might take, into a process of continuous learning and improvement based on evidence-based guidelines, national standards, and best practices that is relevant to what a physician actually does within his or her practice of medicine and one that enhances, rather than impedes, the care of patients. Delegates at the 2014 House of Delegates meeting, held October 17-19 in Hershey, debated the merits of the task force’s initial recommendations, as well as other resolutions and reports related to MOC. One of the documents developed by the task force and adopted by the PAMED Board is a Maintenance of Certification Statement of Principles which outlines PAMED’s position on what MOC should be: • PAMED is committed to lifelong learning, cognitive expertise, practice quality improvement, and adherence to the highest standards of medical practice. • PAMED supports a process of continuous learning and improvement based on evidence-based guidelines, national standards, and best practices, in combination with customized continuing education. • The MOC process should be designed to identify performance gaps and unmet needs, providing direction and guidance for improvement in physician performance and delivery of care. • The MOC process should be evaluated periodically to measure physician satisfaction, knowledge uptake, and intent to maintain or change practice. • Board certificates should have lifetime status, with MOC used as a tool for continuous improvement. • The MOC program should not be associated with hospital privileges, insurance reimbursements, or network participation. • The MOC program should not be required for Maintenance of Licensure (MOL). • Specialty boards, which develop MOC standards, may approve curriculum, but should be independent from entities designing and delivering that curriculum, and should have no financial interest in the process. • A majority of specialty board members who are involved with the MOC program should be actively practicing physicians directly engaged in patient care. • MOC activities and measurement should be relevant to real world clinical practice. • MOC process should not be cost prohibitive or present barriers to patient care. The delegates also asked that several items be referred to the AMA: • Work with the ABMS to eliminate practice performance assessment modules as currently written from the Bulletin / November 2014 Special Report requirements of MOC. • Develop and disseminate a public statement, with simultaneous direct notification to the American Board of Internal Medicine (ABIM) and other ABMS-sponsoring boards that their current MOC program appears to be focused too heavily on enhancing ABIM revenues and fails to provide a meaningful, evidence-based, and accurate assessment of clinical skills. • Investigate and/or establish alternative pathways for MOC. • Report back to the House of Delegates at the Annual AMA Meeting in June 2015. The delegates also recommended that PAMED ask the AMA to revoke its support for MOC if no action is taken by the ABMS in working with the AMA to make MOC requirements less onerous. PAMED will continue to support efforts to create a reasonable and economical assessment process that provides physicians with the information necessary to improve the quality and efficiency of their practices. Meanwhile, to get more input from PA’s physicians, PAMED will be emailing physicians a brief survey the week of November 10. Please watch for this email. It will take no more than two minutes to complete so please add your voice to the conversation! For more information on PAMED’s Task Force on Continuous Professional Education or next steps on MOC, please email Scot Chadwick at schadwick@pamedsoc.org or call Scot at (717) 909-7814. Leslie Howell is director of CME, training and physician leadership programs at PAMED. Legal Summary Court rejects contempt application Michael A. Cassidy, Esq. Commonwealth Court has rejected the application by the Pennsylvania Attorney General to hold Highmark in contempt of the Consent Decrees approved by the Court involving the Commonwealth of Pennsylvania, Highmark and UPMC on July 1, 2014. By way of background, Highmark and UPMC entered into identical but separate reciprocal Consent Decrees in July arising out of UPMC’s termination of its participation agreements with Highmark. The purpose of the Consent Decrees was to clarify ongoing access to UPMC hospitals, physicians and services for beneficiaries covered by Highmark insurance products. One of the issues included in the Consent Decrees was continued access to UPMC hospitals, physicians and services by “vulnerable populations”, which was defined to include eligible Medicare beneficiaries. Pursuant to the Consent Decrees, the vulnerable populations which were covered by Highmark Medicare products, such as Medicare Advantage, were granted continued access at in-network rates to UPMC hospiBulletin / November 2014 tals, physicians and services. As has already been reported in the news, in September Highmark began offering the Community Blue program which does not provide Medicare beneficiaries access to UPMC facilities, physicians and services, although Highmark also offers Medicare products with UPMC access but at a different premium structure. UPMC and the Pennsylvania Attorney General asserted that Highmark’s actions violated the Consent Decrees and the Attorney General applied to Commonwealth Court for a holding that Highmark was in contempt of the Consent Decrees. The Commonwealth Court denied the application, holding that the Consent Decrees do not require that UPMC be included in all Highmark Medicare products. Mr. Cassidy is a shareholder with Tucker Arensburg and chair of the firm’s Healthcare Practice Group; he also serves as legal counsel to ACMS. He can be reached at (412) 594-5515 or mcassidy@tuckerlaw.com. 463 Special Report 2014 Annual Meeting Recap: Helping Physicians Adapt to Change A s the rate of change in our health care system – and our medical practices – continues to accelerate, more doctors are feeling the weight of blame for costs, outcomes, and quality, says Karen Rizzo, MD, FACS, newly installed president of the Pennsylvania Medical Society (PAMED). Dr. Rizzo, an otolaryngologist/ENT from Lancaster, was sworn in as the 165th president of PAMED on Oct. 18 during the annual statewide meeting in Hershey. Several other Pennsylvania physicians also were elected to PAMED’s Board during the meeting. “The cost of health care rests squarely on their [physicians’] backs as their burden,” she said, along with the blame for poor outcomes, ordering too many tests, and not spending enough time with patients. Dr. Rizzo told the more than 300 delegates attending the PAMED House of Delegates and Annual Education Conference that instead of carrying that blame, they must adopt physician-led solutions to address the changes happening all around us. While continuing to support PAMED’s strong advocacy agenda, she will advocate for three strategic directions during her year in office: • Promote PAMED programs that help physicians learn about and respond to all the changes taking place around them; • Develop and then implement an intentional, thoughtful strategy to engage with insurance companies to 464 understand how they measure our performance, how they measure quality, and how they measure the costs we generate to their covered lives; • Develop our vibrant and enthusiastic young physician community by creating a Leadership Academy for Young Physicians. 2014 House of Delegates Actions As a result of deliberations at the 2014 House of Delegates, PAMED’s already robust agenda for the coming year will add important issues such as: • Maintenance of Certification (MOC) – Ask the American Medical Association (AMA) to: • Work with the American Board of Medical Specialties (ABMS) to eliminate practice performance assessment modules as currently written from the requirements of MOC. • Develop and disseminate a public statement, with simultaneous direct notification to the American Board of Internal Medicine (ABIM) and other ABMS sponsoring boards, that their current MOC program appears to be focused too heavily on enhancing ABIM revenues and fails to provide a meaningful, evidence-based, and accurate assessment of clinical skills. • Investigate and/or establish alternative pathways for MOC. • Report back to the House of Delegates at the Annual AMA Meeting in June 2015. The PAMED Board was asked to study a recommendation to then ask the AMA to revoke its support for MOC if no action is taken by the ABMS in working with the AMA to make MOC requirements less onerous. PAMED will continue to support efforts to create a reasonable and economical assessment process that provides physicians with the information necessary to improve the quality and efficiency of their practices. • E-Cigarette advertising/endorsement – Ask the AMA to work through an appropriate federal process to prohibit e-cigarette companies from paying for product placement in films and hiring celebrity spokespersons, and to prohibit e-cigarette advertising on television. • Ebola preparedness – Continue to provide Pennsylvania physicians with important information, such as local and state guidelines, how to put on and remove personal protective equipment, identification of containment facilities, and access to sensitive and specific surveillance tools. PAMED will continue to work with the Pennsylvania Department of Health and other state preparedness partners to ensure that health care facilities are prepared in the event that Pennsylvania faces an Ebola outbreak. • Medicare coverage of vaccines – Aggressively petition the Centers for Medicare and Medicaid Services (CMS) to include tetanus and Tdap at both the “Welcome to Medicare” and Annual Medicare Wellness visits, and Bulletin / November 2014 Special Report John G. Krah / ACMS Executive Director Members of the ACMS Delegation attend the House of Delegates meeting in Hershey Oct. 25. other clinically appropriate encounters, that allows for coverage and payment of these vaccines to Medicare recipients who have not been vaccinated within the past 10 years. • Barriers to getting health care – Work with insurers to provide payments to physicians and physician-supervised designees for medications, vaccines, and their administration, without the burden of prior-authorization or any other administrative barriers. • Telemedicine – Work with stakeholders to evaluate the different applications and uses of electronic technology to adopt standard definitions of what constitutes telemedicine, identify standards for coverage and payment for the use of telemedicine, and work to establish policy in Pennsylvania for the licensure of providers and payment for services. • Urgent care clinics – Work to educate urgent and retail clinics on the Bulletin / November 2014 importance of transmission of point of service patient medical records to primary care physicians and specialists, and investigate any complaints of non-disclosure of medical records by a facility due to alleged financial and network associations. • Single national narcotic provider number – Ask the AMA to continue to work with the Drug Enforcement Administration (DEA) and Congress to move toward a system in which individual physician DEA registration numbers are person-specific rather than site-specific within a state. • Unification of GME accreditation standards – Seek legislation to: 1) drop the licensure requirement for DOs to do at least one AOA approved year; and 2) make the number of required GME years the same, whether for DOs or MDs, to get a full, unrestricted license. • Independent practice access to facilities and insurance program participation – Seek legislation to provide access to participation in insurance networks and hospital facilities for independent physicians that meet the accepted quality measures. • Hospital privileges for private practice physicians – Pursue legislation concerning the enforcement of the Community Benefit Standard in Pennsylvania; research ways to provide legal support to aid PAMED member physicians who are impacted by hospitals’ exclusionary tactics; and work to maintain private physician health care network relationships. • Contracts with insurers – Pursue fairer insurer contracts and consider support of legislation to provide for contracts between insurers and networks to assure access to care with a level of insurance coverage for patients. • Universal Patient Transfer Form – Work with state government agencies 465 Special Report and hospitals to develop a Universal Patient Transfer Form (UPTF) and an understanding of how it will work in Pennsylvania. • Membership dues – The PAMED Board, working with the Membership Task Force, will be studying alternative dues models. At the annual meeting, members provided a lot of good feedback and ideas that will be incorporated into the task force’s discussion. *Reprinted with permission from the Pennsylvania Medical Society. The ACMS Delegation was led by Amelia A. Paré, MD, FACS, ACMS Delegation chair; and Christopher Daly, MD, ACMS Delegation vice chair. ACMS Delegation Taiwen Chen, MD Douglas F. Clough, MD Patricia L. Dalby, MD Christopher J. Daly, MD, Vice Chair M. Sabina Daroski, MD David J. Deitrick, MD H. Jordan Garber, MD Kevin O. Garrett, MD, FACS Sharon L. Goldstein, MD Mark A. Goodman, MD Mindy B. Hutchinson, MD Lawrence R. John, MD Ronald A. Landay, MD Phillip R. Levine, MD Jan W. Madison, MD Deval M. Paranjpe, MD, FACS Amelia A. Pare, MD, FACS, Chair Gerald W. Pifer, MD John P. Williams, MD William F. Coppula, MD Lora A. Cox-Vance, MD Todd M. Hertzberg, MD Bruce L. Wilder, MD, JD *Prabir K. Mullick, MD *William Simmons, MD *Carl A. Sirio, MD *Rajiv R. Varma, MD *John F. Delaney Jr, MD *Bruce A. MacLeod, MD Medical students: Ryan Williamson Ben Ware Alexis Chidi Reportable Diseases 2014: Q3 Allegheny County Health Department Selected Reportable Diseases Jan.–Sept. Disease/Condition 2014 2013 Campylobacteriosis Cryptosporidiosis Shiga-toxin producing Ecoli Giardiasis Guillain-Barre Syndrome Hepatitis A Hepatitis B (acute) Hepatitis C (confirmed) Legionellosis Listeriosis Malaria Meningitis, Viral Haemophilus influenza Invasive Disease S. pneumoniae Invasive Disease, drug resistant Meningococcal Invasive Disease Pertussis Salmonellosis Shigellosis West Nile Virus Infection Tuberculosis AIDS* HIV* Gonorrhea Chlamydia Syphilis, Primary & Secondary Carbon Monoxide Poisoning 2012 78 129118 2122 21 4 34 13 5596 62 9 10 4 4 4 8 11 8 1 848 734 701 5294 55 23 3 34 6 25 35 56 8 19 20 0 3 0 0 2 2 9946 209 77 105127 79 10 0 0 2 1615 17 5290 87 116147 137 1,5862,171 2,392 4,2906,095 6,442 44 24 55 9 13 26 *Subject to adjustment due to lag in case reporting. Disease reports may be filed weekdays during regular business hours from 8:30 a.m. to 4:30 p.m. by calling 412-578-8060. At all other times, please call the Health Department’s 24-hour telephone line, 412-687-2243. For display or classified advertising information, call Bulletin Managing Editor Meagan Welling at (412) 321-5030, ext. 105; email mwelling@acms.org; or visit www.acms.org. 466 Bulletin / November 2014 Proud to be endorsed by the Allegheny County Medical Society SAY HELLO TO NORCAL EXPERIENCE THE MUTUAL BENEFIT PMSLIC Insurance Company is transitioning to its parent company— NORCAL Mutual Insurance Company. Same exceptional service and enhanced products, plus the added benefit of being part of a national mutual. As a policyholder-owned and directed mutual, you can practice with confidence knowing that we put you first. Contact an agent/broker today. 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