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A publication of the Alabama Chapter, American College of Surgeons

WINTER 2019

Alabama Chapter, ACS Annual ConferenceJuly 25­27, 2019

The Lodge at Gulf State Park, A Hilton Hotel ­ Gulf Shores, AL

The Alabama and Mississippi Chapters of the American College of Surgeons will hold their annual conferenceJuly 25­27, 2019 at The Lodge at Gulf State Park, a Hilton Hotel in Gulf Shores, Alabama. The new Lodge,is located on Alabama’s Gulf Coast and part of the 6,150­acre Gulf State Park. The hotel offers a uniqueoutdoor experience. You’ll find yourself just steps from the park’s hiking and biking trails as well as the emer­ald green waters of the Gulf.

Don't miss this exceptional educational CME conference that will include time to network with other surgeons

from our state. The Alabama and Mississippi chapters are currently working to finalize the agenda. Join us

on Thursday evening, July 25th for the Thomas Hansel Pea­

cock, Jr., Memorial Welcome Reception. The conference will

allow time with our Exhibitors and will also feature Resident

Presentations on Friday evening. We will have our complete

agenda and additional information out to all members in the

very near future. We hope to see you there!

L_tt_r from th_ Pr_si^_nt2018­2019 Executive Council

President

Sidney B. Brevard, M.D., FACSUSA, Department of Surgery

President Elect /

Commission on Cancer

Paul Rider, M.D., FACSUSA, Department of Surgery

Secretary

Mark Parker, MD, FACSAlabama Colon & Rectal Institute

Treasurer

Jamie Cannon, M.D., FACSUniversity of Alabama at Birmingham,Dept. of Surgery

Board of Governors

E. Shields Frey, M.D., FACS Baptist Health System of Alabama

Board of Governors

Donna L. Dyess, M.D., FACS University of South Alabama, Mitchell Cancer Institute

Past President

John Porterfield, M.D., FACS Univ. of Alabama at Birmingham

Young Surgeons Representative

Emily Cannon, M.D. Wiregrass Surgical Associates

Member at Large

L. Randolph Buckner, M.D., FACSSurgical Associates of North Alabama, P.C.

Member At Large

Martin J. Heslin, MD., FACSUniversity of Alabama at Birmingham,Surgical Oncology

Member At Large

Howard J. Falgout, M.D., FACSSurgical Specialists of Alabama

Member at Large, Committee on

Trauma Representative

Kimberly Hendershot, MD, FACSUniversity of Alabama at Birmingham,Trauma Surgery

Member at Large

Steven W. Kinsey, MD, FACSIMC ­ Baldwin Surgery, PC

Dear Colleagues:

Our annual meeting is moving to a new location and we are ex­

cited about the change! We will be at the Lodge at Gulf State

Park in Gulf Shores. Also, the meeting is moving from June to

July 25th­27th to avoid conflict with other meetings. The Lodge

was just opened in November and appears to be an outstand­

ing venue for the annual meeting. We will again team up with

the Mississippi chapter as we plan and support the meeting.

Many of you attended the Clinical Congress in Boston and have

reported that once again the meeting was very educational and

a great opportunity to network with other surgeons. The 2019

Clinical Congress will be in San Francisco this year from Octo­

ber 27th through October 31st.

We will again engage our legislators during Lobby Day in Montgomery. Although

an exact date has not been selected, we will send out a notice when that is deter­

mined. I encourage you to reach out to your representatives about medical issues

that concern you. We have heard that some of the issues that may come up this

year include Medicaid expansion, trauma funding, the certificate of need process,

a biosimilar substitution bill, and more.

As always, I remain open to telephone calls or e­mail about how we can make our

chapter and annual meeting more relevant to your practice!

See you in Gulf Shores,

Sidney B. Brevard, MD, MPH, FACS

President, Alabama Chapter of the American College of Surgeons

Director of the Division of Acute Care Surgery and BurnsProgram Director for Surgical Critical Care FellowshipProfessor of Surgery

Sidney B. Brevard,

M.D., FACS

Alabama Chapter,

American College of

Surgeons, President

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2018­2019 Executive Council

Member At Large

Mark Taylor, M.D., FACSCentral Alabama Veterans Healthcare

System

UAB ­ Chairman, Dept. of Surgery

Herbert Chen, M.D., FACS University of Alabama at Birmingham

USA Chair, Dept. of Surgery

William Richards, M.D., FACSUSA, Department of Surgery

Chapter Administrator

Lisa O. Beard M3Solutions, LLCP.O. Box 382647Birmingham, AL 35238­2647Office phone: (205) 585­4000info@acsalabama.com

The Lodge at Gulf State ParkA Hilton Hotel

The Lodge at Gulf State Park, A Hilton Hotel is thelocation of the 2019 Alabama and MississippiChapters of the American College of Surgeons AnnualConference. This new hotel opened in November2018!

Experience a unique piece of paradise on the Alabama Gulf Coast where nature is atyour doorstep. The Lodge at Gulf State Park, a Hilton Hotel, is located on the whitesands of Gulf Shores, Alabama, inside the naturally beautiful 6,150­acre Gulf StatePark. Your Lodge experience is defined by unique architecture designed to allow youto enjoy this distinctive environment and community. Enjoy beautiful beach and parkviews from our guest rooms, suites and restaurants.

Our location offers guests access to 28 miles of educational hiking and biking trails aswell as a nature center, outdoor classrooms, interpretive center, tennis, kayaking,guided nature walks, butterfly garden, forest and beach pavilions. Our beach locationprovides easy access to a host of water activities.

Enjoy beautiful views of the beach or park. Choose a room with one king or two queen­sized beds. All rooms feature a 50­inch TV, spacious shower or bathtub, Hilton SerenityBed with plush, allergen­free comforter, pillows and a mattress set custom designedfor added support and comfort.

Make Your Hotel Reservations

You can make your hotel reservations by calling The Lodge at Gulf State Park, a Hilton Hotel, at (251)

540­4000 and mentioning ACS Annual Meeting. Group rates start at $279 per night for a Standard room andgo up depending on Room Type chosen. These rates are available until June 25th or until Group block sells

out. You can also make your reservations directly through the hotel website at:http://www.hilton.com/en/hi/groups/personalized/P/PNSLGHH­ACS­20190724/index.jhtml or visit our chap­ter website: www.alabamaacs.org and click on the Annual Conference Tab and the 2019 Annual Conference

page and clicking on the Blue Button that will direct you to the The Lodge at Gulf State Park website.

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2018 Alabama & Mississippi Chapters Annual ConferenceSandestin Resort, Village of Baytowne Wharf

Dr. Brevard presents Dr. Porterfield with

the President’s Plaque for his year of service

as President of the Alabama Chapter.

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What Physicians Need to Know About the SUPPORT Act

Over the past two years, Congress has taken steps to address the opioid crisis. Most recently, the legislaturehas done this through the passage of the Substance Use­Disorder Prevention that Promotes Opioid Recoveryand Treatment for Patients and Communities Act (SUPPORT Act).

The SUPPORT Act addresses various aspects related to the opioid crisis through a series of more than 120 sep­arate bills. Here are five sections in particular that physicians should hone in on.

Section 6032

The Centers for Medicare and Medicaid Services (CMS) has been tasked with recommending changes to theirprograms to enhance the treatment and prevention of opioid addiction as well as coverage and payment of med­ication­assisted treatment. Physicians should check the CMS website for announcements.

Section 6001

The Center for Medicare and Medicaid Innovation may test models for behavioral health providers. Theseproviders may be offered incentive payments for adopting electronic health records and for using that technologyto improve the quality and coordination of care. There are two crucial items related to this section:1. as with Meaningful Use incentive payments in general, care should be taken not to misrepresent compliance2. this funding, at least at this time, is limited to behavioral health providers.

Section 5042

States must establish a qualifying prescription drug monitoring program (PDMP) and require healthcare providersto check the PDMP for a Medicaid enrollee’s prescription drug history before prescribing controlled substances.For physicians, this means checking the PDMP database. There has been a great deal of discussion about theability for physicians and pharmacies to track usage in other states as well. Tennessee, for example, has six bor­dering states. Detection becomes hard and more problematic because “drug seekers” merely need to cross stateborders to fill a prescription.

Section 3003

The bill increases the maximum number of patients that healthcare providers may initially treat with medication­assisted treatment (i.e., under a buprenorphine waiver). The U.S. Department of Health and Human Services, inconjunction with the Centers for Disease Control and Prevention, has released guidance that naloxone shouldbe prescribed with opioids for certain individuals.

Section 8122

This section of Eliminating Kickbacks in Recovery Act of 2018 (EKRA) is one of the SUPPORT Act’s related bills.This provision makes it a federal crime to receive or offer “[i]llegal remunerations for referrals to recovery homes,clinical treatment facilities, and laboratories,” the Recovery Kickback Prohibition.

This wording is broad and extends beyond clinical laboratory arrangements with treatment facilities. It includesother payers in addition to federal and state government programs, such as Medicare and Medicaid. Penaltiesunder this new law carry a $200,000 per occurrence fine and up to 10 years in prison. Although similar to the fed­eral Anti­Kickback Statute, which includes some of the AKS safe harbors, EKRA created an entirely new offense.

In sum, the SUPPORT Act and its constituent laws create both new opportunities—and new liabilities—for physi­cians. From my perspective, if physicians are charting medical necessity, prescribing in accordance with the law,checking the PDMP, and staying abreast of the changes in both the prescribing of opioids and treatment of patients

with opioid disorders, then these changes could lead to better patient outcomes.

­ Rachel V. Rose, JD, MBA

www.rvrose.com

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The prescription opioid epidemic ravaging the countryclaims almost a hundred lives daily with an annual eco­nomic cost upward of $500 billion. This epidemic is sowidespread that current estimates are that almost 2 mil­lion Americans are dependent on or abuse prescriptionopioids.

As would be expected, there is no lack of finger­pointingat who is to blame. But curiously, there hasn’t beenmuch focus on who should take responsibility for ade­quately addressing it.

The usual suspects are the pharmaceutical companiesthat promote highly addictive opioid painkillers throughaggressive marketing programs, providers who pre­scribe the drugs — and the distribution channel of phar­macies that make them available 24/7.

When it comes to payers, however, their role has notbeen the subject of much attention. They now, however,find themselves under much closer scrutiny for their rolein allegedly getting and keeping patients addicted to opi­oid painkillers while not doing enough to help fix a prob­lem they are accused of helping create and perpetuate.

Fueling the epidemic

Various studies, most recently one by the Johns Hop­kins University Bloomberg School of Public Health,strongly suggest that payers have not done enough tocombat the opioid epidemic. The study, for example,concluded that major insurer coverage policies for drugsto treat lower back pain — one of the more commontypes of chronic, non­cancer pain for which prescriptionopioids have been overused — “missed important op­portunities” to steer patients toward safer and more ef­fective treatments than prescription opioids.

While there are a variety of payer policies and actionsblamed for the ongoing increase in prescription opioiduse (and abuse), they fall into three basic areas:

1. Prescription opioids are too price accessible

In an open market, there is usually a direct relationshipbetween price and demand. This is perhaps nowheremore evident than with prescription opioid painkillers.The logic is simple and unavoidable: If opioid­basedmedicines cost less than safer alternatives — includingnon­narcotic medicines — then prescribers and con­sumers will opt for the addictive opioids rather than less­addictive medicines.

This economic reality has been consistently borne outby researchers. In the Johns Hopkins study, for exam­ple, it was shown that both public and commercial in­surance plans tend to make covered opioids availablerelatively cheaply to patients. How cheaply? The me­dian commercial plan, for example, places 74% of opi­oid painkillers in Tier 1, the lowest cost category, andthe median commercial copay for Tier 1 opioids was just$10 for a month’s supply.

In stark contrast, studies show that only one­third of themore than 40 million people covered by Medicare haveaccess to an available painkiller skin patch that containsa much less risky opioid as its key active ingredient.Other plans simply do not cover non­addictive alterna­tives to opioids or have copays that are higher thanthose for opioids. Many plans also require pre­autho­rization for the safer, alternative painkillers.

According to Elijah Cummings, ranking member of theHouse Committee on Oversight and Government Re­form, the insurance industry has, in effect, created in­centives that may steer patients to the very drugsfueling the opioid crisis.

The price preference for opioids also tends to maketamper­resistant and abuse­deterrent formulationsmore expensive than their alternatives.

2. Prescribers are rewarded for patients being on

opioids

The inclusion of pain questions on Medicare’s patientsatisfaction surveys may have contributed to the opioidepidemic. The belief is that these surveys pressure doc­tors to prescribe unnecessary opioids in hopes of get­ting a better score on patient surveys. The results ofpatient surveys are used to determine a hospital’s re­imbursement rate.

It is easy to spot the conflict here. Tying money to greatreviews can easily lead to undue pressure on doctorsto prescribe opioids to make a patient happy to get agood score. And, perhaps the biggest area affected bypatient satisfaction surveys has been the emergencyroom. Several studies suggest that ER doctors havedrastically changed their practice to avoid negative pa­tient satisfaction reviews. They may sometimes pre­scribe painkillers, even when not entirely necessary, toget paid by Uncle Sam.

Up for Grabs: Payers Share Responsibility for Opioid Epidemic

continued on page 7

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Two surveys of more than 800 emergency physiciansby Emergency Physicians Monthly and the South Car­olina Medical Association reported that more than 50%of ER docs routinely ordered tests and procedures, pre­scribed medications and even admitted patients to thehospital unnecessarily. Why? Because patient satisfac­tion affects their bottom line.

Compounding the problem are savvy patients aware ofhow the system now works. One physician wrote thatdrug seekers “are well aware of the patient satisfactionscores and how they can use these threats and com­plaints to obtain narcotics.”

3. Lax application of utility management protocols

Another factor identified by the Johns Hopkins study isthat many insurers failed to apply evidence­based “uti­lization management” rules to discourage opioid over­use and encourage safer and more effectivealternatives. What’s more, many of the utilization man­agement rules in place were applied as often to non­opioids as opioids.

While utilization management takes various forms de­pending on the clinical setting and payer policies, themost common are quantity limits, step therapy and priorauthorization. Here are ways in which not correctly ap­plying these rules exacerbates the opioid crisis:

Quantity limits. While the U.S. Centers for DiseaseControl and Prevention guideline for prescribing opioidsfor chronic pain is for a short­term supply, many insur­ance policies allow for 30­day supplies. The danger isthat duration of early prescriptions is associated with apatient converting to chronic use.

Step therapy. This is a strategy that makes riskier opi­oids the “last resort” for pain management after other,non­narcotic medications have failed to provide pain re­lief. By permitting opioids to be a “first step,” the risk ofaddiction and/or chronic use increases. Unfortunately,fewer than 10% of government and commercial plansrequire step therapy for opioids.

Prior authorization. The idea is that requiring aprovider to get in touch with the insurer before prescrib­ing an opioid will help reduce the number of prescrip­tions or encourage quantity control or step therapy. Thereality is that only a minority of plans require this.

The way forward

Providers have a stake in working with payers — com­

mercial and public — as well as with distribution chan­nels to continue to develop integrated solutions to theopioid crisis. Aside from the human toll on their commu­nities, they also are not immune to the economic costs.Studies have clearly shown that the epidemic is increas­ing hospitalizations and that it hits emergency roomsespecially hard.

Some estimates put the average cost of treating anoverdose patient in the intensive care unit at almost$100,000. If a majority — or even a minority — of thesepatients are underinsured or uninsured, the resultinguncompensated care costs can easily cripple a providerthat is already operating on a razor­thin margin.

Three things that providers can do now to contribute toa solution are to support initiatives being undertaken bysuch groups as America’s Health Insurance Plans(AHIP) that seek to combat opioid abuse. They also candevelop, implement and maximize the value of pro­grams designed to identify potential opioid abusers andlimit the prescribing of opioid painkillers. Finally, theycan negotiate contracts with payers that require promptauthorization and reimbursement for non­opioid alter­natives where indicated.

Key takeaways

Although pharmaceutical companies are often targetedfor their role in the opioid epidemic, studies suggest thatpayer policies and actions also result in the ongoing in­crease of prescription opioid use.

These policies and actions fall under three generalideas that result in consumers choosing addictive opi­oids rather than safer and more effective treatments:1. Prescription opioids cost less than alternativepainkillers2. Providers benefit from prescribing addictive opioids,which is perpetuated by cost­driven initiatives such aspatient satisfaction surveys3. Lack of “utilization management” rules to limit opioidoveruse including quantity limits, step therapy and priorauthorization

Providers should support initiatives that combat opioidabuse, implement and maximize programs to identifypotential abusers and limit the number of painkiller pre­scriptions and finally, reconfigure contracts with payersrequiring timely authorization and reimbursement fornon­opioid alternatives.

­ Joy Stephenson­Laws, JD

Up for Grabs: Payers Share Responsibility for Opioid Epidemic

A publication of the Alabama Chapter, American College of Surgeons

A Few Words About Physician Burnout

It’s critical for you to know when to take time foryourself and your family and when to say no. It isalso critical to know how to set boundaries that couldsave your career and your health. A moderateamount of stress and fatigue come as part of anydemanding profession, but you can’t and shouldn’tgive in to them. Instead, try some simple strategiesto reenergize your personal and professional life.

First, define what’s really important in your life asidefrom being a physician – That’s when you’ll noticethat your life is out of balance. Think of the ambitionsyou had before becoming a physician. Working to­ward goals that once brought you joy might relievesome of the stress in your life right now.

Here are a few helpful hints to battle burnout fromvarious sources I have read:

Designate quiet time for yourself every day.

Every day, carve five minutes, whether it’s a five­minute walk, or five minutes at lunch—just do some­thing to quiet your work life.

Pick up old hobbies or find new ones. It could beshooting hoops with your kids or gardening — justlook for a hobby that is missing and fill that void.

Focus on family time. Spend more time with yourfamily—not in between running to the hospital andanswering pages, but really doing something of highquality; Maybe it’s bike­riding, or renting a movie,but set aside that time in a calendar and make it aweekly engagement.

Take better care of your own health. As the sayinggoes, sometimes we individually are our own worstclient (patient). Try to focus on eating better andmoving your body more. This is obviously basic stuffyou would tell your patients—move your body, getsome exercise, drink some water.

Get as much sleep as possible. Sound impossible?Try your best to get at least one good night of sleepper week.

Learn to set boundaries. If you know that some­thing adds stress to your life, try to cut back on it.Doctors have to learn how to draw the line, espe­cially if they want to stay in business and stayhealthy.

Also, try to reshape how you actually think aboutstress and be aware of how you react to situations.For example, if particular appointments or patientsfrustrate you, try to describe them more positively.Use words like “difficult” as opposed to “horrible” or“unbearable.” Don’t dwell on every problem. Con­structive discussion is okay but fixating on problemscan just create more stress.

Also pay attention to when and where you do wellwith stress, and don’t keep having the same nega­tive reactions to things over and over again. Stopthinking like a victim and stop dwelling on eventsthat stress you out. Events don’t stress you out.They might be a pain, but you have choices abouthow you deal with them.

Finally, you should keep what’s most important toyou in the forefront of your mind. When stress startsto eat at you, take a picture of your children out ofyour wallet and remind yourself of the good thingsyou have.

­ Reed Tinsley, CPA

www.rtacpa.com