mcms physician summer 2014

Responding to Negative ONliNe COmmeNts

What’s Driving Physician

Uncertainty Around the AffordableCare Act?

Summer 2014

MontgomeryCounty

Dermatologists: Skin Protection

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SUMMER 2014Contents

MCMS Physician is published by Hoffmann Publishing Group, Inc. I Reading, PA HoffmannPublishing.com I 610.685.0914 I for advertising information: [email protected] or [email protected]

MCMS Physician is a publication of the Montgomery County Medical Society of Pennsylvania (MCMS).

The Montgomery County Medical Society’s mission has evolved to represent and serve all physicians of Montgomery County and their patients in order to preserve the doctor-patient relationship, maintain

safe and quality care, advance the practice of medicine and enhance the role of medicine and health care within the community, Montgomery

County and Pennsylvania.

2014-2016MCMS BOARD OF DIRECTORS

Stanley Askin MDFrederic (Rocky) Becker MD

Charles Cutler MD Madeline Danny DO

Immediate Past President

Tita de la CruzPresident, MCMS Alliance

Walter I. Hofman MD Secretary

James A. Goodyear MD Immediate Past Chairman

George R. Green MDDennis Jerdan MDWalter Klein MD

William W. Lander MDMark A. Lopatin MD

Robert M. McNamara MD Rudolph J. Panaro MD

Mark F. Pyfer MDChairman, Public Relations Committee

Jay Rothkopf MDPresident-Elect and Treasurer

Carl F. Schultheis Jr. MDScott E Shapiro MD

Chairman

James Thomas MDPresident

Martin D. Trichtinger MDChairman, Political Committee

Patricia TurnerPractice Manager

MCMS StaffToyca WilliamsExecutive Director

[email protected]

Editorial BoardJay E. Rothkopf MD, editor

George Green MDMark F. Pyfer MD

Scott E. Shapiro MDToyca D. Williams

Features

4 Chairman’s Remarks5 Editor’s Comments34 Membership News & Announcements

In Every Issue

6

18

Responding to Negative Online Comments

Three Generations to OSHKOSH

Managing an Incurable Disease, A Physician’s Journey With Crohn’s

10

9 Meet Your County Medical Society President

16 Political Update: What’s Happening on the Hill

20 A High Flying Life

22 Physician Revalidation Requirements:

Avoiding Disruption to Reimbursement

24 Physicians Can Help Patients Reduce the Risk of Fall-Related Injuries

25 Frontline Groups

26 What’s Driving Physician Uncertainty Around the Affordable Care Act?

28 ‘You Make So Much Money’... Think Again

29 Healthcare Leaders: Are You Energizing Your Human Capital While Delivering Quality Patient Care?

30 Montgomery County Dermatologists: Skin Protection Not Just for the Beach

31 Free HIPAA Risk Assessment Tool Can Help Ensure Compliance

32 From My Viewpoint: Medical Marijuana

33 Through the Eyes of a Patient

M C M S 4 P H Y S I C I A N

m o n t m e d s o c . c o m

Chairman’s Remarks

The Price of Freedom Too Great to Squander

montmedsoc.com

I would love to hear from you. If you have suggestions, general comments or ideas for future issues, please email Scott E. Shapiro MD or the MCMS Executive Director Toyca Williams, [email protected].

Freedom – a priceless privilege that greatly impacts our very existence as physicians, family men and women, leaders in our

community and individuals moving between activities that are part of our daily routines. Yet, it is often taken for granted. Recently, I heard a speech from a proud veteran who knows all too well the importance of freedom. Harry Ettlinger’s memory at 88 years of age is rich with detail. The retired engineer spoke at our Annual Membership Dinner on June 3. (See some of the pictures from the dinner inside this issue of MCMS Physician. A good time was

had by all.) His platoon of soldiers was tasked with helping groups of people reclaim their heritage and his own. Mr. Ettlinger and his family fled his native Germany just before the onslaught of coordinated attacks on Jewish families throughout Nazi Germany and Austria. Thousands of Jews were arrested and incarcerated in concentration camps. Jewish homes, hospitals, schools, businesses and synagogues were destroyed or damaged. His family was fortunate to escape and find freedom while many others did not. After nine days on a ship, he said they settled in Upper Manhattan and then a year and a half later moved to Newark, N.J. When he left Germany at the age of 13, he didn’t understand the price of freedom. But now he does and enjoys talking about the time he served in the U.S. Army as a member of the Monuments, Fine Arts and Archives section. He played a small part in restoring freedom abroad to protect our freedom at home.

Ironically, he returned to Germany as a U.S. soldier to find, secure and return millions of pieces of art, sculpture, books, jewelry, furniture and other cultural treasures that were looted by the Nazis during the war. Many of the valuables were stored in salt mines and castles throughout Germany and Austria. He said he supervised the German workers and spoke their language. The role of this special platoon of soldiers is documented in a movie aptly titled “The Monuments Men.” Mr. Ettlinger and many others helped to restore freedom in many parts of the world after World War II. Because of their sacrifice, we all live and work freely.

Use Your Voice A price has been paid so that we can enjoy the freedoms to practice as physicians. You are on the front lines of patient care and they expect you to safeguard the doctor-patient relationship and provide safe and quality care for all who need it. Our voice is important in organized medicine’s mission to advance quality patient care, advocate for them and promote professional satisfaction and practice sustainability. To sit idly by and not engage in organized medicine’s mission is not an option for me. And it should not be an option for you. Just like Mr. Ettlinger, we need to continually reclaim our privilege as the leader in team-based care. If you don’t protect your freedoms, other groups will loot what you take for granted. You are critical in accomplishing the mission. Join the army.

Scott E. Shapiro MDChairman, MCMS Board of Directors


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Editor’s Comments

O kay, you’re probably starting to see a pattern here. There are only four seasons, and I’ve

already written about two of them. Eventually, I’m gonna have to move on, but I love the summer, so it gets an honorable mention. Long days, warm nights, after-dinner walks...you get the picture. As we head into the middle of 2014, the world of health care remains challenging and active. To start off,

we take a look at the phenomena of online ratings. Over the past decade, a plethora of free opinion sites and forums have exploded across the net, often with little or no regulation governing what may be said. It only takes a single bad review to potentially ruin a reputation, and the legal options for dealing with a disgruntled poster are limited. Fortunately, steps can be taken to not only monitor content, but also to deal with negative reviews. While our instinct may be to “take the bull by the horns,” often, that is not the best option. In our cover story, we explore this frequently nebulous and complex world, and the dos and don’ts of online reputation management. Next, we go somewhere a little different, and explore an issue often talked about in hushed tones: the physician who’s sick. For decades, doctors often felt compelled to always go to work, even when ill. Anything else was viewed as a sign of weakness, and part of being there for our patients meant sometimes putting our own health aside. In an article that is very personal, I explore my struggles of living with Crohn’s disease, and the challenges it has posed during my residency training, personal life, and career as an attending. It’s a subject that’s gathering more and more attention, and something many professionals will have to face.

We’ll spend some time exploring what our patients often feel lying in a bed and our passions outside of medicine. You will meet Dr. George Green, a long-serving member of the MCMS Board of Directors, who details his life-long love of flying, and what it has meant to him and his family. We also profile our new President James W. Thomas M.D., an interventional radiologist who has a love for technology that stretches beyond the profession. He has numerous ideas of how advances in technology can improve patient care. Other features include exploring the challenges physicians and practices face in this ever-changing environment, a political update, and educating the community through the county’s Department of Health. We will feature a special article on work-life challenges submitted by The Inspiration and Wellness Studio. It explores the issue of how health-care leaders can motivate their staff while simultaneously giving quality patient care. Like our previous issues, we cover a lot of ground, and hope to continue to cover more. With that in mind, I would like to invite our readers to share their thoughts. This magazine is for you, the citizens of Montgomery County, and we want to know what you expect from us. If there’s an issue you would like to see explored, drop us a line, and we’ll do our best to put it together. A lot of passion has gone into these pages, but it’s a labor of love, and ultimately, we’re here for you. In the meantime, I sincerely hope you enjoy the read...and the summer that always seems to go too fast.

Warm regards,

Jay Rothkopf MDEditor

The Chill of Winter is Gone... Bask in the Summer Sun

Summertime.



With the advent of social media and online marketing outlets,

physicians, healthcare practitioners and facilities are experiencing, in a new medium, a not-so-new phenomenon — bad publicity. There are many online sites that allow patients to rate their physicians on various scales, and often they can leave narratives about their experiences. “Dozens of websites that permit people to rate, review, spin or flame their doctors have sprung up in the last year, operating in much the same way as online services that help people find the best hotels or avoid plumbers who overcharge,”1 reported the Los Angeles Times in 2008. As such websites increase in popularity, so does the significance of such ratings. Many patients are using the sites to report negative comments about physicians, and physicians often feel unable to defend themselves due to HIPAA and other privacy regulations. Negative reviews can come from angry patients, disgruntled employees, and sometimes even members of the public just trying to create unsubstantiated problems. When physicians have attempted to use the legal system to stop this form of harassment, the courts have been less than accommodating to

them. Two cases have been made public to demonstrate the courts’ attitude towards physicians attempting to protect their reputations. In 2007, the California 3rd District Court of Appeal ruled that a University of California Davis plastic surgeon could not stop a patient from making negative comments about him in an online forum because the court felt he was a “limited purpose public official.” This was evidenced to the court based on television appearances and advertising of his practice. The second case involved a neurologist in Minnesota who filed a lawsuit in June of 2010 against the son of a former patient claiming defamation. In April 2011, the judge

dismissed the case by stating, “… the

court does not find defamatory meaning,

but rather a sometimes emotional discussion of

the issues.” Because of this lawsuit, the case was widely publicized through newspaper, internet and television media

outlets resulting in a negative impact on his practice. Kevin

Pho MD (founder and editor of KevinMD.com) stated, “…doctors who sue patients for online ratings are going to lose in the more influential court of public opinion.”2

When these attacks occur, sometimes the physician wants to go into a defensive mode to preserve both integrity and reputation. But impulsive responses may do more harm than good.

BY JOSH HYATT, RISK MANAGEMENT SPECIALIST, NORCAL MUTUAL INSURANCE CO.

Feature COVERSTORYResponding to

Negative ONliNe COmmeNts


S U M M E R 2 0 1 4

Positive ratings will help to counter balance negative comments.• Provideapatientcomplaintprocesssodisgruntled patients can receive timely resolution.

Reactive Steps • Don’tpanic.• Donotrespondimmediatelyorimpulsively.Take time to consider the comment, to reflect on why the individual felt compelled to post, and to decide if it warrants a response. Not all negative comments are worthy of your time to respond. A response may start a chain reaction of negative slurs and comments, potentially leading to litigation. • Ifyoufeeltheinformationis“clearlyfalse, inappropriate and solely inflammatory, contact the (Internet) site administrator.”3 Legitimate sites have content guidelines and will probably remove information that violates them.

Continued on page 8

Responding to Negative Online Comments

Responding to Negative ONliNe

COmmeNts

R e C O m m e N d a t i O N s Because negative online reviews can affect a physician and his or her practice, the issue warrants a two-fold plan of action that is both proactive and reactive in nature. Proactive Steps • Setupyourownpracticewebpagewhereyoucan control the content and message you want to share with the community. Work with your group administrator or medical director as necessary. • Developasocialmediaplanforyourpractice.Thiscould include Facebook or Twitter accounts where postings can be controlled. • Periodicallycheckwebsitesforyourselforyourpractice to identify any specific issue or trends. You may want to explore setting up online alerts that advise when comments have been posted about you as a physician. • Askpatientstogoonlineandrateyourservices.

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Feature Responding to Negative Online Comments

• Ifyouareconsideringsuingareviewer,thereare many potential issues you need to be aware of to avoid pitfalls and countersuits. Consult with your attorney as soon as possible before taking any steps in that direction.• Periodicallyfollowupwithpositiveinformationabout your practice on the sites. NEVER post fake consumer reviews, as this may result in significant fines and penalties. • Ifyouchoosetorespondinwriting,limittheresponse to general information, NEVER use patient identifiers or reveal any protected health information, and do not directly or personally attack the individual posting the comment.

1. Roan, Shari. The Rating Room. Los Angeles Times. May 19, 2008.2. Pho, Kevin. Doctors should not sue patients for negative online reviews. KevinMD.com. 3. California Medical Association. CMA On-Call, Document 0822: Online Consumer Review and Rating Sites. www.cmanet.org.This article has been adapted from “Responding to Negative Online Comments,” one of 100+ risk management articles, sample forms and sample policies available online to PMSLIC Insurance Company policyholders. Josh Hyatt is a Risk Management Specialist with NORCAL Mutual Insurance Company, the parent company of PMSLIC.

Copyright 2014 PMSLIC Insurance Company. All rights reserved. This material is intended for reproduction in the publications of PMSLIC approved-producers and sponsoring medical societies that have been granted prior permission. No part of this publication may be otherwise reproduced, edited or modified without the prior written permission of PMSLIC.

Responding to Negative Online Comments continued from page 7

DOCTOR RATING SITES:Angie’s List: www.angielist.comDoctor.com: www.doctor.comDrScore: www.drscore.comGoogle+Local: www.google.com/+/learnmore/localHealthcare Reviews: www.healthcarereviews.comHealth Grades: www.healthgrades.comInsider Pages: www.insiderpages.com/doctorfinderKudzu: www.kudzu.comRateMDs: www.ratemds.comVitals: www.vitals.comYelp: www.yelp.com

While physicians are wary of these web sites,

more and more consumers are turning to the

Internet for their health care information.

DOCTOR RATING SITES:Angie’s List: www.angielist.comDoctor.com: www.doctor.comDrScore: www.drscore.comGoogle+Local: www.google.com/+/learnmore/localHealthcare Reviews: www.healthcarereviews.comHealth Grades: www.healthgrades.comInsider Pages: www.insiderpages.com/doctorfinderKudzu: www.kudzu.comRateMDs: www.ratemds.comVitals: www.vitals.comYelp: www.yelp.com


S U M M E R 2 0 1 4

Feature

James (Jim) W. Thomas MD, MBA,an interventional radiologist in the Montgomery County, is the new president of the Montgomery County Medical Society (MCMS). A member of the 21-member MCMS Board of Directors since 2007, Dr. Thomas advocates for physicians and patients at the local, state, and national levels. In each issue of the MCMS Physician, we will profile a member of your county medical society leadership team.

Name: James (Jim) W. Thomas MD, MBA Specialty: Interventional RadiologyCurrently Practices: Interventional Radiology Associates Practice: Outpatient Facilities and Radiology Consultative Services– Licensed in Pennsylvania, New Jersey, Virginia, Washington, DC and New YorkMedical School: University of Pennsylvania, 1985–1990Graduate School: The Wharton School of Business, University of Pennsylvania 1988-1990Internship: Naval Hospital, Oakland, Calif., 1990–1991Naval Aerospace Medical Institute: 1991–1992Flight Surgeon: HM-14 HC-2 HC-6, 1992–1995Residency: University of Texas/MD Anderson Cancer Center, 1995–1999Fellowship: Georgetown University/National Institutes of Health, 1999–2000Hometown: Washington, DC; raised in Montclair, NJResidence: Lower Gwynedd; lived in Montgomery County since 2004.

ON A PROFESSIONAL NOTEWhy I chose a career in medicine: As an undergraduate dual Economics and BBB (Biological Basis of Behavior) major, I had a strong desire to bring health care and economics together to provide the best possible care to patients. Why interventional radiology? I wanted to specialize in a field where I could evaluate anatomy and solve significant vascular maladies in an elegant manner. In certain circumstances, correcting medical problems through tiny incisions under direct guidance can be a very beneficial and less invasive alternative to larger surgeries.

Most rewarding elements of my career: Finding innovative and elegant solutions to complex problems, and also having the patient survive for many years, are very rewarding. Sometimes this does not happen. When it does, the patients are appreciative of us, and we, in turn, are grateful to our teachers.Leadership positions: Since 1989, I’ve held various positions within MCMS and the Pennsylvania Medical Society (PAMED). I have been a member of the Society of Interventional Radiology since 1999 and the Pennsylvania Radiological Society since 2002.•GoverningCouncilChairman,PAMEDMedical Students Section, 1988–1989•Chair,PAMEDPatientAdvocacyExecutive Council & Board Work Group, 2012–present•President,MCMSBoardofDirectors,2014–present; MCMS Board Member since 2007

ON A PERSONAL NOTEInteresting childhood fact: My father was a sociology professor, and he traveled much early in his career. This gave our family the opportunity to experience various cities and peoples throughout the country, moving from Washington, DC to places as varied as Laramie, Wyo., Dayton, Ohio and then to Montclair, N.J. Friends from grade school, college and medical school are still important parts of my daily life.An achievement most proud of: Daily activities with my children, all of which are, to me, extraordinary.What interests me outside medicine: I enjoyed windsurfing, biking, running as well as golf in the past. I now spend more time in activities with my children. My family: I have two children, James, 12, and Julianna, 10. I have three sisters, two of whom are physicians and one is an attorney. You may not know: The U.S. Navy provided me with incredible experiences and medical opportunities; it also provided

me with opportunities to see parts of the world most people do not generally visit as tourists. I appreciated each of those professional and travel opportunities. Most important were the dedicated members of the Navy; working side by side with and treating a community of patriots on land and aboard a ship, locally and abroad, was both a rewarding experience and a humbling honor. If I could be anything other than a physician: I would be a hospital or health care insurance administrator or work in corporate health care. Helping to get the best possible care to the consumers is a responsibility of all who work in the health care industry. Those with opportunity and influence in the coordination of care, costs and access can indeed help many people, and in a very direct and immediate way.I greatly admire: Innovators and creative thinkers such as Leonardo DaVinci and Benjamin Franklin and similar mindset inventors of today who are able to bring many of their ideas to reality within their lifetimes.

WORTh NOTINgMost interesting moment in medicine: The most interesting moment in medicine is yet to come. It will come when the citizens of the United States are empowered through knowledge to make informed and autonomous decisions about accessibility to health care, and when they are given available technology, pricing and outcomes information that would allow market forces to supply the people of the United States with health care goods and services. This would better ensure that finite resources are utilized and allocated for the maximum benefit of all.Why do you stay involved in organized medicine? With the hope of helping physicians balance allegiances due first and foremost to patients, with obligations to family, hospitals, health care organizations, insurers, payors, the government and the community.


Feature


Ilooked down at the thermometer, twisting it in the dim light. It was old, and still had liquid in the mid-

dle, like from when I was a kid. Rustic, perhaps, but it worked. I squinted at the thin red line, and frowned. 104.2oF. “Uh-oh,” I said to no one in particu-lar. Next to me, my wife stirred. “Are you okay?” she asked. Her voice was throaty and full of sleep. It was 3 a.m. “No,” I said, staring at the glass cylinder. “I think I need to go to the hospital.” “Now?” “Tomorrow, right after rush hour.” Silly, really, since the ER was only five miles away, but it made me feel better to say it. “I’m running a high fever.” “How high?” I told her. Suddenly, she was wide awake. “Are you sure it can wait?” “I’m sure.” That was a lie; I wasn’t at all sure, but I was too tired to move, not to mention I needed to stay close to the bathroom. “I’ll take a couple Tylenol. That’ll bring it down.” She clicked on the light. “Isn’t it bad to have a fever on steroids?” I nodded, surprised by the question. “It sure is.” It had been almost two weeks, but the 40 mg of daily predni-sone had done little to ease the myriad

of symptoms. If anything, the constant mood swings and grinding insomnia had made me feel even worse. The ab-dominal pain, of course, laughed at the pills, as if mocking my attempt to force the Crohn’s into remission. Her eyes glinted in the harsh light. “I still think you should go now,” she said. “What if something happens?” “It can happen in the morning,” I informed her. “The only place I’m going is back to bed.” And so we did. Once the medication kicked in, I finally drifted off into an uneasy sleep. The next morning, after a shower and some breakfast, I packed a small bag and promptly hit the road. The ED physician was surprised to see me, a resident with whom he’d frequently worked, but was all business as soon as he heard my explanation. I was regis-tered, gowned, hooked to an IV, and given a room. Later, as I was sitting on a stretcher waiting for a CT scan, it occurred to me that downing one last bowl of cereal before being sentenced to NPO might not have been such a smart idea, especially since I now had to pound a two-barium chaser. Fortunate-ly, the restroom was right next to my cubicle, and for the next several hours, stayed relatively unoccupied....except for me.

It was my first hospitalization for Crohn’s, but would be far from my last.

Diagnosed at 8 I turned 38 this past April, marking three decades since I was first diagnosed.Sparked by three months of worsening illness, I vividly remember the trips to the pediatrician, who grew increasingly baffled by the diarrhea and weight loss that stubbornly refused to go away. Final-ly, he referred me to an infectious disease specialist who, after a thorough history and physical, sent me to the Department of Pediatric Gastroenterology down at The Children’s Hospital of Philadelphia. There I met John Watkins MD, a physi-cian who would become a major part of my life for the next 10 years. That first day was a frightening array of tests: blood draws, a chest x-ray, and an upper-GI with small-bowel follow-through, which necessitated the consumption of “fuzzies”—tiny granules of salt designed to blow up the stomach for better visualization. I can still recall watching the monitor after drinking the barium; the radiologist stood over me, explaining each new image in a thick Russian accent while my mother, decked out in a lead apron, held my hand. After six hours of poking and prodding, the diagnosis was made: Crohn’s.

Managing an Incurable DiseaseA Physician’s Journey

with Crohn’sBY JAY E. ROTHKOPf MD


S U M M E R 2 0 1 4

Managing an Incurable Disease

Back in the office, I sat quietly while Dr. Watkins held up a film of my abdomen and showed my father the String Sign of Kantor. The look on dad’s face was grim, and he did not speak. I left the hospital with a small order of fries from the McDonald’s in the lobby and a three-month supply of liquid sulfasalazine. I don’t remember much about the weeks that came after, other than vague recollectionsof the nasty orange goo I had to swallow four times a day. Both sets of grandpar-ents became constant fixtures, drawn to the house like moths to a flame. I dreaded that bright plastic bottle and its slimy contents, and as I discovered years later, so did my mother. An eight-year old is not the world’s most reasonable being, and when gentle words and hugs from his father failed to produce an aura of calm, a package of Reese’s Peanut-Butter cups often became the last resort. In retrospect, I think I may have single-handedly increased their bottom-line that year. Whatever the outcome, the drug worked, and fairly quickly, too. Within a month, the cramps and constant diar-rhea began to fade, and I started to gain weight.

Back to Normal By the time Labor Day rolled around, I was pretty much back to normal. I was still being shuttled down to Center City four times a year, but other than the needle sticks and physical exams, the disease became a distant memory. Time gradually sped up. Eighties became nineties, and I entered high school. The orange goo gave way to pills, which were not only better-tasting but easier on the teeth (which still bear the stains of my affair with Big Sulfa). I watched the first Gulf War on TV, found a girlfriend, and tried to fathom the next big step: college. My mother’s father, the one who used to hold my hand as I choked down the medication and whisper “Good, mein kind” (Yiddish for “my child”) passed away, the first in a

steady march of attrition that would eventually swallow my uncle and father. At the age of 16, with acne on my face and the mantle of invincibility in tow, I quietly stopped taking my meds. I was too busy trying to figure out who I was to be bothered with Crohn’s, and besides, I didn’t want to lug a conspicuous bottle of pills out on dates. My parents

grumbled somewhat, but didn’t protest. I seemed healthy, and after a discussion with my doctors, permission for a trial off meds was quietly granted. College came and went, then med school, and no Crohn’s. I still had yearly follow-ups, but no one seemed concerned. In conversation, the words “lifelong remission” began to pass the doctor’s lips. My confidence grew, along with my sense of invulnerability. In college, I picked up medium-distance running as a hobby, and began to follow what I thought was a healthy diet (although that took a significant amount of trial-and-error). I was young, in shape, and disease-free. Or so I thought.

Continued on page 12

Crohn’s Rears its Ugly Head The first hint that something was beginning to go wrong came early in the spring of 2003, two-thirds of the way through my intern year. Despite an at-times challenging schedule, I was running 30 miles a week, and while I felt well, I began to notice some mild pain after 20 minutes of zipping along. I didn’t think much of it at first, but soon the discomfort led to urgency, and I found myself dashing home to get to the bathroom at the end of every workout. By the summer, I could no longer finish a full four miles, and kept my routes close to home. Still, I had no other symptoms, my weight was stable, and I was invincible, right? In 2004, my father, just shy of turn-ing 58, was diagnosed with multiple myeloma.

The shock of that news, combined with the stress of being in a residency I didn’t like, began to send my health downhill. In an environment where the mantra was “suck it up!,” I felt com-pelled to internalize my feelings. The abdominal pain grew, as did the urgency, but I simply chalked it up to stress. I was working longer and harder than I ever had in my life, and everybody needs time to adapt. Besides, doctors don’t get sick, and residents are supposed to be tough, right? By 2005, I could no longer ignore the obvious. I had searing pain that woke me nightly from sleep, drenched head-to-toe in freezing sweats as if someone had dumped a bucket of ice water on me. Working in an OR, I wore scrubs almost every day, and failed to notice that I’d lost twenty pounds. Come July, the act of climbing the stairs would send me running to the bathroom, and my joints began to swell. After a week of high fever, I finally got help.

I Finally Sought Help The blood work raised serious alarms, and I was immediately scheduled for acolonoscopy. Despite a generous helping of propofol, I vividly remember sitting in the recovery room at Temple Uni-versity Hospital, my wife standing close by as the gastroenterologist gave me the sad news: it was back, and very severe. Only his confidence in my ability to be strictly compliant with his instructions kept me from hospitalization, and we left with a handful of scripts for more blood work, prednisone, and azathio-prine. Two months later, with minimal remittance of symptoms, I was switched to a medication called Remicaid. I didn’t have much hope, but I was willing to try anything at that point. I’m not exaggerating when I say that two weeks later, I was nearly back to normal.

Managing an Incurable Disease continued from page 11

Feature



Waves of pain had been replaced by waves of euphoria, and I literally felt like a new man. I wasn’t 100 percent, but I was pretty darn close, and after months of illness and fatigue, I was happy to take whatever I could. I had been given a second chance. The medication would no doubt keep the disease at bay. It was now time to get back to my life, and put all worries behind me.

Not So Fast... Doc Says We Need to Talk He shut the door, pulled over a chair, and sat down. My chart was in his hand. He draped it nonchalantly across his knees and flipped it open. “How are you feeling?” he asked. “Better,” I said. He nodded. “Good.” He pointed to

the bag of IV fluids. “We’ve given you almost four liters. You were pretty dehy-drated.” “I’m not surprised. Eating hurt.” “Yes.” His eyes narrowed. “I got your last biopsy reports from Temple, and I think we need to talk about them.” My heart sped up. “Okay.” He settled back and flipped into “lecture mode,” which I had seen often as a resident in morning report but had never experienced as a patient. Twenty-four hours into my hospitalization, I was still coming to grips with the fact that the disease had come back, along with the irony that I was now being cared for by the same resident team I had been a part of not two weeks before. He stared at me for a moment, head cocked to one side, then spoke: “Here’s where we are: you just had a flair on standard dose Remicade, you have severe inflammation both proximal and distal, and you’re currently on bowel

rest.” He paused. “I think you need to talk to a sur-geon.” My mouth, already nearly devoid of saliva, promptly went from desert to moonscape. “Surgeon?” I repeated. “Yes.” “But I’m feeling much better.” “That’s the steroids.” “Can’t we just up the Remicade?” “We will, but it’s not going to last.” He leaned forward. “In cases like yours, the disease almost always gets away from the drugs.” “What about switching to Humira?” He shook his head. “There’s no real data to support that. I can buy you some time, but once we taper the prednisone, chances are it’s going to come back.” “But surgery?” “I know it sounds scary, but I’d like you to consider it. The improvement in your quality of life would be significant.”

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Crohn’s disease is a chronic inflammatory condition of the gastrointestinal (gI) tract. It is one of a group of conditions known as Inflammatory Bowel Disease (IBD) that affects almost 700,000 Americans. Crohn’s most commonly affects the end of the small bowel and the beginning of the colon, but it may affect any part of the (GI) tract, from the mouth to the anus. Its exact cause is unknown, but it occurs when your body’s immune system mistakenly attacks and destroys healthy body tissue (autoimmune disorder). While symptoms vary from patient to patient and some may be more common than others, the tell-tale symptoms of Crohn’s disease include:

general symptoms that may also be associated with IBD: • Fever • Loss of appetite • Weight Loss • Fatigue • Night sweats • Loss of normal menstrual cycle

Symptoms related to inflammation of the GI tract: • Persistent Diarrhea • Rectal bleeding • Urgent need to move bowels • Abdominal cramps and pain • Sensation of incomplete evacuation • Constipation (can lead to bowel obstruction) People suffering from Crohn’s often experience loss of appetite and may lose weight as a result. A feeling of low energy and fatigue is also common. Crohn’s is more prevalent among adolescents and young adults between the ages of 15 and 35. Recent research suggests hereditary, genetic, and/or environmental factors contribute to the development of Crohn’s disease.

Although Crohn’s disease cannot be cured even with surgery, treatment can offer significant help to most patients. The condition is marked by periods of improvement followed by flare-ups of symptoms. The Crohn’s and Colitis Foundation of American offers support groups throughout the United States,

www.ccfa.org.

“There are no options?” “This is the best one. You don’t have to decide right now, but you’re heading in that direction.” “How long?” “A month, a year. It all depends on how you respond.” I sat back and tried to digest his words. I knew it was bad, but I wasn’t ready. Not yet. That would change sooner than I thought.

Medication Buys Me Some Time After five days, I made it home, and life resumed. Over the next month, I gradually weaned off the little white pill that I had come to hate with a furious passion. I was doing better, but in many ways, life on high-dose prednisone is trading one form of hell for another. The summer waned, and transitioned into fall. My health, while more or less okay, wasn’t great. I’d settled into a “new normal:” functional, but operating in a lower gear. November brought the first test: an ICU rotation as the senior resident, with a month full of overnight call. This was back during the era of “24+6”, not quite the “old” system, and not the current shift-based model designed to alleviate sleep deprivation. With winter coming, the unit was busy, but I managed. By the fourth week, the cramps had returned with a vengeance, along with a low-grade fever, and a healthy dose of fear. As the rotation ended, giving way to a floor month with no nights, it was time for my scheduled injection. Fortunately, it worked. Within 24 hours of the infusion, my symptoms were mostly gone. It was a game I would continue to play over the next several months. My life became a sliding-scale of wellness, with peaks just after receiv-ing Remicade and troughs as the drug gradually disappeared over the ensuing weeks. Approaching graduation, I began to make plans for the next phase of my career. The disease was still there, but I did my best to move forward. On the home front, there was news both good and bad. My second son Matthew was born, and my father entered the terminal phase of his illness, which stressed my family to the breaking point. Depressed and in pain, not to mention furious at being cheated out of the rest of his life, his anguish knew no bounds. I’ll never forget bringing his new grandson, two-days old, over to the house and setting him down in dad’s arms. I thought it would cheer him up. I was wrong. Sitting in the large green recliner in my parents’ den that had now become his prison, he looked down at the peacefully sleeping infant and promptly burst into tears. When asked what was wrong, his answer was simple, direct, and utterly heart-wrenching: “He’s never going to know me.”

A Personal Loss Weakens Me From there, it was all downhill, at least for a time. Residency ended, and I started my new job. Scarcely a week in, the raging fevers were back. I knew I wouldn’t be able to function, and after talking to


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the powers that be, I checked myself into the hospital for the second time. Upon admission, I looked the gastroenterologist directly in the eye and said: “Surgery.” I was done. Whatever unknowns a major operation would bring, I was finally ready to embrace them. I simply was no longer able to live this way. Too weak for the OR, and after another bout of saline, clears, and Solu-Medrol, I was discharged home with an appointment and date in tow: Aug. 12, 2009. Five days after my pre-op discharge, on the floor of the very same room in the house where I grew up, the visiting nurse from Penn and I did dad’s final round of CPR, and his words became true. The image of shining a flashlight into his fixed and dilated pupils will haunt me for the rest of my life. It was July 24, 2009. Two weeks after his funeral, I underwent a laparoscopic total proctocolectomy. Despite discovering an abscess, the procedure was relatively straightforward, and after a week in the hospital, I finally went home. Those first few days were an incredible eye-opener: I needed a walker to get around my house, and assistance to climb the stairs. I broke out in a sweat simply from drinking a can of Ensure. The weakness, fatigue, and sense of mortality were absolutely terrifying. I spent numerous days sitting on the couch, watching the open wound that steroids had left in my belly, and wondered if I would ever heal. I feared contracting every complication from pulmonary embolism to overwhelming sepsis, but nothing materialized. As the weeks progressed, the pain and exhaustion gradually faded, and a sense of well being slowly returned. At the age of 33, my body wasn’t ready to pack it in, and went about the business of conducting repairs. Three months later, I was back at work. Although I suffered a brief flare in the summer of 2011, my health, thank God, has been otherwise good.

Many Lessons Learned on this Journey So where did I get this idea that doctors don’t get sick? Some of that came from home, from a parent and grandpar-ent who practiced in a different era, a time of black bags and house calls, solo practices and around-the-clock call. Grow-ing up, my father never missed a day of work, no matter how bad he felt, and neither did my grandfather (except for his two bypass surgeries). I once remember asking dad, shak-ing with chills from a case of the flu, why he didn’t just stay in bed. His answer, “Because my patients need me,” helped cement into place a paradigm that colored my viewpoint for years to come. Doctors were expected to be tough, to pull through; anything else was viewed as weakness. About a month before his death, when I broached the subject of tak-


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ing time off, he glared at me and grunted: “Don’t do it. People will talk, they’ll think you can’t cut it. You’re almost done. Don’t risk it.” In a lifetime of imparted wisdom, it was the only piece of bad advice he ever gave me. Looking back, my choices should’ve been clear, but at the time, they were not. A fear of failure, along with a sense of not wishing to be a burden to my family (or be at the perceived mercy of another person’s charity) led me to try and hide what was wrong. In retrospect, it was very foolish, and I could’ve easily died from the complications of my disease. In the grand scheme of things, however, I am very lucky, and have no re-grets. The opportunity to treat the sick is a privilege I find very humbling. I know now it’s not about me, and the experience of living with a chronic illness has helped me learn to put my ego aside. It’s also given me a better understanding of some of the flaws in our health-care system, and ideas on how we can better improve the patient experience. I don’t know what the future will bring, but the disease will always be with me, a reminder that good health is, in many ways, the best reward...and also not to sweat the small stuff. Hopefully, it’s a sense of perspective that will never depart.

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As the June 30 deadline approaches for the enactment of Pennsylvania’s annual state

budget, concern is growing over the Commonwealth’s fiscal health. Revenues are lagging projections by several hundred million dollars, and it now appears that Gov. Corbett’s proposed spending plan, delivered in February, may be more than a billion dollars out of balance. There are two primary culprits: a revenue shortfall caused by a slower-than-expected economic recovery, and a badly underfunded state pension system. The latter concern is serious enough that all three major credit rating agencies have threatened to lower the state’s credit rating. This will certainly create a challenging environment in which to obtain new funding for important health care-related programs, but the work goes on. The past few months have seen a flurry of activity, as lawmakers rush

to finish as much of the 2013-2014 session’s work as possible before they break for the summer. Traditionally, few controversial issues are addressed in the fall of the second year of a two-year term, as most House and Senate members are focused on their reelection efforts and the Nov. 4 general election. So, expect June to be a very busy month, culminating in the enactment of a state budget on or before (hopefully) the June 30 constitutional deadline. Following are highlights of recent legislative and regulatory actions.

Controlled Substance Database

Progress continues to be made on the Pennsylvania Medical Society’s drive to enact legislation establishing a statewide controlled substance database. As reported earlier, the House of Representatives passed House Bill 1694 back on Oct. 21, 2013, by a vote

of 191-7. The success was the result of two years of effort by PAMED and its members, who recognize the value such a database would have in reducing doctor-shopping and controlled substance abuse. Our “Pills for Ills, Not Thrills” campaign has played a major role in generating public support for the legislation. Subsequently, Sen. Pat Vance (R-Cumberland) introduced her own version of the legislation, Senate Bill 1180. The bill differs in several respects from the House-passed bill, and PAMED has been working to reconcile those differences and get a final product to Gov. Corbett’s desk to make this important tool a reality for Pennsylvania physicians. On May 6, the Senate passed Sen.Vance’s bill 47-2. While PAMED supported the Senate action, we made it clear that we still have a number of concerns about the Senate version, particularly in the area of patient privacy and law enforcement access to the database. The bill now goes to the House, and at this point it is unclear whether there will be an opportunity to strengthen the patient privacy provisions, but in any case PAMED will continue to press for enactment of the best possible final product.

Medical Marijuana

There has been a surge of interest in legislation that would legalize medical marijuana in Pennsylvania, culminating in a Senate public hearing on January 28. Senate Bill 1182 is based on the premise that there is some evidence that marijuana may provide relief from nausea to cancer patients, and that it may aid in the treatment of glaucoma and post-traumatic stress disorder. There are also recent stories that oil derived from cannabidiol has aided some suffers of Dravet syndrome, a rare form of epilepsy. PAMED testified at the hearing, where we expressed concern that much of the evidence is anecdotal, and that one individual’s experience cannot be applied to others with any degree of confidence. In the absence of reliable scientific studies,

Political Update:What’s Happening on the Hill

BY SCOT CHADWICK, LEGISLATIVE COUNSEL, PENNSYLVANIA MEDICAL SOCIETY

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we worried that there is no sure way to know whether the observed changes resulted from the administration of marijuana or from some other source or combination of sources. And might it be possible that two cases in which an individual benefited from marijuana were offset by three other cases where patients suffered harm? PAMED also testified that serious questions remain even if one assumes that medical marijuana may benefit a certain class of patients. Was it the tetrahydrocannabinol (THC) that produced the result, or was it the cannabidiol (CBD), or a particular combination of the two? Or perhaps it was one of the dozens of other compounds in the particular strain that was used. What dosage or potency produces maximal efficacy, and how often should it be administered? And importantly, is there a dosage or frequency of administration that causes harm, and what are the long term effects? Until these questions have been answered, PAMED testified that we cannot support the legalization of marijuana for medical use. However, PAMED believes a compelling case exists for a serious scientific examination of the potential medical use of marijuana, and four years ago joined the AMA in urging that marijuana’s status as a federal Schedule I controlled substance be reviewed, with the goal of facilitating the conduct of clinical research and development of cannabinoid-based medicines, and alternate delivery methods. PAMED has also called for further adequate, well-controlled studies of marijuana and related cannabinoids in patients who have serious conditions for which preclinical, anecdotal, or controlled evidence suggests possible efficacy, and the application of such results to the understanding and treatment of disease. While the bill’s fate is uncertain at this time, Gov. Corbett recently announced his support for legislation creating a pilot program allowing the use of so-called “Charlotte’s Web” oil from cannabidiol to treat children with Dravet syndrome.

Naloxone Bills Being Considered

House Bill 2090 and Senate Bill 1299 would significantly expand access to naloxone, a drug used to counteract the effects of an opioid drug overdose. The bills provide for educational materials and training for law enforcement personnel, firefighters, and persons at risk and their friends and family members on how to identify a person experiencing an overdose, administer naloxone, and seek medical help. The scope of practice of EMS providers would be expanded to permit them to administer naloxone once they have received the necessary training. And importantly, prescribers would be authorized to prescribe

and dispense naloxone to law enforcement personnel, firefighters, and persons at risk, along with their friends, family members and others in a position to help them.Prescribers who prescribe and dispense naloxone in good faith would be immune from civil, criminal, and professional disciplinary liability for doing so, and persons seeking medical help for someone experiencing an opioid overdose would also be immune from criminal liability. While it is clear that naloxone saves lives, lawmakers are wrestling with the question of whether wide availability also encourages opioid abuse by reassuring potential abusers that an antidote is at hand.

Regulation of Tanning Salons

Culminating years of hard work by PAMED and its allies, on May 6, Gov. Corbett signed a new law banning use of tanning facilities by minors under the age of 17 and requiring parental consent for 17 year olds. The new law (formerly HB 1259, now Act 41) also requires: •Tanningfacilitiestopostwarningsignsonthepremises,andkeep records for three years •Customerstosignawrittenwarningstatementpriortotanning •Tanningdevicestomeetfederalandstatestandards•Employeesoftanningfacilitiestohavetraininginboththeuse of the devices and recognition of customer skin types. There have been several versions of tanning bills over the years supported by the Pennsylvania Medical Society (PAMED), the Pennsylvania Academy of Dermatology and Dermatologic Surgery, and the Pennsylvania Chapter of the American Academy of Pediatrics. In past sessions, tanning legislation would pass the Senate but stall in the House. However, persistence has paid off, and the new law goes into effect on July 5, 2014.

Political Update

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My 10-year-old grandson, Harrison, called me last spring and asked if I could

fly him to “the big air show at Oshkosh.” He was reading about WW II airplanes and saw that there is an annual gathering of “warbirds.” Even the Harrier would be there. I agreed and suggested he invite some cousins as well as his dad. He arranged to fill the remaining four seats of my Saratoga with grandsons Taylor (15), Kyle (12), his dad, Matthew, a licensed pilot, and his uncle, George, Jr. Harrison did the weight and balance and flight planning with me, and we planned to make a fuel stop at KFWA. This plan involved limiting the fuel to stay within the Saratoga’s gross weight limit including our tents and sleeping bags. He also made large signs, as required by the NOTAM for general aviation camping (GAC) while in Oshkosh. We arrived at KPNE (N.E. Philadelphia PA) at 7 a.m., July 28, but take off was delayed a

bit due to fog and convective activity crossing V-12 in mid-Pennsylvania. We moved our IFR clearance back, and the weather improved well above minimums. Fortunately, the convective weather also moved north of our route, so we had an easy IFR trip regarding weather. Takeoff went well but departure control was having trouble hearing our transmissions. They were very helpful by allowing us to ident by transponder to reply to their instructions and frequency changes all the way to KFWA (Fort Wayne, Ind.). After refueling and a snack, weproceeded around Chicago airspace

VFR to avoid the transmission issue.We knew that the approach to KOSH(Oshkosh, Wis.) is a “no radio transmission approach.” Other than the noon bumps, it was a good VFR flight to the Ripon intersection. On the approach to KOSH, it is good to have six pairs of eyes onboard, all looking for the heavy traffic. We had to make a 180-degree turn back to Ripon and got in line again for better traffic flow. We then followed the procedure to a right downwind for Runway 27. As we were about to turn base, we saw two planes on final that were clearly too close. The controllers

called the biplane to turn right and the highwing plane to turn left immediately. Our landing went well, and we were directed efficiently to the last lineof the north 40 General Aviation Camping (GAC) area. We parked and set up our tents. We were pleased that there had been improvements in the shower/toilet area, and there was a large, new tent serving good meals nearby in the north 40

Feature

Three Generations to OSHKOSH

BY GEORGE R. GREEN MD

Passion Outside of Medicine

L-R: George Green MD, Kyle, Matt, Harrison and Taylor

Reprinted with permission from the Flying Physicians Association, Inc. Dr. Green is a longtime member of the FPA.


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area. We still had time for shuttle rides through the show grounds and a good dinner before settling in for a cool night in our sleeping bags. Monday was a full day with lots of time spent among the great warbird display and even catching the presentation by some WWII pilots while the cadets painted D-Day stripes on a B 25 and a P 38. The afternoon four-hour air show was the real highlight. The Harrier flight even increased the excitement; it is a remarkable airplane. I tried to troubleshoot the transmission issue. Both the radio shop person I reached by phone as well as the radio expert at the Bendix-King display agreed: the most likely single point that would affect the transmission volume on both radios, without affecting reception, was the audio panel. Therefore, off I went looking for a KMA 24 audio panel. I finally located one on Tuesday. However, when we met at the plane at 1 p.m., we found it made little difference in transmission volume. Fortunately, the morning weather briefing called for CAVU weather for our return trip, and we had two handheld radios as back up. The KOSH departure is a no-transmission release by the controllers. A final check of weather before start up provided another surprise. There was a low-pressure area with possible convective activity forming to the southwest of Chicago. This could block our route around the south-west of Chicago airspace. Fortunately, it was slow moving, and we were able to take the lakefront route to the east of Chicago in good VFR conditions. We enjoyed a nice tailwind to our refueling and dinner stop at KBTP (Butler PA) north of Pittsburgh, PA. The last leg to KPNE went well, and the tower at KPNE was watching for our arrival. I had called the tower with our ETA, so 8374P was in the hanger by 9 p.m. It was a beautiful end of flying fun with three generations of our family.

Three Generations to Oshkosh

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L-R: Harrison, Taylor & Kyle (front)Pilot Geo. Green and Co-pilot, son Matt (rear)


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When George R. Green MD, a Philadelphia native and board certified internist, volunteers through Angel Flight East to fly children and adults with medical conditions who need treatment far from home, he combines three passions in his life: medicine, flight, and volunteer service. Green, 79, who was recognized by MCMS in 2012 for 50 years of medical service, currently practices part-time with Abington Medical Specialists and is on the faculty at the University of Pennsylvania. He is the emeritus chief of allergy and immunology at Abington Memorial Hospital and clinical professor of medicine at the Hospital of the University of Pennsylvania. He feels fortunate to be able to combine a challenging internal medicine and hospital practice with a teaching career. A licensed pilot for nearly as long as he has been a physician, Dr. Green would rather fly than drive to his destination on a clear day. “Flying is more enjoyable and convenient if the weather is O.K.,” he says. He bases the Piper Saratoga that he co-owns at the Jet Center at North Philadelphia Airport and flies frequently, including the free flights for patients through Angel Wings East, based at Wings Field in Blue Bell. Dr. Green also served for several years as a volunteer internist for the U.S. Public Health Service Indian Health Service at the Indian Health Clinic in Tohatchi, New Mexico. His service to the MCMS Board of Directors has spanned 25 years. The greatest joy in Dr. Green’s life is his family. He and his wife Trudy have four children and eight grandchildren. He is proud that all of children have been able to use their education fully in their careers: George Jr., an architect; Trudi, a high school art teacher, Matthew, U.S. finance director of a Swiss drug manufacturer and David, a hospitalist and chief of medicine at Latter Day Saints Hospital in Salt Lake City, Utah. Visits to family allow Dr. Green to log more hours in the cockpit.

A High Flying Life

BY DONNA KLINGER


Feature Three Generations to Oshkosh

FOR THE REST OF THE STORY, we later took the plane to Penn Avionics at KOQN (West Chester PA) and found the hand-held microphone jack, which I had failed to unplug while testing the system, caused the weak transmission issue.

FROM MATTHEW GREEN,middle son and co-pilot

Dad Thanks again for a memorable trip. Both Harrison and I had a great time. 2013 was my first trip to Oshkosh, but hopefully not my last. Camping out among the planes and roaming the grounds with thousands of other pilots is truly a unique adventure. It was especially memorable sharing the trip with three generations of Greens.

Matt

Three Generations to Oshkosh continued from page 19


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Three Generations to Oshkosh

FROM SON, G. R. GREEN JR.

Dad, Thanks again for bringing us all to Oshkosh. The whole experience was great but I think Matt and I can really appreciate it because we grew up flying with you. Now, that has been passed on the next generation. There are not many people who think it is perfectly normal to get to the airport pre-dawn, jumpstart the plane, and fly halfway across the country with their camping gear. I knew it was getting interesting when, after hours of not seeing a single airplane, we found the train tracks -- and suddenly the skies around us were full of every size, shape, and description; the controller calling out blue Bonanza, red Stinson, yellow Cub, flight of four Mustangs and, finally, white and red Cherokee (close enough to a Saratoga at that distance). The sheer quantity of beautiful, historic, and interesting airplanes was staggering, the air show was crazy, and the people were great. One of the neatest parts was the talk by three WW II pilots while re-enactors painted D-Day stripes on a DC3 in the background. Harrison was the first to catch on to what they were doing.

Thanks Dad.Love,GR

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Revalidation, the process by which the Centers for Medicare

and Medicaid Services (CMS) requires a physician to certify the accuracy of their existing enrollment information, can be a new and confusing process for physicians. With the passage of the Affordable Care Act (ACA), revalidation requires physicians to be screened under new program integrity rules.

Complying with these requests within the specified time is crucial to avoid deactivation of billing privileges. Here’s what you need to know about Medicare and Medicaid revalidation to avoid disruption to your reimbursement.

Medicare Revalidation

Medicare requires revalidation every five years, but they may also perform “off-cycle” revalidations under certain circumstances. The revalidation letter will be mailed in a colored envelope to the physician’s practice address and/or their pay to address. Do not submit a revalidation application unless specifically requested by Medicare. Upon receipt of the request to revalidate, you have 60 days from the postmark date of the letter to submit complete enrollment information using one of the following methods: • Internet-basedProviderEnrollment,Chain, and Ownership System (PECOS) – This system, accessible at https://pecos.cms.hhs.gov/pecos/login.do, allows you to review information currently on file, upload supporting documentation, and electronically sign and submit your revalidation application. • Paperapplicationform–Torevalidate by paper, download the appropriate and current CMS-855 Medicare Enrollment Application and mail the completed application and all required supporting documentation to Novitas Solutions. The requests are issued by NPI; thus a group practice may have multiple enrollments that must be revalidated. While CMS has instructed their Medicare carriers to work with physicians to ensure compliance

(e.g., calling a physician that fails to respond to a revalidation request), physicians should seek out with diligence revalidation requests to prevent deactivation and disruption of reimbursement. Physicians should review the CMS website at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html for a list of providers/suppliers by NPI number to see if a revalidation request has been sent. The Provider Enrollment Inquiry Tool, available on CMS’ website at www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004864, provides the status history of all enrollment applications submitted to Medicare. The Pennsylvania Medical Society (PAMED) strongly encourages physicians to utilize this tool for tracking enrollment applications. If there is a discrepancy with the application, requests for additional information from Medicare may be sent to an email address if provided on the application. CMS began the process of revalidating physicians and group practices that were enrolled in Medicare prior to March 25, 2011. Medicare will continue to send revalidation notices on an intermittent and regular basis until all affected physicians revalidate their information with CMS by March 2015.

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Physician Revalidation Requirements:

Avoiding Disruption to Reimbursement BY: LARA BROOKS, ASSOCIATE DIRECTOR Of PRACTICE ECONOMICS

AND PAYER RELATIONS, PAMED

pamedsoc.orgto learn more about CME requirements


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Medicaid Revalidation

The ACA also requires the Department of Public Welfare (DPW) to validate all new physicians and revalidate all currently enrolled physicians by March 24, 2016, and at least every five years thereafter. In order to do this, DPW is requiring that all physicians re-enroll by submitting a fully completed Pennsylvania PROMISe™ Provider Enrollment Application, along with any required additional documentation for every active and current service location. As of May, only 18 percent of Medicaid physicians revalidated their enrollment, with over 83,884 service locations set to expire in March 2016. Unlike Medicare which notifies physicians when it’s time to revalidate enrollment, the onus is on the physician to initiate this process. While March 24, 2016, might sound far away, physicians should complete the process as soon as possible for several reasons:

1. March 24, 2016, is not the deadline by which DPW has to receive your application. It’s the deadline by which your application must be processed and in the system.2. DPW expects longer wait times for approvals. 3. Waiting for a written notice? Don’t. DPW has confirmed that providers will not receive written notices. It’s imperative that physicians submit applications immediately to avoid disruptions in claim payment as all service locations that are not revalidated will expire. Physicians also are reminded of the ongoing requirement to inform DPW of any changes, including changes of direct or indirect ownership and controlling interest five percent or greater, contact information changes (including email), address changes, closed or invalid service locations, or any other change to the information provided on their enrollment record that would otherwise render the

Physician Revalidation Requirements

information in their current provider file inaccurate. All provider letters and portal login screens will indicate your next revalidation due date. Verify this information on the DPW provider portal for each 13-digit logon at each service location. Information about this helpful tool can be found on DPW’s website at www.dpw.state.pa.us/cs/groups/webcontent/documents/communication/p_034770.pdf.

Physicians who have not yet revalidated will be well served by advance preparation by gathering the information needed to complete the appropriate Medicare and/or Medicaid enrollment applications. Diligence on the front end can help avoid a costly and disruptive enrollment deactivation.

Physician Revalidation Requirements:

Avoiding Disruption to Reimbursement

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Physicians Can Help Patients Reduce Risk of Fall-Related Injuries



Feature

Physical changes associated with aging have the potential to negatively affect quality of life.

If not managed appropriately, these changes can contribute to unintentional falls in older adults. The devastation of a fall on an older adult is far reaching, affecting family, friends, work, confidence and mobility. While there are many programs to address balance, fear of falling and the role of physical activity in preventing falls, many older adults look to their physician for guidance. The Centers for Disease Control and Prevention’s STEADI Toolkit (Stopping Elderly Accidents, Deaths, & Injuries) gives health care providers the information and tools needed to assess and address their older patients’ fall risk. The Montgomery County Health Department provides the STEADI Toolkits and technical support free of charge to any Montgomery County health care provider. Falls are the number one threat to the health, well being and budgets of an older population. In 2012, 2,775 Montgomery County adults ages 65 and older were hospitalized due to injuries sustained in a fall. The costs related to these injuries totaled $185 million.

The STEADI Toolkit is designed to help physicians incorporate fall risk assessment and fall prevention into clinical practice. The toolkit contains basic information about falls, case studies, conversation starters, and standardized gait and balance assessment tests (with instructional videos). In addition, there are educational handouts about fall prevention specifically designed for patients and their friends and family. An aging population is more likely to have regular visits with a healthcare provider due to a natural decline in health. During these visits, the physician can conduct a fall risk assessment and discuss with the patient medications linked to falls, staying independent and home safety checks. In most women and some men, bone density begins to decrease around age 30 and steadily decreases due to physical changes related to hormonal changes, breast feeding, medications, as well as an increased sedentary lifestyle. Participating in regular physical activity will slow bone loss and may even build bone mass, further reducing the risk of a fracture. The aging adult begins to see diminishing sensory input and output

such as vision loss, impaired hearing, and decreased reaction time. Regular screenings and awareness of how such changes can affect balance are necessary to ensure proper interventions to minimize the risk of an unintentional injury. Additionally, there is a growing concern about the fall risk associated with prescription medication mismanagement. According to a report on prescription drug use in the United States, among older adults aged 60 years and over, more than 76 percent use two or more prescription drugs and 37 percent use five or more on a regular basis. If not managed properly, the risk of a fall increases because certain medications may have an impact on vision, mobility or cognitive awareness. Falling is not an inevitable result of aging. Many falls are preventable. Through intervention, practical home modifications, increased physical activity and strong partnerships, the number of falls by older adults can be reduced. For more information about the STEADI program or to have the Toolkit sent to your practice, contact Brent Daubenspeck at 610-278-5117 x6781 or [email protected].

Physicians Can Help Patients Reduce the Risk of Fall-Related Injuries

Every 29 minutes, an older adult dies

from a fall. Every 15 seconds, an older

adult is treated in an emergency room

for a fall-related injury.

BY BRANDI CHAWAGA, DIRECTOR Of HEALTH PROMOTION, MONTGOMERY COUNTY HEALTH DEPARTMENT

Physicians Can Help Patients Reduce the Risk of Fall-Related Injuries


S U M M E R 2 0 1 4

Feature Frontline Groups

Is your practice among an elite group who is 100 percent committed to the Montgomery County Medical Society? You can be. . .

frontline practices – three or more physicians in a group – stand on the front line of the medical profession by making a commitment to 100 percent membership in the Montgomery County Medical Society and the

Pennsylvania Medical Society (PAMED). MCMS continues to provide a forum for physicians to work collectively for the profession, patients and practice.

The Montgomery County Medical Society says thank you.

through your membership, the montgomery Frontline members and practices receive special recognition and benefits including: • A5percentdiscountonyourcountyandstatedues. • Acertificateofrecognitiontohanginyouroffice. • Regionalmeetingscoveringtopicssuchasriskmanagement,employmentlawandpayerandregulatorymatters. Thesemeetingsaredesignedexclusivelyformemberpracticemanagersandofficestaff,freeofcharge. • Additionaldiscountsandservicesfromcountyandstateendorsedvendors.

For more information on how your practice can become a Frontline practice, e-mail [email protected] or call (610) 878-9530 or Pamed group relations at (800) 228-7823 or (717) 558-7750, ext. 1337.

Abington Medical Specialists Abington Neurological Associates, Ltd. Abington Perinatal Associates PC Abington Reproductive Medicine Academic Urology-Pottstown Advocare Main Line Pediatrics Annesley Flanagan Stefanyszyn & Penne Armstrong Colt George Ophthalmology Berger/Henry ENT Specialty Group Cardiology Consultants of Philadelphia-Blue Bell Cardiology Consultants of Philadelphia-Lansdale Cardiology Consultants of Philadelphia-Norristown Endocrine Metabolic Associates PC Endocrine Specialists PC ENT & Facial Plastic Assoc. of Montgomery County Family Practice Associates of King of Prussia Gastrointestinal Specialists Inc. Green & Seidner Family Practice Hatboro Medical Associates Healthcare for Women Only Division King of Prussia Medicine LMG Family Practice PC Lower Merion Rehab Main Line Gastroenterology Associates-Lankenau

Main Line Gynecologic & Urogynecology Marvin H Greenbaum MD PC Neurological Group of Bucks/Montgomery County Northern Ophthalmic Associates Inc. North Penn Surgical Associates North Willow Grove Family Medicine Otolaryngology Associates Patient First - Montgomeryville Pediatric Associates of Plymouth Inc. Pediatric Medical Associates Performance Spine and Sports Physicians PC Respiratory Associates Ltd. Rheumatic Disease Associates Rheumatology Associates Ltd. Surgical Care Specialists Inc. The Philadelphia Hand Center PC Thorp Bailey Weber Eye Associates Inc. Tri County Pediatrics Inc. TriValley Primary Care/Franconia Office TriValley Primary Care/Lower Salford Office TriValley Primary Care/Upper Perkiomen William J. Lewis MD PC

Frontline Groups 100% Committed to MCMS

mCms Frontline groups as of June 2014:


Feature


pamedsoc.orgto learn more

#1. Practice Consolidation

The trend toward the consolidation of independent physician practices into larger medical groups, including hospital and health plan purchases of physician practices, was clearly taking place in Pennsylvania well before the passage of the ACA. However, the ACA has driven an increase in practice consolidations for a number of reasons such as declining reimbursement rates, increased regulation of physician practices, complicated e-Health systems, new patient referral patterns, and a movement from “volume-based” payment models to “value-based” models.

#2. New Payment Models

The ACA codifies what was once labeled an “innovation” – the trend toward physician payment based on population health or bundled services rather than fee-for-service. While not universal, physician offices are now living in two worlds: payments based on fee-for-service and payments based on new models such as patient-centered medical homes or shared savings plans.

#3. Changing Physician-Insurer Relations

Because the central goal of the ACA was to expand health insurance coverage to uninsured Americans, much of the physician uncertainty about the ACA

What’s Driving Physician Uncertainty Around the

Affordable Care Act? 7 Issues for Pennsylvania Physicians to ConsiderBY DENNIS OLMSTEAD, CHIEf STRATEGY OffICER &

MEDICAL ECONOMIST, PENNSYLVANIA MEDICAL SOCIETY

The Business of Medicine

Why this Brief?With the Affordable Care Act (ACA) moving closer to full implementation in 2014, many Pennsylvania physicians continue to express concern over how the ACA will impact their practice and care of patients in the state. One of the biggest concerns about the ACA is the degree of uncertainty that it has introduced to an already complicated, competitive, and increasingly consolidated health care system. This Brief provides an overview of some of the factors that contribute to physician uncertainty surrounding the ACA and highlights seven issues that physicians should consider as the ACA unfolds in Pennsylvania. There are several unknowns related to ACA implementation in Pennsylvania, for example the state’s Medicaid waiver proposal to expand health insurance to over 500,000 residents of the state; and the insurance products that Pennsylvania insurers will offer in the state as part of the new Marketplace.

PAMED has a number of resources available to assist physicians in each of the areas of uncertainty identified in this article. Please contact MCMS staff or PAMED at

800-228-7823 or ask your question at [email protected].


What’s Driving Physicians Uncertainty Around the Affordable Care Act?

S U M M E R 2 0 1 4

relates to specific issues concerning physician-insurer relationships. There are a number of issues related to the changing physician-insurer relationship: a downward trend in physician reimbursement rates, use of insurer contract language to require provider acceptance of lower rates, the creation of narrow and tiered provider networks, and an increase in patient out-of-pocket costs that the physician must collect.

#4. New Penalties

The ACA and other federal laws contain several penalties for physicians who do not comply with certain policies or procedures. For example, physicians who do not prescribe electronically after 2013 will face a 2 percent penalty in 2014. Likewise, physicians who do not participate in the Physician Quality Reporting System (PQRS) as of 2014 will face a 2 percent penalty in 2016.

#5. Patient Demand

One major uncertainty with regards to the ACA is the patient demand for physician services, especially primary care services, as the newly insured obtain coverage. PAMED will continue to work with partners at the state and national level working to address physician workforce issues, including the leadership of Pennsylvania’s nine medical schools.

#6. Patient Insurance Changes or “Churn”

While patients currently change insurers on a periodic basis because their employer-sponsored coverage changes and/or a provider is no longer “in network,” this issue could be compounded by the ACA. Under the ACA, small businesses may be able to shift their employees to Marketplace plans, rather than provide employer-sponsored insurance. If a physician is not in that patient’s Marketplace plan network, they may have to terminate care to that patient because the patient will not be able to afford out-of-network costs of care.

#7. Quality Measures

As the trend in reimbursement moves from “volume” to “value,” new measures will be needed to monitor the quality of care. Many existing quality measures and standards are based on a fee-for-service model. PAMED is working to assure that physicians are represented in statewide discussions on physician quality, especially as they relate to payment reform and reimbursement policies.

Friedman Schuman has been successfully representing clients who have been injured in

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Summary

Uncertainty regarding the implementation of the ACA is a major issue for physicians across the state. These seven challenges clearly indicate that the ACA will impact physicians and patients. As the statewide advocate and resource for Pennsylvania physicians, PAMED will continue to share information and resources to members about the impact of the ACA and our work to address physician concerns moving forward.

Sources:Paige, Leigh. “How Insurance Exchanges Will Affect Doctors’ Income.” July 10, 2013 in Medscape, Business of Medicine, 2013, available at www.medscape.com, last accessed 12/18/13.

Paige, Leigh. “8 Ways that the ACA is Affecting Doctors’ Income.” August 15, 2013 in Medscape Business of Medicine, 2013, available at www.medscape.com, last accessed 12/18/13.



Feature ‘You Make So Much Money’


The Centers for Medicare and Medicaid Services (CMS) recently released Medicare

physician payment data. As the pundits, the press, and analysts pore through the data, it reminds me of the need for context and, yes, the devilish details. I once had an attorney tell me I obviously made too much money. Of course, this was as she was leaving our primary care office visit and I thought we were done. I stopped, sighed (internally), recalled my prior year income filing with the IRS, reflected on the fact that this year’s would probably be even less, and asked, “What makes you say that?” She continued: “You charge $65 an office visit, it says so on your bills, and you see about four patients an hour, so you make over $260 an hour, counting all the extra stuff you charge for. I only charge half that. So you make too much money.” I see how you could come to that conclusion. Simple math, right? So I asked some straightforward questions. “Were you aware that not one single insurer pays me the charge on the bill? Every single one pays much less, most close to half that and less than a third for Medicaid. “How many staff did you see at the desk? Two receptionists to handle phone calls and check people in and out and collect co-pays and deductibles. A medical assistant to bring people into the room, check blood pressures, and do other clinical tasks. You don’t see my biller, she’s in the basement, nor my records technician, who makes sure all the information coming in gets scanned and entered into the EHR, nor the person in a back room who sits on

the phone all day and does paperwork required for insurance authorizations, forms, and all the non-clinical stuff that comes with running a practice. Oh, and the office manager, who does all the tasks that anyone else is behind on, as well as managing the staff, payroll, health insurance, accounts, ordering, etc. For every provider in this office, we have about 3.3 full-time employees. How many employees do you have in your office? “Do you know how much that little thingy I look in your ear with costs? The exam table? The paper for the exam table, and those nice cloth gowns we give you? “Or that my overpaid job included being on call and available 24 hours every third day and every third weekend (with two associates at the time.) Not counting the 2½ years after I started the practice solo when I was on call 24/7/365. “Oh, and all those extra things you say I make money on? The money I get for shots looks like a lot, but when you subtract the cost of the vaccine, the time it takes for the medical assistant to draw it up and the cost of the syringe, needle, disposal of sharp nasty things in an OSHA compliant way, we actually lose money on every shot, even though you see money flowing in the form of payment. “As an attorney, you have a desk, a PC, a receptionist, and one consulting room. We have three for every provider, each of which has to have a PC, exam table, and instruments. We haven’t even discussed the one room with the power table we use for procedures on older folks who can’t scoot onto a normal exam table. Do you have any idea what that costs to

buy and maintain? “Let’s not count the fact that I don’t always see four patients an hour, and three 20-minute visits actually pay less than four 15-minute visits.” I didn’t bother telling her that we actually lose money on some of the “expensive procedures” we do because the cost of the equipment, cleaning time, etc., costs us more than we were reimbursed. But at that time, we did them anyway because it was the right thing to do. I did, however, remind her that our malpractice bill was about $10 for every office hour, and that along with rent and everything else had to be paid in order to see a single patient.

Money in does not equal money in a physician’s pocket

Let’s pause for a second here. Most physicians are not poor, so I’m not going to say collectively we don’t make any money. But before you draw conclusions about anything, look carefully at the facts. Don’t just look at what a payer pays, but also look at your expenses. Money in does not equal money in a physician’s pocket. Of all the specialties, primary care is the lowest-paid specialty, and that’s what drove me out of primary care and into administration, where I fight to fix that issue. As my physician son says: “You always worked too hard and never made enough money.” He went into surgery, but that’s another story.

Reprinted with permission from the Pennsylvania Medical Society (PAMED). The author, Gaspere Geraci MD, is PAMED’s chief medical officer and writes PAMED’s Quality-Value blog, which can be found at www.pamedicalsociety.wordpress.com. Prior to joining PAMED, Dr. Geraci worked for multiple health care entities, including health systems, insurers, and health care vendors. His special interests include IT in medicine, physician management and profiling, and quality improvement.

‘You Make So Much Money’

… Think Again


S U M M E R 2 0 1 4

Feature Healthcare Leaders

T he 4th quarter is upon us. After all the cost cutting measures, mergers and the

implementation of the Affordable Care Act, there are many stressors lurking in your workplace. How are you handling the wellness of your staff while continuing to deliver quality care to your patients? The information and suggestions below should be shared with your staff and patients. As a leader, what do you do to release stress and stay motivated? I’m positive it’s some type of physical or mind-body connection activity like running, shooting hoops, swimming,

yoga or perhaps meditation. Health care professionals tell patients/clients that these activities are a gold mine for relieving stress, lowering blood pressure, assisting with mental clarity, etc. We actively promote the scientifically-based effects of these types of engagements. We know it’s amazing how you feel once the endorphins kick in after an engaging activity. You feel like you can conquer any task and you are focused with more energy. Just think, if you feel that way after a workout, imagine how your employees will feel with the same types

of varied activities? Those same tools of wellness that you incorporate in your personal life will re-energize and motivate your employees, particularly if you lead by example. You may be saying, you’re not in the position to offer a wellness program for your office or you don’t have the time to “recharge” during the day. The healthcare industry is stress filled, therefore time must be given to “recharge” so employees will remain focused on patient care. Also, a change of scenery goes a long way. So get out of the office and breathe in the fresh outdoor air.

Here are a few suggestions to get you started: •Morningorlunchtime yoga •Afternoonmeditation •Exercisesemployeescan doattheirdesks:squats, heelraises,calfwork, breathingtechniques,etc. •Changeofscenery;joina localwellnessstudiothat offerscomprehensive services •Startawalkingoryoga &meditationclub

You should be very creative with the reward system as it creates more employee engagement and commitment. There are many ways to energize your staff. Having access to an active wellness program makes the opportunities endless and the benefits measurable, not to mention the increase in retention rate and job satisfaction. Treat your employees well. They matter.

Lisa Dent, M.S., Hed, is the founder & executive director of The Women’s Empowerment Series, home of The Inspiration & Wellness Studio.

Healthcare Leaders: AreYouEnergizingYourHumanCapital WhileDelivering

Quality PatientCare?

BY LISA DENT

Formoresuggestionsforenergizingyouremployeesandpatientsvisit www.TheWomensEmpowermentSeries.org.

We’reyourpartnerinwellness.Continuetoinspire!

Montgomery County Dermatologists

Protecting your body’s largest organ – your skin – should be part of your daily routine, local dermatologists say. “People only attribute sun exposure with going to

the beach or doing things outside,” said Dr. Eric Bernstein, a MCMS member who practices in Ardmore. “They don’t think about it when they walk out of the house or drive in their car.” Unprotected sun exposure, along with an explosion in the use of indoor tanning facilities, has helped make melanoma the deadliest form of cancer for people in their late 20s. With summer sun heating up Montgomery County, here are seven tips from MCMS member dermatologists about ways you can protect your skin:

1. Be aware of reflection. Dermatologist Dr. William Horn, who practices in Hatboro, said water, snow, sand and even concrete reflect the damaging rays of the sun, and can often increase your chance of sunburn. Just to be safe, he advised that you should reapply sunscreen every two hours, even if you’re under a cover.

2. Consider adding window film to your car. Dr. Bernstein said skin cancer is more common on the left side of the face for Americans, providing proof that people receive unsafe amounts of sun exposure while driving. He recommended adding UV Shield window films on your car, which block 99.9 percent of harmful ultraviolet rays.

3. Be cautious during peak sun-light hours. Because the sun emits its most intense rays between 10 a.m. and 3 p.m., Dr. Horn advised it’s best to avoid sun exposure during that time if possible. If you are outside during peak hours, Dr. Horn recommended that you should wear a wide-brim hat and long-sleeve shirts.

4. Apply sunscreen daily, even if you’re just going to work. Dr. Bernstein said he spends 30 seconds every day putting sunscreen on his face, chest, ears, hands and the back of his neck. “A lot of sunscreens are too thick and I like a lotion that’s not too thick for everyday use,” he said. He also advised applying two coats if you’re headed to the beach.

5. Use SPF 30 sunscreen. Dr. Horn said there is no statistical evidence that higher SFPs protect your skin better than SFP 30. Just as important as the SPF, you should look for sunscreen that protects against both UVA and UVB rays.

6. Look for suspicious moles. If you have a mole that has changed in size, shape or color over the past few weeks, a dermatologist should check it out. “You can have a mole that’s rather large and it can be fine, provided it doesn’t change,” Dr. Horn said. “Change trumps everything. I tell my patients that (a suspicious mole) is something that doesn’t look the way it used to look.”

7. Avoid indoor tanning facilities. The known health risks have done little to slow the growth of indoor tanning. The World Health Organization classified tanning beds as carcinogenic in 2009, and yet a recent CDC report said that 6 percent of all adults in the U.S. used indoor tanning over the past year.

Both dermatologists and many of their colleagues have supported legislation in Pennsylvania that would regulate the indoor tanning industry. Culminating years of hard work by the Pennsylvania Medical Society and its allies, on May 6, Gov. Corbett signed a new law banning use of tanning facilities by minors under the age of 17 and requiring parental consent for 17 year olds. The law goes into effect on July 5, 2014. More than 30 states have similar regulations.

Montgomery County Dermatologists:

Skin ProtectionNot Just for the Beach


Feature



Physicians in small to mid-sized practices can conduct their own risk assessments using a free tool newly available from the U.S. Department of Health and

Human Services. The security risk assessment (SRA) tool is designed to help practices conduct and document a risk assessment to evaluate potential security risks in their organizations under the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. Conducting an SRA is a core requirement for physicians seeking payment through the federal meaningful use program for electronic health records. Visit http://www.healthit.gov/providers-professionals/security-risk-assessment-tool for more information. Physicians can watch a tutorial and other videos about risk analysis and contingency planning to provide further context. The assessment tool is also available through the Apple App Store (search for “HHS SRA tool”) for use on iPads, and can be downloaded onto computers running Windows operating systems. HIPAA regulations were updated last year in what were called the “most sweeping changes” since the law was implemented. The AMA offers free resources to help physicians ensure their practices are HIPAA-compliant, including a new HIPAA toolkit and an associated continuing medical education activity, www.ama-assn.org . Additional HIPAA resources and training are available from the AMA Store, including AMA HIPAA School.

Free HIPAA Risk

Assessment Tool

Can Help Ensure

CompliancefROM THE AMERICAN MEDICAL ASSOCIATION

S U M M E R 2 0 1 4

Feature Free HIPAA Risk Assessment Tool Can Help Ensure Compliance



Feature

A recent trip to the Federation of State Physician Health Programs Annual Conference, in Denver, highlighted some of the controversy surrounding

the legalization of marijuana. It has raised several complex issues. I endorse the American Society of Addiction Medicine policy on medical marijuana. Marijuana is not a standardized product. It has not been adequately studied as a treatment for the many indications for which it is recommended. Also smoking is an unhealthy delivery system. In states with medical marijuana, physicians do not prescribe it in a specific fashion but rather give the patients a certificate which allows them to use any dose they choose. There is some consensus in the medical field that marijuana is not good for growing brains. Studies have suggested stunted intellect and emotional growth in young people who use large amounts of marijuana on a regular basis. The use of cannabis, similar to the use of alcohol, should be restricted to adults. The safe operation of motor vehicles is extremely important. Mothers Against Drunk Driving has been an exceptionally influential and informative group—no doubt saving countless lives on our highways. The correlation between blood THC level (the active chemical fraction of marijuana) and performance is quite complex. It is difficult to set a safe level of THC for driving or other critical functions. In the addiction field, we frequently refer to the common final chemical nature pathway of a variety of substances in the brain. People in recovery are advised to avoid all mood altering substances, including marijuana to avoid triggering urges and relapse. Never forget the law of unintended consequences. Colorado is reporting an increase in THC poisoning. The

new marijuana is much stronger than the classic weed of the 1970s so adults are showing up in emergency rooms with anxiety and other symptoms of overdose. There is also concern that candy and pastries laced with THC could be eaten accidentally by children. Research with airline pilots has demonstrated that marijuana can reduce performance. Importantly, test pilots were unaware of their own temporary impairment. Until safe levels of marijuana usage are determined, its use must be prohibited in people in critical positions. A zero tolerance policy should be advocated for transportation workers and health care workers. What is at issue for us here is not the public policy of legalization of marijuana but rather maintenance of public safety. Marijuana use should be disallowed for young people, for recovering addicts and for those in whom we entrust our lives.

This article is the opinion of Jon Shapiro MD, who serves as Physicians’ Health Programs medical director. He can be reached at [email protected]. PHP is a program of the Foundation of the Pennsylvania Medical Society, www.foundationpamedsoc.org. PHP has restored careers, families and confidence by helping more than 3,000 physicians seek and receive the recovery care that enables them to remain a vibrant part of the physician workforce.

From my viewpoint: Medical

Marijuana

CONTACT US777 East Park Drive, PO Box 8820harrisburg, PA 17105-8820Toll Free: (866) 747-2255 (in PA only)Phone: (717) 558-7819Friday–Emergencies Only– 7:30 a.m. to 5 p.m.: (717) 558-7817Email: [email protected]

BY JON SHAPIRO MD, PHYSICIANS HEALTH PROGRAMS MEDICAL DIRECTOR


S U M M E R 2 0 1 4

Feature Through the Eyes of a Patient

Ihave Judy today. I like Judy. She’s old school: sweet, unassuming, here because she cares as opposed to the money. Not that there’s all that much money in nursing.

The doctor comes in. He’s handsome and professional, but has a lot on his mind. He probably thinks I can’t tell, but it’s obvious. He sits down to talk, but still only spends five minutes with me. It’s the new thing in medical school: how to make patients feel as if they’re the center of the universe. Sitting down has to be at the top of that list. Listening is a close second. I hurt. Not just physically, but in other ways, too. I tell him, and he nods silently. I think I have his full attention, but I’m not sure. He looks right at me, but doesn’t blink. Maybe he’s worrying about the labs he needs to check. His beeper goes off four times, but he’s polite enough to ignore it. I don’t know. I want to eat, but he says no. Something about being too weak to swallow. I ask him how I’m going to get better without nutrition. He points to the big yellow bag and says I’m getting everything I need. I say that’s a matter of opinion. He shrugs, but there’s nothing he can do. It’s a “safety” issue. So my mouth is dry, but who wants to hear about that? What about the tube in my bladder? Oh yes, we can try and take that out. He’s not sure if I’ll be able to go, but the bean counters want their patients to have as few lines as possible. They took the special one in my arm out yesterday. It’s supposed to mean ‘progress’, but now they’re going to stick me every day for labs instead. My arms are starting to look like I played “six inches” with a professional football team. I mention this to him, but he shakes his head. Those are the new rules, he tells me. It’s called quality. The suits downstairs have set a quota for infections, and lines are a risk, so mine had to go. What about the gowns? I ask. Another shake of the head. You’re colonized, I’m told. Whatever that means. I guess that’s why my baby grandson can’t visit; something about “protecting the community.” We’re smart, he says, but the bugs are smarter. There’ll be no more antibiotics soon, just like in the olden days. Prevention is the new cure. I promise not to touch him, but no dice. I guess even looking spreads infection. It would’ve been nice to hear his laughter, to forget for a little while why I’m here, but the answer is no. Oh well. I’ll get there, he assures me. Slow but steady wins the race. A reassuring hand on my shoulder through the latex glove, then he’s gone until tomorrow. I’m still sad, but Judy will be back. She loves to try to cheer me up. I think it’s her mission. I miss my kids. Most live far, but my youngest comes every day. The others call, but they have busy lives, and flying is expensive. Health care is too, but unlike them, I don’t have

a choice. I know they care, but my pain is a distant thing, separate from their daily routines. I got a big card for my birthday, but more chemo too, and spent it throwing up. It will all be worth it, or so I am told. It is what it is —another challenge in life’s journey. I pray often. It brings me comfort. I believe God is listening. That’s what the Book says, and I’ve never had reason to doubt it. Have faith, and he will give you strength. Sometimes, though, I feel very scared. I hope I can pass his test. I hope I’m worthy. The days blend together. A week? A month? If there’s a world outside, it’s going on without me. Will I ever get my life back? I don’t know. I just want to be normal again, to have to worry about things like dinner and the holidays and what to wear to the neighbor’s party, not tumors and drugs and living wills.

I just want to be normal again.- A Patient.

Through the Eyes of a Patient BY JAY E. ROTHKOPf MD

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News & Announcements

Although activities for MCMS wind down a bit after the annual membership dinner, work is being done on your behalf throughout the summer to prepare for several activities, including a fall practice

manager meeting, a physician wealth management conference, another great issue of MCMS Physician and the annual House of Delegates in Hershey. Keep your email communications open during the summer months for further notice on these and other activities.

MCMS Annual Membership Dinner – A Monumental Event


S U M M E R 2 0 1 4

Congratulations to five member physicians who have served the medical

community for 50 years – John R. filip MD

Donald E. Holmberg MD Harold P. Koller MD fACS Nicholas C. Tenaglia MD James J. Thornton III MD

Each has served the community with compassion and care. These physicians

were honored at the Annual Membership Dinner, held June 3 at the historic

William Penn in Gwynedd.

MCMS Honors 50-year Members

Retired mechanical engineer and veteran Harry Ettlinger shared his amaz-ing story as one of the original Monuments Men. Ettlinger is a surviv-ing member of a special platoon that in the aftermath of World War II recovered priceless art stolen by the Nazis. In promoting the movie about the platoon’s experiences, “The Monuments Men,” Ettlinger traveled with director George Clooney and cast members, including Matt Damon and Bill Murray. Ettlinger and his family fled Karlsruhe, Germany for the United States in 1938 when he was 13 and ultimately settled in New Jersey. Within several years, he was drafted by the U.S. Army and volun-

teered for the Monuments, Fine Arts, and Archives unit. As the only member of the platoon who was fluent in German, he provided valuable translation and summarization services. PAMED Executive Vice President Mike Fraser also gave brief remarks about physician concerns as it relates to the Affordable Care Act and PAMED’s role in educating its members to alleviate some of these concerns. A great deal of concern surrounds the state’s Medicaid waiver proposal to expand health

insurance to more than 500,000 residents, how the uninsured will access the health insurance “Marketplace” and the insurance products that Pennsylvania insurers will offer in the state as part of the “Marketplace.” PAMED Medical Economist Dennis Olmstead addresses some of those concerns in this issue of MCMS Physician in his article, “What’s Driving Physician Uncer-tainty Around the Affordable Care Act.” In addition to great speakers, MCMS recognized and presented a framed certificate to Hallie A. Rozansky of Rydal, one of two first-year medical students who received $1,000 scholarship from MCMS. Rozansky is a medical student at the University of Pennsylvania Perelman School of Medicine.

Monumental Speakers at Annual Dinner

THANK YOU SPONSORS – Financial support from corporate sponsors is essential to the success of the annual membership dinner. MCMS would like to sincerely thank this year’s sponsors.

Platinum Support PMSLIC Insurance Company

Silver SupportAllen Investment Group of Raymond James

Bronze Support Nixon Uniform Service and Medical Wear Leise Wealth Management Group of Janney Montgomery Scott LLC Rheumatic Disease Associates, LtdUSI Affinity

Special Bronze SupportWills Eye Hospital who supported this event in honor of one of its top docs and 50-year member, Dr. Harold P. Koller

Also, MCMS officers were elected for the 2014-2016 term –

James W. Thomas MD, president Jay E. Rothkopf MD, president elect

Walter I. Hofman MD, secretaryJay E. Rothkopf MD, treasurer




Features

2014 Legislative DinnerEach year MCMS physician leaders travel to Harrisburg to host a dinner with Montgomery County legislators.


S U M M E R 2 0 1 4

MCMS member and Practice Manager Joan Telesford was all smiles as one of the raffle winners at the 2014 Tools for Success Practice Manager Conference. MCMS was a co-host to the conference, held in May in Springfield, PA. More than 50 practice managers from Southeastern PA attended the daylong conference.

2014 Tools for Success Medical Practice Management Conference

Contact MCMS staff to schedule a speaker for your organization, 610-878-9530 or visit the MCMS web site for more information, www.montmedsoc.com .

MCMS Speakers Bureau

MCMS member and Practice Manager Kathryn Eiler gave colleagues practice tips in developing compliance plans for your practice.


In April, Mark A. Lopatin MD spoke to the Huntingdon-Valley-Churchville Rotary Club on the subject, “Medical Liability Reform: How it Affects the Practice of Medicine in PA.” Dr. Lopatin, a rheumatologist, also spoke at the Upper Merion Senior Service Center on the topic of arthritis.

Welcome New Members...

MCMS is pleased to welcome the following individuals who joined the Society in 2014:

January 2014 Kyle Solomon MDStuart Z. Dershaw MDSandeep Dhand MD

February 2014Luciano Lorenzana MDSonia Mehta MDAllen Chiang MDLaMar Christian, Medical Student

March 2014Jerilyn Custer, Practice AdministratorAnnie Wang DO

April 2014Lee P. Adler MDMark Anderson MDMarcus E. Carr MDRotem Friede MDRavi J. Kumar MDMark L. Sobczak MDAnnie N. Kotto MDHasan S. Khawaja MDSteven M. Domsky MD

May 2014Amy J. Aronsky DOJoan M. Addley DOTulin Budak-Alpdogan MDAntonio D. Marrero, Medical StudentMichael Rachshtut MDGerald F. Tremblay MD

June 2014Ramona F. Swaby MD

Necrology ReportMCMS regrets the loss of these society members in 2014:

Andrew R. Bolmann MDJean K. Devine MDJuanito L. Lagunilla MDJorj F. Selhat MDDonald A. Sivick, Jr. MD


Applications are being taken for the Howard F. Pyfer Fund. Though the fund, MCMS members under the age of 45 are awarded

CME reimbursement up to $500 per year. Visit MCMS web site, www.montmedsoc.com, for an application. Deadline to apply is Jan. 12, 2015.

The next board of directors meeting is Tuesday, Sept. 2, 6 p.m., MCMS office, 491 Allendale Road, Ste. 323, King of Prussia. If you are

interested in attending a board meeting, contact Toyca Williams, MCMS executive director, [email protected] or call (610) 878-9530. The MCMS Board represents you. For a listing of board members, visit the MCMS web site, www.montmedsoc.com.

Free CME Reimbursement

MCMS Members Welcomed To Attend Board of Directors Meeting



CHAMBER MAGAZINE AD PROOFLocal Pages Publishing, LLC

1055 W. Germantown PikeEast Norriton, PA 19403

Ph: 610.579.3809Fax: 610.579.3818

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THIS IS A COPY OF YOUR ADVERTISEMENT AS IT WILL APPEAR IN THE (NOTE: this copy may be scaled to fit on this page)Montgomery County Chamber of Commerce Magazine

Montgomery County Medical Society

610.878.9530

Since 1847, MCMS has been the leading healthcare advocate for physicians, patients and practices inSoutheastern Pennsylvania.

Is your doctor a member?

MCMS SPEAKERS BUREAUVisit www.montmedsoc.com/speakersbureau to schedule

a medical professional to speak to your organization.

Call MCMS for more information.

Email: [email protected]

To publish photos ofnew MCMS member physicians, please submit digital copies to [email protected]

The 2014 PAMED Annual Business Meeting (House of Delegates) will be held October 18-19, at the Hershey Lodge in Hershey. If you want MCMS’s

support of your resolutions, please submit by Friday, Aug. 22. The MCMS Board will review all resolutions at its September 2 Board of Directors meeting, 6 p.m., King of Prussia office. Business may be introduced into the House through the presentation of resolutions by voting delegates. MCMS has 11 delegates attending the October meeting. A resolution conveys to the House of Delegates a proposal from an individual, a component or specialty society, or a special section on a particular subject. Statements beginning with “Whereas” comprise the first part of the resolution. These usually include the introductory facts or circumstances, which logically develop into a formal conclusion or the “Resolved.” Resolutions may be authored by any member of the Pennsylvania Medical Society; however, they are introduced into the House by delegates acting on their own behalf or for the component or special sections they are representing. It is incumbent upon the authors, if they are not delegates, to secure delegates who agree to introduce the resolutions. For more information on submitting resolutions, contact Toyca Williams, your MCMS executive director, [email protected] or Kay Barrett, PAMED Director of House Operations & Policy Maintenance, [email protected].

Free CME Reimbursement

Want to Be Heard . . . Draft a Resolution


S U M M E R 2 0 1 4

Employed vs. IndependentA Physician’s PerspectiveThree things you can do to ensure you’re prepared for ICD-10 ImplementationHealth system Snapshots : Who is Taking Care of Your Community?

Winter 2014

610.685.0914

HoffPubs.com

Connect your products and services directly to your targetaudience.Advertise in the MCMSPhysicianFor advertising information contact Andrea M. Krantz, 610-685-0914 [email protected] Karen Zach, [email protected]

Coach Chaney knew who to trust for the win.When Hall of Fame basketball coach John Chaney needed treatment for complications related to diabetes, he knew where to turn. The caring staff at Chestnut Hill Hospital jumped into action. After treatment, Coach Chaney was able to return to his daily activities, giving high fives along the way. If you have a problem with wounds that won’t heal, lack of circulation or similar health issues, talk to your primary care physician about a referral.

Clutch.

John ChaneyRetired Hall of Fame Basketball Coach,Temple University

John Scanlon, DPM, is a Member of the Medical Staff at Chestnut Hill Hospital.

John Scanlon, DPMCo-Director, Comprehensive Center for

Wound Healing

8835 Germantown Avenue Philadelphia, PA 19118

215-248-8601

Our physicians treat a variety of wounds, including:

Diabetic foot woundsVenous ulcers • Arterial ulcers

Surgical and pressure-related woundsOsteomyelitis • Radiation injury/necrosis

Necrotizing infections

Hyperbaric oxygen therapy is available.

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PMSLIC is committed to its physician-policyholders, therefore

we promise to treat your individual needs as our own. You

can expect caring and personal service, as you are our

first priority. For more information contact your agent, or

call Laurie Bush at PMSLIC at 800-445-1212, ext. 5558 or

email [email protected]. Or visit www.pmslic.com/start

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