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Robert “Bob” Ward Lehmberg, MD, FACS

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PHYSICIAN SPOTLIGHT

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FOCUS TOPIC SENIOR HEALTH

Impossible Task?Telemedicine to help meet reform objectives of improving outcomes, reducing costs

COURTESY OF UAMS/TIM TAYLOR

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By BECKy GILLETTE

Healthcare reform requires that providers become more effective, improving outcomes while reducing costs at the same time. An im-possible task? Not so, says Curtis Lowery, MD, chair of the Department of Obstetrics and Gy-necology at the University of Arkansas for Med-ical Sciences (UAMS), who has pioneered the Angels Network in Arkansas using telemedicine to help provide the best medical care possible for women throughout Arkansas with high-risk pregnancies.

“Improving outcomes at lower costs seem opposed to one another, but I don’t think it is,” Lowery said. “There is a lot of waste and inef-fi ciency in healthcare, and by focusing on qual-ity, we can begin to reduce expenditures and improve outcomes. Increasingly, the healthcare system is looking more at putting the patients fi rst and managing the patient’s lives, and less

(CONTINUED ON PAGE 13)

Could Healthcare Reform Deny Care to High Risk Seniors? The growing demand for medical services for seniors because of the baby boomer demographic bulge comes at the same time that the impacts of healthcare reforms being instituted as part of the Affordable Care Act are just starting to be felt ... 4

Family Medicine Specialist Includes Acupuncture and Nutrition Counseling as Part of Integrative Medicine PracticeSPRINGDALE – Carlos Alberto Suarez, MD, FAAMA, a native of Peru, has found that combining conventional and alternative medicine in one practice is well received by his patients at Springdale Health LLC. In addition to being board certifi ed in family medicine, Suarez also practices acupuncture and does nutritional and herb\supplement counseling ... 7

Dr. Curtis Lowery checking on an ultrasound at a telemedicine workstation.

By LyNNE JETER

Roxane Townsend’s career was unplanned, yet her recent appointment as CEO of UAMS Medical Center and UAMS vice chancellor for clinical programs seems like the crowning glory of a meticulously detailed blueprint.

“I really didn’t plan to be a physician ex-ecutive, but I really love working in and running hospitals,” said Townsend. “For an academic medical center, it makes sense. You need to be able to talk to physicians in their language.”

Townsend’s meteoric rise began in her hometown of Vandergrift, Pa., a small farming town near Pittsburgh. The second of four chil-dren born to fi rst-generation Italian-Americans – Tony Angiulli, a coal miner-turned-carpenter, and his wife, Regina, a homemaker – Townsend was the fi rst family member to graduate from college.

After graduating from nursing school at Duquesne University, Townsend focused on intensive care. That position quickly led to pro-


HealthcareLeader

Roxane Angiulli Townsend, MDCEO, UAMS Medical Center

2 > JUNE/JULY 2013 m e d i c a l n e w s o f a r k a n s a s . c o m


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STRAIGHT TO THE SOURCE

Robert “Bob” Ward Lehmberg, MD, FACSPalliative and Hospice Care Specialist, Assistant Professor of Hospice and Palliative Medicine in the Department of Hematology and Oncology, UAMS

PhysicianSpotlight

By LyNNE JETER

Bob Lehmberg, MD, FACS, has ac-complished a remarkable feat that’s very rare among physicians. In the prime of his career, he changed specialties from plastic surgery to palliative and hospice care – a very rare combination in medical circles.

“I can understand why people may initially see plastic surgery and palliative care as opposite but really they aren’t,” said Lehmberg, who switched specialties after a neck injury prevented him from continuing his nearly 30-year plastic sur-gery practice. “In a way, (my earliest) job as an orderly influenced me in my selec-tion of palliative care and hospice. I’ve always been concerned with both easing patients’ suffering and preserving their dignity.”

The eldest of three children born to Seth Lehmberg, MD, a general practitio-ner in a small farming community near Austin, Texas, and his wife, Rose Mary Lehmberg, he grew up listening with fas-cination as his dad told stories of deliver-ing babies, treating heart attack victims, setting fractures, visiting nursing home patients, and treating a full range of medi-cal conditions.

“Being the oldest son of a country doctor in a German family, there was never really any question that I would become a physician,” recalled Lehmberg. “Still, my father insisted that I work in a hospital before college.”

In the summer of 1965, before he started college as a freshman at Univer-sity of Texas, he worked as an orderly at Breckenridge Hospital, the Travis County hospital in Austin.

“Before that summer, becoming a physician was simply the plan for me,” he said. “During that summer job, it became clear to me that becoming a physician was what I wanted to do – what I was meant to do. Even as an orderly, doing all the tasks that no one else wants to do, I knew then I liked hospitals and healthcare. I contin-ued to work as an orderly at that hospital throughout my four years at University of Texas.”

In medical school at the University of Texas Medical Branch in Galveston, Lehmberg was immediately drawn to sur-gical specialties. When he rotated on the plastic surgery service at the Baylor Col-lege of Medicine in Houston, he was of-fered and accepted a position in that field.

“We practiced classic plastic and reconstructive surgery, meaning trauma, burns, congenital anomalies, hand sur-gery, reconstructive surgery following mastectomy, microsurgery,” said Lehm-berg, board-certified in plastic surgery in 1982. “Plastic surgeons like me were mainstream physicians in the hospital be-

fore ‘plastic surgery’ was considered syn-onymous with ‘cosmetic surgery.’”

Lehmberg completed preceptor training under Al Blue, MD, in Seattle, Wash., in 1978, and a fellowship focusing on reconstructive surgery of the hand at the University of Colorado in 1979.

Also in 1979, Lehmberg relocated to Arkansas as one of the first plastic surgeons in the community, managing a majority of trauma work during the first half of his career, and later reconstructing breasts for women with mastectomies.

He was named a fellow of the Ameri-can College of Surgeons in 1983, and be-came active in the American Society of Aesthetic Plastic Surgery. In 1998, he was appointed chief of surgery at Baptist Medi-cal Center in Little Rock, board chairman at Columbia Doctors Hospital in Little Rock, and assistant professor of plastic surgery in the Department of Surgery at UAMS, where he taught for five years. From 1982 to 1989, Lehmberg served on the hand surgery staff for the Central Ar-kansas Veterans Healthcare System.

Then the unthinkable hap-pened.

In the prime of his plastic surgery ca-reer, when Lehmberg had a nice balance of elective, cosmetic and reconstructive surgery, the pain from a previous neck injury made performing surgery unbear-able.

“When it became obvious that I could no longer continue my career in surgery, I began meeting with my priest, Susan Sims Smith,” recalled Lehmberg, who consid-ered teaching full-time as an early career option. His grandfather was a college pro-fessor; several aunts were teachers. “Over the course of about a year, we discussed the options for my new career. With her guidance, I decided that hospice and palli-ative care would be a good fit. At the time, there was no formal fellowship program in Arkansas. Dr. Reed Thompson was kind enough to be my preceptor.”

Lehmberg completed a palliative care

fellowship with the Central Arkansas Vet-erans Healthcare System and UAMS in 2008, and further training at UAMS be-fore becoming board-certified in palliative medicine on Nov. 16, 2010. He’s involved with the American Academy of Hospice and Palliative Medicine and the Arkansas Academy of Palliative Medicine.

“My goal is to continue to support the success of the palliative care and hos-pice programs at UAMS and the VA,” he explained. “As recently as 2007, when I did a preceptorship because there was no formal fellowship program, our service received 400 requests for consultation for the entire year. Now we have three fel-lowship positions. This year, it looks like we’ll have more than 2,200 requests for consultations.”

Lehmberg, who serves as assistant professor of hospice and palliative medi-cine in the Department of Hematology and Oncology at UAMS, would also like to better educate families about the range of palliative care options.

“Most people, physicians included, think of us only in terms of hospice and end of life,” he said. “However, palliative

care improves the quality of life of patients and their families with life-threatening conditions through the prevention and relief of suffering, as well as treatment of pain and other problems – physical, psy-chosocial and spiritual.”

Palliative care may be extremely help-ful to physicians and patients in conjunc-tion with therapeutic treatments, such as chemotherapy and radiation, Lehmberg noted.

“As evidenced by our program growth, an awareness of the role of pal-liative care is increasing,” he said. “Still, I’d like to continue to contribute to a better understanding of our subspecialty and how we can help. Once a patient has been diagnosed with a life-threatening ill-ness, it’s really never too early to involve a multi-disciplinary palliative care team.”

Surprisingly painfully shy, Lehmberg recently discovered new joy in his personal life. In a small, quiet ceremony last De-cember, he wed Jennifer O’Brien, former executive director of Arkansas Specialty Orthopaedics. Now, in his spare time, his favorite activity is to “spend quiet time with my lovely wife,” he said.


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By BECKy GILLETTE

The growing demand for medical services for seniors because of the baby boomer demographic bulge comes at the same time that the impacts of health-care reforms being instituted as part of the Affordable Care Act are just starting to be felt. It is possible that some well-intentioned provisions such as a Medi-care program being piloted in Arkansas for bundled reimbursements for episodes of care based on the quality of outcomes could end up having the unintended con-sequences of denying care to seniors at high risk for complications after surgery.

The Longevity Center at St. Vin-cent is playing a major role in the pilot program in Arkansas where Medicare and some private insurance providers are bundling payment reimbursements to hos-pitals with the intention of improving pa-tient outcomes and decreasing costs. Right now Arkansas Blue Cross & Blue Shield and QualChoice are participating in the pilot programs, but only a few providers have been chosen to participate.

“The Longevity Center had to go through stringent criteria to qualify,” said K. Morgan Sauer, MD, a senior physi-cian at The Longevity Center. “I do have high hopes because the team-based model of care has been the foundation of geriat-ric training for the past 15 years. But we have never had a reimbursement model to

allow us to truly practice in that superior style.”

Bundled care is being instituted first with a few procedures. Exam-ple: Medicare has started to make one payment to hospitals for elective knee replacements, and the hospital is respon-sible for paying all costs associated with that knee for the next 90 days. That includes the cost of surgeons, hardware, operating room costs, rehab and rental machines.

“There is one payment, and that cov-ers everything,” Sauer said. “If someone’s knee goes bad and he or she has to come back in for a revision because the knee got infected, Medicare will not pay any more money for that. If a patient has to be on antibiotics for six weeks, Medicare won’t pay extra. It is all the responsibility of the hospital.

“The effects of bundled payments are very scary for me because I have con-cerns that people who may be at higher risk for complications for knee replace-ments may not get knee replacements in the future because only people who have the best chance for quality outcomes will be selected. When healthcare providers were incentivized to operate on everyone, they have generally operated on everyone. Now if they are paid by hospitals, they may

come up with criterion that doesn’t allow for people who may benefit, but who are at higher risk, to get these procedures be-cause it puts the hospitals at greater risk.” Sauer said his mother had knee replace-ment with no health problems. She did fine. But what if someone comes in with diabetes, arthritis or emphysema, and is classified too high risk even though they need the surgery?

“Just because Medicare pays for it doesn’t mean hospitals and physicians are required to provide the service,” Sauer said “What is very concerning with this also is that this model of reimbursement is being expanded over the next five years to many conditions including coronary ar-tery disease, congestive health failure and other common medical problems.”

Problems could spiral. If there is decreased access to procedures for high-risk patients, that may ultimately cause increased debility that would cause more seniors to enter long-term care.

“Long-term care is horrendously ex-pensive for the healthcare system and the U.S. government,” Sauer said. “The ini-tial idea was really a good idea. The gov-ernment came out and said, ‘We are going to make you do quality work to make any money.’ But they never anticipated the counter reaction, which is to essentially cherry pick the best patients. What hap-pens to those who are moderate or high risk? If they don’t have procedures and are

forced to go into long-term care, people’s savings are quickly depleted. They apply for Medicaid, and the government is hav-ing to pay for that.”

Sauer said the expectations of qual-ity in medical home settings are helpful. It puts more emphasis on making sure patients are getting the right kinds of medicines for the type of diseases. It al-lows more attention to seeing if patients are meeting goals for certain preventive measures. And it is a way for physicians to get feedback on how they are doing, and how they can improve.

The medical home model at The Longevity Center includes family medi-cine and internal medicine physicians, specialists, nurses, and mid level providers working as a team to provide care geared specifically for seniors.

“Healthcare changes are pushing us toward having a group of people who take care of patients in a doctor’s office or clinic, the hospital, long-term care and end- of-life settings,” Sauer said.

Sauer said a lot of physicians are limiting the number of Medicare patients they accept or have even stopped seeing some or all of their previous Medicare pa-tients. The cost of reimbursement, espe-cially from government programs, has not kept pace with the cost of living.

The Longevity Center in Little Rock started in 2003 with three physicians, two of whom – David Liu, MD, and Bushra Shah, MD – are still with the center. It has grown to eight physicians, with their ninth physician joining in July, and four mid level providers.

Many seniors have a primary care doctor used for simple coughs, colds, uri-nary tract infections and other work-in conditions. But people with chronic dis-eases are usually managed by multiple specialists.

“In the medical home model, the pri-mary care physician assumes the most re-sponsibility for managing all of the chronic disease conditions, as well as work-in con-ditions,” Sauer said. “What this does is eliminate having too many cooks in the kitchen that can actually cause harm to patients through unnecessary testing, re-dundant testing and multiple medication prescribers. It is very surprising to me how with almost all of my patients I admit to hospital, I have to spend a significant time worrying about medication interactions, and how these medications affect different conditions of patients.”

Sauer said it is common that seniors are on too many prescriptions, and it is necessary to detoxify patients from over medication. He said this sometimes results in dramatic improvements with increased independence and functional abilities.

Could Healthcare Reform Deny Care to High Risk Seniors?

Dr. K. Morgan Sauer


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By BECKy GILLETTE

EUREKA SPRINGS – Francesca Garcia Giri, LAc, practiced in Minneapo-lis, Minn., for a few years after receiving a degree in Oriental medicine from North-western Health Sciences University, and then moved back to a rural area of Arkan-sas near Eureka Springs. There aren’t a lot of high paying jobs in the area, with many jobs being in service industries related to seasonal tourism.

“When I started back up practic-ing acupuncture, I realized people in our area just couldn’t afford private practice treatment,” said Giri. “People desper-ately wanted this traditional medicine and couldn’t afford it. It weighed on me a lot. When I realized even my own par-ents weren’t able to afford the medicine I was offering in private practice, I thought, ‘How can I practice medicine my own family can’t receive?’ I started looking into how I could treat in a group setting and, in doing an Internet search, came across Community Acupuncture Network, which is now the People’s Organization of Com-munity Acupuncture. Pretty much from the moment I saw that model, I knew I was going to practice that way. It made so much sense to me. It took something that was af-

fordable for some to affordable for many. I wanted to separate the issue of money and treatment so more people are able to come in and receive this type of medicine.”

Giri opened Flora Roja Community Acupuncture in early 2010 with a treat-ment room with seven reclining chairs or tables. She inserts the acupuncture needles in one patient, and then goes to the next as patients get their treatment while listening to soft music in the tranquil, dimly lighted room.

Acupuncture treatments lasting 30 minutes to an hour cost $15 for the ini-tial intake session and then $15 to $35 per treatment, compared to private acupunc-ture treatments that can cost between $60 to $150 per session or more.

Patients decide what to pay. “Each person knows themselves what they can afford,” Giri said. “If they are coming in more than once a week, most people pay a little less. If they are coming in less, they pay more. Maybe there are some people who can’t afford even $15 per treatment, but most working people or even people on Social Security will be able to afford that. I get a lot of people on a fixed in-come in my practice and treating them is really the heart and soul of what I do.” Retirees Glen and Nancy Evans travel from

their home in Branson, Mo., to Eureka Springs once a week to receive treatment. They became interested in this alternative after Nancy had a treatment on a cruise ship that helped her a lot. Rick said that in addition to getting relief from hay fever after the first visit, he has been impressed with how much it has helped his diabetes.

“We came because we wanted the numbers to go down,” Evans said. “My blood sugar was running 300 to 400, and now is down to 99. We both feel it greatly reduces stress, as well. It is very relaxing and the results are amazing.”

Like most patients, the Evans said they don’t resent the lack of privacy, and instead enjoy the feeling of being a part of a com-munity healing session.

Giri makes provisions to maintain patient privacy. The initial intake is in her private office, and patients are told that the treatment setting is not completely private. If they have something they want to say in confidence, it can be done in Giri’s office or by sending her an email.

“Patients are totally aware there are other people in the room, so they are going to share only what they are comfortable with,” Giri said. “I’m pretty discreet. No one has voiced it as a concern. If someone wants to receive private treatment, I refer him or her to other acupuncturists or do on occasion offer it. It is more expensive. My main focus is to provide community acu-puncture that is affordable. I would rather see four people in an hour than one.”

While some patients are nervous at first about doing a different kind of medical treatment, that quickly evaporates.

“What happens there is magical,” Giri said. “What I’ve heard over and over again is people like to have other people around while they get treatment. There is a collec-tive energy and stillness that seems to be very conducive to healing. They seem to

prefer it. Sometimes when people are alone because no one has an appointment at the same time, they miss the comfort of having people there. It is a quiet setting; people get needles in and some-times fall asleep. There is a sense of comradery. Everyone has the same goal to feel better and move through their lives with more ease.”

Acupuncture can make people unfa-miliar with it feel nervous if they associate needles with pain. Giri said the needles are hair thin, and often patients feel nothing. Sometimes there is a slight prick and there can even be a sharp pain for a moment, but it passes quickly.

“If needles hurt, we can change them or take them out,” Giri said. “The goal is a relaxing experience. Chinese medicine isn’t for everyone, but many, many people get much relief and improvement from their health concerns from acupuncture and Chinese herbs, and western herbs, too, for that matter. It seems to be most well known for pain management, and that certainly brings a lot of people to my door. I see a lot of people in acute and chronic pain for all sorts of reasons. People with those kinds of conditions often respond very well. I’ve seen lots of improvement and change.”

Giri also has an apothecary room with more than 200 types of western, ayurvedic and Chinese medicine herbs for sale. The business also has expanded adding a class-room.

“We have started offering classes in natural healthcare, and are encouraging people to do their own reading and re-search,” she said. “We have all the prod-ucts people need to make their own herbal preparations. People come into the herb shop, see all these bulk organic herbs, and are awed. Many more western medicine practitioners are also looking for ways to integrate other methods to help their pa-tients. All of us come from ancestors who used herbal medicine. It is not such a far reach. More people concerned about the side effects of drugs are looking for other solutions. It has been an exciting part of our wellness center to add in the herbal apoth-ecary and classroom. It is still part of our overall mission, which is offering affordable healthcare to our whole community.”

Affordability with Community Based Acupuncture

For information, see www.floraroja.com or email [email protected].


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By BECKy GILLETTE

SPRINGDALE – Carlos Alberto Su-arez, MD, FAAMA, a native of Peru, has found that combining conventional and alternative medicine in one practice is well re-ceived by his patients at Springdale Health LLC. In addition to being board certifi ed in fam-ily medicine, Suarez also practices acupuncture and does nutritional and herb\supplement coun-seling.

Suarez said physicians are sometimes worried and frustrated by how to treat con-ditions such as chronic pain and anxiety. These conditions do not respond well to medical therapies, especially when they become a chronic problem.

“These chronic conditions are treated effectively with acupuncture,” said Suarez, who is a diplomat from the American Board of Medical Acupuncture and a Fel-low of the American Academy of Medical Acupuncture. “My colleagues are realiz-ing that there is use for medical acupunc-

ture and alternative medicine as a part of the multi-specialty team for treatment of chronic conditions.”

Patients seem to be interested in new and natural ways of healing. But it isn’t unusual initially for them to have mixed emotions with respect to the acupuncture needles due to the fear of pain. “However, once they try acupuncture, they realize that the procedure is minimally painful and so extremely effective treating many health conditions that they keep coming back for more treatments,” Suarez said.

His patients report that acupuncture can help them when other therapies don’t.

“Issues like chronic depression, fi-bromyalgia, menopause and fatigue are treated effectively and naturally with a combination of acupuncture and Chinese herbs,” Suarez said. “I also offer optimized, researched and sometimes even evidence based supplements and herbs to comple-ment patient treatments. We usually do not talk cures, but do offer serious relief to our patients who get a consult and a stream-lined plan to optimize their health and ef-fectively treat their ailments.”

Suarez received his medical degree from Universidad Peruana Cayetano Here-

dia in Lima, Peru, and was licensed in 2000 by the Peruvian College of Physicians. In 2003 he moved to Kingsport, Tenn., to at-tend East Tennessee State University. He completed his family medicine residency program in 2006, and became board certi-fi ed in family medicine.

Suarez got interested in medical alter-natives because while he was at East Ten-nessee, he had a program director – Reid Blackwelder, MD, FAAFP, who’s now president-elect of the American Academy of Family Medicine – who was very alter-native medicine oriented. Blackwelder rec-ommended Suarez take a nutrition course at the University of Arizona with Andrew Weil, MD, who has authored many best selling health books and is considered the father of integrative medicine in the U.S.

“There I heard about what medi-cal acupuncture could do and met a few practitioners at that course,” Suarez said. “At that point, I was extremely impressed. Then I decided to take the Helms Medical Institute Acupuncture course, which is for physicians only. Later on, I took the board exams and got my Fellowship in Medical Acupuncture. It is likely the best investment and best learning path of my life so far.”

His patients are not surprised by what he offers. Most of them embrace old, new and natural ways of healing.

“Some of them take advantage of us as being a one-stop place to get their health taken care of holistically,” Suarez said. “I practice what is called integrative medi-cine, an all-inclusive medicine rather than the fragmented specialty driven medicine which is so prevalent these days.” Treat-ment offered is in addition t0 –rather than as a replacement for – conventional medi-cal treatments.

“For example, if a patient comes to us and is under the care of another health pro-fessional for primary care, we would never take their pills away,” Suarez said. “We are not against pills. However, we would start nutrition therapies that can lower the need for pharmaceuticals. We help the patient’s bodies heal from within.”

Suarez said he feels he is able to offer his patients the best of both worlds.

“That is exactly what integrative medicine is all about,” he said. “I try my best to offer options and treatment plans to patients that actually try to address the cause of the problem, rather than chasing symptoms.”

Family Medicine Specialist Includes Acupuncture and Nutrition Counseling as Part of Integrative Medicine Practice

Dr. Carlos Alberto Suarez


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By BECKy GILLETTE

Weight is a touchy subject. It can be hard for healthcare professionals to know how to be effective when talking to patients who are overweight or obese about what steps they need to take to improve their health. The best approach may be to tell patients that small improvements can have a major positive impact, said Betsy Day, clinic director, University of Arkansas for Medical Sciences Center for Weight Loss and Met-abolic Control.

“Focus on starting with small, simple steps,” Day said. “It doesn’t have to be eating alfalfa and running three hours a day. They can make little changes they are more likely to stick with. I advise them to limit sodas or cut out 120 calories per day with something else, and exercise 15 min-utes. And then build on it.”

A lot of people who come in to lose weight want to look they like did when they graduated from high school. That is unre-alistic. But even losing fi ve to ten percent of your weight can dramatically help. Day said even people who may still be medically clas-sifi ed as obese could be healthier by losing a modest amount.

“If the overall picture is that you need to lose 100 pounds, that can seem like an overwhelming challenge,” Day said. “Start by losing ten pounds this year and build on that. That can help physically and mentally. As you see success, it will build on that be-cause you feel better.”

If a patient backslides and regains lost weight, it might be helpful to know that is common. Day said a National Weight Loss Registry of people who have lost more than 30 pounds shows that it takes on average three times to lose the weight before being successful.

“So don’t be so gloomy if you lose weight and gain it back,” she said. “Just keep trying.”

She also advises doctors and other healthcare professionals to assess the pa-tients’ willingness to change. Ask questions like, ‘How do you feel about your health and weight?’ If the patient is asking how to loose weight, that is better than just the doc-tor saying, ‘You are obese and need to lose weight.’ See how interested the patient is in making changes to improve their health.

If people say they hate to exercise or go to a gym, she recommends they fi nd some-

thing fun to do. Throw a Frisbee for the dog. Play with the kids. Take a walk with a friend.

“You don’t need a personal trainer,” she said. “Just increase your overall move-ment.”

Sodas loaded with high fructose corn syrup are a good place to start for reducing calories. It can be easy to consume the 120 calories from one soft drink and not think much about it.

“And most people aren’t doing only a 12-ounce soda,” Day said. “They are doing 16 ounce or even larger fountain drinks. That is just mindless. People look at a cheeseburger and say, ‘That is a lot of calories,’ but don’t think about how many calories are in these drinks.”

People often defend consuming soft drinks because it gives them energy. But Day said there is a rebound that leaves people fatigued – and craving another soft drink.

Instead of sodas, drink water. Day doesn’t recommend diet sodas since stud-ies show artifi cial sweeteners increase sugar cravings. The weight loss clinic also is not big on appetite suppressants.

“Unless patients make lifestyle changes, it doesn’t matter what pill they take or even if they have weight-loss surgery,” Day said. “Once you stop taking a pill, you will go back to where you were. I can think of 20 to 25 patients with gastric bypass who didn’t change their diet or lifestyle habits, and went back to where they were. The impor-tant thing is to establish a healthy relation-ship with food and make lifestyle changes. Eat to live; don’t live to eat. Don’t use food for emotional reasons – stress eating.”

C. Michael Gooden, MD, Surgery As-sociates of Fort Smith, said even with bar-iatric surgery, it requires major lifestyle and diet improvements to keep the weight off on a long-term basis.

“With surgery, you will have some people who are successful and some who are not,” Gooden said. “The bot-tom line is that people who are obese or morbidly obese – people for whom weight has been a lifelong prob-lem – the success rate of diet plans and ex-ercise is pretty low. I’ve seen statistics that 90 percent or more of obese or morbidly obese people will fail to sustain weight loss. Bariatric surgery provides an additional tool

to achieve that success. But it has to be done with the perspective that it is a tool. It is not a one-time fi x where you get it done, and there are no more issues the rest of your life. That isn’t the way it is. It is a tool.”

Gooden tells his patients that surgery is the easiest part of the process. The more diffi cult part is changing the person’s rela-tionship with food.

“That is the main hurdle people have to overcome,” he said. “Most people who have found their way to me are not people looking to be super thin. They do not want to be Victoria Secret models. They want to be healthier. They want to avoid co-mor-bidities, such as hypertension and diabetes. They want to be more active, and do more things they can’t do at their current weight. There is certainly a stigma in our society regarding people being overweight. How-ever, most people do also want to feel better about themselves and how they look.”

Gooden said patients are often very happy about not having as much weight to carry around, and end up sleeping better because they no longer have sleep apnea. Patients are offered lifelong followup.

“Not everyone takes advantages of that,” he said. “If you have gastric bypass, you have to have lifelong follow-up to check vitamin levels. We also encourage lifelong follow-up with sleeve gastrectomy. People need occasional reminders of the right things to be doing. But we never encourage people to have surgery and be done with it. It is a process; it is not a one-time fi x.”

Gastric bypass is now considered the gold standard, the best operation we have that is commonly performed. Gooden said the drawback of gastric bypass in the long run is the risk of vitamin defi ciencies. Sleeve gastrectomy doesn’t carry nearly as great a long-term vitamin defi ciency risk, but not as much is known about the long-term results of sleeve gastrectomy because it hasn’t been done as a standalone procedure as long.

Gooden said sleeve gastrectomy is almost as good overall for the amount of weight loss, and is very good at improving or resolving diabetes and high blood pres-sure.

“I would advise healthcare providers who have patients ask them about bariat-ric surgery to tell them it is certainly some-thing to consider, but it is not for everyone,” Gooden said. “Patients have to prove they are the compliant sort.

Bariatric surgery is a useful tool, but it is just that. It helps people meet their goals; doesn’t make people meet their goals.”

One Step at a TimeHealthcare providers should recommend small, simple steps to help patients lose weight

Betsy Day

Dr. C. Michael Gooden


By BOB WILLIAMS

If you were to die tomorrow, what would happen to your practice? Would your survivors be prepared to transition your patients to your partner or covering physician immediately? This is something worthy of serious thought. It may be ob-vious but have you considered that your medical practice is worth significantly more while you are alive than after you have passed on? That means that all the years of hard work for which you sacri-ficed and dedicated yourself to can evapo-rate at exactly the moment your patients AND loved ones need it most.

This is an uncomfortable topic for most anyone but it’s something that should be discussed. While physicians will purchase the latest medical equipment to provide the best possible care for their pa-tients, I have discovered that many fail to invest their time and efforts toward this in-evitable outcome and the resulting impact on those closest to them.

Ideally, you will craft two exit strat-egies. The first is a plan for an orderly liquidation and sale of your practice at re-tirement. In order to maximize the sale of your practice, you will want to map out a strategy well in advance and take control

with an orderly transition under condi-tions that you control and direct. Your exit plan should be updated periodically as circumstance change. This can help to en-sure that you can turn over your patients and their treatment to a physician that you can trust to uphold the standard of care that you have established. Handled properly, this can allow you to not only maximize the sale price and exit when YOU choose, but also ultimately let you enjoy the benefits of retirement with the knowledge that your patients are being properly cared for.

Your second plan will assist your fam-ily and take care of your patients in the event of an unexpected death or disability. Crafted correctly, your family will know exactly who to call and what needs to take place so that they can maximize the value of your practice and handle the transition of your patients. Think about it this way. If you are disabled, your loved ones will be in shock and the grief will be overwhelming if you are gone. The last thing your family will want to address is the sale or transition of your practice. The very thought may turn their stomachs and make them feel as if they are losing you again.

Do not saddle your family with this burden. You need to plan this out care-

fully. If you are unable to treat them for

any reason, patients will need and are likely to rapidly seek out another physician for treatment. Left unaddressed, once you are out of the picture, the value of your practice will plummet quickly if your pa-tients and staff start departing and your referral sources fade away. Thus whether you are considering a succession plan due to pending retirement or as a precaution, it is essential that you avoid telling your patients prematurely that your practice is on the market.

It’s never too soon to start thinking about your successor. Carefully consider whom you want to assume the care of your patients. Who is the logical choice? Is it the physician who covers for you when you’re on vacation or a younger doctor who will assume your practice? What about your hospital? Do you want a sole practitioner or a group? There can be benefits and costs to all. Do they have the ability and infrastructure to assume your patient load? A younger doctor may be able to join your practice as an associ-ate and allow a smoother transition while choosing a larger group may provide more choices and offer longer office hours to your patients.

What about your liability insurance coverage? Depending upon your type of policy, additional insurance might be needed. Many physicians utilize claims-made coverage and may require tail in-surance in the event a claim is filed after the cessation of their practice. Your agent or carrier should be able to tell you if you qualify for special post-retirement cover-age. As soon as you know when you’ll be leaving your practice, contact your liabil-ity insurance carrier.

Goodwill is a critical factor to con-sider as you craft your succession plan. Think of it as the intangible worth of your practice. The value of your hard assets such as the building, fixtures and equipment can be calculated far more simply than goodwill. While strong standing and clinical expertise can in-crease the value of your practice, it can be difficult to justify to a purchaser. Placing a price tag on goodwill may seem easy but it is an entirely subjec-tive opinion. It can be much easier to add goodwill if the business side of your practice has had recent years of solid re-sults. Remember that your reputation has very limited value to a purchaser AFTER you leave the practice. Gener-

Where Would Your Practice Be Without Succession and Retirement Planning?



gressive leadership roles. She was named charge nurse in the ICU, then shift super-visor, and director of education for a Hu-mana hospital. Her supervisor nominated Townsend for the Nursing Specialist Training Program with Humana, which led to a post as director of nursing.

“My boss was becoming CEO of the hospital at which I trained, and I flippantly said to him that I’d reactivate my nursing license to be his director of nursing, but I ended up being his COO,” said Townsend, of joining the C-suite executives.

Around this time, Townsend’s five-years-younger sister, Marci Morgen-lander, encouraged Townsend to consider furthering her education.

“Since she was a kid, Marci wanted to be a pediatrician,” said Townsend. “She was in medical school when I was director of nursing and kept telling me I needed to go, too. I finally said, ‘ok, I’ll take the pre-requisites and the MCAT and apply, and if anyone actually is willing to take me, I’ll go to medical school.’”

LSU School of Medicine said yes, and Townsend focused on internal medicine. After spending a year as chief resident, Townsend joined the LSU clinical fac-ulty while also working in private practice through the LSU practice network.

In 2004, Gov. Kathleen Blanco tapped Townsend to serve as Medicaid medical director for the Louisiana Depart-ment of Health and Hospitals, which led to roles as deputy secretary in 2006 and

secretary in 2007. “Hurricane Katrina came through on

an early Monday morning, and I was in the Superdome by that afternoon, check-ing on the special needs shelter when the levies breached,” recalled Townsend. “What I thought would be a few hours’ visit or overnight to check on things turned into three days in New Orleans, and it took planes, trains and automobiles to get out while it was still flooded.”

When she returned to Baton Rouge, the state asked Townsend to run the Pete Maravich Assembly Center, where a field hospital had been established.

“We were only open seven or eight days after I got back from the Super-dome, but it seemed like months,” ad-mitted Townsend. “It was the strangest experience to drive onto campus around the lakes to get there by 7 a.m., and see people running. It was very disorienting to see folks carrying on like normal.”

In 2009, Townsend was named in-terim CEO of the LSU Public Hospital in New Orleans, and six months later, CEO of LSU Health Care Services Division of the LSU Health System.

During this time, Townsend marked several milestones, including the LSU Level 1 Trauma Center in New Orleans being named a “Spirit of Charity” four years post-Katrina. The honor was quite a feat; the 10-parish trauma center had been moved from the antiquated Charity Hos-pital before the hurricane. It had regained

Level 1 verification in December 2008. “In 2009, we were still in that ER

preparedness recovery mode, and I had a chance to work with the staff to realize this is the ‘new normal’ for some time to come,” she said. “It was a privilege work-ing with these folks who had also been through trauma. Many of the staff had lost their homes and were living in FEMA trailers and coming to work every day to care for patients. That’s a special group of people. Public hospital employees are a special breed anyway because they’re mis-sion-driven to care for people regardless of their ability to pay. That’s what attracted me to UAMS.”

Townsend also had some tough de-cisions to make, including the closure of labor and delivery services and all nurs-eries at the interim LSU Public Hospital (ILH) on Perdido Street in New Orleans in 2010. The year before, the ILH had aver-aged two births daily. Those services were relocated to the Family Birthing Center at Touro Infirmary in New Orleans and Tu-lane Lakeside Hospital in Metairie.

“I wasn’t very popular at that time,” said Townsend. “Moving labor and deliv-ery out was in part a financial decision; it was also a quality decision. It was the right thing to do for our patients because our neonatal care unit didn’t have enough vol-ume for providers to remain highly profi-cient. By moving it, patients and infants received the best care possible.”

Townsend also served as the project manager to develop a prototype electronic health information exchange as part of the post-Katrina efforts to recover and recre-ate electronic health records for Louisian-ans who were displaced by the storm.

“I’ve held many positions concur-rently and am adept at multi-tasking, thank goodness,” she joked.

Before taking the CEO position at UAMS Medical Center on Feb. 1, Townsend had risen to assistant vice presi-dent of health systems for the LSU Office of Health Affairs and Medical Education.

Townsend hit the ground running at UAMS. She recently implemented bed-side rounding for the nursing staff.

“It’s not the kind of place where the executive can hide in the office,” Townsend said of UAMS, whose office sits just below the helipad. “You need the bedside interaction.”

Townsend noted that interestingly, all clinical services at UAMS aren’t under a director of nursing or chief medical officer.

“Other than the financial manager, all UAMS leaders have clinical services that they’re responsible for,” she said. “As a result, everyone interacts with patient care areas. That’s very important.”

At UAMS, Townsend is focusing on sustaining the medical center’s ability to continue training for the future Arkansas

healthcare workforce.“In the clinical classroom for health-

care professionals, we want to make sure they’re exposed to quality, safe patient care, and that we’re educating our workforce to provide that kind of care,” she said. “That’s a tremendous challenge. We don’t know what will happen with payment reforms as we implement the Affordable Care Act. We’re very fortunate in Arkansas that the governor expanded Medicaid through the private option and our legislature saw fit to approve that. As of January, Arkansans will all have a chance to have insurance cov-erage. That’ll make a huge difference in our ability to care for the state. Also, we’ll continue to expand our role as pioneers in research, providing standardization of care through evidence-based practices.”

So exactly how does Townsend sus-tain such a high level of energy on the job?

“My first job was a dance teacher of tap, ballet and jazz,” said Townsend, who began taking dance lessons at the age of three. “When I was at Spring Hill as di-rector of nursing for Humana, someone learned I’d danced and invited me on their clogging team.”

In her spare time, Townsend toured with the Good & Country Cloggers. But there was one element missing: thigh-skimming, ruffled clogging skirts.

“We always clogged in jeans,” said Townsend, with a laugh. “None of us were going to be caught wearing those short skirts!”

Healthcare Leader: Roxane Angiulli Townsend, MD, continued from page 1

ally, goodwill has the most worth if you are willing to take on some of the risk associated with the transfer of the prac-tice. This can be mutually beneficial if you, as the selling physician, are moti-vated to move patients to the acquiring entity. The most equitable way to influ-ence this is to negotiate incentives for your work in assisting the buyer with obtaining and retaining your patients through the transition and for a reason-able time thereafter.

There are a myriad of variables to consider and I have touched on just a few. Remember that you have spent many years developing your practice. This is not the time to take bids or select the low cost provider. It’s recommended to consult a qualified legal advisor to assist you in the process and with negotiations. You may want to utilize the attorney who drafted your will or consider asking a colleague or a trusted advisor for a referral. Regardless, start crafting your succession plans sooner rather than later.

Where Would Your Practice Be, continued from page 10

Bob Williams brings 30 years of business and financial services experience to Delta Trust Investments. His clients include banks and bank trust departments, corporations, non-profit foundations and numerous individuals. He provides financial market and business analysis for most local broadcast and print media outlets and has been quoted in the Wall Street Journal, Business Week and many other state and national publications.

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By DAVID NELSEN JR., MD, MS

The use of opioid analgesics for the management of non-cancer pain has in-creased dramatically in recent years. Approximately 219 million opioid pre-scriptions were filled in the United States in 2011, almost triple the 76 million filled in 1991. Physician offices have been over-whelmed with patients who expect to have their chronic pain managed with opioids and by administrators who expect high degrees of patient satisfaction. Deaths from prescription drug overdose, however, now exceed deaths from heroin and cocaine combined, according to the Centers for Disease Control and Prevention. This ar-ticle will review evidence-based guidelines for managing chronic non-malignant pain with opioids.

Numerous clinical trials have ad-dressed pain and pain management; the majority are low-quality studies with con-flicting results. The authors of a 2010 Co-chrane review concluded that there is weak evidence in favor of treatment of chronic non-cancer pain with opioids, but that the side effect profile may be significant.

Stronger evidence exists regarding op-timal dosing of opioids and dose escalation. The Washington State Agency Medical Directors Group, an interagency working group, published a summary of the evi-dence and a set of recommendations, avail-able online at www.agencymed directors.wa.gov/Files/OpioidGdline.pdf. The major recommendation is that providers should not prescribe a morphine equivalent dose (MED) greater than 120 mg per day without demonstration of a clear improve-ment in function. Titrations above 120 mg MED per day should only be undertaken with the consultation of a pain manage-ment specialist. The group noted that the evidence supports a sharp increase in side effects above 100 mg MED per day. In general, patients who have a good clinical response below 100 mg MED per day may be continued on treatment without addi-tional consultation.

An equianalgesic dose calculation can be used to convert between the various opi-oid analgesics.

Hydrocodone (HCD) and oxycodone (OCD) are frequently used for pain man-agement. HCD is only available in combi-nation with acetaminophen or ibuprofen as a Schedule III controlled substance; the non-opioid analgesic limits the upper doses that can be obtained with HCD. OCD, a Schedule II controlled substance, is avail-able as a single agent or in combination. OCD is moderately more potent than HCD; however, when swapping opioids, one must always be aware that the cross-tolerance between opioids is incomplete. That is, even though the equianalgesic tables suggest that OCD is about 20 per-cent more potent than HCD, physicians should consider a 25 percent to 50 percent milligram reduction when switching from HCD to OCD.

This incomplete cross-tolerance is

especially pronounced when prescribing methadone. The initiation or conversion dose of methadone should not exceed 30 mg per day, even in patients whose equian-algesic calculation suggests a higher dose. Opioid-naive patients should initiate ther-apy with 2.5 mg of methadone every eight hours and titrate slowly upward. Short-act-ing “breakthrough” opioids may be used concomitantly.

Polypharmacy is a frequent issue in the elderly and chronically ill popula-tions. The risk of adverse drug events rises sharply with polypharmacy. Phar-macologic interactions can alter drug metabolism, resulting in blood levels that are higher or lower than expected. Non-opioid medications with sedative side ef-fects can produce additive sedation and increase the risk of respiratory depression. Methadone and other opioids may pro-long the QT interval and should be used cautiously with drugs that interfere with opioid metabolism or are themselves QT prolongers. Patients with hepatic, renal or cardiovascular disease are at particular risk from polypharmacy. An electronic medical record (EMR) system may assist in the identification and management of pharmacologic interactions.

So-called rational polypharmacy, how-ever, can be beneficial. Multimodal pain management strategies should be individu-alized and may include acetaminophen, NSAIDs, COX-2 inhibitors, tricyclics, se-rotonin norepinephrine reuptake inhibitors and anti spasmodics, as well as topical ther-apies such as lidocaine or capsaicin. Anal-gesics with differing mechanisms may have additive or synergistic effects. Neuropathic pain may benefit from anticonvulsants such as gabapentin or pregabalin. Multimodal approaches may also include non-pharma-cologic modalities such as physical therapy, neurostimulation or cognitive behavioral

therapy. A safe and effective pain manage-ment strategy typically addresses anatomic, physiologic, psychological and spiritual as-pects of care.

Factors that should be routinely as-sessed in association with chronic opioid pain management include:

• Patient selection and risk stratifica-tion. Good candidates for chronic opioids include patients with known pathology and no history of drug misuse.

• Written informed consent and an opioid management plan are es sential to treatment success and are required by the Arkansas Medicaid Practice Act (AMPA).

• Opioid selection, dosing and titration should be individualized and appropriate to therapeutic goals.

• Patients receiving chronic opioid therapy must be monitored closely for therapeutic efficacy and side effects.

• Patients with a history of drug-related or psychiatric issues may be considered for opioid therapy; however, the clinician should consider consulting a mental health or addiction medicine specialist.

• Dose escalation beyond 120 mg MED is rarely indicated. Clinicians should wean or discontinue opioid therapy in pa-tients who fail to participate in their thera-peutic plan or who are not making progress toward their clinical goals.

• Patients receiving chronic opioid therapy may benefit from psychotherapy or other interdisciplinary therapies such as physical therapy.

• Patients receiving chronic opioid therapy benefit from a medical home di-rected by a primary care physician. The PCP may or may not prescribe the opioids but should direct the care and coordinate with other providers.

The AMPA contains very specific lan-guage about the use of controlled substances for the management of chronic pain (see

http://170.94.37.152/REGS/060.00.01-006F.pdf, page 31). The Arkansas State Medical Board’s Pain Management Re-view Committee evaluates potential viola-tions relative to controlled substances.

Like most states, Arkansas now has a prescription drug monitoring program (PMP). Pharmacies and other dispensers must submit information about all filled prescriptions for controlled substances within a week of the fill date, and physi-cians are encouraged to check the PMP database before writing prescriptions for opioids. For more information, visit www.arkansaspmp.com. Providers who use elec-tronic prescribing may also be able to view filled prescriptions through SureScripts, a prescription clearinghouse. Physicians can use this external information to verify that a patient is following prescribing guidelines and may be helpful in detecting patients who are seeking opiates from multiple pro-viders and/or selling drugs illegally.

The rise in opioid use over the last 20 years has been accompanied by a rise in opioid diversion for non-medical use, as well as side effects of unintentional over-dose and chronic misuse. Physicians who learn about the regulatory environment, develop standardized approaches to man-aging opioid-using patients and practice within evidence-based guidelines can pro-vide a valuable service to a group of very difficult patients and reduce the burden of care to the provider.

A list of resources available online can be found at www.afmc.org/opioidre-sources.

Opioids for the Management of Non-cancer Pain

David Nelsen Jr., MD, MS, is associate professor of family and preventive medicine and associate chief medical officer for clinical informatics at the University of Arkansas for Medical Sciences, and a consultant for the Arkansas Foundation for Medical Care. Contact him at [email protected]


Read Medical News of Arkansas Online:

MEDICALNEWSOFARKANSAS.COM

By LyNNE JETER

Not long ago, hospice referrals for end-of-life care were typically made only a few weeks before the patient’s death. Now, good hospice referrals are made six months to a year in advance to allow time for patients and their families to transi-tion to the fi nal phase of life. Palliative care comes in sooner for patients suffering from serious illness, with specialists having the advantage of focusing on the patient, not the disease.

“Just about any patient with a seri-ous, life-limiting illness can benefi t from palliative care,” said Robert Lehmberg, MD, FACS, assistant professor of hospice and palliative medicine at the University of Arkan-sas for Medical Sciences (UAMS). “It improves the patient’s quality – and sometimes length – of life.”

Hospice is defi-nitely underutilized in the United States, said Derrick O’Connell, RN, MBA, chief quality of-fi cer for Esse Health, a St. Louis-based practice group with nearly 100 physicians and special-ists.

“There are barriers to hospice be-cause of the inability to confront mortal-ity as a psycho-social issue,” he said, “and barriers within the medical community to refer patients to hospice because phy-sicians and their teams may feel they’ve failed in the medical management of a patient.”

Miguel A. Paniagua, MD, FACP, concurs. Because so many great techno-logical advances in medi-cine have been made, he said a patient’s treating physician may view their death as failure.

O’Connell, a former hospice manager, said the emerging Patient Centered Medical Home (PCMH) model has a

mechanism in place to assist primary care providers (PCPs) with the transition of pa-tients to hospice and palliative care.

“Primary care providers and their teams can facilitate the documentation of advanced directives for each patient,” he explained. “Each patient is counseled on choices in the event of a life-ending medical condition or event. It’s impor-tant when provider teams recognize that the patient is nearing the end of their life cycle and can begin the patient-centered collaboration for appropriate end-of-life care with a statement like: ‘there’s noth-ing more medicine can do for you. We’d like to refer you to hospice care because they’re experts at keeping you comfortable at end-of-life care and can enable you to die with dignity.’”

Paniagua, associate professor and director of the Department of Internal Medicine Residency Program at Saint Louis University (SLU) School of Medi-cine in Missouri, said a smooth transition is easier when the primary care provider (PCP) team clearly communicates the end-of-life plan with patients.

“We similarly teach many high-tech and high-reimbursing procedures in med-icine, but in my view, the most delicate and nuanced procedure we can teach and learn is the bedside conversation about goals of care and treatment planning,” he said. “Like any procedure in medicine, there are effective and ineffective ways of doing it. Unfortunately, not enough emphasis is placed on teaching and learn-ing this procedure, which leads to much variability in the way it’s delivered, as well as providers’ discomfort and unease with doing it.”

Paniagua also noted that mainstream media’s sensationalized coverage of eutha-nasia and physician-assisted suicide issues has hindered progress in the advancement

of the specialty and public perception. “In reality, (euthanasia and physi-

cian-assisted suicide) is such a miniscule practice, and in only three states,” he em-phasized. “But my view is that too often patients feel they have no other way out of their suffering. More often than not, we providers don’t do an adequate job pro-viding palliative care to most of the suf-fering.”

Lehmberg, who switched specialties to hospice and palliative medicine after a neck injury prevented him from con-tinuing his nearly 30-year plastic surgery practice, said the most common misper-ceptions about the specialty are the differ-ences between palliative care and hospice, and getting the team involved early enough to “truly assist the patients, their

families and the treating physicians.” “Most people, physicians in-

cluded, think of us only in terms of hospice and end of life,” said Lehmberg. “However, palliative care improves the quality of life of patients and their families with life-threatening conditions through the prevention and relief of suffering, and also the treatment of pain and other problems – physical, psy-chosocial and spiritual.”

Palliative care may be extremely helpful to physicians and patients in con-junction with therapeutic treatments, such as chemotherapy and radiation, said Lehmberg, noting that requests for hos-pice and palliative care consultations for the UAMS Department of Hematology and Oncology has increased signifi cantly – from 400 in 2007 to more than 2,200 estimated this year.

“As evidenced by our program growth, an awareness of the role of pal-liative care is increasing,” he said. “Still, I’d like to continue to contribute to a better understanding of our subspecialty and how we can help. Once a patient has been diagnosed with a life-threatening ill-ness, it’s really never too early to involve a multi-disciplinary palliative care team.”

Palliative care transitions to hospice care when the illness progresses to the point that therapeutic treatments are no longer applicable, explained Lehmberg.

“In palliative care, an experienced team is best at fi tting in with the primary medical approach, not rivaling it,” said Lehmberg. “As consultants, the palliative care team … complements the treatment and care provided by the primary physi-cians.”

Tapping into Hospice and Palliative MedicinePCPs benefi t from services of underutilized specialty

Palliative v. Hospice CarePalliative care:• provides comfort and relief from pain and other distressing symptoms;• is meant to neither hasten nor postpone death;•integrates the psychological and spiritual aspects of patient care;• affi rms life while regarding dying as a normal process;• assists patients in living as actively as possible until death;• helps the family cope during the patient’s illness;• uses a specialized team approach including physician, nursing, chaplaincy and

social work; and • is provided in conjunction with therapeutic treatments such as chemotherapy

and radiation.

Hospice:• focuses on caring, comfort and dignity at end of life;• provides relief from pain and other distressing symptoms;• is meant to neither hasten nor postpone death;• integrates the psychological and spiritual aspects of patient care;• helps the family cope with the patient’s end of life and their own bereavement• uses a specialized team approach including physician, nursing, chaplaincy and

social work.

Outside the Box When it was established 25 years ago, the American Academy of Hospice

and Palliative Medicine (AAHPM) had 250 charter members. Now, the professional organization has 5,000 members.

Yet even though four of fi ve larger U.S. hospitals now have palliative care programs, and consultations for the specialty have spiked, new growth isn’t keeping pace with the coming demand. New hurdles hinder progress – a rapidly aging baby boomer generation coupled with the existing senior population, continued segmentation of care, and limited funding for specialty training programs.

AAHPM leaders recently proposed a solution to the specialty shortage problem: Timothy E. Quill, MD, FACP, and Amy P. Abernethy, MD, FACP, president and president-elect of the AAHPM, respectively, suggested reserving palliative medicine physicians for more challenging cases, while also increasing the palliative skills of primary care providers (PCPs) and specialists who see patients daily.

Using their model, PCPs would receive appropriate education to address management of pain and other symptoms and other basic palliative care needs. Palliative medicine physicians would be called in to manage diffi cult-to-treat pain, complicated depression, anxiety and grief and other more complex needs.

SOURCE: AAHPM. Dr. Robert Lehmberg

Derrick O’Connell

Dr. Miguel A. Paniagua


NEA Baptist Memorial Hospital Receives Award for Heart Attack Care

NEA Baptist Memorial Hospital has achieved the Mission: Lifeline Receiving Center Bronze level recognition Award from the American Heart Association. With this recognition, the hospital will be listed in a American Heart Association ad in the July 2013 edition of US News and World Report.

The award is presented to hospitals involved in Mission: Lifeline—a program that focuses on improving the system of care for STEMI patients. The most severe form of a heart attack--STEMI or ST—segment elevation myocardial infarctions—occur when a blood clot completely blocks an artery to the heart.

The blockage must be either addressed surgically or by giving clot-busting medi-cation as quickly as possible to restore blood flow and prevent death.

New Company Licenses Angel Eye’s Camera Tech from UAMS BioVentures

Angel Eye Camera Systems LLC, a new company, recently licensed Angel Eye™ technology from University of Arkansas for Medical Sciences (UAMS) BioVentures, and received an impor-tant capital investment from a Nashville, Tenn., venture fund.

The Angel Eye system uses a cam-era placed at the baby’s bedside in the neonatal intensive care unit (NICU) so that parents and other family members

who can’t be at the hospital can view the baby 24 hours a day. This system helps promote bonding between parents and their premature babies, who sometimes have to stay in the hospital for weeks or months.

Angel Eye Camera Systems LLC was organized in January 2013 to exclusively license this proprietary technology from UAMS.

Nashville-based TriStar Technology Ventures recently has shown its confi-dence in Angel Eye technology and its appeal to hospitals and families by be-coming one of the leading investors in Angel Eye Camera Systems.

Typically, the process behind mak-ing a capital investment such as TriS-tar’s can take as long as six months but

came together with Angel Eye Camera Systems in one month because of the professionalism and experience of the BioVentures team supporting it.

TriStar is an early-stage venture fund that forms and invests in companies across the spectrum of health care inno-vation, life sciences, diagnostics, medical devices and technologies, health care IT and health care services.

In 2012, the Arkansas Development Finance Authority through its Arkansas Seed & Angel Capital Network program provided $500,000 to the firm’s TriStar Fund II. TriStar’s investment in Angel Eye Camera Systems is its first investment in a company in Arkansas. The ADFA program’s goal is to create a network of investors in Arkansas helping local entre-preneurs.

LAMMICO’s Outlook Revised & Financial Strength Affirmed by A.M. Best

After 19 consecutive years of main-taining an “Excellent” rating, the world’s oldest and most authoritative source of insurer financial performance has revised LAMMICO’s rating outlook to positive from stable and affirmed the company’s financial strength rating of A- (Excellent).

LAMMICO’s revised outlook, ac-cording to Best, reflects the Company’s “continuing growth in balance sheet strength and consistent operating per-formance.” Best recognized that “LAM-MICO also benefits from favorable tort reform laws in its core state of Louisiana, which recently were upheld by the state Supreme Court.” In addition, the affirma-tion of the company’s financial strength “reflects LAMMICO’s excellent capital-ization, driven by its conservation loss reserving philosophy, consistently favor-able operating performance, high poli-cyholder retention and leadership posi-tion in providing medical professional liability insurance coverage to physicians and surgeons, other healthcare practitio-ners and healthcare facilities in the state of Louisiana.”

SOAPware President Randall Oates, M.D. Among First NCQA Certified Medical Home Content Experts

SOAPware Inc. announced that Ran-dall Oates, M.D., SOAPware Founder and President, was named as one of the healthcare professionals from 29 states who was first to earn certification as NCQA Patient-Centered Medical Home (PCMH) Content Experts™.

The first cadre of PCMH Certified Content Experts™ is regionally and pro-fessionally diverse.

Dr. Oates’ certification represents a landmark achievement for himself and SOAPware Inc., as he believes the PCMH model is essential to survival in the future U.S. healthcare environment.

about fees for service. Once we start talking about population management strategies, then what we see is a focusing on efficiency and quality. That is what we are going to have to do. Even if we don’t immediately move away from fee for service, we are going to be asked to be more efficient. We are going to get paid less for the things we do.”

It might mean if, for example, that a primary care provider will avoid doing un-necessary testing.

“If you be can involved with experts in areas who know a lot, you can avoid unnec-essary tests,” Lowery said. “For example, I’m an expert in high risk OB. There are only six high-risk OB experts in Arkansas and five are here at the university. But we have written guidelines and protocols on the Angels website that are best practices for healthcare delivery.”

Telemedicine technology is allowing healthcare providers to be more integrated even if providers are not practicing in the same building or even the same part of the state. For example, this efficiency can be translated to nurse practitioners in health departments across the state who have ac-cess to the same information as people at a teaching university.

“Technology allows that,” Lowery said. “It allows us to bridge distances to do this approach to healthcare. There can be rapid access to sub specialists when needed. For example, health department nurses can do consultations on interactive video with experts at a teaching university. This con-cept is now beginning to spread across our medical school now.”

EPIC is an enterprise wide IP solution with an add on product that allows health-care providers to do video conferences right in the record of the patient. Lowery said it is hard to overemphasize how im-portant this technology and interfacing will become in the future.

“Once you get into managed care sys-tems – and you would have to be living in a Third World country if you didn’t realize ultimately that is the direction we are mov-ing – we will have an accountable care as-sociation,” he said. “Once we get into the

management of patient lives, then these kinds of connected systems will become the standard of care. When you are no longer bound by the fee for service mentality, you want to manage that patient efficiently with as good outcomes as possible. It you spend too little and there are bad outcomes, you pay for that. If you spend too much manag-ing a patient, doing things that don’t help improve the health of that individual, that is a bad result. There is a bell-shaped curve, a receiver operating curve, where you see the maximum benefit for what you are doing.”

An example of spending too little is if you withheld surgery for an appendectomy that was really needed. On the other side of the curve, you decide to do appendecto-mies on everyone and no one would ever have ruptured appendix. “That is where we need to be operating in healthcare, that peak plateau where you get the maximum benefit,” Lowery said. “How many people should you be operating on without an in-flamed appendix? If you don’t operate on some who really need surgery, if you delay too long and the appendix ruptures, that is a bad outcome. It is acceptable to oper-ate on some patients without an inflamed appendix, but 80 percent would be too much. Right now the system rewards doc-tors for procedures. The payment structure promotes interventions, not preventive healthcare, but the patients would be bet-ter served by preventing disease or disease deterioration.

Lowery said what is really missing is feedback loops that are ways of monitor-ing production. He likens it to waiting until there is a car crash before doing anything to monitor the manufacturing process of a car. “To be efficient and have good out-comes, we need feedback loops to deter-mine, for example, if there are problems with blood transfusions or postoperative infections,” Lowery said. “Just not spend-ing money in medicine is not the way to do it. It is like the sequester: Let’s just cut everything across the board. That is not good. We need to cut the things that are not productive. Healthcare needs to look critically at what is being done, and cut out the wasteful things. You may want

to spend money in other areas that im-proves outcomes. Where are the defective processes and how do we correct those? Monitoring needs to be done to make sure it improves. Then make best prac-tices available to everyone in the system. If it is available at UAMS, why not make it available to all hospitals in the state?” While agreed that the patient needs to be placed first, Lowery said that is only going to happen if the fee-for-service world is replaced with a coordinated approach to manage processes more efficiently. Cur-rently doctors and hospitals are separate entities, and doctor practice largely inde-pendent of hospitals. Payment structures are independent. “Until we integrate and work as a team, it is more difficult to make the changes that are necessary,” Lowery said. “Technology is like a nervous system. It allows you to have a nervous system to connect all these independent processes in a more coordinated approach to healthcare delivery. We want to take a sick patient in the health department and, if necessary, moved to a tertiary care setting, treat them and then transfer back into the home en-vironment in an efficient way. Technology can help you do that.

“Conceptually, a woman in rural Ar-kansas who has complications in her preg-nancy is kind of my patient even though I have not seen her. I know if that patient develops a problem acute enough, she will be rapidly moved to the university hospital. We will treat and manage her illness, and if she is healed, she will be moved back to her home. We need to match patients to re-sources they need in a coordinated fashion. By nurses and doctors having support, and rapid intervention from the system, I am confident they can get access to expert help in a short period of time. It can literally be within minutes if necessary.”

Lowery has been recognized as a tele-medicine pioneer through awards received from the Harvard University Ash Institute and the AT&T Center for Telehealth Re-search and Policy. UAMS received the American Telemedicine Association Presi-dent’s Institutional Award for the Advance-ment of Telemedicine in 2011.

Impossible Task? continued from page 1

GrandRounds


UAMS Presents White Coats to First Physician Assistant Students

In a ceremony signifying the transi-tion toward becoming a health care pro-fessional, the first 26 students in the phy-sician assistant program at the University of Arkansas for Medical Sciences (UAMS) received their student white coats today.

The white coat ceremony was the first for the full-time, 28-month master’s degree program, which accepted its first students this year. Physician Assistants are licensed medical providers who work with the supervision of a physician.

They take patient medical histories, conduct physical exams, order diagnos-tic tests, diagnose medical conditions, write prescriptions and manage acute illness and chronic disease with the su-pervision of a physician. The UAMS program, in its College of Health Profes-sions, is the first at a public university in Arkansas.

Each of the students donned a brand new white coat that they will wear during their clinical experiences in the program. The group then recited the Physician Assistant Professional Oath, which highlights their responsibility for professionalism, teamwork and provid-ing the best possible care to patients.

The UAMS physician assistant pro-gram, established in 2011, received ac-creditation in March from the Accredita-tion Review Commission on Education for the Physician Assistant, the final ap-proval needed before admitting its first class of students. Students began class-es in May.

Arkansas ranks 49th in the nation for the number of practicing physician assis-tants.

St. Bernards Center for Weight Loss/HMR Program Earns Gold Standards Achievement

The St. Bernards Center for Weight Loss/HMR Program has been awarded the 2012 HMR Gold Standard Certificate of Achievement.

The award distinguishes the St. Ber-nards Center for Weight Loss from hun-dreds of clinics nationwide using the pro-gram for weight loss developed by HMR (Health Management Resources).

HMR recognizes programs that demonstrate excellence in performance and patient care by presenting gold standard certificates annually to a se-lect group of clinics. Certificates are awarded in categories such as greatest weight loss rates, outstanding group at-tendance and best weight maintenance data. HMR Programs nationwide submit clinical data in these areas, and the top programs can earn the HMR Gold Stan-dard Certificate of Achievement.

St. Bernards offers a comprehensive approach to weight loss that includes in-tensive lifestyle education with medical supervision. With both in-clinic and at-home weight loss options, the clinic has

helped hundreds of individuals take off excess weight.

The local program earned 17 sepa-rate awards based on data for achieving exceptional patient outcomes – and that translates to outstanding weight loss.

The St. Bernards program provides med-ical supervision to lose weight safely, and the center takes physician referrals and files insurance (with the exception of Medicaid for medical services).

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GrandRounds

Batesville Oncology Clinic Moves to New LocationThe Batesville Oncology Clinic, offices of Dr. K. Raman Desikan and Dr. Muham-

mad A. Khan, recently moved into a new location on the ground floor of White River Medical Center’s East Tower, with the entrance being at the end of the Tower.

The new location is more than double the size of the previous clin-ic. Patients and their families have a much larger seating area, employees have a more efficient space to check patients in and store patient records, the number of exam rooms increased from four to six, and the large, open chemotherapy suite holds fourteen chairs with pre-installed televisions. The new location also includes a nutrition area where chemotherapy patients can grab a drink or a snack; and an in-house pharmacy where medications can be mixed right away for use.

The new area allows for the quickest, safest delivery of chemo-therapy medications and allows pa-tients to get treatment comfortably, as well as support each other during the treatment process.

The Batesville Oncology Clinic’s new address is 1710 Harrison Street.

BRMC Receives Diamond Award for Viewpoint NewsletterBaxter Regional Medical Center recently received a Diamond Award from the Ar-

kansas Hospital Association for the Viewpoint quarterly newsletter. The Viewpoint was selected as one of the top healthcare publications in the state of Arkansas.

The competition, co-sponsored by the Arkansas Society for Healthcare Mar-keting and Public Relations and the Arkansas Hospital Association, is designed to recognize excellence in hospital public relations and marketing.

Baxter Regional’s View-point publication is pro-duced quarterly and distrib-uted as a newspaper insert throughout the hospital’s 14-county service area. The publication is also available at Baxter Regional clinics and reception areas within the hospital. The publica-tion is written and compiled by BRMC staff and designed and produced by local firm, Brooks-Jeffrey Marketing, Inc.

Diamond, Excellence, and Merit Awards were pos-

sible in three divisions (based on size of hospital) and 14 categories. Judging for each entry was based on goals and objectives of the publication, audience to whom the publication is directed, reasons for choosing the format, frequency of publication and quantity produced, portions of the publication that were created internally/externally, results/evaluation of the publication and the total budget for the project.


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