Tennessee Medicine
JOURNAL
OF THE
T E N N E S S E E M E D I C A L A S S O C I AT I O N |
V O L . 102, N O . 5
|
M AY 2009
Need Money
for Health IT?
Tapping into stimulus dollars,
incentives for eHealth PAGE 27
Will Obama
Stimulus JumpStart the EMR? PAGE 29
HIT and the State Budget:
TM Interviews F&A Commissioner Dave Goetz PAGE 30
Ask TMA: New WC
Impairment Rating Rules
PAGE 9
Red Flag Rules
PAGE 33
Member News
PAGE 15
Tennessee Contents
Medicine
Vo l u m e 1 0 2 , N u m b e r 5 ~ M a y 2 0 0 9
JOURNAL
OF THE
T E N N E S S E E M E D I C A L A S S O C I AT I O N
Office of Publication
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Phone: (615) 385-2100; Fax (615) 312-1908
e-mail: [email protected]
Editor
David G. Gerkin, MD
Editor Emeritus
John B. Thomison, MD
President
Robert D. Kirkpatrick, MD
Chief Executive Officer
Donald H. Alexander, MPH
Sr. Vice President
Russ Miller, CAE
Managing Editor
Brenda Williams
Editorial Board
Loren Crown, MD
James Ferguson, MD
Deborah German, MD
Ronald Johnson, MD
Robert D. Kirkpatrick, MD
Karl Misulis, MD
Greg Phelps, MD
Bradley Smith, MD
Jonathan Sowell, MD
Jim Talmage, MD
Advertising Representative
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e-mail: [email protected]
Graphic Design
Aaron Grayum / Tinymusicbox Design
Tennessee Medicine
Journal of the Tennessee Medical Association
(ISSN 1088-6222)
Published monthly under the direction of the Board of
Trustees for and by members of the Tennessee Medical
Association, a nonprofit organization with a definite membership
for scientific and educational purposes.
Devoted to the interests of the medical profession of
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price of Tennessee Medicine.
Copyright 2009, Tennessee Medical Association. All material
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VISIT US AT WWW.MEDWIRE.ORG
PRESIDENT’S COMMENTS
5
Too Many Clicks (TMC)—Robert D. Kirkpatrick, MD
EDITORIALS
7
E-Health Can Be a Two-Edged Sword for the Medical Doctor—David G.
Gerkin, MD
10 Letter to the Editor
ASK TMA
9
Impact of New WC Impairment Rating Rules
THE NEW PRESIDENT
13 All in the Family: Dr. Richard J. DePersio to Lead the TMA
TMA MEMBER NEWS
15 TMA Tackles Patient Safety, Disaster Preparedness at 174th Annual
Meeting; 15 TMA in the News: Op-Ed on Health Reform Featured in
Tennessean; 16 TMA Unveils New Graphic Look, Positioning Statement;
16 AMA Supports SGR Fix in House and Senate Budget Resolutions;
17 Tamper Resistant Pads Required by July 1; 17 TN Medicare: CIGNA
Out, Cahaba In; 18 TMA Physician Leadership College Class of 2010;
20 TMA Photo Gallery; 21 IIC Commentary: Tight Funds May Mean More
Aggressive RACs; 21 IMPACT Capitol Hill Club; 22 Match Day at TN
Medical Schools; 26 Member Notes
PRACTICING MEDICINE
27 Health IT Stimulus Dollars Available to TN Hospitals, Physicians—Dawn
Fitzgerald
Can
the Obama Stimulus Plan Jump-Start the EMR?—Bruce Taffel, MD
29
Tennessee’s
HIT Efforts Unaffected by Budget Shortfalls: An Interview
30
with Comm. Dave Goetz—Brenda Williams
32 Loss Prevention Case of the Month—Good Offense is the Best
Defense—J. Kelley Avery, MD
SPECIAL FEATURES
33 Red Flag Rules – Are You Ready?—John D. Fitzgerald, Jr., JD
34 TN Property Tax Due on Physician Drug Inventories—Kirk Low, Jr., CPA;
Brett R. Carter, Esq.
35 Medicare Administrative Contractor (MAC): Have You Met Yours?—
Bethany Wylie, CPC, CPMA
36 To End Recession, We Must Change Our Culture—Chris Low
THE JOURNAL
37 Original Contribution—A Very Late Stent Thrombosis in a Patient with
Diabetes: A Call for Lifelong Dual Anti-platelet Therapy—Chad V. Pecot,
MD; Michael Fuller, MD; James A.S. Muldowney, III, MD; Sumathi Misra,
MD, MPH
41 Medicine & Law Series—HIPAA Impacting Patient Medical Information
—Judy Regan, MD, JD, MBA; Lauren Smith, JD
FOR THE RECORD
44 TMA Alliance Report—TMAA Year-End Report—Darlene Vickers
45 New Members; In Memoriam; AMA Physician Recognition Awards
46 Advertisers in this Issue; Instructions for Authors
PRESIDENT’S COMMENTS
Too Many Clicks (TMC)
By Robert D. Kirkpatrick, MD
President
few days ago, I was reviewing an article on EMRs and a comment
by a reviewer caught my attention. Before you say, “Not another
computer story!” I promise this will be my last computer discussion while president of our TMA. Now back to my comments.
The software reviewer described a particular system as complicated and too difficult to use for even the most basic functions. His
final comment was that it required “too many clicks.” Now that I have
completed my term, I wanted to take the opportunity to comment on
some TMA issues and concerns that require “Too Many Clicks”
(TMC) to be of maximum value to our members. I can only hope that
someone will print my diatribe since not everyone agrees with me.
First, there is our own computer system. In recent months, an MD
friend in the TMA leadership made a very appropriate and accurate comment. He put it this way: “With the old system, you almost had to break into
the system to vote.” This year we actually had more online ballots cast than
paper ones. Does this mean that our older MDs have suddenly become
computer gurus? I think a better explanation is the influx of a new group
of younger physicians who speak computer and are much more comfortable in that world than us “Legacy Doctors.” Now wasn’t that a nice way to
say old? With the advent of an expanded website with innovative options,
maybe we have avoided the “Too Many Clicks” of the past, at least this time.
Our new president, Dr. Richard DePersio, has called for a new
emphasis on women’s healthcare issues in the next year. With over
50 percent of most medical school classes now being women, have
we let the TMA miss this opportunity in the past? Let’s hope it doesn’t require TMC to get it done right this time.
This year marked the defeat of another HOD resolution to
change the annual meeting in ways that were obviously not in keeping with the wishes of the HOD. This is not the first time such a different opinion has surfaced between the Board and the House. To
my friends on the Board and in the House I suggest, let’s swear off
this one for a while. We have too much else to do to continue this
brouhaha. Let’s let ‘er be for a while. If it divides us, we can’t afford
it. Someone has said there is no greater tragedy than doing something perfectly which never should have been done at all. It takes
TMC and we’ve got lots of other things to do.
I know we doctors are extremely intelligent but as one physician
reminded me, we are not very smart at times. How many wasted “clicks”
can our legislative effort afford when the House of Medicine is divided?
There are some things the TMA should not have an opinion on as far
as the Legislature is concerned. Trying to use the TMA’s resources for
narrowly-focused issues usually leaves us myopic or blind to the real
problem. If you don’t agree with the TMA legislative approach, get on the
phone and ask someone at the TMA. The call is free and you just might
appreciate the complexity of an issue you thought was really simple. TMC
on personal issues means less effectiveness for the broader scope.
A
We are embarking on a new phase in the life of the TMA—getting the
young physicians involved. Yes, after 31 years in the organization, I know
we have always welcomed them but we are now going after them.
Whether it’s the Physician’s Leadership College or the new website, it’s
time—no, make that past time—for this effort. There will never be TMC
when it comes to the future members and leaders of our TMA.
Enough of all that. If you read the last column about the
“$44,000 Dollar Question,” you will remember I was writing from
Washington, DC, following the National Advocacy Conference. This
time, it’s from the Waffle House on the way back to Memphis following a Medical/Law Enforcement Summit in Jackson.
“
Now that I have completed my term,
I wanted to take the opportunity to
comment on some TMA issues and
concerns that require ‘Too Many
Clicks’ (TMC) to be of maximum
value to our members.
”
So what’s so special about the Waffle House, other than it’s a good lipid
stress test? My point is twofold. Sooner or later, all these issues become
“down home” issues and secondarily, it’s a little reminder and inside
joke for those who attended the Medicine Ball at the Annual Meeting
in Nashville. To paraphrase one of the comedians at the Ball, my wish
for Dr. Depersio this year is that he, unlike Waffle House hash browns,
doesn’t wind up “scattered, smothered, and covered.”
Well, that’s about all I have to say except to again express my
thanks to the TMA staff, leadership, Board of Directors, House of
Delegates, members of our great organization, and my colleagues
at UTHSC and the St. Francis Family Medicine Residency.
A special thanks to Brenda Williams for her help/prodding/support
in getting my thoughts on paper and enabling me to share them with
you. Like the turtle on the fence post that didn’t get there by himself, a
heartfelt thanks for understanding, tolerance and love to my wife (a.k.a.
Dr. Mom), without whose help this year would not have been possible.
Never forget….together we are stronger!
That’s the way I see it. How about you? TENNESSEE MEDICINE / MAY 2009
5
EDITORIALS
E-Health Can be a TwoEdged Sword for the
Medical Doctor
By David G. Gerkin, MD
Editor
-prescribing and electronic medical records have been edging into our lives and daily practices for the last 15-plus
years. In the last five years, the adoption of this technology
has been driven by arguments related to patient safety issues, better coding ability and thus better reimbursement and improved
patient care. The government and other health entities cite better
care because of better benchmarking, dissemination of record
information, cross-linking to treatment centers and RX safety using
e-prescribing; they have even offered financial rewards and help
with financing for participating doctors.
Even more significant is the millions of dollars invested and
allure of making even more millions that has led high-tech companies to offer this technology, making it sound as though if you are
not using, you are losing!
I am convinced the realities of better patient care are real with
the safety and convenience of e-prescribing, legible records, a
more complete system of health review, availability of access by
emergency rooms, consultants and others in the “need to know”
realm, and all will benefit the patient.
How about the advantages for the doctor? No question, what is
good for the patient is usually good for the doctor but there are
some significant risks that need to be clarified. Now, let me make it
clear, I am strong advocate for e-prescribing, electronic medical
records and telemedicine, and I have learned their value in my
work as a medical waiver authority for the U.S. Amy, but now, consider the other side of the story.
This issue of Tennessee Medicine will cover the funding available
for e-health and e-prescribing and I am sure mostly in a favorable light.
I will approach the subject from primarily risk management issues I
feel should be reviewed to avoid these future pitfalls and which are not
currently as recognized as some of the well-described risks.
A brief definition of EMR (electronic medical records), EHR
(electronic health records) and telemedicine is important. An EMR
refers to an electronic version of the paper record that doctors have
long maintained for their patients. As explained above, the EMR may
be a simple office-based system or a more sophisticated and interconnected system. In contrast, an EHR is a compilation of core data
from multiple sources and it may be comprised of many different erecords, submitted by different providers in different jurisdictions.
The EMR holds all the medical information gained from an individ-
E
ual doctor’s care to a patient and is within its domain, comprehensive. While the EMR has depth, it lacks breadth in that interactions
with other healthcare providers are not generally included.
Conversely, the EHR provides breadth but lacks the depth one would
find within the medical record. Put another way, the EHR does not
necessarily contain all the information from the EMRs.
“
I am thankful I am bound by ethical
standards and a desire to promote
what is best for our patients,
otherwise I could see only a ‘pot
of gold’ at the end of the chart.
”
The two elements I will address are the medical liability related to
(1) records content and (2) the federal anti-kickback statute,
including the so-called “Stark” laws prohibiting physician selfreferral. It is clear to me that some of the more interesting implications of this evolution haven’t yet turned up on the policy radar
or in writings by medical liability experts.
First we address the medical liability for the content of the electronic medical records. I am told by several of our state’s best known
and successful medical litigation defense attorneys that this will be the
new “breadbasket” for plaintiff’s lawyers. Although they have the
potential to improve patient care because of their reliability, portability and tractability, they create sober issues of liability yet to be resolved.
The most pressing issues deal with the doctor’s duty to both access the
EMR and manage its contents when developing a diagnosis or treatment. Another issue is the wide range of information from other
healthcare providers that is included, often unknown to the attending
doctor, that raises important questions that require close recognition.
In my review of thousands of electronic medical records, mostly
in the form of consults I request or am sent, I am stunned by the
amount of content and number of pages as compared to written or
typed charts. I also understand this is one of the advantages of EMRs:
to provide more information on the “chart” for review created in the
same amount of time or less. I also am aware the templates are creat-
TENNESSEE MEDICINE / MAY 2009
7
EDITORIALS
ed so many aspects of history or patient care are not overlooked during the assessment. In my review as I search for the “hard evidence,”
I often find five-to-six pages of “normal” checked findings covering
many diagnostic areas. I have come to realize the examiner, although
meaning well, is often exposing himself to a new scrutiny that can lead
to disaster. Of course, the other reason for this large document is to
satisfy the government bureaucracy in an attempt to increase the ability to be paid a reasonable amount for the service provided. As I review
the pages of an ophthalmology or urology record that often describes
a limited psychiatric evaluation, the cardiovascular status, and details
of systems review, in a certain number of patients a medical event
affecting one of these systems will occur at some time, often near the
initial encounter. This can force the treating doctor to explain why
there was not further evaluation of a problem listed as “normal” or a
referral for care when it should have been evident in even a limited
assessment. Even as a non-attorney, I believe I could “call the question” and seek remedy in many listed as normal evaluations.
I believe attorneys could develop a group of clients in which they
allege clinical decision-making was not followed, leading to injurious outcomes. In addition, both attorneys and regulatory agencies could contend
that a doctor did not really engage in the care he or she said they did.
It is clear to me the solution is the careful adding of complex information to achieve best patient care, but adding information solely to
beef up content or give the appearance of completeness is dangerous.
David Steed, the TMA’s outside attorney and an expert in medical liability, enforces my concern with the following comment:
“Physicians need to realize the profoundly adverse consequences
that can occur from failure to exercise a high degree of discipline
and wariness in creation of the EMR. The ease with which data can
be created, intentionally or unintentionally, can result in such a loss
of credibility that the record could be construed as non-existent.
Physicians should personally validate their records regularly, perhaps by a daily spot-check of one or two of their own records at the
end of the day. There should also be a regular, but perhaps less frequent, review of the records by another individual, preferably a
coder to compare the records to the CPT code billed.
“It is essential that a group practice have the records of all physicians and extenders audited by a third party at some interval. A group
practice cannot afford to have one of its physicians misusing the
EMR; it may need to have appropriate potential sanctions in place to
address members of the practice with sloppy EMR practices.
“Systemic or chronic problems with the EMR are likely to be discovered in the close scrutiny given the records in a payer audit or
malpractice case. However, this scrutiny may not occur or be communicated to the practice until several years after the record was created. Consider the potential consequences of a patient’s record being
deemed totally unreliable in a multi-million dollar malpractice case,
or consider the possibility that an entire year of Medicare billings is
deemed unsupported because of unreliable records. Clearly, this
potential loss justifies extreme caution on the front end to validate the
8
TENNESSEE MEDICINE / MAY 2009
records to assure they are an accurate representation of events that
occurred. Problems with the EMR simply must be identified and corrected promptly, with a high level of suspicion for those problems.”
After my careful assessment and David Steed’s words of caution, I am thankful I am bound by ethical standards and a desire to
promote what is best for our patients; otherwise I could see only a
“pot of gold” at the end of the chart.
Now, there is the problem of the federal anti-kickback laws and
the “Stark” laws on prohibiting physician self-referral. Although the
Centers for Medicare and Medicaid Services (CMS), the Office of
the Inspector General (OIG) and Congress have tried for several
years to address these barriers, progress so far has been slow and
when the government says it is “here to help” I am not comforted.
I believe a major reason for the lack of widespread EMR implementation in the current economic climate is related to who will pay
for the necessary infrastructure. A common solution is for large hospital systems and other entities, like pharmaceutical manufacturers
and medical product vendors, to provide their community, doctors
and clinics with the necessary hardware, software and expertise.
However, when the computer and software provided to a physician
permits communication with entities other than the one offering the
computer and software, the network often falls out of the range covered
by the rules of CMS’s and the OIG’s safe harbor exceptions. This form of
relationship often challenges EHRs and the anti-kickback statute. Even
if a network can conform to anti-kickback requirements, it faces the
obstacles of complying with the Stark laws. The Stark law prohibits a
doctor from referring Medicare-Medicaid patients to certain health
entities the doctor has a financial relationship with, unless a safe harbor
exception is present. Since almost any exchange of remuneration with
a doctor could create a financial relationship under the Stark law, the
statute presents an obstacle when an EHR network is directly or indirectly funded by a hospital, health provider entity or vendor.
Congress and CMS have implemented Stark exceptions and
anti-kickback statute safe harbors for the planning of health information technology at a discount or below cost by a medical facility
to doctors, as long as it increases patient safety and is able to
exchange and use information. This is encouraging but can still be
a problem when dealing with so many parts of federal oversight.
Technology is transforming the practice of medicine. The emergence
of e-health records storage and web-based communication in the delivery
of patient care, although offering significant benefits, presents new legal
and ethical challenges to doctors. If doctors are going to integrate electronic record systems into their practices, they need to be aware of the
unique issues about such systems, particularly in chart content and safe
harbor issues, and adopt suitable policies, procedures and safeguards to
meet the obligations associated with the use of such technology.
What should we do? Simply put down what you do or know,
avoiding the allure of the auto-fill or template to maximize the chart
information. Of course it is much more complex than that, but that
is my “auto fill” answer. ASK
T M A
A FORUM FOR QUESTIONS ANSWERS AND COMMENTS
IMPACT OF NEW WC IMPAIRMENT RATING RULES
Q: My practice is concerned about the impact of the impairment rating rules that the Department of Labor enacted in
January of this year. What has the TMA’s involvement been in the
creation of these rules? Also, does the TMA have any tips for
practices regarding these rules?
ment these suggested changes. Below is a summary of the
comments the TMA made about the changes to the Medical Care
Cost Containment Rules (0800-2-17) published in the February
Tennessee Administrative Register (accessible at
http://state.tn.us/sos/pub/tar/2009/200902TARList.xml):
A: Prior to the enactment of these rules, TMA General Counsel
• The TMA supported proposed amendments to delete the flat
$10,000 civil penalties per violation against providers and
replace it with the “up to” language. As currently written, these
rules give the commissioner limited discretion: he can choose
to either issue no penalty, or issue a penalty of a flat $10,000.
While we are not aware of any civil penalties having been
issued, physicians have reported that the threat of a $10,000
civil penalty for even a minor or technical violation is a barrier to them serving injured workers. This change acknowledges
that unforeseen and unintended violations occur and that the
DOL could be flexible in assessing penalties.
• Second, the TMA asked the DOL to consider revising the language of Rule 0800-2-17-.03(42) to correct conflicting provisions. The second sentence prohibits a physician from receiving reimbursement in excess of the division’s Medical Fee
Schedule. However, the third sentence prohibits physicians
from billing in excess of the Medical Fee Schedule, an issue
that was raised and adequately addressed when the Medical
Fee Schedule was first proposed. The terms “reimbursement”
and “billing” are not synonymous. The TMA proposed that
physicians should be allowed to bill at a rate above the
Medical Fee schedule in order to receive payment (reimbursement or fee) at a rate at or below the Medical Fee
Schedule ceiling.
• The TMA takes the position that the same concept applies to
proposed Rule 0800-2-17-.25(6). The rule as written makes
it difficult for physicians to receive $250 reimbursement for
conducting a medical impairment rating. Because Medicare
does not have a charge for medical impairments, many workers’ compensation health plans are unilaterally using the 80percent equation to pay physicians around $200 instead of the
$250 allowed by the rule. For example, if physicians were
allowed to charge $312.50 for a medical impairment rating,
physicians could be reimbursed $250 per impairment evaluation. However, as written, the rule does not allow physicians to
charge more than $250 without violating the rule. The TMA
has received examples of how the current wording of this rule
Yarnell Beatty and Director of Government Affairs Gary Zelizer met
and corresponded several times with officials at the Tennessee
Department of Labor (DOL) to discuss the impact of the impairment rating rules on access to care for workers’ comp patients. It
was emphasized that a requirement for an impairment rating (IR)
for every single workers’ comp injury would be extra hassle for
physicians who do not routinely conduct impairment ratings and
may force physicians to stop seeing these patients, resulting in limited access to care. It was also emphasized that copious discounts
routinely taken by so-called “Silent PPOs” would limit the ability of
physicians to receive the $250 ceiling fee for conducting an impairment rating unless physicians could bill more than $250.
The DOL declined to accept any of the concerns raised by the
TMA and enacted the rules that were effective January 8, 2009. For
a summary of the rules and FAQs, log on to the TMA Insurance
Resource Center at www.medwire.org/irc and click on the
“Workers’ Compensation” section (member login required).
Recently the DOL proposed some amendments to existing
Medical Care Cost Containment Rules and the TMA submitted comments at a rulemaking hearing on March 20. In Tennessee, when
rules or changes to rules are proposed a rulemaking hearing must
be held to accept comments from interested parties. The state
agency accepting the comments is under no requirement to imple-
TMA MEMBERS CAN “ASK TMA...”
Online: www.medwire.org/asktma
E-mail: [email protected]
Phone: 800-659-1-TMA • Fax: 615-312-1894
Mail: P.O. Box 120909 • Nashville, TN 37212-0909
Questions and comments will be answered personally and
may appear in reprint for the benefit of our members.
TENNESSEE MEDICINE / MAY 2009
9
ASK TMA
has hampered the ability of physicians to collect $250 reimbursement for a permanent medical impairment rating.
• The TMA supported proposed changes to Rule 0800-2-17.25(2) but believes one additional change was required. The
rule clarifies the interpretation the TMA has been given orally
by the DOL that the treating physician is only required to provide a medical impairment rating when it is believed the
injured employee has a permanent impairment. It is not
required if the employee has no impairment or a partial
impairment. The current language will permit insurance plans
to deny reimbursement in cases where the treating physician
had good reason to believe there might be a permanent
impairment but, after evaluating the case by use of the AMA
Guides, a zero impairment is determined. In such a case, the
physician should still be reimbursed for completion of the rating; in fact, the department took just such a position when this
scenario was discussed last fall. As such, we propose the last
sentence of 0800-2-17-.25(2) be changed to the following:
>> The treating physician shall only be required to provide an impairment rating when the physician
believes in good faith the employee retains or could
retain a permanent impairment upon reaching maximum medical improvement. If, after completion of
the rating, it is determined the employee has no permanent impairment, the provisions of 0800-2-17.25(6) shall still apply.
• Finally, the TMA supported proposed changes to Rule 08002-18-.02(4) that would set a conversion factor floor to prevent reimbursements from going below a certain level. LETTER TO THE EDITOR
“Shocking” Numbers of Prescriptions Indeed a Problem
To the Editor,
hank you for again expressing the concerns of Tennessee
physicians eloquently in our journal (“Over-Prescribing,
Under-Prescribing: Who is Responsible and What is at Risk?”
Tennessee Medicine, Vol. 102, No. 4, p. 9). The shocking numbers
of prescriptions our citizens are taking is indeed a problem, though
perhaps only in degree. When I was a freshman med student at Ole
Miss, we had J. Willis Hurst speak at an assembly (this was 1969,
about five years after he was flown to Bethesda to take care of LBJ
after his heart attack). Dr. Hurst’s best quote of the speech was,
“When a patient is referred to you for definitive care, you should discontinue all medications except two—any two!” Today, with the
statins and other drugs available, he might agree to three, though I
cannot imagine his agreeing to a half-dozen or more.
On a related note, I have followed with interest the controversy about pharmaceutical manufacturers’ gifts to physicians, includ-
T
10
TENNESSEE MEDICINE / MAY 2009
ing sponsorship of journal clubs for residents, etc. I saw that their
association has gone on record as being in favor of doing away with
these generosities. I am certain that they intend to use this money
to increase direct-to-consumer advertising, since their studies
show this is a more effective use of their money! Perhaps organized
medicine’s best response is to seek regulation requiring more
information to be included in the commercials, with fewer scenes
of patients strolling in flower-filled fields and enjoying the wonderful life that the drug supposedly provides!
Noli illegitimi carborundum!
Ronald J. Johnson, MD, FACS
Germantown
THE NEW PRESIDENT
All in the Family: Dr. Richard J.
DePersio to Lead the TMA
By Brenda Williams
ichard DePersio always knew he would be a doctor. “My
father was a physician; both my older brothers, who are
twins, are physicians (one an anesthesiologist and the other
a radiation therapist); my uncle was a physician and two of his sons
are physicians – one of them was a classmate of mine in medical
school,” he explained. “I really never gave it much consideration to
do anything else.”
Choosing a specialty took a bit longer. In medical school at the
University of Tennessee-Memphis he was leaning toward cardiology
until he met Dr. Charles Gross, chair of the Department of
Otolaryngology and a national leader in the field. “It was a last
minute change due to his influence,” he said, adding he still keeps in
touch with his mentor, who is now a professor emeritus at the
University of Virginia.
Now with 28 years of practice under his stethoscope, Dr.
DePersio said otolaryngology is a field he never grows tired of – it
offers a variety of patients, conditions and procedures, both office
and surgical. In Knoxville, where he partners with six other physicians in Greater Knoxville Ear Nose & Throat Associates, PC, he also
serves as chief of otolaryngology and a clinical associate professor of
surgery at UT Medical Center, and shares his wisdom about choosing
a specialty with his trainees. “I tell them, ‘You need to make sure you
like what you do – find something you like and spend time doing
that, because in medicine there are aspects of what we do that
become work,’” he said.
Dr. DePersio is just as adamant in his view of organized medicine – that it is a necessity in today’s changing medical environment.
R
Dr. DePersio - At a Glance
• Age: 59
• Education: BS, University of Tennessee, Knoxville;
MD, University of Tennessee Health Science Center,
Memphis
• Family: Wife Melissa; children Lauren, age 27,
Katie, 24, Gerard, 23, Richard, 9, Robert, 7,
Elizabeth, 5, and Danny, 2.
• Interests: Family, golf, basketball
• Favorite quote: “Nothing is impossible for those
who don’t have to do it.” – Unknown
• Currently reading: The Invention of Air by Steven
Johnson.
• Most important accomplishment: My MD and
this honor
“The ability to obtain information is greatly facilitated so learning is
easier; on the other hand, many things are harder – dealing with
insurance companies, the government, increased regulation, more
work for less pay, increased patient expectations and their own information or misinformation,” he stated, adding that doctors increasingly need a strong, unified voice to protect patient care and their
profession.
That belief has driven his own involvement in the family of medicine – locally as a past president of the Knoxville Academy of
Medicine and the current president of the Knoxville Academy of
Medicine Foundation; within the TMA as a Board of Trustees member, vice speaker of the TMA House of Delegates, chair and member
of several committees; and nationally as a delegate to the American
Medical Association.
Those convictions also drive Dr. DePersio’s stated goals as the
TMA’s new president. He plans to focus on increasing membership
through an intense recruitment campaign, asking his fellow leaders
to step up and personally invite non-members to join. “It’s not a huge
thing we’re asking them to do; it takes just a little bit of time. We’ve
TENNESSEE MEDICINE / MAY 2009
13
THE NEW PRESIDENT
Dr. DePersio conducts an exam at one of three practice locations in Knoxville.
done this at the AMA level and it’s been greatly successful.” He said
most physicians already realize they should join and for many, all it
takes is to point out the obvious.
“You may not see it but the TMA stopped well over 200 (legislative) bills that could have adversely affected you; what we do
greatly helps your practice,” he said. “We could all do a Frank
Capra It’s a Wonderful Life thing and look at how life would be
without the TMA. I don’t think the non-members would like that –
it would be a real nightmare.”
A related priority is to increase the ranks of TMA’s female members. “What’s behind that is the obvious lack of a female presence
and the fact that at least half of all med school graduates today are
women,” he emphasized, adding he hopes to create a TMA Women’s
Issues Summit, similar to a successful program within the Michigan
State Medical Society. “I just hope to be a catalyst to get this going;
it’s certainly something we can get going just like we did with our PLC
(Physician Leadership College), and I look to those two entities to be
big factors in helping us grow.”
Along with continued advocacy on medical liability, insurance,
patient care, quality and practice issues, another important issue for
his presidency is continued work on the TMA’s strategic plan, includ-
14
TENNESSEE MEDICINE / MAY 2009
ing a restructuring, rebranding and new online resources. “The TMA
has been around for 180 years because we have at our core a strong
self-critical element,” he said. “We don’t always get everything right
but we’re critically looking at our operations today from top to bottom … so that when I’m gone and the current board is gone, there
will be a path for future leaders to follow.”
Dr. DePersio thanks his partners – Drs. Leslie Baker, Robert
Crawley, William Horton, Christopher Rathfoot, Allan Rosenbaum
and Ronald Sandberg – for supporting his organized medicine activities in the past and in the coming year as he steps into a new leadership role in the family of medicine. He also credits his own family
– wife Missy and their seven children – for being willing to put up
with his responsibilities and required absences. “Probably the work
load is what you make it and what events happen during the year,”
he said, adding, “I intend to work pretty hard.” Share your thoughts with Dr. DePersio at
[email protected].
Member News
Visit www.medwire.org for the latest TMA news, information and opportunities!
TMA Tackles Patient Safety, Disaster
Preparedness at 174th Annual Meeting
The Tennessee Medical
Association took policy
action on a number of
public health and
patient safety concerns
during MedTenn 2009,
the TMA’s 174th
Annual Meeting in
Nashville on April 3-4.
The group also installed
new officers and hosted
the launch of the LEAPS
(Law Enforcement and
Prescriber
Summit)
Outgoing TMA President Dr. Robert
statewide
conference
Kirkpatrick of Memphis (left) presents
series.
the gavel to incoming President
“As a practicing physiDr. Richard DePersio of Knoxville.
cian in Tennessee, it is
certainly reassuring to see physicians giving of their personal time, outside
of their practices, to give back to the profession and give serious consideration to the issues challenging or patients and our peers,” said newly
installed TMA President Dr. Richard J. DePersio, a Knoxville otolaryngologist. “This meeting marks the largest concentration of physicians to congregate in our state each year. We have dozens of medical specialties
come from all corners of our state, representing all levels of medical
careers, from students to retired physicians, but we all have one mission
for this meeting and that’s to make Tennessee a better, healthier place to
live and work.”
RESOLUTIONS OF INTEREST
The TMA’s policy-making body, the House of Delegates (HOD), debated
policy on a variety of healthcare issues facing Tennessee doctors and their
patients. From a slate of 13 resolutions, delegates discussed and took final
action on the following:
Disaster Preparedness - The TMA will seek to collaborate with existing
federal and state disaster preparedness plans to help enroll physicians to
serve as disaster volunteers, educate physicians on their role as a disaster
responder, and coordinate physician response in times of emergency.
Patient Safety - The TMA will explore options to set a statewide standard for identification badges for all healthcare providers. Delegates
debated the numerous and inconsistent approaches currently used for
professional identification in health care settings, the increased potential
for patient confusion and their concern for patient safety problems that
could result.
Public Health - Additional resolutions to mandate colon cancer screening, to strengthen liability protection for federally-mandated emergency
(Continued on page 25)
TMA in the News: Op-Ed on Health
Reform Featured in Tennessean
The following editorial by TMA Board of Trustees Vice-Chairman Charles
Eckstein, of Nashville, was featured in the Tennessean newspaper on
Sunday, April 12.
PHYSICIANS AGREE ON MANY POINTS FOR REFORM
The Rolling Hills Group proposal for health system reform contains many
principles that physicians in Tennessee and across our nation can agree
on. We are unified in our belief that the U.S. healthcare system needs
reform if we expect to deliver the quality care that Americans demand
and deserve without breaking the bank.
We need to change the way health insurance
is purchased, close business tax advantages
that work against the poor and uninsured,
and discourage abuse of our system.
Dr. Eckstein
Requiring everyone to have coverage and
providing the mechanism to get coverage is
good start, but we must realize that access to coverage does not always
mean access to care.
(Continued on page 17)
Member News
15
Member News
TMA Unveils New Graphic Look,
Positioning Statement
A new graphic look and brand positioning statement has been
unveiled for the Tennessee Medical Association, part of its ongoing effort to update, streamline and focus the state’s largest professional organization for medical doctors.
“The TMA is proud to present its new graphic identity and
brand positioning,”
said TMA’s newlyinstalled President
Richard DePersio,
MD. “The new look
represents
the
changing dynamics
of the organization
and its services, and
will become the iconic representation of our revitalized purpose
and mission.”
The contemporary logo and tagline, “Physicians Caring for
Tennesseans,” will provide the visual context to the association’s
work to be an innovative, respected, established, progressminded physicians’ organization. “The logo provides us an opportunity to mark a renewed commitment to growth and future direction, as well as reflect our continued purpose of helping physicians protect the integrity and quality of medical care for patients
and communities
across the state,”
said Dr. DePersio.
The new graphic
identity and value
proposition for the
TMA is the result of
two years of topdown assessment
and evaluation by the Futures II Task Force. Changes are being
made in the organization’s focus, priorities, resources and structure and will soon be evident in a new web site, and in all forthcoming TMA materials and advertising. AMA Supports SGR Fix in House and Senate
Budget Resolutions
The House and Senate approved separate versions of the fiscal
year (FY) 2010 Congressional Budget Resolution on April 2, by
votes of 233-196 and 55-43, respectively. The budget resolutions
lay out five-year Congressional plans for taxes and spending, and
each includes differing provisions impacting the Medicare/SGR
dilemma.
The House resolution contains provisions that would facilitate
passage of legislation to replace the flawed sustainable growth
rate (SGR) formula used to calculate Medicare physician payment
updates. Congress will still have to enact additional legislation to
replace the SGR. The House budget resolution also includes a
provision known as a “budget neutral reserve fund” that represents support for health system reform legislation. Of note, the
costs of health system reform legislation would have to be fully
offset by spending cuts or increased revenue. Additionally, the
House version of the budget contained “reconciliation instructions,” which would require the Committee on Ways and Means
and the Committee on Energy and Commerce to each report
bills by September 29 that would save $1 billion between FY
16
Member News
2009 through FY 2013. The budget reconciliation procedure
could be used to advance health system reform legislation that
would not be subject to a filibuster in the Senate, thus requiring
only 51 votes for passage.
The Senate version of the budget resolution contains a “budget-neutral reserve fund” to avert projected Medicare physician
payment cuts. However, it does not specifically stop the 21-percent payment cut scheduled for 2010, nor does it provide budgetary protection for legislation to replace the SGR. The cost of
reforming the Medicare physician payment system would have
to be fully offset by other spending cuts or by revenue increases.
Similarly, the Senate budget resolution contains a “budget neutral reserve fund” for health system reform legislation.
As the House and Senate work to reconcile differences and
pass a final version of the budget framework, the AMA will work
to ensure that provisions that create a pathway toward permanent reform of the Medicare physician payment system are
included. Member News
Tamper Resistant
Pads Required by
July 1
Beginning July 1, 2009, all written or printed prescriptions
from Tennessee prescribers must be on tamper resistant
prescription paper. In 2008 the federal government
required that all Medicaid prescriptions be written on
tamper resistant paper beginning April 1. The Tennessee
General Assembly passed a law in the 2008 session to
extend this requirement to all prescriptions (T.C.A. §53-10401). This law states that the prescription paper must meet
the same requirements as required by the federal government for Medicaid prescriptions. A physician does not
have to order new pads; he or she simply must remember
to write all prescriptions on this paper now. Members can
access the TMA online Law Guide at www.medwire.org to
see the topic on “Prescriptions Pads – Tamper Resistant –
Medicaid Patients” for more information on this requirement, including the original federal law, details of the law
and what information must be included on the prescription. Any questions should be directed to the TMA Legal
Department at 800-659-1862. Members can also take
advantage of special TMA pricing on tamper-resistant RX
pads by logging on to www.medwire.org. TN Medicare:
CIGNA Out, Cahaba In
In January 2009 the U.S. Centers for Medicare & Medicaid
Services (CMS) awarded the Medicare Administrative
Contract (MAC) for Jurisdiction 10 (Tennessee, Alabama
and Georgia) to Cahaba Benefit Administrators (CBA). CBA
will begin processing Tennessee Part B claims on September
1, 2009. During this transition there will be the need for you
to test claims and questions will arise regarding issues like
credentialing and ongoing care, so TMA members and staff
need to check frequently for updates.
The TMA has created TN Transition Updates to assist
members during the change from Cigna Medicare to CBA.
To find Updates on our Insurance Resource Center at
www.medwire.org/irc, scroll down the page and click on
“Medicare.” This information is for TMA members only and
the member’s username and
password will be required to
access. Please check this page
frequently as it will be updated
as news is received.
For more information, contact the TMA Legal Department
at 800-659-1862 or [email protected]. TMA in the News: Health Reform Op-Ed
(Continued from page 15)
We agree that reforms need to allow more resources for wellness, prevention and health maintenance, but we cannot simply take dollars from
one sector of health care to fund another. Achieved savings through new
efficiencies and premiums and co-pays by individuals contributing to
their own care should provide these necessary resources.
Manpower is an area that needs immediate attention. We already
have a shortage of primary care physicians being overwhelmed by a rapidly growing population in need of basic healthcare services and a medical home. We have to address the negative aspects of our system that discourage medical students from going into primary care and steer potential doctors away from medicine altogether. We also must ensure that the
health care professionals who treat patients are adequately trained to diagnose and treat complex medical conditions and multiple diseases.
Administrative red tape, frivolous lawsuits, and burdensome mandates also need to be identified and removed because they take personnel and financial resources away from patient care.
Plans are being developed to help pay for electronic health records
which may help doctors share data with other providers to eliminate
redundancies, lower costs and increase safety. With the creation of uniform standards, hopefully we will soon have a fully connected and interoperable health information technology network. Until then, mandating
the use of these technologies will waste valuable funds and further complicate the sharing of health data.
Ensuring quality and value is another critical area. We must use comparative information to improve patient care, not simply penalize
providers for non-conformance. Programs which allow patients to know
how well physicians and facilities perform can have the unintended consequence of actually reducing access to care for sicker patients and this is
unacceptable. Policymakers need to recognize that not every patient is
the same and a system that pays to promote “cookie cutter” medicine
will not improve care.
Properly managing expectations is probably the greatest need and
challenge of any healthcare system in the future. Making the tough decisions regarding what our healthcare system can and cannot provide is
the only way we can afford coverage for all. This will be the most difficult
reform measure because it will be the most politically unpopular. Member News
17
Member News
We are proud to announce the
TMA Physician
David Beaird, MD
Murfreesboro, Surgery
William Gibson, MD
Memphis, General Surgery
Melinda Henderson, MD
Nashville, Hospice/Palliative
Medicine, Geriatrics &
Internal Medicine
Roy Kuhl, MD
Alcoa, Family Practice
Matthew Mancini, MD
Knoxville, General Surgery
Leah Patton, MD
Brentwood, Internal
Medicine
“To date, 24 physicians have completed the Physician Leadership College
and they collectively have assumed over 35 volunteer positions since their
involvement with the program. I look forward to seeing what the future
brings for these rising stars in organized medicine.”
--PLC Chair John Ingram, III, MD
18
Member News
Member News
Leadership College
CLASS OF 2010
Kimberly Rosdeutscher, MD
Hermitage, Pediatrics
Andy Russell, MD
Franklin, Emergency
Medicine
Henry Russell, MD
Franklin, General and
Thoracic Surgery
Scott Sadler, MD
Lexington, Family Medicine
Nita Shumaker, MD
Hixon, Pediatrics
Raymond Walker, MD
Bartlett, Family Medicine
The TMA Physician Leadership College was created to offer opportunities for our physician members to gain invaluable experience and training in the core aptitudes to excel in
leadership positions within organized medicine, medical practice and business.
From April 2009-April 2010, these PLC candidates will undergo training sessions in collaboration and influence in the medical environment, decision making and conflict resolution, leadership and communication, and legislative advocacy.
www.medwire.org/leadershipcollege
Member News
19
Member News
T M A
P H O T O
G A L L E R Y
On April 2, TMA President-elect B.W. Ruffner, Jr., of Chattanooga (left photo) was honored in the Tennessee House chamber in
Nashville for his new TMA leadership post, while former TMA President Dr. Nat Hyder, Jr., (right)
was simultaneously honored in the Senate chamber for his life accomplishments on the occasion of his 80th birthday.
Mapping the TMA’s new strategic direction, LBMC
Planning Services Facilitator Jody Lentz (center)
reviews strategy notes from a full-day session with
TMA Board of Trustees members Richard DePersio,
MD, TMA's new president, and Nita Shumaker, MD,
a Chattanooga pediatrician and new president of the
Chattanooga Hamilton County Medical Society.
Stones River Academy of Medicine President Dr. David Beaird presents
a check for $5,000 to Billie Little, executive director of the Discovery
Center in Murfreesboro; the gift, matched by an anonymous donor,
was given in honor of the Center’s commitment to child development
and hands-on learning.
20
Member News
Member News
IIC Commentary: Tight Funds May
Mean More Aggressive RACs
By Jerome W. Thompson, MD, MBA
Chairman, TMA Insurance Issues Committee
The TMA Insurance Issues Committee (IIC) is closely monitoring national health reform, details of which are slowly emerging. A lot is at stake for physicians because money to fund it will
be tight. The Obama administration expects all stakeholders to
contribute to achieve the goal of universal health care. In
Tennessee, we see the results of the TennCare Program and the
massive funding it requires to provide coverage for approximately a quarter of the population.
There are several possible theories being bantered around
as to how the new system will be funded, although logic dictates they all will be tapped to a certain extent. This is because
of the impact of hundreds of billions of dollars spent on the
bailouts and so-called “stimulus package” already this year.
Some of these solutions might include:
•
•
•
Tax increases for individuals and businesses.
Removal of insurance companies’ profit margins.
Reduced reimbursement to all providers combined with
“quality” initiatives like pay-for-performance standards.
Capitol Hill Club
The IMPACT Board of Trustees recognizes the following IMPACT donors
who have become Capitol Hill Club
members in the past month. We
greatly appreciate all IMPACT contributors for their help in assuring that
candidates supportive of organized
medicine receive generous financial
support from IMPACT. To join IMPACT
or the Capitol Hill Club, please contact
Rachel Smith at 800-659-1862 or email [email protected].
I surmise that both government and
Dr. Thompson
commercial payers will resort to more
aggressive means to recover funds from prior insurance payments. As we see with Recovery Audit Contractor (RAC) audits,
those who participate in Medicare will be targeted. Targeting
will be made easier in the coming years because of the shift
from ICD-9 to ICD-10 in 2013. Unless providers precisely code,
auditors will have a field day.
The TMA’s recent member alert regarding HRI auditing on
behalf of self-funded employer health benefit plans also illustrates the point. Physicians who received HRI’s letter proclaiming them guilty of upcoding E&M bills before even a medical
record review got a sour taste of what these audits can do to a
practice in terms of time spent collecting mountains of records
to prove their innocence.
The IIC is committed to bring fairness to the audit process
in order to preserve reimbursement for services we have performed. Like the rating and tiering schemes out there, we must
stand up to the second-guessing going on about the care we
deliver that is claims-based and not a real measure of quality. Lee Berkenstock, MD, Memphis
John Binhlam, MD, Brentwood
Leonard Brabson, MD, Knoxville
Ed Capparelli, MD, Oak Ridge
Charles Cesare, Jr., MD, Jonesborough
Nancy Chase, MD, Memphis
Keith Cryar, MD, Columbia
Steve Dickens, Brentwood
Robert Dimick, MD, Hermitage
Karen Duffy, MD, Madison
Charles Eckstein, MD, Nashville
Don Ellenburg, MD, Knoxville
Charles Goodman, MD, Murfreesboro
Charles Handorf, MD, Memphis
Robert Herring, MD, Nashville
John Ingram, MD, Alcoa
Beth Kasper, Clarksville
Gary Kimzey, MD, Germantown
Roy King, MD, Knoxville
Charles Leonard, MD, Talbot
Keith Lovelady, MD, Manchester
William McKissick, MD, Knoxville
Phyllis Miller, MD, Chattanooga
Edmund Palmer, Jr., MD, Jackson
Avinash Reddy, MD, Jackson
B.W. Ruffner, MD, Signal Mountain
Scott Sadler, MD, Jackson
Nicole Schlechter, MD, Nashville
Orville Swarner, MD, Chuckey
Darlene Vickers, Knoxville
Raymond Walker, MD, Bartlett
Clarence Watridge, MD, Memphis
Charles White, Sr., MD, Lexington
Joseph Wieck, MD, Nashville
Charles Womack, MD, Cookeville Member News
21
Member News
Match Day at TN Medical Schools
The TMA is honored to recognize its student members on their graduation and celebrate their respective matches for residency training:
East Tennessee State University Quillen College of Medicine
Shivon Abdullah - U OK COM, Surg-Prelim/Urol
Saad Al-Khatib - Wake Forest Bapt Med Ctr, Em Med
Terri Alford - Wake Forest Bapt Med Ctr, Int Med
John Beddies - U TN GSM, Surg-Prelim/Urol
BethanyBessom - Greenville Hosp Sys/U So Carolina SOM, Peds
Richard Brooksbank - Palmetto Hlth Richland, Em Med
Ryan Buckley - Wake Forest Bapt Med Ctr, Gen Surg
Emily Campbell - ETSU, Fam Med
Jonathan Columbia - Madigan Army Med Ctr, Trans
Josh Combs - San Antonio USHEC, ObGyn
Carrie Conatser - ETSU, ObGyn
Elizabeth Dabbs - SIU SOM & Affil Hosps-IL, Int Med
Ryan Dabbs - SIU SOM & Affil Hosps, Ortho Surg
Erin Gallagher - ETSU, ObGyn
Jennifer Gibson - ETSU, Peds
Matt Goldman - Wake Forest Bapt Med Ctr, Surg-Gen
Jena Groth - U VA, Psych
Sarah Gustafson - Pitt Co Mem Hosp/Brody SOM, Em Med
Beth Jackson - ETSU, Surg-Gen
Erin Jackson - U VA, Int Med
Lori Kral - U KY Med Ctr, Anesth
Erika Lubsey - Meharry/Metro General, ObGyn
Ryan McAuley - Hosp U PA, Int Med/Peds
Mary McCormick - ETSU, Fam Med
Brad McCormick - ETSU, Fam Med
Lindsay McKnight - Greenville Hosp Sys/U So Carolina SOM, Surg-Gen
Matt Neff – Emory U SOM U SOM, Int Med
Bennett Pafford - UC Davis Med Ctr, Int Med
Stephanie Pierce - U TN COM, ObGyn
Katherine Rochelle – UAB Med Ctr, Peds
Jennifer Sauceman – Wake Forest Bapt Med Ctr, Peds
Kathryn Shipp – Carolinas Med Ctr, Peds
Justin Sigmon – ETSU, Int Med-Prelim; Med Coll Georgia, Derm
David Smith – San Antonio USHEC, Int Med
Keiko Suzuki – ETSU, Fam Med
Rebecca Taliaferro – ETSU, ObGyn
Dwight Willett – John Peter Smith Hosp, Fam Med
Graduating students at the University of Tennessee Health Science Center in Memphis react during Match Day
ceremonies on March 19. Of 136 M4s at UTHSC, 63 will remain at hospitals in Tennessee.
22
Member News
Member News
Meharry Medical College
Alana Anthony – LA St U SOM, Fam Med
Dominique Arce – U TN COM, Trans; Brigham & Women’s Hosp, Anesth
Ronald Atwater – Howard U Hosp, Gen Surg
Angela Bailey – U ILL COM, Em Med
Jabari Capp – U Louisville SOM, Anesth
Candice Chipman – Atlanta Med Ctr, Surg-Prelim
Teethena Cooper – U Chicago Med Ctr, Anesth
Sean Crane – Maricopa Integ Hlth Sys, Surg-Prelim
Crystal Davis – Providence Hosp, Fam Med
Lashea Davis – IN U SOM, ObGyn
Reina Davis – U TX Med Sch, Peds
Irma Fleming – U Chicago Med Ctr-Provident Hosp Cook Co, Gen Surg
Joshua Gilchrist – Baylor Med Ctr, Fam Med
Shannon Glanton – Atlanta Med Ctr, Fam Med
Katherine Glover-Collins – U AR, Gen Surg
Katrina Gordon – OH St U Med Ctr, Fam Med
Darryl Hall – U FL Hlth Sci Ctr, Surg-Prelim
Allison Harriott – SUNY Hlth Sci Ctr, Em Med
Jeffrey Harrow – Los Angeles Co. Harbor–UCLA Med Ctr, Surg-Prelim
Joseph Hayek, Banner Good Samaritan Med Ctr, Gen Surg
Ellen Howard – U TX Med Brnch, Peds
Ahmad Hussain – VUMC, Surg-Prelim
Aisha Jennings - Beth Israel Med Ctr, Em Med
Tiphany Jolly – Albert Einstein COM/Jacobi-Montefiore Med Ctr, Em Med
Erica Jones – U AL SOM, Fam Med
Rachael-Ann Joseph – Kaiser Permanente-Oakland Med Ctr, Int Med
Vernon Mackie – National Naval Med Ctr, Int Med
Joe Mayor – Brooklyn Hosp Ctr-Weill Med Coll Cornell U, Em Med
Scott McIntosh – U OK COM, Gen Surg
Doshandra Newton – Ball Mem Hosp, Psych
Benjamin Nti – IN U SOM, Med-Peds
Jilma Patrick – U FL Hlth Sci Ctr, Gen Surg
Maureen Seitz – Meharry Med Coll/Metro Nashville Gen Hosp, Fam Med
Anthony Simms – St. Luke’s-Roosevelt Hosp Ctr-Columbia U, Gen Surg
Ellana Stinson – Med Coll GA, Em Med
Reginald Tally – U AR, Phys Med & Rehab
Djeunou Tchamba – Med U So Carolina, Int Med
La Nikqua Thomas - Emory U SOM, Em Med
Dominic Tutera – U NM Hlth Sci Ctr, Em Med
Phillip Walton – MA Gen Hosp-Harvard Combined Pgm, Ortho Surg
Eliot Wickliff – Loyola U-Chicago Stritch SOM, Surg-Prelim
University of Tennessee Health Science Center
Alexandria Allen - U TN COM, Int Med
Abdelhamid Alsharif - Jersey Shore U Med Ctr, Med-Prelim
Morgan Anderson - U TN/Bapt-Nashville, Med-Prelim; VUMC, Rad-Diag
Wesley Angel - U TN COM, Rad-Diag
Aditya Bagrodia - U TX, Surg-Prelim/Urol
Benjamin Baker - U TN COM, Em Med
David Bennett - UAMS-AHEC-Jonesboro, Fam Med
Jaclyn Bergeron - U TN COM, Med-Peds
Corey Bolac - Duke U Med Ctr, ObGyn
Prentice Bowman – Wright-Patterson Med Ctr, Int Med
Brian Brotherton – USC, Med-Peds
Joshua Byrd - UCLA Med Ctr, Surg-Prelim; UCLA Sch Med, Urol
Timothy Cahill - John Peter Smith Hosp, Fam Med
Jimmy Carroll - U TN COM, Med-Prelim; Bapt Mem Hosp, Rad-Diag
Aron Chary - U TN COM, Med-Prelim
Amy Cline - U IL COM, ObGyn
Jeffery Cunningham - U TN COM, Med-Peds
Karen Damico - U TN COM, Peds
David Dean - U TN COM, Med-Prelim; Bapt Mem Hosp, Rad-Diag
Vanderbilt M4 Atia Jordan, center, embraces classmate
Jill Richman as her parents, Poritia and Anthony Jordan look on.
Jordan is going to Cincinatti Children’s Hosp.
George Dehoff - U TN COM, Med-Prelim; UAB Med Ctr, Rad-Diag
Evan Dunn - U TN COM, Surg-Prelim/Urol
Jonathan English - U TN COM/JXN, Fam Med
Amber Jo Evans - U TN COM, Trans; OR Hlth Sci U, Anesth
Jennifer Feldhaus – UAB Med Ctr, Peds
Anne Gill – Emory U SOM, Radiology-Prelim/Rad-Diag
Ernest Gray - U TN COM, Trans; Mem Hlth/Univ Med Ctr, Rad-Diag
Stephanie Grissom – St. Louis Children’s Hosp, Peds
Katherine Habenicht - Wake Forest Bapt Med Ctr, Gen Surg
Jennifer Hamm - U TN COM, Peds
Carolyn Hanger – UAB Med Ctr, Anesth
Lauren Harris – USC, Surg-Prelim; U TN COM, Ophthal
Anthony Hollins - U TN COM, Ortho Surg
Anna Hollmann - U Hosps Case Med Ctr, Ortho Surg
Stephanie Holt - U TX Med Sch, Peds
Anthony Huang - U TN COM, Med-Prelim; Loyola Univ Med Ctr, Anesth
Kenneth Illingworth - Dlyd Res/Rsrch
Conrad Ivie - U Hosps-Columbia, Ortho Surg
William Johnson - U TN GSM, Trans/Rad-Diag
Emily Jones - U TN COM, Derm
Benjamin Jordan - U TN COM, Med-Prelim; U FL COM, Rad-Diag
Christopher Joshi - U Hosps-Columbia, Rad-Diag
Michele Kamp - U TN COM, Int Med
Kirk Kleinfeld – VUMC, Med-Prelim/Neurol
Ashley Laing - U TN COM, Trans; U Colorado SOM, Ophthal
Rebecca Lasseter – Children’s Mercy Hosp, Peds
William Laxton - U TN COM, Rad-Diag
Shubin Ling - Med U of SC, Int Med
Monica Lynch - Resurrection Med Ctr, Trans; U TX SW Med Sch, Ophthal
Laura Miller - U TN COM, Int Med
Manal Moustafa - UPMC Med Ed Prog, Peds-Prelim; U Pitt, Child Neurol
Jason Nicely - U TN COM, Em Med
Andrew Nickels – U Chicago Med Ctr, Med-Peds
Ellen O'Shea – Presb Hosp, Med-Prelim; VUMC, Derm
Oluwole Odunusi - Duke U Med Ctr, Int Med
Richard Ogles - U Hosps-Columbia, Rad-Diag
Susan Ore - U TN/Bapt Hosp, Int Med
Jashmin Patel – UAB Med Ctr, Int Med
Manish Patel - U TN COM, Med-Prelim; UAB Med Ctr, Rad-Diag
Minesh Patel - U TN COM, Med-Prelim; U TX SW Med Sch, Rad-Diag
Neil Patel - U TN COM, Rad-Diag
(Cont.)
Member News
23
Member News
(Cont.)
Ahmad Hussain accepts his residency match at
Meharry Medical College’s Match Day 2009.
Elena Paulus - U TN COM, Gen Surg
Ryan Peterson - Emory U SOM U SOM, Rad-Prelim/Rad-Diag; VA
Commonwlth U Hlth Sys, Med-Prelim/Rad-Diag
Sirinya Prasertvit - U TN COM, Gen Surg
Katherine Privratsky - U TN COM/STF, Fam Med
Fielding Randolph - U TN COM/JXN, Fam Med
Priya Sahu - U TN COM, Trans; Mt Sinai SOM, Ophthal; UNC SOM, Surg-Prelim/Urol
Emerson Sharpe - Exempla St. Joseph Hosp, Surg-Prelim; U CO SOM, Rad-Diag
Denil Shekhat - U TN COM, Med-Prelim
George Sinclair – UMDNJ-NJ Med, Neurol Surg
Anju Singhal - U Hosp-Cin, Med-Peds
Brad Stair - U TN COM, Int Med
Mildred Stinson - U TN COM/JXN, Fam Med
Erin Stover - Carolinas Med Ctr, ObGyn
Charles Sutton - John Peter Smith Hosp, Fam Med
James Truett - U TN COM/JXN, Fam Med
Peter Vu - U TX SW Med Sch, Anesth
Justin Walker - Palmetto Hlth Richland, Ortho Surg
Amelia Watkins - U MD Med Ctr, Gen Surg
Geoffrey Watson - U Hosps-Jackson, Ortho Surg
Christopher Waynick, U KY Med Ctr, Em Med
Xin Wei - Naval Med Ctr, Int Med
Eric Weirich - Mayo Sch GME, Trans/Anesth
Katherine Wells – VUMC, Med-Peds
Jonathan Whaley - Hosp U PA, Rad Onc
Nathan Wilds - U TN COM, Med-Peds
Katie Williams - U Hosps-Jackson, Med-Prelim/Ophthal
Frederick Wittber - Riverside Reg Med Ctr, Trans; Bapt Mem Hosp, Rad-Diag
Aaron Wolfe - U TN COM, Gen Surg
Emily Wolfe - Ochsner Clinic Found, Gen Surg
Joshua Worthington - U TN COM, Gen Surg
Jason Yaun - U TN COM, Med-Peds
Matthew Zak - Eisenhower Army Med Ctr, Trans
Vanderbilt University School of Medicine
Vivek Agarwal – Cedars-Sinai Med Ctr, Int Med
Jose Alvarado – VUMC, Peds
Douglas Anderson – Emory U SOM, Gen Surg
Brigham Au – U TX SW Med Sch, Ortho Surg
Desi Banani – OH St U Med Ctr, Anesth
Cole Barfield – VUMC, Int Med
Ellika Bartlett – U Wash Aff Hosps, Peds
24
Member News
Jo Ellen Bennett – VUMC, Psych
Charlotte Brown – VUMC, Peds
James Carlucci – VUMC, Med-Peds
Emily Castellanos – VUMC, Int Med
Jason Castellanos – VUMC, Gen Surg
Jonathan Chrispin – Johns Hopkins, Int Med
Ross Coleman – U Mich Hosps, Neurol
Andrew Conrad – VUMC, Surg-Prelim; Med U So Carolina, Rad-Diag
Bradley Corr – Hosp U Penn, ObGyn
Samuel Crosby – VUMC, Ortho Surg
Catherine Dale – VUMC, Gen Surg
Rebecca Dezube – Johns Hopkins, Int Med
Brian Drolet – RI Hosp/Brown U, Plast Surg
Sarah Dunn – VUMC, Surg-Prelim
Matthew Emanuel – Arrowhead Reg Med Ctr, Trans; Emory U SOM, Ophthal
David Frank – Children’s Hosp-U Pennsylvania, Peds
Marc Gauthier – U Pitt Med Ctr, Int Med
Sweta Ghodasara – U Wash Aff Hosps, Med-Prelim
Abigail Gilbert – Maine Med Ctr, Med-Peds
Nina Glass – NYU Sch Med, Gen Surg
Bryan Harris – VUMC, Int Med
Josh Heck – VUMC, Surg-Prelim; Rad-Diag
Megan Herceg – VUMC, Ortho Surg
John Humphrey – Lahey Clinic Med Ctr, Surg-Prelim/Urol
Atia Jordan – Cin Children’s Hosp, Peds
Caroline Kim – VUMC, Surg-Prelim
Caroline Knox – St. Mary’s Hosp, Fam Med
David Leiman – Hosp U Penn, Int Med
Brenessa Lindeman – Johns Hopkins, Gen Surg
Ronald Loch – Scripps Mercy Hosp, Trans; Barnes-Jewish Hosp, Rad-Diag
Johnny Lu – VUMC, Peds
Laura Meints – Barnes-Jewish Hosp, ObGyn
Alexandra Mieczkowski – U Pitt Med Ctr, Med-Prelim
Shamaal Miller – NY Presb-Weill Cornell Med Ctr, Anesth
Arthur Moore – May Sch GME, Neurol
Nizar Mukhtar – UCSF, Int Med
Mark Newton – U IA Hosps and Clinics, Surg-Prelim/Urol
Megan O’Neill – VUMC, Med-Prelim; Derm
Rina Patel – U Chicago Med Ctr, Rad-Diag
Michael Paxten – Baylor Coll Med, Ortho Surg
Jim Phillips – UAB Med Ctr, Otolar
John Pitts – Emory U SOM, Med-Prelim/Phys Med Rehab
Sofie Rahman – Wash Hosp Center, Em Med
Vernon Rayford – Mass Gen Hosp, Med-Peds
Jill Richman – McGaw Med Ctr of NW U, Gen Surg
Liz Rinker – VUMC, Path
Sara Risner-Adler – U TX Med Sch, Trans; Baylor College of Med, Derm
Kim Sandler – VUMC, Med-Prelim; Rad-Diag
Stephen Stahr – U ND, Med-Prelim; U of North Carolina Hosps, Derm
Jillian Tsai – U TX Med Sch, Med-Prelim; U of TX MD Anderson Cancer
Center, Rad-Onc
Jose Vitale – St. Louis Children’s Hosp, Peds
Michelle Walther – VUMC, Em Med
Durham Weeks – Hosp Special Surg, Ortho Surg
Jill Wilmoth – OH St U Hosp Program, Ortho Surg
John Wood – Jackson Mem Hosp, Otolar
Jordan Yokley – Tripler Army Med Ctr, Trans
Naomi Yoo – Yale-New Haven Hosp, Path
David Young – VUMC, Psych
Michael Young – VUMC, Int Med
Member News
TMA's 174th Annual Meeting
(Continued from page 15)
care (EMTALA), and to enhance TMA resources on
electronic health records and personal health records
were referred to the Association’s Board of Trustees for
further study and action.
Other Action - Meanwhile, the HOD rejected proposals to protect the titles of “doctor,” “resident” and
the term of “residency” for use only by those in the
medical, dental or podiatric fields or training programs,
and to oppose any restrictions on availability of nonFDA-approved pharmaceutical agents to treat HIV and
oncology patients. Complete text of these resolutions
is available online at www.medwire.org.
NEW LEADERS
Delegates to the annual meeting also finalized the
installation of other new TMA leaders:
• Dr. B.W. Ruffner, a Chattanooga oncologist
and internal medicine specialist, will serve as
president-elect for 2009-2010.
• Dr. Robert A. Kerlan, a gastroenterologist from
Memphis, will serve as chairman of the TMA
Board of Trustees for the next three years
TMA House delegates listen as State Finance & Administration Commissioner
Dave Goetz explains the impact of state cutbacks and federal stimulus dollars
on programs to advance health information technology in Tennessee.
New members selected to serve three-year terms on
the TMA Board of Trustees are:
• Dr. Channappa Chandra, Chattanooga;
orthopaedic surgeon
• Dr. Roy King, Knoxville; pathologist/
dermatopathologist
• Dr. Matthew L. Mancini, Knoxville; general
surgeon
• Dr. Charles E. Leonard, Talbott; family medicine
• Dr. Edmund T. Palmer, Jackson; internal medicine specialist
• Dr. Charles T. Womack, Cookeville; urologist
• Dr. Michael D. Zanolli, Nashville; dermatologist
LEAPS CONFERENCE
MedTenn 2009 saw the first in a series of regional
meetings bringing the law enforcement and prescriber
communities together to address Tennessee’s prescription drug problem. Some 50 attenders from the midstate area gathered to share their perspectives on prescription drug abuse and misuse, “doctor shopping,”
new drug-seeker scams and new technology that will
hopefully aid in reducing the problem. Additional sessions were scheduled for April 16 in Jackson and May 7
in Knoxville. Coinciding with MedTenn 2009 was the first of three regional LEAPS
sessions, bringing law enforcement officers and prescribers together to
cooperate on Tennessee’s prescription drug abuse problem.
Member News
25
Member News
MEMBER NOTES
Rieta Agarwal, MD, MBA, MS, and her husband Dr.
Rajesh Agarwal, an associate professor of Computer
Information Systems at Middle Tennessee State
University, donated $10,000 for disaster relief aid for victims of recent tornados that swept through Rutherford
County. Board certified in internal medicine, Dr. Agarwal
also offered medical care at her practice, Good Health
Associates, PLLC, and housing for those displaced from
their homes. Members of the Rutherford County legislative delegation joined her effort, donating $1,000 each
to a fund for local tornado victims.
John J. McGraw, MD, of
Jefferson City, was elected by
the Southern Orthopaedic
Association to the Board of
Councilors (BOC) of the
American
Academy
of
Orthopaedic Surgeons. He joins
two Tennessee Orthopaedic
Society
representatives,
Thomas Currey, MD, of Chattanooga and Robert Miller,
MD, of Memphis, on the BOC. Dr. McGraw is a partner
with the Knoxville Orthopaedic Clinic and recently
completed 18 months as chief of staff of St. Mary’s
Jefferson Memorial Hospital.
Wiley T. Robinson, MD, , of
Memphis, has earned the
Fellow in Hospital Medicine
designation from the Society of
Hospital Medicine. The honor is
bestowed on Society members
who have distinguished themselves among their colleagues
and the hospital medicine specialty. Dr. Robinson, president of Inpatient Physicians of
the Mid-South, is a former president of The Memphis
Medical Society and former secretary of the MMS
Board of Trustees; he has served on MMS’ Grievance
and Ethics committees and chaired the Membership
committee. He served on the TMA Board of Trustees
from 1997-2000, has been a TMA delegate since 1998
and is currently the speaker for the TMA House of
Delegates. Are you a TMA member who has been recognized for an
honor, award, election, appointment or other noteworthy
achievement? Send items for consideration to Member
Notes, Tennessee Medicine, 2301 21st Ave. South, PO
Box 120909, Nashville, TN, 37212; fax 615-312-1908;
e-mail [email protected]. High resolution (300
dpi) digital (.tif or .eps) or hard copy photos welcome.
26
Member News
PRACTICING MEDICINE
Health IT Stimulus Dollars
Available to TN Hospitals,
Physicians
BY DAWN FITZGERALD
T
he pressure is on for states and providers to adopt health information technology and the recently-passed economic stimulus
package provides at least partial funding.
Under the American Recovery and Reinvestment Act (ARRA),
approximately $19 billion has been allocated to Medicare and
Medicaid programs for the purpose of increasing reimbursements
to hospitals and physicians who become meaningful electronic
health record (HER) users. Under the Medicare program, if a physician or hospital becomes a meaningful EHR user after 2014, they
are not entitled to any incentive payments.
MEDICARE, MEDICAID INCENTIVES
To become a meaningful EHR user and qualify for full
payment of stimulus dollars, Medicare providers must
demonstrate that they are using certified EHR technology. The technology must be connected in a manner
that provides for the electronic exchange of
health information to improve the
…Only 1.5 percent of
hospitals nationwide use
an EHR and the number
is in line with Tennessee
hospital implementation.
TENNESSEE MEDICINE / MAY 2009
27
PRACTICING MEDICINE
quality of health and they must
submit information on clinical
quality measures.
Incentives will begin in
2011, with those achieving
meaningful adoption receiving
incentives for up to five years.
The maximum available for those
qualifying in 2011 is $44,000.
After 2014, anyone who treats
Medicare patients without an
EHR will see reimbursements
decrease by one percent that
year; the pay cut grows to two perDawn Fitzgerald
cent in 2016 and three percent in
2017 and every year afterward.
Last year, Congress applied the same carrot-and-stick
approach to e-prescribing in the Medicare Improvements for
Patients and Providers Act of 2008 (MIPPA). Those who e-prescribe in 2009 and in 2010 qualify for a two-percent raise
based on their total Medicare revenue. The bonus decreases to
one percent in 2011 and 2012, to 0.5 percent in 2013, and
then disappears (physicians who receive the EHR bonus cannot
receive the e-prescribing bonus). MIPPA also imposes a onepercent penalty on physicians who do not begin e-prescribing
by 2012. The penalty increases to 1.5 percent in 2013 and to
two percent in 2014 and beyond.
Details of the Medicaid health IT dollars are not as clear
but under the Medicaid incentive program, a larger group of
medical professionals is eligible for the funds as long as they
serve a sufficient percentage of Medicaid patients. Unlike
Medicare, which only funds doctors and hospitals, eligible professionals under Medicaid include a physician, dentist, certified nurse mid-wife, nurse practitioner, and a physician assistant serving in rural health clinic or federally qualified health
center. Medicaid payouts are also more significant. Across five
years, practitioners could collect a sum total of $64,000 —
calculated as 85 percent of EHR purchase costs not exceeding
$25,000 in the first year, followed by 85 percent of the annual maintenance costs not exceeding $10,000 for the next five
years. To be eligible for the Medicaid incentive payout, physicians must have a 30-percent Medicaid patient case threshold
or 20 percent for pediatricians.
HIT USE IMPROVING
According to a U.S. Department of Health and Human Services
report, only 1.5 percent of hospitals nationwide use an EHR
and the number is in line with Tennessee hospital implementation. However, e-Prescribing or eRx (the ability to electronically order prescriptions) use in Tennessee has increased by 749
percent since 2006. During 2008, 1,950 Tennessee healthcare providers issued 1.5 million electronic prescriptions, representing three percent of all prescriptions written in the state.
“The sheer number of e-prescriptions speaks volumes to
the potential for physicians and hospital that have yet to implement an EHR,” said Jennifer McAnally, Health Information
Technology Program manager for QSource, Tennessee’s
Medicare Quality Improvement Organization. “In this instance,
time literally is money. The longer a hospital or physician
chooses to wait to implement HIT, the less money they could
receive. QSource has helped 300 of physician offices implement an EHR and e-prescribing,” she added.
Hospitals and physicians interested in learning more
about the Medicare physician HIT stimulus program can contact McAnally at [email protected] or 800-528-2655,
ext. 2635. Ms. Fitzgerald is chief executive officer of QSource, an independent, not-forprofit healthcare consulting firm holding multiple state and national government contracts with offices in Memphis, Nashville and Little Rock, AK. Under
a contract with Centers for Medicare & Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services (DHS), QSource provides
healthcare quality improvement collaborative opportunities for the providers,
practitioners and managed care plans that care for more than 900,000
Medicare beneficiaries in Tennessee. Learn more at www.qsource.org.
Tap into TMA eHealth Resources online at www.medwire.org.
Click on "Member" and then "eHealth Resources.
28
TENNESSEE MEDICINE / MAY 2009
PRACTICING MEDICINE
Can the Obama Stimulus Plan
Jump-Start the EMR? BY BRUCE TAFFEL, MD
ess than 100 days into his
presidency, Barack Obama
may have ushered in the longawaited era of information-driven
health care delivery, led by the proliferation of electronic medical
record technologies and the “electronic exchange of health information” among stakeholders “to
improve the quality of health care.”
The Obama Stimulus Plan, also
known as the American Recovery
and Reinvestment Act (ARRA) of
2009,
allocates $2 billion in disDr. Taffel
cretionary health IT funding
through the Office of the National Coordinator for Health
Information Technology (ONCHIT) plus $18 billion in investments
and incentives through Medicare and Medicaid. Beginning in
2011, those incentives will include payments to physicians of
between $44,000 and $64,000 over five years to implement a certified EMR (the language used in the bill to describe EMR technologies is “EHR”) – and use it in a “meaningful” way. Practices
that don’t implement a certified EHR technology by 2014 will see
their Medicare reimbursement cut by up to three percent.
“Meaningful use” is described in the legislation as:
• Using certified EHR technology that includes electronic prescribing
• Using EHR technology that allows electronic
exchange of information to promote care coordination
• Reporting on clinical quality measures (TBD)
L
There are several caveats: a full definition of “meaningful use” has
not yet been fully articulated, and may be interpreted independently by the states, the term “certified EHR technology” has yet to be
determined by the Secretary of HHS, and the National Coordinator
is to identify “certification entities” in consultation with the Director
of the National Institute of Standards and Technology (NIST).
A second ARRA provision, the electronic exchange of information, paves the way for the creation and expansion of Health
Information Exchanges (HIEs), which are intended to overcome the
deficiencies inherent within our currently fragmented and siloed
delivery system. HIEs will promote enhanced coordination of care
amongst clinicians, ambulatory and inpatient facilities, referral centers, payers, employers, and consumers. Here in Tennessee we have
already seen the benefits of HIE. (At Shared Health®, we have documented clinical, workflow and economic benefits directly attributable to Shared Health’s HIE.) Viewed as related technologies, the EHR
and HIE lay the regional and community groundwork for the muchanticipated, overarching National Health Information Network. Think
of it this way: the EHR provides the 360-degree clinical view of the
patient, and the HIE establishes a community of care for that patient.
ARRA may turn out to be
just what the doctor
ordered for the healthcare
industry – an economic jolt
that finally pushes EHR
technology adoption to the
tipping point.
Gaining access to ARRA’s stimulus dollars will require careful planning to avoid some of the pitfalls that have stymied EHR adoption
in the past. Selecting the right EHR technologies in terms of intraorganizational functionality, usability, and interoperability is fundamental. However, these decisions become increasingly daunting in
an environment where current applications will certainly change and
new types of products and services will emerge to meet the forthcoming guidelines for meaningful use and certification. In addition
to all the complexities providers must consider in evaluating a system purchase, there is another layer to the decision process: data
sharing and data integration capabilities. It is more than just a question of meeting the ARRA data exchange incentive criteria – it’s also
about thinking through the technology, compliance, security and
business implications of selecting the optimal solution.
ARRA may turn out to be just what the doctor ordered for
the healthcare industry – an economic jolt that finally pushes EHR
technology adoption to the tipping point. With a community-based
data exchange infrastructure and new functionality to accommodate a changing delivery system, EHRs may finally be ready to
transform care and create a value proposition that finally trumps
isolated and fragmented paper records. Doctors must thoroughly
understand not just ARRA but the dramatically changing environment the bill represents. Acting wisely during this period of transition will require nimble, collaborative, creative thinking and
careful assessment. A well-placed health information technology
strategy will help put providers in a position to lead health care’s
quantum leap into an era of improved value, safety and quality. Dr. Taffel is vice president and chief medical officer of Chattanooga-based Shared
Health, one of the nation’s largest public/private Health Information Exchanges.
TENNESSEE MEDICINE / MAY 2009
29
PRACTICING MEDICINE
Tennessee’s HIT Efforts Unaffected
by Budget Shortfalls: An Interview
with Comm. Dave Goetz BY BRENDA WILLIAMS
s Tennessee deals with the
challenges of a struggling
economy and a rapidly
changing healthcare environment,
state officials say they are working
to maintain the overall commitment to encouraging and implementing new electronic health
technologies. New funding from
the American Recovery and
Reinvestment Act of 2009
(ARRA) will help stave off some of
the dramatic budget cuts the
state was facing and includes
Commissioner
some monies for the advancement
Goetz
of health information technology
(HIT), to include competitive
grants and loans to physicians and other healthcare providers.
Tennessee Medicine recently talked with State Finance &
Administration Commissioner Dave Goetz about the TMA’s concerns about budget shortfalls affecting TennCare, and the
impact of cuts and new federal dollars on HIT programs.
A
TM: We’ve heard so much about Tennessee’s budget shortfalls;
how will those impact the state’s eHealth Initiative and e-prescribing efforts?
Comm. Goetz: The budget does not impact existing programs
we have for e-prescribing. That money’s already been set aside,
so anyone who has a grant approved, we’ll still have to process
it but that will not be affected. Let me be clear about that.
TM: So what is the state of Tennessee’s budget for 2010?
Comm. Goetz: Broadly we’re a billion dollars down or will be by
the end of this year, so it just affects everything that we do. In
essence what that means is we had originally prepared a budget that just made the cuts necessary to balance the budget. But
then the federal act passed and changed the landscape to
where we are going to use the federal funds on a temporary
basis to get us through the next year to two years. We will still
have to make the reductions but have a longer time over which
to make them. The budget artifice, if you will, is to have
reduced the recurring appropriation and added back non-recurring money, in order to allow this temporary replacement of
funding until the cuts have been implemented. So we are still
going to make the reductions, we just get a little bit more time
over which to do those. It delays having to do layoffs, delays
having to take personnel action, and it gives us the ability to
30
TENNESSEE MEDICINE / MAY 2009
maybe manage our way though this slowdown with attrition and
other means to save money that could lessen the severity overall, particularly as it affects people.
TM: How will the budget shortfall affect TennCare? You spoke to
the TMA Board of Trustees last fall and said reimbursement cuts to
TennCare providers would be a “worst-case scenario.” (The TMA
has since heard about a possible seven-percent reimbursement
reduction.)
Comm. Goetz: We will be making some reductions in TennCare,
but we’re hoping not to make the fullest level. If we had to go
to the full level, it would involve a rate reduction to providers;
that’s something we were hoping to avoid and I still think that’s
the case. The cost of TennCare reductions is $100 million, and
that will come largely in contracts outside of the direct provision of care – such as computer services, etc.
TM: How is Tennessee using its share of the ARRA stimulus package, and how much money will the state be receiving?
Comm. Goetz: Broadly we’re using it again to temporarily
replace the loss of state funds. The total amount is right at $5
billion, but for now only about $2 billion affects state expenditures, and the bulk of it is to shore up education – higher education in particular – and health care. For health care we’ve
earmarked $256 million.
TM: How much of that will go to health information technology
(HIT)?
Comm. Goetz: Nationally there’s $32 billion; in Tennessee it
will depend on how good a job we do getting people prepared
to draw down the money and how much they want to do that.
We could get more than our share. It’s not one of those things
given out by a formula, but if we’re successful in helping people to get ready for it, it’s possible we can draw down more
than our share. There’s no figure on it; it’s a competitive grant.
On the health IT piece, we very much want to work with
doctors and hospitals and do this in a way that makes sense
so that it actually improves care at the point of care, as
opposed to just becoming a burden. That is something we’re
committed to doing. We’re going to be making several applications for funds and then for administrative purposes to
assist people in preparing for this, to pay for connectivity, to
kind of plow the ground, if you will, before the grants directly
to doctors and providers start in 2011. There’s a lot of work to
be done now and then to be sure this is being done in a way
that make sense.
PRACTICING MEDICINE
TM: there are still a lot of issues to be resolved with health IT. These
systems are expensive, there are some discouraging reports that
other parties benefit more than doctors do from these transitions,
even though they bear all the cost, and there is still the issue of
incompatibility – not all these systems can talk to each other yet.
Comm. Goetz: I think what we have to do is sit down and join
arms to work together. We’re not selling a product from the
state side, we’re trying to make sure a solution is found that
works for doctors and hospitals and everybody else. I think
there are ways we can work together to make sure that we have
a successful implementation here in Tennessee, so that systems can talk to each other. While there are going to always be
burdens in any change like that, we can make them as light as
possible and help people make the best decisions.
For more information on Tennessee’s e-Health Initiatives,
including e-prescribing, connectivity and grant opportunities,
log on to www.tennesseeanytime.org/ehealth. For more on federal funds available to stimulate the adoption of HIT, click on
the “ARRA and HIT in Tennessee” link or go directly to
www.tennesseeanytime.org/ehealth/Recovery.htm. I
Comm. Goetz addressed the TMA House of Delegates in
April on the topic of state budget reductions and health
information technology.
TENNESSEE MEDICINE / MAY 2009
31
PRACTICING MEDICINE
Loss Prevention Case of the Month
Good Offense is the Best
Defense
B y J . K e l l e y Av e r y, M D
he patient, a 45-year-old mother of two,
was seen by the local ob/gyn upon referral
from the local health department.
Examination and ultrasound revealed the patient
was several weeks pregnant with twins. The medical history revealed a psychiatric diagnosis with
use of multiple medications. The ob/gyn referred
the patient to the academic center for evaluation
and assessment for managing what was assumed to
be a high-risk pregnancy.
The patient was evaluated by the center
and seen in follow-up several weeks later. At 20
weeks, following a visit to the center, the local
ob/gyn was sent a letter that was reassuring,
stating that the non-stress tests on each twin
were acceptable; however, it recommended
bed rest for the patient, cautioned about an
elevated blood pressure and suggested repeat
stress tests in about two weeks. When the stress
tests were repeated locally, the ob/gyn returned
the patient to the center because of some
abnormal findings.
At this point, the center recommended the
babies be delivered at its site because of the highrisk nature of the pregnancy and the rising blood
pressure. The patient returned to the center at 36
weeks as recommended for follow-up. The studies
revealed that Twin A was not growing as expected.
The center suggested induction of labor should be
done within a few days and again recommended
delivery at their site.
The local ob/gyn felt as though the babies could
be delivered locally and so notified the center. The
patient told her local doctor that she was to enter the
center for the induction of labor; however, on Friday
her blood pressure began rising and she was admitted to the local hospital. Over the weekend the blood
T
32
TENNESSEE MEDICINE / MAY 2009
pressure continued to rise, leading to placental
abruption and fetal jeopardy.
There was some difficulty in maintaining
fetal monitoring. Twin A was monitored internally and Twin B externally. Twin A was delivered vaginally in good condition. The physician
sent the C-section team home after Twin A was
delivered. However, Twin B’s fetal heart rate
became erratic and dropped significantly. The
C-section team was ordered to return and Twin
B was delivered an hour later with Apgars of 1
at 1 and 4 at 5. Twin B was transferred to the
academic center for care.
Twin B has had developmental problems
with significant medical expenses. The patient
alleges that she had been unable to work
because of the medical demands of Twin B. The
patient filed suit charging that the delay in delivery led to the disabilities and expenses.
LOSS PREVENTION COMMENTS
Any time there is a “bad baby,” there is the tendency to look for a medical mishap. It is necessary to
have a good offense in the form of documentation
to support the standard of care. When a claim is
filed, the medical records and opinions from
experts in the field become the source of information and influence the decisions. Was the bad outcome a direct result of the delay in delivery? Had the
physician discussed the risks apparent in this pregnancy based on the patient’s age and then with the
pregnancy-induced hypertension with the patient?
There is no documentation of detailed consent discussion. There is no record of treatment of the
hypertension.
In this case, there was the decision to admit the
patient to the local hospital when there was the
option of going to the academic center. The local
ob/gyn had sent the patient there for advice and
opinion. The patient stated after filing the lawsuit
that she felt she had no choice but to stay at the local
hospital. After Twin A (the smaller twin) was delivered, the doctor sent the surgery team home. Why?
There was difficulty with the monitoring equipment.
The non-stress tests done locally were of poor quality. The tracing on Twin B was unreadable. It is hard
to defend a physician without the data.
The alleged “delay in delivery” might not
explain the developmental problems. On the
positive side, the decision to time of incision was
20 minutes, which was well within the guidelines. The cord pH was 7.262. Umbilical cord
blood pH and acid-base balance is most useful in
association with the delivery of an infant with a
low APGAR score. There should have been no
problem delivering in the local hospital. The
infant has improved steadily.
This case lacked the documentation to fight
a good offense. High risk pregnancy, poor communication between the physician and the patient
and her family, lack of documentation about the
consent process, and hard-to-read progress
notes and tracings led to a settlement in this case
in the low six-figures. The experts felt there was
only about a 35-percent chance of winning if the
case went to trial. Dr. Avery is a consultant with State Volunteer
Mutual Insurance Company, Brentwood.
The Case of the Month is taken from actual
Tennessee closed claims. An attempt is made to
fictionalize the material in order to make it less
easy to identify. If you recognize your own case,
please be assured that it is presented solely for
emphasizing the issues in discussion.
SPECIAL FEATURE
Red Flag Rules – Are You
Ready?
B y J o h n D . F i t z g e r a l d , J r. , J D
ou think you run a good medical clinic.
Files are protected and personal identifier
information, known collectively as
Electronic Personal Health Information (EPHI)
or Electronic Personal Financial Information
(EPFI), is coded and kept separately, but how
about that laptop with patient billing and other
financial data that you took home last night? Did
you think to make sure it was password protected? Do you regularly change passwords? Do you
use security questions that would not normally be
known to a hacker? Better yet, do you refrain from
downloading such data on laptops or other
portable devices altogether? These safeguards
should already be a part of your daily routine, but
do you have them written down for office staff?
Examples of high risk situations where data might
be stolen include:
Y
• A home health nurse collecting and accessing patient data using a PDA or laptop during a home health visit;
• A physician accessing an e-prescribing
application on a PDA while out of the office
to respond to patient requests for refills;
• A health plan employee transporting backup enrollee data on a media storage device
to an offsite facility.
The U.S. Department of Health and Human
Services has already published guidance for compliance with the Health Insurance Portability and
Accountability Act (HIPAA) to minimize this risk.1
However, since medical practices and other
healthcare settings may maintain financial data on
their patients and may extend them credit by
billing third parties first, they may qualify as creditors for purposes of the Fair and Accurate Credit
Transactions Act.2 As the potential for theft of that
data is real,
a) Are you protecting your systems?
b) Do you conduct training sessions with
new employees and refreshers for established ones?
c) Do you review procedures periodically?
d) What if your data systems are compro-
UPDATE FROM TMA GENERAL COUNSEL YARNELL BEATTY:
“The AMA and TMA are still advocating fiercely against the applicability of the Red Flag
Rules. We continue to use all avenues to stop yet another government overreaction and
unfunded mandate. With this kind of administrative malarky being forced down physicians’ throats, why are people sitting up in Washington and wondering why our healthcare system is in crisis – as if HIPAA wasn’t enough? In the meantime, it is my personal
mission to help every TMA member come into compliance with these rules by developing
a template TMA members can adapt to their particular practice. You can find AMA information at www.ama-assn.org/ama1/pub/upload/mm/368/red-flags-rule-policy.pdf
and ours on the TMA website, both as a topic in the online Law Guide and as an Alert in
the Insurance Resource Center at www.medwire.org/irc.”
mised, resulting in financial identity theft
and fraud? What do you do immediately?
What should you have in place already?
These questions are all addressed by new regulations called the Red Flag Rules, recently published
by the Federal Trade Commission. The rules
implement federal laws about certain businesses.3
Those that extend credit and keep financial data on
clients and use credit reports will be required to
secure that data from unauthorized access. They
will also be required to watch for possible identity
theft situations that should raise “red flags;” hence,
we call these the “Red Flag Rules.” The
Commission stated that these rules apply to certain
healthcare providers. These rules were to take
effect on November 1, 2008, but due to confusion
about who has to comply, the credit and financial
data portion of the rules were postponed until May
1, 2009. Assuming the worst – that these rules will
apply to your practice – it would be a good idea to
set up procedures for compliance.
The proposed rules are detailed and refer in
part to financial companies. However, Appendix A
and its supplement offer guidelines which may be
found at 16 Code of Federal Regulations 681.
These guidelines as applied to healthcare deliverers may be summarized, but not limited to, the following:
1. Verify the accuracy of all identifying financial data on patients.
2. Flag any suspicious or duplicative entries.
3. Note and follow up on any billings returned
as undeliverable, especially if participating
in a credit reporting service.
4. Report any obvious breach of EPHI or EPFI
data to the patient immediately, e.g. theft of
laptop or other office device containing
data or reports from laboratories and third
party providers of theft of such data.
5. Require that all third-party service
providers have these safeguards in place.
6. Initiate and maintain, at least annually, a
report to management on the security program undertaken and the incidents of data
theft which were experienced or avoided,
i.e. devices stolen but not compromised,
attempts to hack into office server, etc.
7. Maintain periodic review and training pursuant to guidelines set up in the program
for staff compliance.
8. Periodically require new pass words and
security questions for all data access by
office personnel.
9. Purge all files of outdated financial information.
10. Do not keep credit or debit card on file,
even in encrypted form, after the financial
obligation has been satisfied.
You should consult an attorney before implementing these provisions to insure that all practice
issues have been covered for your particular
(Continued on next page)
TENNESSEE MEDICINE / MAY 2009
33
SPECIAL FEATURE
TN Property Tax Due
on Physician Drug
Inventories
Kirk Low
Brett Carter
B y K i r k L o w, J r. , C PA , a n d B r e t t R . C a r t e r, E s q .
octors and other healthcare
providers should be aware that yearend inventories of drugs are subject
to the Tennessee personal property tax
based on a little-known 2003 ruling issued
by the State’s property tax board. In that ruling, the board concluded that prescription
drugs and medicines stocked by a Memphis
dialysis clinic for patient use were not inventories of merchandise held for sale and were
therefore subject to Tennessee property tax.
The ruling highlights the unique interplay
between Tennessee’s property tax and the separately imposed, local business license tax,
which taxes sales of tangible property and most
services. The property tax exempts inventories
that are held for sale, provided the sale of inventory is subject to the business license tax. As a
result, sellers of tangible goods typically do not
pay the property tax on inventories. Healthcare
providers, on the other hand, are service
providers, and the business license tax includes
a specific exemption for medical, dental, and
other health services providers, including
providers of sanitorial, convalescent and rest
home care. In the ruling, the board ultimately
concluded that because the dialysis clinic was
exempt from the business license tax it was not
D
“subject to the business tax” and, therefore, had
to pay property tax on the prescription drugs.
Paying personal property taxes on yearend inventory is definitely preferable to being
subject to the business tax for most doctors.
As an example, assuming a doctor in
Memphis, which has one of Tennessee’s highest property tax rates, has an inventory of
drugs of $100,000 on January 1, the assessment date, and administered $2 million of
drugs during the previous year, the property
tax would be approximately $2,187 as compared to a business license tax of $7,500.
There is some opportunity for doctors to
lower personal property taxes on these prescription drugs and other medical supplies by
reducing inventories on hand on January 1 of
each year – the date local jurisdictions use as the
measurement date for the value of tangible personal property that is subject to tax. This may not
be a realistic option for some doctors considering the holidays and the possibility that new shipments of prescription drugs after the first of the
year could be delayed due to inclement weather.
However, it is worth discussing with providers.
Maintaining adequate records of inventory on
January 1 is also essential as auditors will often
attempt to use average inventory levels to deter-
mine the tax in the absence of sufficient records.
Ultimately, this is an issue that may not be obvious to many tax return preparers filing personal
property tax returns, especially considering the
board’s decisions are not easily accessible. As this
is a topic state auditors will raise during routine
property tax audits of medical service providers,
extra care should be taken when evaluating drug
inventories to avoid unnecessary assessments.
If your practice has already filed its property tax schedule for 2009, the schedules for
Tennessee business property taxes may be
amended until August 31, 2010. I
Mr. Low is a manager with Carr, Riggs and
Ingram, LLC, a regional CPA firm with offices
in Tennessee, Alabama, Florida, Georgia and
Mississippi. He specializes in state and local
taxation. He may be contacted at 615-6651811 or by e-mail at [email protected].
Brett Carter is a partner with Waller
Lansden Dortch & Davis, PLLC, of
Nashville, Los Angeles, CA, and
Birmingham, AL. He practices primarily in
the area of state and local tax controversy
and state tax planning and can be contacted at 615-850-8762 or by e-mail at
[email protected].
Red Flag Rules
(Continued from previous page)
organization. Remember the proposed effective
date for enforcement compliance set by the Federal
Trade Commission was May 1, 2009. I
References:
1. It should be noted that the Department of Health and Human
Services provided this guidance to healthcare providers in
2006 in order to avoid the compromise of health data.
Guidelines published then are attached to this article as
Appendix A. The purpose of the Red Flag Rules is to guard
against compromise of financial data. Guidance for health-
34
TENNESSEE MEDICINE / MAY 2009
care practices regarding possible financial data breaches is
contained in the proposed rules discussed herein.
2. Fair and Accurate Credit Transactions Act of 2003, 72 Fed.
Reg. 63718, 63727 (Nov 9, 2007).
3 16 CFR Part 681.
A former general counsel for the Tennessee
Department of Health, Mr. Fitzgerald is an associate with Tune, Entrekin & White, PC, of
Nashville, with a broad background in health
care law and regulation.
This document is not intended to be
individual legal advice nor does it constitute advice for a particular client. The
matters discussed herein are general in
nature and should not be applied to a
particular practice setting without consulting an attorney.
SPECIAL FEATURE
Medicare Administrative
Contractor (MAC): Have You
Met Yours?
By Bethany Wylie, CPC, CPMA
edicare has decided to reorganize its
Part A and Part B Carriers into one
distribution center that will process
both sets of claims. These new organizations
will be known as Medicare Administrative
Contractors (MACs). This change is being
made to group the states into more equal sections by the amount of Medicare enrollees.
All providers will be affected by this
except for one specialized group: those that
are Qualified Chain Providers (QCP). These
are providers associated with 10 or more hospitals under common ownership with 500
Medicare beds, or five or more hospitals
under common ownership with 300 beds.
These providers will continue to work and bill
the same way with no changes.
Another group, called Specialty Service
Providers, are those that fall into several categories due to the different types of providers
and patients serviced. These are grouped by
their different categories into corresponding
MAC Jurisdictions (Table).
All providers must send claims to the
MACs in their home base state unless they are
a Qualified Chain Provider (QCP) or in one of
the Medicare Specialty Service groups. The
specialty groups and all other providers are
M
broken down into the 15 different jurisdictions. Once the changeover occurs in each
jurisdiction, all past and present business is
handled by the new MAC.
Each jurisdiction has chosen its new MAC
and has begun publishing a “go live” schedule,
in a process that began in January 2006.
Tennessee is in jurisdiction 10 and goes live
under MAC Jurisdiction 10 with Part-A claims
on August 3, 2009, and Part-B claims on
September 1, 2009. Medicare has chosen
Cahaba, GBA as the MAC for Tennessee; also in
Jurisdiction 10 with Tennessee will be Georgia
and Alabama, which already employ Cahaba as
their Part A and Part B claims processor.
Cahaba has asked that Tennessee providers go to
its website, www.Cahabagba.gov, and get used
to the layout; it also asks that each provider
sign up on its listserv that works synonymously with the current Cigna Listserv. Cahaba does
not call this product Listserv; instead, Cahaba
shows this service as “E-mail Updates.” There
is a link on the top of the home page that has
J10 as a header. This section contains all the
update articles for the Tennessee conversion
from Cigna Medicare Services to Cahaba.
Providers must also fill out and submit a new
Medicare EFT form (588) at least 30 days prior
Table. Specialty Service Provider Groups and Corresponding MAC Jurisdictions.
Specialty Service or Demonstration
Centralized Billing for Mass Immunizers
Indian Health Services
Low Vision Demonstration
Rural Community Hospital Demonstration
Veterans Affairs Medicare Equivalent Remittance Advice Project
Chiropractic Services Demonstration
Home Health Third Party Liability Demonstration Project
Medicare Adult Day Care Demonstration
Independent Organ Procurement Organization
Religious Non-medical Health Care Institution (RNHCI)
Histocompatibility
MAC Jurisdiction
4
4
5,10,11,13, 14
1,2,4, 5
4
4, 5
14
11,14, 15
10
10
10
to the conversion; otherwise, payments may be
suspended. These guidelines would establish a
deadline of July 17, 2009, for Part A and August
14, 2009, for Part B. The Medicare 588 EFT
form is a standard Medicare form that allows
electronic payments for Medicare services to
come to a group and/or provider’s bank
account directly from Cahaba, GBA. There is a
guide on how to fill this form out on the Cahaba
website under the J10 tab.
Providers currently receiving paper
checks from Cigna Medicare may need to contact Cahaba immediately. Those with a combined staff of less than 10 employees need to
obtain a small practice waiver; this waiver will
prevent your practice from having to make this
transformation. Practices with more than 10
employees must contact Cahaba, as they will
be required to begin utilizing the EFT program.
It may be that your practice never went
through the revalidation process, which makes
the EFT practice mandatory. The revalidation
process was made mandatory by Medicare in
order to load providers in their PACOS system.
If you have not revalidated your provider or
group, you must do so immediately.
Do not wait until close to the deadline to
submit your forms – you do not want to your
forms held up due to a mass influx from
providers/groups across the region. If you
need the Medicare EFT form or have any questions, please contact Doctors Management; we
are willing to help TMA members get the correct resources. Contact us at [email protected]. I
Ms. Wylie is with the Coding Department
at DoctorsManagement, LLC.
DoctorsManagement, LLC, is a
TMA Corporate Partner. This information was supplied by DoctorsManagement
exclusively and for the benefit of our
members. The TMA does not accept responsibility for the information provided.
TENNESSEE MEDICINE / MAY 2009
35
SPECIAL FEATURE
To End Recession, We Must
Change Our Credit Culture
By Chris Low
he U.S. entered its 17th month of recession in April, making the current downturn the longest since World War II. At the
same time, the World Bank and Organization
for Economic Cooperation and Development
(OECD) now expect a global recession, with
world output falling from two percent to five
percent in 2009. It’s the biggest economic challenge the world has faced since the 1930s, with
one significant difference: policymakers are taking a more constructive recovery approach this
time. Nonetheless, this recession will require
more than government stimulus to end it. The
fundamentals of our consumer culture must
change before the economy can fully heal.
T
MEASURING UP
By some measures, the current recession is
not yet the worst in post-war history. The
unemployment rate today is 8.5 percent; in
1983, it was 10.8 percent. GDP fell at a 6.3
percent rate in the fourth quarter of 2008 –
the worst in decades, but not as bad as in
1980 or 1982. Finally, the misery index, which
measures the sum of the unemployment rate
and the inflation rate, is just 8.3, well below
the peak in the 1970s, when it reached 26.0.
And yet, there is little doubt the economy is
broken in a way we have not seen in the modern era. The world’s biggest banks survive only
thanks to hundreds of billions of dollars in government loans and support programs. Jobs are
being cut at an unprecedented rate. GM and
Chrysler are on the brink of bankruptcy, and
global trade has fallen by a stunning six percent.
ROOTS OF THE PROBLEM
How did we get into this mess? Nobel
Laureate Vernon Smith says it is because bubbles built on consumer debt tend to have bigger ramifications than bubbles that are not.
This recession was caused by the bursting of
a consumer debt bubble bigger than the one
preceding the Great Depression of the 1930s.
36
When the ability of consumers to borrow falls
dramatically, it has outsized ramifications, as
consumers are 70 percent of the economy.
The consumer credit culture has been an
integral part of American life since Diners’ Club
introduced the first modern credit card in 1950,
but the way we borrow changed in recent years.
First, Americans grew far too comfortable using
their homes as collateral for an increasing number of non-house related expenses. Second,
mortgage lenders stopped worrying about being
paid back by household income over time,
because they figured the value of homes would
always raise enough to make the lender whole.
But as soon as house prices started falling in
2006, the bubble had to burst. Home prices are
now, on average, 30 percent lower than they were
at the peak of the housing boom. As a result,
bankers and bondholders have come to realize
they were hugely mistaken to offer loans so freely.
Tumbling home values has created three
significant problems when it comes to growing
the economy again: 1) Lenders are left holding
loans worth considerably less than they thought.
These toxic assets (or legacy loans, as the new
administration prefers to call them) prevent
banks from committing more resources into a
sector where their exposure already is too high;
2) Most homeowners are unable to refinance
their mortgages. For some, who relied on teaser rates to afford their mortgage payments and
occasional cash out of equity to support their
lifestyles, this means bankruptcy; for others, it
means years of austerity. They are “house
poor;” 3) Policymakers are left with a seemingly insurmountable dilemma. On one hand, they
feel they must tighten regulation to prevent the
next bubble; on the other, they want to make it
easier to borrow to speed the recovery.
THE END GAME
Economists say, “There’s no such thing as a
free lunch,” which is another way of saying
nothing can be created without a cost.
TENNESSEE MEDICINE / MAY 2009
Subprime straw cannot be spun into AAA
mortgage-backed CDO (centralized debt obligations) gold without someone, somewhere
paying the cost of the transmutation. Financial
engineering gave us the ability to pretend such
things were sustainable long enough for
investors to forget this basic rule for a time,
but like Wile E. Coyote, eventually they looked
down and realized they were defying gravity.
Once the truth is out, it’s hard to ignore it
or forget the devastating consequences. Now
that we know house prices can fall, no one
will make home loans without being certain
the borrower can pay. That sounds like common sense, but consider what it means.
Substantial down payments and stringent
income tests will be the new norm in mortgage lending. Which means, among other
things, Americans cannot use their homes to
subsidize spending for the next few years.
The most important economic effect is
that people won’t be allowed to borrow without saving something first and, because so
many people are carrying a significant debt
load, that could take a long time. Policymakers
are doing their best to shorten the process, but
because lending standards must be stricter in
the future before anyone will be willing to
advance credit again, consumers must learn to
live within their means. I
References:
1. Gjerstad S, Smith VJ: From Bubble to Depression? Wall
St. J, Apr 6, 2009.
Mr. Low is chief economist at FTN
Financial, a division of First Tennessee
Bank. He can be reached at 800-456-5460
or [email protected]
First Tennessee Bank is a TMA
Corporate Partner. This information
was supplied by First Tennessee Bank
exclusively and for the benefit of our
members. The TMA does not accept responsibility for the information provided.
THE JOURNAL
Original Contribution
A Very Late Stent Thrombosis
in a Patient with Diabetes:
A Call for Lifelong Dual
Anti-platelet Therapy
By Chad V. Pecot, MD; Michael Fuller, MD; James A.S. Muldowney, III, MD; and Sumathi Misra, MD, MPH
INTRODUCTION
Drug-eluting stents have reduced the incidence of restenosis compared to bare metal
stents, but not without a price. Patients receiving drug eluting stents require a prolonged
course of antiplatelet agents, such as clopidogrel, to receive this benefit while preventing
late stent thrombosis (LST). LST, defined as
an instent thrombosis greater than 30 days
after PCI, is a catastrophic event that is classically observed in those who prematurely discontinue clopidogrel. An observational
cohort study after nine months in patients
receiving DES showed the strongest predictor
of instent thrombosis was premature discontinuation of dual anti-platelet therapy, occurring at a rate of 29 percent in those who discontinued and accounting for a dramatic 45
percent case-fatality rate.1 Current guidelines
state that clopidogrel should be taken at least
three months after sirolimus stent implantation, six months after paclitaxel stent implantation, but ideally for up to 12 months for
each in those not considered at high risk of
bleeding.2 There are no standard guidelines
on how to discontinue clopidogrel perioperatively in patients who are within this recommended period. A recent analysis of 36 case
reports of LST showed the median time to
thrombosis after dual antiplatelet therapy cessation was seven days, occurring, on average,
eight months after stent placement. There was
no significant difference between sirolimusand paclitaxel-eluting stents, and 83 percent
of LST events occurred after the recommended duration of clopidogrel therapy.3 Currently
there are no reliable predictors to identify
those patients at highest risk of LST, and optimal duration of therapy is still undetermined.
CASE REPORT
In March 2004, a 48-year-old male with
hyperlipidemia, diabetes, hypertension and
a chronic smoking history underwent angioplasty and stenting of a 70 percent concentric stenosis of the mid-left anterior
descending coronary artery (LAD) with a
sirolimus-eluting stent (Cypher® 3.0 x 33
mm, Cordis/Johnson & Johnson Co., USA).
He remained on dual antiplatelet therapy
with aspirin and clopidogrel for 15 months.
He then underwent stent placement to the
proximal LAD using a second sirolimus-eluting stent (Cypher® 3.5 x 18 mm,
Cordis/Johnson & Johnson Co., USA) for a
95 percent eccentric thrombotic stenosis.
For the subsequent 27 months the patient
remained on dual anti-platelet therapy with
aspirin and clopidogrel because of multiple
risk factors. In September 2007 the patient
was admitted for acute onset of hemoptysis.
He underwent bronchoscopy which revealed
old blood but no active bleeding; however,
he was told to discontinue aspirin and clopidogrel for a few days until this process subsided. Seven days after discontinuing dualantiplatelet therapy – 1,293 days after initial
drug-eluting stent implantation – the patient
presented within 30 minutes of acute substernal chest pain. Electrocardiogram
showed sinus rhythm, bpm of 86, old Qwaves in inferior leads and pronounced STelevations in the precordial leads (Figure
1A). He was loaded with a heparin and eptifibatide infusion, given aspirin 325mg, clopidogrel 300mg and taken immediately to
catheterization. This revealed instent thrombosis and 100 percent occlusion of the midLAD with TIMI-0 flow (Figure 1B).
Thrombectomy with a 6 French Q4
guide with Graphics wire was performed followed by angioplasty with a 4 x 12 mm
Liberte balloon to 6 atmospheres to treat
residual stenosis. TIMI-III flow was restored.
Echocardiographic examination the following day revealed hypokinesis of the apical
and distal anterior wall. The patient was discharged after three days without complications with a prescription for aspirin and
clopidogrel indefinitely.
DISCUSSION
Recent trials have been pivotal in establishing the need for increased duration of clopidogrel use after DES implantation. The PCICURE study, a subset analysis from a larger
cohort of patients receiving DES for UA or
NSTEMI, showed a significant 25 percent
risk reduction in MI or cardiovascular death
when comparing clopidogrel between three
and 12 months after PCI.4,5 Soon after this the
CREDO trial showed a 26.9 percent relative
TENNESSEE MEDICINE / MAY 2009
37
THE JOURNAL
Figure 1A. Electrocardiogram showing STEMI in precordial leads.
Figure 1B. Instent thrombosis in LAD (arrow).
reduction in death and MI in less acute
patients who received clopidogrel for 12
months versus 28 days when receiving DES
for elective revascularization.6 While these
two trials make a strong case for prolonged
dual anti-platelet therapy for at least 12
months after DES implantation, the optimal
duration for specific individuals is unknown.
38
TENNESSEE MEDICINE / MAY 2009
A recent observational study assessed
patients receiving clopidogrel after PCI with
either BMS or DES for up to 24 months.
Event-free patients at either six months or 12
months (defined as no death, myocardial
infarction or revascularization) after PCI
with DES, whom either continued clopidogrel for up to two years versus discontinuing
therapy at the mentioned dividing points,
were shown to be statistically different. In
fact, even in those patients who had
remained event-free at 12 months, continued therapy was superior to stopping clopidogrel, showing a markedly lower incidence
in death or myocardial infarction (0 percent
versus 4.5 percent) when taken for the full
24 months.7 Although not a randomized
trial, this study is not without implications.
In the PREMIER study, premature discontinuation of clopidogrel from the recommended timeline after DES implantation
(13.6 percent had discontinued within 30
days) was associated with increased age, not
completing high school, being single, more
likely to avoid health care because of costs,
pre-existing cardiovascular disease and anemia. At 12 months this was associated with a
7.5 percent versus 0.7 percent risk of death
when compared to those still compliant.8
This trial suggests that noncompliance is as
important as technical aspects of stent placement with regard to risk of thrombosis.
A topic that has recently gained significant attention is the concept of clopidogrel
resistance. Some studies have revealed variability in platelet inhibitory response from
clopidogrel which can be detected early
after coronary intervention by assessing
platelet aggregation.9 Patients undergoing
PCI for either a NSTEMI or STEMI found to
be “low responders” to clopidogrel are at
increased risk of repeat cardiovascular
events.10,11 Particularly of interest are diabetics, who show a decreased response to P2Y
receptor antagonists such as clopidogrel.
They have increased platelet reactivity compared to nondiabetics on combined aspirin
and clopidogrel. This reduced sensitivity
may contribute to increased risk of in-stent
thrombosis in diabetics.12 In the OPTIMUS
study, type II diabetics with proven suboptimal clopidogrel-induced anti-platelet
response with standard dosing had
enhanced activity with 150mg over 75mg.
This raises the question of whether diabetics
should be dosed higher due to enhanced
platelet reactivity.13
Another area of interest is the understanding that the anti-proliferative effects of
THE JOURNAL
sirolimus- and paclitaxel-eluting stents may
be countered by prothrombotic properties.
Recent gene expression profiling on human
coronary artery endothelial cells treated with
either sirolimus or paclitaxel found a dosedependent increase in expression of plasminogen activator inhibitor-1 (PAI-1), a protein that regulates the fibrinolytic system and
is associated with increased risk of myocardial infarction.14 Type II diabetics have been
shown to constitutively overproduce PAI-1,
again making subset analysis of patients
receiving DES an important next step.15
CONCLUSION
In summary, our patient had a very late stent
thrombosis after brief discontinuation of dual
antiplatelet therapy, which he had been taking far beyond the recommended duration. It
is clear there is a sub-group of patients at
greater risk of LST beyond 12 months, and
also cohorts who may potentially require
higher doses of clopidogrel. Until these
patients, in particular diabetics, can be studied more closely, one has to question
whether a drug-eluting stent is appropriate if
the patient is at higher risk of thrombosis, or
if co-morbidities may necessitate non-cardiac surgery in the foreseeable future. I
References:
1. Iakovou I, Schmidt T, Bonizzoni E, et al: Incidence,
predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA
293:2126-2130, 2005.
2. Smith SC, Feldman TE, Hirshfeld JW, et al: ACC/AHA/
SCAI 2005 guideline update for percutaneous coro-
nary intervention: a report of the American College of
Cardiology/ American Heart Association Task Force
on Practice Guidelines (ACC/AHA/SCAI Writing
Committee to Update 2001 Guidelines for
Percutaneous Coronary Intervention). J Am Coll Card
47:e1-121, 2006.
3. Artang R, Dieter RS: Analysis of 36 Reported Cases of
Late Thrombosis in DES Placed in Coronary Arteries.
Am J Card 99:1039-1043, 2007.
4. Yusuf S, Zhao F, Mehta SR, et al: Clopidogrel in
Unstable Angina to Prevent Recurrent Events Trial
Investigators. Effects of clopidogrel in addition to
aspirin in patients with acute coronary syndromes
without ST-sement elevation. N Engl J Med 345:494502, Aug 16, 2001.
5. Mehta SR, Yusuf S, Peters RJG, et al: Effects of pretreatment with clopidogrel and aspirin followed by
long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study.
The Clopidogrel in Unstable angina to prevent
Recurrent Events trial (CURE) Investigators. Lancet
358:527-33, Aug 18, 2001.
6. Steinhubl SR, Berger PB, Tift Mann J III, et al: Early
and sustained dual oral antiplatelet therapy following
percutaneous coronary intervention: a randomized
controlled trial. CREDO Investigators. JAMA
288(19):2411-20, Nov 20, 2002.
7. Eisenstein EL, Anstrom KJ, Kong DF, et al: Clopidogrel
use and long-term clinical outcomes after drug-eluting stent implantation. JAMA 297:159-168, 2007.
8. Spertus JA, Kettelkamp R, Vance C, et al: Prevalence,
predictors, and outcomes of premature discontinuation of thienopyridine therapy after drug-eluting stent
placement: results from the PREMIER Registry. Circ
113:2803-9, 2006.
9. Gurbel PA, Bliden KP, Hiatt BL, et al: Clopidogrel for
coronary stenting: response variability, drug resistance, and the effect of pretreatment platelet reactivity. Circ 107:2908–13, 2003.
10. Matetzky S, Shenkman B, Guetta V, et al: Clopidogrel
resistance is associated with increased risk of recurrent atherothrombotic events in patients with acute
myocardial infarction. Circ 109:3171–3175, 2004.
11. Cuisset T, Frere C, Quilici J, et al: High post-treat-
ment platelet reactivity identified low responders to
dual antiplatelet therapy at increased risk of recurrent cardiovascular events after stenting for acute
coronary syndrome. J Thromb Haemost 4:542–549,
2006.
12. Angiolillo DJ, Fernandez-Ortiz A, Bernardo E, et al:
Platelet function profiles in patients with type 2 diabetes and coronary artery disease on combined
aspirin and clopidogrel treatment. Diab 54:2430–
35, 2005.
13. Angiolillo DJ, Shoemaker SB, Desai B, et al:
Randomized Comparison of a High Clopidogrel
Maintenance Dose in Patients With Diabetes
Mellitus and Coronary Artery Disease: Results of the
Optimizing Antiplatelet Therapy in Diabetes Mellitus
(OPTIMUS) Study. Circ 115:708-716, 2007.
14. Muldowney JAS III, Stringham JR, Levy SE, et al:
Antiproliferative agents alter Plasminogen Activator
Inhibitor-1: A Potential Prothrombotic Mechanism
of Drug-Eluting Stents. Arterio Thromb Vasc Biol
27:400-406, 2007.
15. Auwerx J, Bouillon R, Collen D, et al: Tissue-type
plasminogen activator antigen and plasminogen
activator inhibitor in diabetes mellitus. Arterio
8:68–72, 1988.
Dr. Pecot is a resident with the
Department of Internal Medicine, and Dr.
Fuller is a resident with the Department
of Psychiatry at Vanderbilt University
Medical Center (VUMC) in Nashville. Dr.
Muldowney is an assistant professor of
Medicine with the Vanderbilt Heart and
Vascular Institute. Dr. Misra is an assistant professor of Medicine and Geriatrics
with the Department of Geriatrics and
Palliative Care at VUMC, Nashville.
For reprints, contact Dr. Pecot at
6820 Highway 70 S., #406, Nashville, TN
37221; phone: 615-353-0679; cell: 615300-2507; e-mail: [email protected].
R E A D
U S
ONLINE
www.medwire.org
TENNESSEE MEDICINE / MAY 2009
39
THE JOURNAL
Medicine & Law Series
HIPAA Impacting Patient Medical
Information
By Judy Regan, MD, JD, MBA, and Lauren Smith, JD
s of April 14, 2003, HIPAA set forth
Privacy Standards requiring physicians
to protect the privacy of patients’ medical information. The HIPAA Privacy Rule
requires covered entities, such as most medical practices, to implement appropriate
administrative, technical and physical safeguards for protected health information
(PHI) in any form, including electronic storage. The HIPAA Security and Privacy Rules
also require all covered entities to protect the
electronic protected health information
(EPHI) they use or disclose to business associates, trading partners or other entities since
electronic data can increase the risk of loss
and unauthorized use with disclosure of this
sensitive information.1
Failure to comply with HIPAA Privacy
Standards can now result in civil and criminal penalties.2 Civil penalties may be assessed
at $100 for each violation of the Rules with
an annual cap of $25,000 per person per violated provision. On the criminal end, covered
entities and specified individuals who “knowingly” obtain or disclose individually identifiable health information in violation of the
Privacy Standards can face both monetary
fines as well as imprisonment. Fines range
from up to $50,000 and one year of imprisonment to up to $250,000 and up to 10 years
imprisonment.2
While HIPAA protects the health information of individuals, to date, courts have determined that it does not create a private cause
of action for those aggrieved. However, state
laws can provide other opportunities for
which patients can assert liability for privacy
violations. As plaintiff attorneys have become
more creative, some states have allowed
alternative routes for patients to sue physicians for HIPAA violations in state courts.3
A
In Acosta v. Byrum, (180 N.C. App. 562, 638
S.E. 2d 246 (2006)), a North Carolina case,
an employee and patient sued a physician
because the patient’s medical records access
password was given to an office manager. The
office manager later disclosed Acosta’s confidential information to a third party without
her consent. Acosta sued the physician for
negligence, accusing the physician of breaching his duty under the privacy regulations
established under HIPAA and the rules adopted at the hospital system where the medical
records were stored. Acosta alleged the
physician should have known his negligence
would lead to emotional distress. Although
initially dismissed by the trial court, which
stated that HIPAA does not create a private
right of action, the Appeals Court disagreed.
According to the Court, the patient was not
making her claim under HIPAA but rather
was using the privacy statute to establish the
standard of care the physician should have
followed. The tactic used by the plaintiff was
to substitute the HIPAA standard to determine
if the physician exercised reasonable care to
prevent whatever was going to happen. The
Appeals Court assumed that HIPAA set the
standard for negligent conduct.4
According to the Mississippi State
Medical Association, plaintiff attorneys
recently have found a unique way to file privacy lawsuits in state court involving HIPAA
violations. Several patients have filed lawsuits
against physicians alleging the physician
breached the patient’s privacy rights under
HIPAA by including “protected health information” and other personal data about the
patient in the Proof of Claim form, a public
document required by the bankruptcy
courts. These new lawsuits revolve around
bankruptcy proceedings by a patient with
unpaid bills from a physician. A physician
who is owed money must file a Proof of Claim
form with the Bankruptcy Court to get paid
for debts owed by the patient. The Proof of
Claim usually contains information about the
amount owed by the patient and the documents used to support the claim are
attached. The supporting documents may
include billing and coding information as
well as personal information about the
patient, such as social security numbers. The
relief sought in these lawsuits includes “disallowing the claim by the physician or clinic
for the money owed or total forgiveness of
the patient’s debt, money damages for violating the HIPAA standard of privacy, contempt
of court sanctions for violating bankruptcy
policies against disclosure or sensitive data
and damages for negligent infliction of emotional distress.” Although this issue has not
been determined in the Mississippi courts, a
successful suit could mean the debt against
the patient is canceled and the patient awarded damages and attorney fees.5
Although no Tennessee cases have
addressed this issue directly, a patient’s
expectation that his or her medical records
will remain private has constitutional, statutory and decisional protection. The
Tennessee General Assembly has recognized
the sensitivity of medical records and has
enacted statutes limiting their disclosure.
And while Tennessee has never recognized a
common law physician-patient privilege, the
Tennessee Supreme Court has recognized the
existence of an implied covenant of confidentiality between physicians and their patients.6
Extending the idea of implied covenant of
confidentiality to HIPAA violations, then,
would not be a far stretch for courts in
Tennessee to make.
TENNESSEE MEDICINE / MAY 2009
41
THE JOURNAL
To hopefully avoid a lawsuit involving a physician violating the HIPAA Privacy Standards,
especially in situations where a provider
receives a request from a third party for a
patient’s medical records, all healthcare
providers should obtain signed HIPAA-compliant authorizations before releasing privileged medical records. In situations such as
bankruptcy court, physicians should consider withholding or redacting all “protected
health information” and any other personal
data about the patient. As more medical
records become electronically stored, physicians need to follow the HIPAA Security
Policy by completing an assessment of their
42
TENNESSEE MEDICINE / MAY 2009
risks and vulnerabilities and implementing
security measures to ensure protection of
this information. I
References:
1. 45 CFR §164.308, §164.508
2. 42 USC § 1320d-5
3. 65 Fed. Reg. 82566, 82582, 82604.
4. Sorrell AS: North Carolina appeals court allows new
use of HIPAA in lawsuit. Am Med Nws Mar 12, 2007.
Available at: http://www.amednews.com. Accessed
Apr 3, 3009.
5. Mississippi State Medical Association: Beware of New
Lawsuits Aimed at Doctors, Feb 5, 2009. Available at:
http://www.msmaonline.com. Accessed Apr 3, 2009.
6. The recent workers’ compensation case of
Overstreet v. TRW Commercial Steering Division,
(No. M2007-01817-SC-R10-WC) held that an injured
employee has the benefit of confidentiality with his
treating physician and forbids the employer, workers’
compensation insurance company, and defense attorneys from participating in ex parte communications
with the employee’s physician. Regardless of who
pays the medical bills of the patient, Tennessee
Courts will enforce physician-patient confidentiality.
Givens v. Mullikin, 75 S.W.3d 383 (Tenn. 2002) also
sets forth the doctrine of implied covenant of confidentiality.
Dr. Regan is an associate clinical professor of psychiatry at Vanderbilt University
School of Medicine and an associate with
North Pursell Ramos & Jameson, PLC, in
Nashville. Ms. Smith is an associate with
NPRJ.
FOR THE RECORD
TMA Alliance Report
TMAA Year-End Report
By Darlene Vickers, TMAA President
ime has passed so quickly since I began my year as president of the Tennessee Medical Association Alliance. It has
been a very exciting, educational and inspiring journey, as
well as one with many challenges.
During the summer I traveled to the AMAA Convention in June,
and in July to the TMA Board of Trustees Retreat in Huntsville, AL.
Plans were made by Amy Sowell and Carrie Fowler of Chattanooga,
the two co-chairs, for the Fall Update meeting, which was held in
Chattanooga on September 7-8.
Madeline Becker, TMAA’s vice-president for the American
Medical Association Foundation (AMAF), worked diligently selecting the artist and leading the sale of the holiday sharing cards. This
project is very important as it raises the funds for medical
research and for support of various medical school and nursing
education scholarships.
Sharon Gerkin, our vice-president for Health Promotions,
continued work on the national “Screen Out!” project by collecting signatures from individuals, corporations and other businesses for the purpose of stopping media advertising influences in PGrated movies seen by many of our children and adolescents. There
were a variety of other health-related projects supported by the
Alliances across the state.
Melissa Portera, vice-president of Legislative Affairs, kept all of
us informed about the many legislative changes related to health
care. Many physicians and their representatives attended PITCH
(Physicians Involved in Tennessee’s Capitol Hill) Day in Nashville on
different dates according to various regions in the state. They met and
talked with our legislative representatives regarding the important
health issues as they relate to the practice of medicine in Tennessee.
Robin Hutchins, vice-president for Membership, worked hard
to recruit new members, maintain our current ones and keep
those members-at-large who do not have an Alliance in their
areas. Personal touch means everything and Robin worked extra
T
hard in this area. Although there has been some membership
decline, most of our members remain loyal, active supporters of
our medical family.
Robin, who is also our president-elect, traveled many miles with
me to attend a variety of meetings – local, state, and national. We visited most of our Alliances from west, middle, and east Tennessee.
Sarah Higgins, our Strategic Planning Chairperson, hosted a
planning meeting in January in Knoxville where most of the plans
for our upcoming annual convention, as well as future goals, were
set and organized.
And finally, April 3-4 was the joint meeting for the TMA and the
TMAA.
Over the past year, I have traveled many miles across this great
state of Tennessee visiting Alliances and attending several conferences in Atlanta, Chicago, and Washington, DC. I have met leaders
of many organizations as well as legislators, both state and federal, and I feel there are many people who are attentive and listening to our concerns for health care and the practice of medicine.
I am honored to have served as president of the Tennessee
Medical Association Alliance (TMAA) and to represent them on an
advisory position on the TMA Board. Although it is a time of many
changes, I am positive that the practice of medicine will continue
to be of great benefit for all our fellow Tennesseans. I
For membership information contact Ms. Hutchins at 865-693-5997, 865-680-6502 (cell),
or [email protected]; or TMAA Executive Assistant Judy Ginsberg at 615-385-2100,
ext. 151, 800-659-1862 (toll-free) or [email protected].
44
TENNESSEE MEDICINE / MAY 2009
NEW MEMBERS
Tennessee Medicine takes this opportunity to welcome these new members to the Tennessee Medical Association
BLOUNT COUNTY MEDICAL SOCIETY
Michael Todd Damron, MD, Maryville
Ty Ann Heath, MD, Knoxville
Roy E. Kuhl, Jr., MD, Alcoa
Heather Stevens Wight, MD, Maryville
CHATTANOOGA-HAMILTON COUNTY
MEDICAL SOCIETY
Karin M. Covi, MD, Chattanooga
Alan E. Kohrt, MD, Chattanooga
Catherine Meitin Martinez, MD, Chattanooga
CONSOLIDATED MEDICAL ASSEMBLY OF
WEST TENNESSEE
James Roy Appleton, III, MD, Lexington
Brent Vaziri, MD, Jackson
KNOXVILLE ACADEMY OF MEDICINE
Curtis R. Markham, MD, Knoxville
Russel W. Rhea, III, MD, Knoxville
THE MEMPHIS MEDICAL SOCIETY
Tommy J. Campbell, MD, Germantown
Avrahm Cohen, MD, Memphis
James Eric Gardner, MD, Collierville
Jeffery N. Hoover, MD, Memphis
Henry Baines Stamps, MD, Collierville
NASHVILLE ACADEMY OF MEDICINE
John A. Barwise, MD, Franklin
Ian Robert Byram, MD, Nashville
Eric Earl Colgrove, MD, Madison
Justin Thomas Collier, MD, Nashville
Tony A. Freeman, MD, Madison
James Donald Green, MD, Nashville
Kirby Robert Gross, MD, Nashville
Ashraf H. Hamdan, MD, Nashville
J. Michael Lynch, MD, Hermitage
Karen Schilf Meredith, MD, Madison
Howard R Mertz, MD, Nashville
Thomas Michael Numnum, MD, Nashville
Douglas J. Pearce, MD, Nashville
Kimberly M. Rosdeutscher, MD, Hermitage
Bruce L. Wolf, MD, Nashville
Mr. Michael Kwame Poku, Nashville
OVERTON COUNTY MEDICAL SOCIETY
Kenneth Lee Colburn, MD, Livingston
STONES RIVER ACADEMY OF MEDICINE
Afam C. Ikejiani, MD, Smyrna
SULLIVAN COUNTY MEDICAL SOCIETY
Jill Olinger Moore, MD, Kingsport
WILLIAMSON COUNTY MEDICAL SOCIETY
Joel M. Phares, MD, Franklin
IN MEMORIUM
Powell Maden Trusler, MD, age 82. Died March 20, 2006.
Graduate of University of Tennessee Health Science Center.
Member of Lakeway Medical Society.
Lewis F. Cosby, MD, age 89. Died March 13, 2009. Graduate
of University of Virginia School of Medicine. Member of
Washington-Unicoi-Johnson Medical Society.
Emily T. Hamilton, MD, age 59. Died March 11, 2009.
Graduate of University of Tennessee Health Science Center.
Member of The Memphis Medical Society.
James William Christofferson, MD, age 89. Died March
14, 2009. Graduate of Medical College of Wisconsin. Member
of Blount County Medical Society.
Robert M. Miles, MD, age 90. Died March 11, 2009.
Graduate of University of Tennessee Health Science Center.
Member of The Memphis Medical Society.
Waverly S. Green Jr, MD, age 89. Died March 17, 2009.
Graduate of Johns Hopkins University School of Medicine.
Member of Sullivan County Medical Society.
AMA PRA
Physicians who earn the American Medical Association (AMA) Physician’s Recognition Award (PRA) have been recognized
by the AMA for their commitment to patient care and lifelong learning through continuing medical education (CME). The
Tennessee Medical Association would like to commend our members who have earned the AMA PRA recently by demonstrating that they earned an average of at least 50 CME credits per year. Congratulations to the following:
David Chaffin, MD, Cleveland
TENNESSEE MEDICINE / MAY 2009
45
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TENNESSEE MEDICINE / MAY 2009
LIST OF ADVERTISERS
BlueCross/ BlueShield of Tennessee....................................12
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DoctorsManagement, LLC ..................................................43
Drs. Wesley & Klippenstein ................................................31
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State Volunteer Mutual Insurance Company ........................48
Tennessee Medical Foundation ..........................................40
The TMA Association Insurance Agency, Inc. ................4, 47
TMA Physician Services, Inc. ................................................2