c m s bulletin - allegheny county medical societyjul 16, 2019 · on the cover ravenel bridge –...

Allegheny County MediCAl SoCiety

BulletinJAnuAry 2016

2016 ACMS president & officersWhen is a physician an ‘agent’ of a hospital?

hh-law.com

Business • Employment • Estates and Trusts • Health Care Litigation • Oil and Gas • Public Finance • Real Estate

Care is Your Business, Change is OursThe healthcare environment is changing. Physicians must focus on providing the highest quality care with intense competition for their time. Medical practices face increased challenges tied to changes to regulation, insurance protocols, cost-management and revenue management.

Houston Harbaugh has over 30 years of experience in helping physicians and medical practices manage change through contract negotiations with hospitals and payors; contract management; advocacy and new practice start-up counsel. We have provided critical support in practice mergers and acquisitions. And we have provided sound advocacy on issues ranging from HIPAA compliance to medical staff and peer review matters.

Every challenge a medical practice can face, we have seen. We have helped practices of all size and structure meet these challenges. And we know what is ahead.

BulletinJAnuAry 2016 / Vol. 106 No. 1


ArtiCleS

PerSPeCtiveS

dePArtMentS

Feature .................................. 122016 ACMS president and officers

Materia Medica ...................... 24Rolapitant: Expanding the arsenal against chemotherapy-induced nausea and vomitingBrent L. Scott Karen M. Fancher, PharmD, BCOP

Practice Management .......... 28Nine strategies to get employees talking during one-on-onesJoe Mull, MEd

Legal Report ......................... 30When is a physician an ‘agent’ of a hospital?William H. Maruca, Esq.

Financial Health ................... 32Don’t try to ‘beat the market!’Gary S. Weinstein, MD, FACS

Special Report ..................... 34Maximize your EHR, maximize your reimbursement: Quality Insights offers free help with meaningful use attestation

Special Report ..................... 36Social Media and HIPAA: Can They Coexist Successfully in Your Practice? Sherry Migliore, MPA, FACMPE, FACHE

Editorial ................................... 6NourishmentDeval (Reshma) Paranjpe, MD, FACS

Editorial ................................... 8Old years’ resolutionsCharles Horton, MD

Editorial ................................. 10A man, by his deedsTimothy G. Lesaca, MD

Society News ........................ 16• 2016 Clinical Update in Geriatric Medicine• 14th International HELP conference• Pittsburgh Ophthalmology Society• Practice Managers Section• ACMSF awards medical student scholarship

ACMS Alliance News ............ 22

In Memoriam ......................... 22• Gregory M. Hoyson, MD

Activities & Accolades ......... 23

On the coverRavenel Bridge – Charleston, S.C.

by Frederick Doerfler Jr., MDDr. Doerfler specializes in internal medicine and was the

first-place winner of the 2015 Bulletin Photo Contest.

hh-law.com

Business • Employment • Estates and Trusts • Health Care Litigation • Oil and Gas • Public Finance • Real Estate

Care is Your Business, Change is OursThe healthcare environment is changing. Physicians must focus on providing the highest quality care with intense competition for their time. Medical practices face increased challenges tied to changes to regulation, insurance protocols, cost-management and revenue management.

Houston Harbaugh has over 30 years of experience in helping physicians and medical practices manage change through contract negotiations with hospitals and payors; contract management; advocacy and new practice start-up counsel. We have provided critical support in practice mergers and acquisitions. And we have provided sound advocacy on issues ranging from HIPAA compliance to medical staff and peer review matters.

Every challenge a medical practice can face, we have seen. We have helped practices of all size and structure meet these challenges. And we know what is ahead.

ArtiCleS

Special Report ..................... 38Supporting quality health care for people with intellectual, developmental disabilities Cheryl Pursley, RN, CDDN

Special Report ..................... 412016 Medicare fee schedule: Here’s what you need to know Pennsylvania Medical Society

ACMS ALLIANCEPresident

Kathleen ReshmiFirst Vice President

Patty BarnettSecond Vice President

Joyce Orr Recording Secretary

Justina Purpura Corresponding Secretary

Doris DelseroneTreasurer

Josephine MartinezAssistant Treasurer

Sandra Da Costa

2016 Executive Committee

and Board of Directors

PresidentLawrence R. JohnPresident-elect

David J. DeitrickVice PresidentRobert C. Cicco

SecretaryAdele L. Towers

TreasurerWilliam K. Johnjulio

Board ChairJohn P. Williams

DIRECTORS 2016

David L. BlinnRobert W. Bragdon

Thomas B. CampbellDouglas F. Clough

Jason J. Lamb2017

Peter G. EllisDavid A. LoganJan W. Madison

Matthew B. StrakaAngela M. Stupi

2018Patricia L. Bononi William F. Coppula

Kevin O. Garrett Todd M. Hertzberg Barbara A. Kevish

Amelia A. Paré Raymond E. Pontzer

PEER REVIEW BOARD2016

John G. GuehlRajiv R. Varma

2017Donald B. Middleton

Ralph Schmeltz2018

Sharon L. Goldstein Bruce A. MacLeod

PAMED DISTRICT TRUSTEEJohn F. Delaney Jr.

COMMITTEESAwards

Donald B. MiddletonBylaws

Robert C. CiccoCommunications

Amelia A. ParéFinance

Karl R. OlsenGala

Patricia BononiAdele L. Towers

Nominating Rajiv R. VarmaPrimary Care

Lawrence R. John

COPYRIGHT 2015: ALLEGHENY COUNTY MEDICAL SOCIETYPOSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 713 Ridge Avenue, Pittsburgh, PA 15212.

ADMINISTRATIVE STAFFExecutive Director

John G. Krah([email protected])

Assistant to the DirectorDorothy S. Hostovich

([email protected])Bookkeeper

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Director of PublicationsMeagan K. Welling

([email protected])Assistant Executive Director, Director of Member Relations

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Membership Relations ManagerNadine M. Popovich

([email protected])

EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 713 Ridge Avenue, Pittsburgh, PA 15212; (412) 321-5030; fax (412) 321-5323. USPS #072920. PUBLISHER: Allegheny County Medical Society at above address.

The Bulletin of the Allegheny County Medical Society welcomes contributions from readers, physicians, medical students, members of allied professions, spouses, etc. Items may be letters, informal clinical reports, editorials, or articles. Contributions are received with the understanding that they are not under simultaneous consideration by another publication.

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ISSN: 0098-3772Leadership and Advocacy for Patients and Physicians

Affiliated with Pennsylvania Medical Society and American Medical Association

www.acms.org

Bulletin Medical Editor

Deval (Reshma) Paranjpe([email protected])

Associate EditorsCharles Horton

([email protected])Robert H. Howland

([email protected]))Timothy Lesaca

([email protected])Scott Miller

([email protected])Amelia A. Paré

([email protected])Gregory B. Patrick

([email protected])Brahma N. Sharma

([email protected])

Managing EditorMeagan K. Welling

([email protected])

q


ACMS selects vendors for quality and value. Contact our Endorsed Vendors for special pricing.

Leadership and Advocacy for Patients and Physicians

Banking, Financial and Leasing ServicesMedical Banking, Office VISA/MC ServicePNC Bank Brian Wozniak, 412.779.1692 [email protected]

Real Estate ServicesHelen Lynch, Coldwell Banker Your Neighborhood Realtor 412.605.7259 (cell) 412.366.1600, ext. 319 (office) [email protected] Group Insurance ProgramsMedical, Disability, Property and CasualtyUSI AffinityBob Cagna, [email protected]

Professional Liability InsuranceNORCAL MutualLaurie Bush, 800-445-1212, ext. 5558; [email protected]

Medical and Surgical SuppliesAllegheny MedcareMichael Gomber, 412.580.7900 [email protected]

Life InsuranceMalachy Whalen & Co.Malachy Whalen, 412.281.4050 [email protected]

Telecommunications and IT solutionsconnecTel, Inc.Scott McKinney, 412.315.6020, [email protected]

Printing Services and Professional AnnouncementsService for New Associates, Offices and Address ChangesAllegheny County Medical SocietySusan Brown, [email protected]

Auto and Home InsuranceLiberty MutualWalter E. Jackson IV, 412.859.6605, ext. 51907; [email protected]

Member ResourcesBMI Charts, Healthy Lifestyle Posters, Where-to-Turn cardsAllegheny County Medical [email protected]

It’s January. It’s cold. And while the sensible and most tempting thing to

do would be to come home after work and snuggle under a pile of blankets while drinking soup and watching tele-vision, I am here to suggest that you do otherwise.

What on Earth is there to do in Pitts-burgh in January, beyond hoping that there’s enough snow at Seven Springs to ski? Plenty.

For starters, check out some new restaurants in our fair city. Pittsburgh was recently voted Zagat’s #1 Food Town of 2015, based on beauties like these examples of epicurean enlight-enment:

1. Morcilla (3519 Butler St., Law-renceville): Well-known Pittsburgh chef Justin Severino (of Cure fame) has opened a classic tapas joint that promises to please.

2. Tako (214 Sixth Ave., down-town –- across from Heinz Hall): Rick DeShantz (of Meat and Potatoes and Butcher and the Rye) has opened an eatery with undersea decor featuring Mexican/Asian/fusion street food and wondrous cocktails. Try the eponymous octopus tako taco, which features fla-vorful octopus that is so creamy it has to have spent time sous vide, and the Mezcal Old-Fashioned.

3. The Commoner (458 Strawberry Way – in the Hotel Monaco, next to the Omni William Penn downtown): Although you may not be able to enjoy the rooftop biergarten in this weather, you can enjoy the art deco ambiance of the hotel and the beautiful decor and fare in this new hot spot.

4. Grapperia (3801 Butler St., Lawrenceville): A bar directly attached to and around the corner from Piccolo Forno; ideal for an aperitif or after din-ner. A lovely little place serving many kinds of grappa (brandy distilled from grape pomace), bitter amari, Italian wines, beer and small bites. Look for the grappa cocktails – try the smooth, cola-like Grappa 75 with its balsamic, rosemary and prosecco flavors, or the perfectly balanced Lavanda, which improbably and deliciously features lavender.

5. Station (4744 Liberty Ave., Bloomfield): Innovative and delightful seasonal menu from alumni of Grit and Grace and Craftwork Kitchen.

6. The Vandal (4306 Butler St., Lawrenceville): European inspired, Wednesday-Saturday breakfast/brunch/dinner; Sunday brunch.

7. Smoke BBQ Taqueria (4115 But-ler St., Lawrenceville): Run by Austin expats armed with an indoor smoker, expect delectable brisket and apricot/habanero-laced Berkshire pork tacos in this beautifully appointed taqueria.

8. Whitfield (120 S. Whitfield St., East Liberty – in the new Ace Ho-tel – the former YMCA): An upscale neighborhood gastropub featuring a meat-centric menu with a few vegetari-an options. Brunch and dinner daily.

9. Smallman Galley (2016 Small-man St., Strip District): Pittsburgh’s first restaurant incubator features restau-rants from four handpicked up-and-coming chefs. Carota Cafe, Aubergine Bistro, Josephine’s Toast and Provision Pgh are open for brunch and dinner Tuesday-Saturday, Sunday brunch. Closed Monday.

10. Muddy Waters Oyster Bar (130 S. Highland Ave., East End): Oysters and classic New Orleans favorites, along with Sazeracs, Ramos Gin Fizzes and champagne.

11. Gaucho Parrilla (1601 Penn Ave., Strip District – right by the 16th St. Bridge): Argentinian wood-fired grill with multiple mouthwatering dishes of steak, pork, chicken and shrimp and four delicious sauces. A must try – and among Yelp’s Top 10 Places to Eat Nationally. Lunch and dinner Tues-day-Saturday.

12. 424 Walnut (424 Walnut St., Sewickley): Delicious classic American fare with an emphasis on Italian spe-cialties in a cozy neighborhood restau-rant. Intimate, romantic and friendly ambiance. Steaks and chops par excellence, award-winning crab and

Editorial

6 Bulletin / January 2016

NourishmentDeval (Reshma) PaRanjPe, mD, FaCs

Please consider donating to your local food pantry this winter or to the Greater Pittsburgh Community Food Bank ... You also might consider collecting canned goods in your office ...

sausage soup, beautiful desserts and excellent service. Lunch and dinner Monday-Saturday.

13. The Twisted Frenchman (128 S. Highland Ave., East End): French featuring steak, lamb, duck, pheasant and a chef’s eight-course tasting menu.

14. Chaz and Odette (5102 Baum Blvd., Shadyside): “Locally sourced, Globally inspired” cuisine featuring eclectic entrees and a selection of international flatbreads ranging from Korean BBQ chicken to Mumbai curry and everything in between.

These are but a few of the new gems to be discovered in Pittsburgh; no doubt you have more in your neigh-borhood that I haven’t found. Even if you missed January’s Winter restau-

rant week, go forth and nibble on the culinary bonanza that has popped up in our fair city. It will make the winter go faster and the weather more bearable. Stop in after work, or take someone you care about to a special night out – spread warmth and fill both belly and soul.

And speaking of filling both belly and soul, please consider donating to your local food pantry this winter or to the Greater Pittsburgh Community Food Bank, and spread the love. You also might consider collecting canned goods in your office, to spread goodwill among your patients as well. Also, don’t miss the annual Southside Soup Contest, which takes place Saturday, Feb. 20 from noon to 3 p.m., and bene-

fits two local food pantries while letting you sample delicious hot soups from local restaurants in a three-hour soup crawl that has become a cherished local tradition.

Stay warm and nourished inside and out this winter, so that you may warm and nourish those in your care.

Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bul-letin. She can be reached at [email protected].

Editorial

7Bulletin / January 2016

The opinion expressed in this column is that of the writer and does not

necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

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As we start the new year, a com-mon topic of conversation is how

many New Year’s resolutions have been made, adjusted and – inevita-bly – broken. By the second or third week of 2016, exercise machines are starting to regrow their protective layer of clutter, TVs across the nation are starting to feel like family members again, and “short breaks” from diets of various sorts are starting to look a lot like habits. (Eat a well-rounded diet? Sounds great! Pizzas are round, pies are round, Oreos are round ... yep, I’ll eat plenty of round things!)

This year, I’m going to try something a little different. I’m making old years’ resolutions.

By way of explaining, let me give a little background. As I write this, I’m in the midst of a very unintended break from a pretty busy lifestyle, courtesy of an equally unintended break in my right fibula. While I wouldn’t recom-mend that as a fun experience in itself, the chance to slow down and catch up with life has been unexpectedly refreshing. Already I’ve finished a book

I’d long meant to read (C.S. Lewis’ “The Pilgrim’s Regress”), spent time just sitting and talking with my family, gone through emails from past years to reconnect with old friends, and started filling in my address book so that future rounds of Christmas-card writing can skip the ever-popular game of “Does anyone remember where we wrote Dave’s address last year?”

It all started like so many habits do, really – it was just something to fill the time. The elaborate brace on my ankle made it clear that anything especially physical was out of the question, and while I was able to get around without assistance, taking it easy was the order of the day (and, for that matter, the order of the orthopedic surgeon). But as time passed, I realized that redeem-ing the time – to use that wonderful old expression – felt really good. It felt like … the way things used to be.

Call an old family friend? Sorry, too bus- … actually, sounds like a great idea. Sit and read a book with my daughter? Yep, right aft- … hmm. Right after I sit down here on the sofa – come sit with Daddy! Take a leisurely walk through Trader Joe’s and think up a surprise dinner for my wife? Sure,

nex- … next aisle might have just what goes with that. (For the record, the fish tacos were a hit.)

The more I slowed down and en-joyed life, the more I remembered how life used to be. It’s not that I didn’t have projects and goals; rather, it’s that I had allowed life to be about more than just those projects and goals. There was work, there was sweat ... and there was enjoyment. So while my original plan had been to hit the ground running in 2016 and embark on a lengthy list of projects with renewed vigor, I’m going to take the opposite approach now. I’m go-ing to slow down, enjoy the serendipity of each new day, and count my bless-ings. I’d say it’s a New Year’s resolution ... but given how far back those ideas go, it’s more like an old years’ resolution.

Dr. Horton specializes in anesthe-siology and is associate editor of the ACMS Bulletin. He can be reached at [email protected].

ExEcutivE committEEEditorial


Old years’ resolutions



ChaRles hoRton, mD


Leadership and Advocacy for Patients and Physicians

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Editorial


Is Martin Shkreli a name that will live in health care infamy? Fortunately

for him, he is a young man, and thus has many years to live before history proclaims a final verdict. On the other hand, if his ultimate aspiration was to be an example of corporate psycho-pathic behavior, then he might have already succeeded.

Several months ago, Turing Phar-maceuticals, led by chief executive Shkreli, purchased the rights to the medication Daraprim. Hardly a new drug, nor for that matter an undiscov-ered financial goldmine, Daraprim had been on the market for more than 60 years and is considered a standard of care for toxoplasmosis.

Almost immediately after the purchase, Turing Pharmaceuticals dramatically increased the price of Daraprim from $13.50 per pill to $750. Alarmed patients, HIV and AIDS patient advocacy groups, the HIV Medicine Association and politicians including Hillary Clinton, Donald Trump and Elijah Cummings responded in uncharacteristic unity and agreement, calling the actions of Turing and Shkreli “price gouging” and unjustifiable for the medically vulnerable patient popula-tions affected by this decision.

Shkreli’s response to this controver-sy was revealing and possibly defin-ing. His defense was based upon the assertion that Daraprim was unprofit-able at its former price, and from his perspective it was virtually being given away. He also cast himself as a victim of media hyperbole and went so far as to challenge one of his most outspoken critics, John Carroll of Fierce Bio-

tech, by calling him “a moron.”The missing essential from Shkreli’s

retort was acknowledgement that his decision might cause considerable hardship upon others. Instead he pro-claimed, “We needed to go to a price where we could make a profit,” seem-ingly oblivious to the fact that the price was increased by about 5,000 percent.

If anything positive could come from this, it would be that Mr. Shkreli has, at least for the sake of intellectual discussion, given an identifiable face to the concept of the corporate psy-chopath. To be fair, I have never met him, and it would be inappropriate for me to proclaim him mentally ill. I do not know what lives in his heart, but I believe it was St. Basil who said, “A tree is known by its fruit, a man, by his deeds.”

Unlike the prototypical psychopath who exerts control through physical vi-olence, corporate psychopaths victim-ize primarily by psychological means. Emotionally disconnected from others, they view people as objects to be used, thriving from the feeling of power and control. They are skilled at convincing others that they are trustworthy and talented, yet in reality their influence upon corporations is usually destruc-tive. As managers, they are character-istically poorly organized and adversely influence organizational productivity

and effectiveness. Although often found to be su-

perficially charming and successful, corporate psychopaths are ruthlessly manipulative. They typically are patho-logic liars, emotionally shallow, without empathy or remorse, and fail to take responsibility for their actions.

Dr. Robert Hare, a renowned re-searcher in the area of criminal psy-chology, has said that if he didn’t look for psychopaths to study in prisons, he would instead look for them in stock exchanges. One might contemplate that the health care industry is the new fertile ground for the emergence of the corporate psychopath. There are several reasons why this might be the case.

At this point in history, many health care organizations across the country are administratively and financially un-stable and chaotic. The future of health care has never been more uncertain, with a constantly changing corporate climate characterized by frequent turn-over of key personnel.

The health care industry is vulnera-ble because history has taught us that the destabilization of modern corpora-tions has led to the ascendency of the corporate psychopath. Furthermore, the corporate psychopath is often singled out for rapid promotion in other industries due to perceived attributes of charm and decisiveness. History also shows that the corporate psychopath is more likely to be drawn to large lucrative financial organizations due to the potential rewards.

Such a person could easily assim-ilate into a chaotic and high turnover

A man, by his deedstimothy G. lesaCa, mD

Editorial


workplace and be welcomed and promoted as the ideal leader due to charisma and charm. Possibly the greatest risk, however, underlies the question of whether the health care industry is either willing or capable of identifying the corporate psychopath. I personally find it difficult to imagine our industry willingly submitting to the use of instruments and protocols designed to identify psychopathic managers. Even worse is my suspicion that most health care systems are in denial that such a problem could even exist.

The typical provider in the health care industry, including the physician, might be among the easiest population for the corporate psychopath to de-ceive. You were trained to be benevo-lent and to not render harsh judgment

upon others. Many of you have sur-rendered your administrative tasks to others due to lack of time. Most of you do not own your own practices, cannot control or influence your payers, and are usually not consulted when major administrative decisions are made that impact your practices and your lives. You have more patients than you have time, and each day the disarray is greater than the day before. You have few alternatives than to have hope and faith that those who are tasked with administration are equally benevolent.

In his book, “Without Conscience,” Dr. Hare wrote of the corporate psy-chopath, “If we cannot spot them, we are doomed to be their victims, both as individuals and as a society.” If Martin Shkreli is the modern embodiment of

the corporate psychopath in health care, he was fortunately relatively easy to identify. Our concern should be those who go totally unrecognized. Otherwise, if we are too late, then each of us already has a Shkreli in our lives, smiling smugly and laughing to himself, convinced that we, too, are morons.

Dr. Lesaca is a psychiatrist special-izing in children and adolescents and is associate editor of the ACMS Bulle-tin. He can be reached at [email protected].



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Lawrence R. John, MD 2016 ACMS president

Dr. John is a board-certified family physician with UPMC. He is a native of Uniontown, Pa., and a graduate of the University of Notre Dame. He attend-ed Case Western Reserve University School of Medicine in Cleveland, Ohio, and completed his residency training in family practice in Pittsburgh at the St. Margaret Hospital Residency Program. He has practiced medicine his entire career at UPMC St. Margaret Hospital. He is grateful for the continued support of his five partners.

Dr. John also received certificates from the University of Pittsburgh’s Joseph M. Katz Graduate School of Business for Physician Leadership and Management while completing a mini-MBA program.

Dr. John has been a member of ACMS since 1977 and has served on the Board of Directors since 2007. He has co-chaired the ACMS Primary

Care Working Group since 2008. He was ACMS treasurer in 2012, secretary in 2013, vice president in 2014 and president-elect this past year while also serving on the Executive Commit-tee during these years. Dr. John also served on the Communications Com-mittee from 2007 to 2010, the Finance Committee in 2012 and the Bylaws Committee in 2014.

At the state level, Dr. John partici-pated as an alternate delegate to the Pennsylvania Medical Society from 2008 to 2009, then as a delegate since 2010. He served as vice chair of the ACMS delegation from 2011 to 2013.

In addition to his responsibilities with ACMS, Dr. John also serves on the By-Laws and Credentialing com-mittees at UPMC St. Margaret. He is a member of committees at UPMC including the Risk Management (CMI) and the PAC Committee (Advisory Panel for University Service Organiza-tion). He has been a clinical instructor in the Department of Family Medicine, University of Pittsburgh School of Medicine, since 1997. Dr. John served as the team physician for Fox Chapel Area School District from 1980 to 2014, providing athlete physical exams and on-field coverage for high school foot-ball games. He has been inducted into the Fox Chapel Area School District Hall of Fame for his years of service.

Dr. John’s wife, Martha D. John, MD, is a practicing pediatrician with Children’s Community Pediatrics – Allegheny, and they reside in Fox Chapel. They have four children: Joseph F. John, DSc, MHA, FACHE, Vice President of Operations, The

Emory Clinic, Inc., Assistant Dean of Administration for the Robert W. Wood-ruff Health Sciences Center, Emory University, Atlanta, Ga.; Jeffrey Law-rence John, JD, with Amatis Controls in Aspen, Colo.; Kathryn S. John, with the Blum-Kovler Foundation in Chicago, Ill.; and Jeremy R. John, MD, MPH, a general surgery resident at the Tulane University School of Medicine, New Orleans, La.

David J. Deitrick, DO 2016 ACMS president-elect

Dr. Deitrick is board certified in obstetrics and gynecology. He is a member of Jefferson Wom-ens’ Health / Metropolitan OB/GYN Associates and is on the staff of Jefferson Hospital of Allegheny Health Network.

A member of ACMS since 1990, Dr. Deitrick served on the Board of Direc-tors from 2004 to 2006 and was the Board of Directors Presidential Appoin-tee from 2007 to 2011. He was ACMS treasurer in 2013, secretary in 2014 and vice president in 2015, serving on the Executive Committee during that time. Dr. Deitrick participated on the Communications Committee from 1999 to 2004 and the Nominating Committee from 2001 to 2002. He chaired the Leg-islative Committee from 2002 to 2006. Dr. Deitrick also served on the Finance Committee from 2011 to 2013, as well as the Membership Committee from 2007 to 2012, serving as chair in 2007.

2016 ACMS president and officers

FEaturE


At the state level, Dr. Deitrick was an alternate delegate to the Pennsylva-nia Medical Society House of Dele-gates from 1999 to 2001 and again in 2008. He served as delegate from 2002 to 2007 and again from 2009 to 2013. Dr. Deitrick also was a member of the Pennsylvania Medical Society Political Action Committee (PAMPAC) Board of Directors from 2001 to 2005.

Dr. Deitrick served as the division director for University of Pittsburgh Physicians Womens’ Health in the Department of Obstetrics, Gynecology and Reproductive Sciences at UPMC Mercy Hospital for many years and was a member of the Medical Execu-tive Committee at UPMC Mercy.

Dr. Deitrick graduated from the Kansas City University of Medicine and Biosciences in Kansas City, Mo., in 1993. He completed his residency at Bridgeport Hospital in Bridgeport, Conn., in 1997. Dr. Deitrick is a Fellow of the American College of Obstetri-cians and Gynecologists.

Dr. Deitrick and his wife, Gretchen, reside in McMurray with their sons, Adam, Nathaniel and Benjamin.

Robert C. Cicco, MD 2016 ACMS vice president

Dr. Cicco is board certified in pediatrics and neonatal-peri-natal medicine. He most recently served as associ-ate director of the Neonatal Intensive Care Unit at West Penn Hos-pital and clinical assistant professor, pediatrics, at Temple University School of Medicine.

A member of ACMS since 1980,

Dr. Cicco has served on the Board of Directors and Executive Committee since 2014. He was the ACMS trea-surer in 2014 and secretary in 2015. At the state level, Dr. Cicco served as a delegate to the Pennsylvania Medical Society in 2013. He was a member of the PAMED Task Force on State of Medicine from 2010 to 2013. In addition, he has been the recipient of several prestigious awards including the ACMS Physician Volunteer Award and the PAMED Physician Volunteer Award. In 2012, the Pennsylvania Chapter of the American Academy of Pediatrics named Dr. Cicco Pediatri-cian of the Year.

Dr. Cicco is a past president of Parent Care, a national association of parents and professionals that advo-cates for family-centered NICU care. Dr. Cicco is a past president of the Pennsylvania Chapter of the American Academy of Pediatrics and also serves as the co-chairman of the Committee of the Fetus and Newborn for the state chapter. In addition, he is a member of the Committee to Establish Rec-ommended Standards for Newborn ICU Design; has served on numerous health department advisory committees over the years; and currently serves on the Advisory Committee for the Penn-sylvania metabolic screening program and the Allegheny County Health Department’s child death review team.

Dr. Cicco graduated from Case Western Reserve University School of Medicine in 1976. He completed his residency at Children’s Hospital in Pittsburgh and a fellowship at Magee Womens Hospital of UPMC.

Dr. Cicco and his wife, Anita, reside in Scott Township. They have four sons, Brian, Michael, Steven and Patrick.

Adele Towers, MD, MPH 2016 ACMS secretary

Dr. Towers, board certified in internal medicine and geriatric medicine, is affiliated with UPMC Presby-terian Shadyside Hospital, and sees patients at the Benedum Geriatric Center at Montefiore Hospital.

A member of ACMS since 1988, Dr. Towers has served on the Board of Directors since 2011. She served as ACMS treasurer in 2015 and also was a member of the Executive Committee and ACMS Foundation Board that same year. In addition, Dr. Towers has been a member of the Awards Com-mittee since 2011 and the Foundation Gala Committee, serving as co-chair since 2014.

Dr. Towers has been an associate professor of Medicine and Psychiatry at the University of Pittsburgh School of Medicine since 1992. She was the medical director of UPMC Health Information Management from 2007 to 2013. Dr. Towers currently serves as medical director of UPMC Home Health and is senior clinical advisor of the UPMC Technology Development Center.

Dr. Towers also is a member of several professional societies including the American College of Physicians, American Geriatrics Society, Ameri-can Medical Association and Western Pennsylvania / West Virginia Geriatrics Society.

Dr. Towers graduated from the University of Connecticut School of Medicine in 1986. She completed

Continued on Page 14


an internship and residency in internal medicine at the University of Pittsburgh School of Medicine in 1989. She also fulfilled a fellowship in geriatric medicine from the University of Pittsburgh School of Medicine in 1991, and received her Masters in Public Health the same year from the Department of Epidemiology, Graduate School of Public Health at the University of Pittsburgh.

Dr. Towers resides in Wilkinsburg, Pa.

William K. Johnjulio, MD 2016 ACMS treasurer

Dr. Johnjulio is certified by the American Board of Family Medi-cine. He is chair of the Department of Family Medicine at Allegheny Health Network (AHN) and is responsible for overseeing all clin-ical, administrative and academic components of the department. Dr. Johnjulio was formerly the program director of Forbes Family Medicine Residency at AHN.

A member of ACMS since 2004, Dr. Johnjulio has served on the Board of Directors since 2013. He was a member of the Awards Committee in 2013 and the Mem-bership Committee in 2015. He currently serves on the Executive Committee and ACMS Foundation Board.

Dr. Johnjulio has held academic appointments in the departments of family medicine at Forbes Regional Hos-pital, Temple University and Lake Erie College of Medi-cine, as well as at the University of Pittsburgh College of Pharmacy.

Dr. Johnjulio graduated from the University of Iowa College of Medicine and completed postgraduate train-ing with a family medicine internship at the University of Rochester/Highland Hospital and a residency in family medicine at the University of Iowa Hospitals and Clinics. He also completed a Faculty Development program at Duke University and a Physicians Leadership Academy Fellowship at UPMC Mercy Hospital.

Dr. Johnjulio is a member of the American Academy of Family Physicians and the Society of Teachers of Family Medicine. He also is a member of the Medical Staff Exec-utive Committee at AHN.

Dr. Johnjulio and his wife, Margot, reside in Fox Chap-el and have two children, Will and Grace.

From Page 13

PErsPEctivE

Ruby Marcocelli


Allegheny County Medical Society members: The new world of Health Care ushered in by the Patient Protection and Affordable Care Act (ACA) has created uncertainty and confusion for most people. There are new regulations and requirements. Individual and employer mandates. Penalties for not purchasing coverage. On Exchange and Off Exchange access. As an Allegheny County Medical Society member, you have help.

Talk to USI Affinity, the ACMS’s endorsed insurance broker and partner. Our benefits specialists are experts in Health Care Reform. We can help you choose a health plan that provides the best coverage and value while ensuring you will be in compliance with complex new IRS and Department of Labor regulations. We’ll also provide you the kind of world class service and support you need to make sure you get the most out of your health care benefits after you buy.

You can also check out the NEW Allegheny County Medical Society Insurance Exchange, a convenient and secure online portal where you can find competitively priced insurance coverage for all your needs, including a wide variety of medical and dental plans.

The New World of Health Care is complicated.

Are You Prepared?

To learn more, contact USI Affinity today!

Call 800.327.1550, or visit the ACMS Insurance Exchange at www.usiaffinityex.com/acms

sociEty NEws


2016 Clinical Update in Geriatric Medicine set

The Clinical Update in Geriatric Medicine will be held April 7-9 at the Marriott Pittsburgh City Center. This award-winning course has been a pop-ular and respected resource for more than 24 years. It is jointly sponsored by the Pennsylvania Geriatrics Society – Western Division (PAGS-WD), Uni-versity of Pittsburgh Institute on Aging and University of Pittsburgh School of Medicine Center for Continuing Education in the Health Sciences. The program is designed by course direc-tors Shuja Hassan, MD; Judith Black, MD; and Neil Resnick, MD, along with the PAGS-WD planning committee.

As our population continues to age, the number of elderly persons in our area hospitals, clinics and nursing homes has grown significantly. The fastest-growing segment of the popu-lation are those above the age of 85 years. The conference aims to provide an evidence-based approach to help clinicians take exceptional care of these often frail individuals. Highlights of the three-day conference include:

• Geriatric Pharmacology – helpful tips on managing medications in your complex older patients

• Acute Care of the Elderly – clinical pearls from a national expert on inpa-tient care of the older adult

• Symposium on Geriatric Syn-dromes – updated, evidence-based information on falls, delirium, osteopo-rosis and depression

• Geriatric Cardiology – updated information on hypertension specific to the older patient, atrial fibrillation management along with using novel oral anticoagulants, and chronic heart failure

• Appropriate prescribing of antibiot-

ics for older adults • Symposium

focusing on patient care at the end of life, and living with hospice care

• Advanced Practice Providers session

The conference continually attracts distinguished guest faculty. This year’s exceptional guest presenters include: Dan G. Blazer, MD, MPH, PhD, vice chair of Psychiatry, Duke University, Durham, N.C.; Sha-ron K. Inouye, MD, MPH, director of the Aging Brain Center at the Institute for Aging Research, Hebrew SeniorLife, Boston, Mass.; Lewis A. Lipsitz, MD, director, Institute for Aging Research and Senior Scientist, professor of Med-icine, Harvard Medical School, Boston, Mass.; Barbara Messinger-Rapport, MD, chief medical officer/ Hospice Care at Hospice of the Western Re-serve, Cleveland, Ohio; and Robert M. Palmer, MD, MPH, John Franklin Chair of Geriatrics at the Glennan Center for Geriatrics and Gerontology, Eastern Virginia Medical School, Norfolk, Va. Local expert faculty also will enhance the program and provide key evi-dence-based sessions.

Registration will be accepted in January at https://ccehs.upmc.com/liveFormalCourses.jsf. For additional information, contact (412) 647-8232 or email [email protected].

Members of the PAGS-WD receive a discount when registering for the conference! To inquire about becom-ing a member or current membership status, contact Nadine Popovich, administrator, (412) 321-5035, ext. 110, or email [email protected]. Apply for membership on the Society website at www.pagswd.org.

14th International HELP conference slated in Pittsburgh

The International Hospital Elder Life Program (HELP) conference will be held in conjunction with the Clinical Update conference April 7-8 at the Mar-riot Pittsburgh City Center. Designed by course directors Sharon Inouye, MD, MPH; Fred Rubin, MD; and Shin-Yi Lao, MPH, BSN, RN, this two-day international conference educates HELP teams regard-ing strategies for delirium prevention, using HELP to improve hospital-wide care of the elderly, and creating a climate of change.

Expert clinicians and experienced members of the HELP sites will share evidence-based information and clinical insights on selected topics re-garding the influence of HELP, delirium updates and the larger policy implica-tions of care for the elderly. Updates on collaborative papers, expansion of the program and innovative site projects also will be presented.

For more information, please con-tact Krystal Golacinski, UPMC Center

Dr. Blazer

Dr. Lipsitz

Dr. Palmer

Dr. Inouye

Dr. Rubin

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for Continuing Education in the Health Sciences, at (412) 647-7050 or email [email protected].

Pittsburgh Ophthalmology Society meets at ACMS

The Pittsburgh Ophthalmology Society (POS), under the direction of Thierry Verstraeten, MD, president, welcomed guest speaker Andrew Huang, MD, MPH, Dec. 3 at the Allegheny County Medical Society (ACMS) building. Dr. Huang, professor, Ophthalmology and Visual Sciences, and director, Cornea Lab, Washington University School of Medicine, St. Lou-is, Mo., presented “Recent Advances in Ocular Surface Reconstruction” and “Surgical Management of IOL Dislo-cation and Iris Defect.” He was invited by POS member Deval Paranjpe, MD, FACS. Jason Hooton, MD, resident at the University of Pittsburgh Eye Center, presented a case for review and discussion. The POS would like to thank Alimera Sciences for supporting the evening’s program.

POS member honoredMichael Azar, MD, POS chair of the

by-laws and rules committee, Thorpe Circle administrator and past president, was honored at the Dec. 3 meeting with the Pennsylvania Academy of Ophthalmology’s (PAO’s) Distinguished Service Award. The award is presented to a member of the Academy for ex-traordinary work on behalf of the PAO of contributions to their specialty. Dr. Azar has been a member of the PAO Board of Directors for 20 years. His previous positions on the PAO Board include secretary of Medical Practice and Payment Systems, representa-tive on the Medicare Carrier Advisory

Above, from left, Deval Paranjpe, MD, FACS; POS President Thierry Verstraeten, MD; and guest speaker Andrew Huang, MD, MPH, are pictured at the Dec. 3 POS meeting.

At left, Michael Azar, MD, left, is pictured with Ken-neth Cheng, MD, after being present-ed with the Penn-sylvania Academy of Ophthalmology’s Distinguished Ser-vice Award.

NadiNe M. PoPovich /acMS



WelcomingJamil B. Alkhaddo, MDEndocrinology

Dr. Alkhaddo is a fellowship-trained endocrinologist specializing in diabetes, thyroid and adrenal conditions in adult patients. He joins The Center for Diabetes and Endocrine Health.

He received his medical degree from the Aleppo University in Aleppo, Syria. He completed his internal medicine internship and residency at the State University of New York in Buffalo, N.Y., serving as chief resident. He completed his clinical fellowship at the University of Minnesota in Minneapolis. He is board-certified by the American Board of Internal Medicine.

Dr. Alkhaddo holds memberships with a number of medical societies, including the American Medical Association, the American Association of Clinical Endocrinologists, the Endocrine Society and the American Diabetes Association.

He has medical staff privileges at Allegheny General Hospital and Canonsburg Hospital.

As always, new patients are welcome. Most major insurances are accepted.

Ad Size: 7 .5 x 9.75

For an appointment, please call

The Center for Diabetes and Endocrine Health 1900 Waterdam Plaza Building 3, Second Floor McMurray, PA 15317

724.941.7490AHN.org

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Committee and president (2003-2005). Kenneth Cheng, MD, PAO Board member and secretary, Legislation and Representation, presented the award during the business meeting.

POS speaker announcedPrem Subramani-

an, MD, PhD, profes-sor of Ophthalmolo-gy, Neurology, and Neurosurgery; vice chair for Academic Affairs, Ophthalmol-ogy; division chief, Neuro-ophthalmol-ogy, University of Colorado School of Medicine, will be the guest speaker for the Feb. 4 POS meeting. POS member John Charley, MD, invited Dr. Subra-manian. Faizan Pathan, MD, resident at the University of Pittsburgh Eye Center, is scheduled as the resident presenter for the evening.

POS Annual Meeting to be held March 18

The Pittsburgh Ophthalmology Society’s Annual Meeting will be held March 18, 2016, at a new location, the Pittsburgh Marriott City Center Hotel. The society is pleased to announce Michael E. Snyder, MD, as the 36th Thorpe Lecturer. Dr. Snyder serves on the Board of Directors, Cincinnati Eye Institute (CEI), and is chair, Clinical Research Steering Committee. The Harvey E. Thorpe Lecture, established in 1980, when the Society named Dr. Thorpe “man of the year,” recognizes an individual of Dr. Thorpe’s stature as a researcher, teacher and inventor.

Dr. Snyder specializes in diseases and surgery of the front of the eye, in-cluding small-incision, topical anesthe-

sia cataract surgery. Along with Dr. Robert Osher, he has pio-neered artificial iris prosthesis use in the United States, aiding in the rehabilitation of acquired traumatic iris defects or con-genital iris defects such as aniridia and ocular albinism. He is a diplomate of the American Board of Ophthalmology, a fellow of the Amer-ican Academy of Ophthalmology and a member of the American Society of Cataract and Refrac-tive Surgeons. He is actively involved in teaching other ophthalmologists through these organizations and serves as a frequent “guest professor” nationally and internationally.

He continues to contribute to ophthalmology textbooks and scientific journals as author, editor and reviewer; sits on the editorial boards of EyeWorld and Cataract & Refractive Surgery Today; and has produced several award-winning surgical videos. He is actively involved in developing new devices for intraocular implantation and new ophthalmic applications for pharmaceuticals including FDA studies. Dr. Snyder was the first in the United States to implant an artificial iris cus-tom-matched to the uninjured eye.

Additionally, the POS is honored to welcome guest faculty Sean Blay-don, MD, FACS, and Carl Regillo, MD, FACS. Dr. Blaydon is program

director for the Oculofacial Plastic and Reconstructive Surgery Fellowship at Texas Oculoplastic Consultants, Austin, Texas; and clinical assistant professor at the University of Texas Health Sci-ence Center in San Antonio. Dr. Regillo is director, Retina Service, Wills Eye Hospital; and professor of Ophthal-mology, Thomas Jefferson University, Philadelphia, Pa.

Running concurrently with the POS Annual Meeting will be the Annual Meeting for Ophthalmic Personnel. Ophthalmic technicians, assistants, coders, photographers and front office staff are invited to attend this dynamic meeting. The program is broken into four segments, allowing attendees to select from numerous courses. The ap-plication for JCAHPO credits for each course has been submitted. Courses (with credit designation) will be listed on the online registration. Registration for both programs will begin Jan. 7. To register, please visit pghophg.org and click on “Registration.”

Practice Managers Section meets at ACMS

Practice administrators had the opportunity to sharpen their skills at the Dec. 3 meeting of the ACMS Practice Managers Section. Expert facilitators presented a quick overview of their topic and then allowed participants to share their perspectives, experiences and ideas, as well as having the oppor-tunity to ask questions. Each session was 20 minutes, giving attendees the opportunity to engage and interact with all six facilitators.

Thank you to the following present-ers who provided a dynamic atmo-sphere for this first-time offering: Billing and Coding, presented by Ruby Marco-

From Page 17

Dr. Subramanian

Dr. Snyder

Dr. Regillo

Dr. Blaydon



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celli, Fenner Consulting; Fraud Pre-vention, presented by Heidi Danko and Drew Besket, PNC Healthcare Banking; Leadership and Office Culture, present-ed by Joe Mull, Ally Training & Devel-opment; Legal Tune-Up, presented by Jim Southworth, Dickie, McCamey & Chilcote, PC; OSHA and Office Safety, presented by Matthew Spady, CLYM Environmental Services; and Technolo-gy Update, presented by Marty Strang-es, Pittsburgh Computer Solutions.

Door prizes were graciously donat-ed by Joe Mull, MEd, of Ally Training & Development. Congratulations to the following lucky winners: Kathy Kubicky, Mary Florio, Carolyn Lanzendorfer and Celeste Rhodes. Each received a $25 gift card to a local restaurant.

The next meeting will be held Jan. 21 and will feature Curtis Solomon, CPHRN, of NORCAL Mutual, who will present “Pain Management & Opioid Prescribing: Managing the Risks.” Reg-ister online at www.acms.org/events or call (412) 321-5030.

From Page 19

Attendees of the Dec. 3 Practice Managers meeting discuss legal issues with Jim Southworth of Dickie, McCamey & Chilcote, PC.

Attendees of the Dec. 3 Practice Man-agers meeting listen to Drew Besket and Heidi Dan-ko of PNC Healthcare Banking.

Allegheny County MediCAl SoCiety FoundAtion

March 5, 2016www.acmsgala.org

Awards GalaJOIN US FOR

Wine & Chocolate

ACMS Foundation awards medical student scholarship

The Allegheny County Medical Society Foundation (ACMSF) recently awarded a $4,000 scholarship to med-ical student Diana Huang of Pittsburgh.

Ms. Huang, daughter of David Huang and Tracy Zheng, attends the Lewis Katz School of Medicine at Temple University, Philadelphia.

“I am so grateful to the Allegheny

County Medical Society for continuing to fund this important scholarship. Although I am currently attending med-ical school in Philadelphia, growing up in Pittsburgh helped form my interest in medicine. Throughout my under-graduate career at the University of Pittsburgh, I shadowed many doctors at UPMC and volunteered my time at the former UPMC South Side and the UPMC Urgent Care in Shadyside. I continue to learn from patients and physicians in Pittsburgh through rotations at the West Penn Allegheny Health System. Participating in orga-nized medicine through the PA Medical

Society and AMA has helped me build connections with so many wonderful physicians from across the state and nation, and it inspires me to be able to work together to create a better envi-ronment of health for patients.

“This scholarship helps to lessen the financial burden of training for me as I continue on my path to become a family physician and serve on the front lines of patient care. Again, thank you for your support of medical students, and know that your contributions make a huge difference in our lives.”

Ms. Huang is considering a special-ty in family medicine.


Ms. Huang

Medical Director Opportunity at Uniontown HospitalEmergency Resource Management, Inc., (ERMI) is now accepting EM BE/BC or other board-certified physicians with experience for the Medical Director position at Uniontown Hospital.

ERMI is the largest employer of emergency medicine physicians in Pennsylvania and is part of UPMC, one of the nation’s leading integrated health care systems. We offer an outstanding compensation and benefit package, including occurrence malpractice insurance, an employer-funded retirement plan, paid health insurance, CME allowance, and more.

For more information, contact our recruiter at 412-432-7400 or email at [email protected].

EOE Minority/Female/Vet/Disabled

UniOntOwn, PA

72504 TACS

www.EmergencyResourceManagement.com

sociEty NEws


alliaNcE NEws

Gregory M. Hoyson, MD, 59, of McCandless Township, died Sunday, December 27, 2015.

Dr. Hoyson graduated in medicine from the University of Pittsburgh and served his internship and residency at Children’s Hospital of Pittsburgh of UPMC.

For three decades, Dr. Hoyson was an admired pediatrician at his practice, Bellevue Pediatric Associ-ates of Bellevue, Richland and Cranberry.

Surviving are his wife, Ann Schratz Hoyson; children Elizabeth Tobay (Jason), Katherine Baeder (Daniel) and Mitchell Hoyson; his mother, Patricia Hoyson; siblings Jimmy Hoyson and Tammie Ammon (Drew); and mother-in-law Rita Schratz.

Services were held Thursday, December 31, at St. Sebastian Church, Ross.

ALLIANCE MEMBERSHIP AREAS OF OPPORTUNITY

Please check to indicate your area of interest. We’ll be in touch to welcome you with enthusiasm. We will mentor you into activities you’ve selected.

We will acknowledge your support of events and projects.

Thanks from all of Alliance for your reply! 412-321-5030□ Community Service

□ Public Health Education □ Event Planning □ Communication

□ Fundraising □ Leadership

□ Unable to actively participate, but will support

Alliance events and projects to benefit Health Education Projects, Community Service Organizations, Disaster Relief

and ACMS Foundation

2016-2017MEMBERSHIP APPLICATION

ALLEGHENY COUNTY MEDICAL SOCIETY ALLIANCE

Level Member ResidentCounty $ 35.00 $ 20.00

Please send me information on: ____ Pennsylvania Medical Society Alliance ____ American Medical Society Alliance

Last Name ______________________________________ First Name ______________________________________ M.I. _____ Address: ________________________________________ City ____________________ State _____ Zip __________ Phone: (Area Code) _______________________________ Fax: (Area Code) _________________________________ Email: __________________________________________

Please Indicate:__ New Member __ Reinstated __ Resident Spouse __ Other

Make Checks Payable to: Allegheny County Medical Society Alliance713 Ridge Avenue, Pittsburgh, PA 15212-6098

ACMSA Calendar 2016Sat., March 5 ACMS Foundation Gala (Heinz Field East Club Lounge – D. Hostovich 412-321-5030) Doctor’s Day Recognition Gala program ad (Donation to ACMS Foundation)

Tue., March 8 Governing Board Meeting: Nominations and Year-End Gifting (ACMS)

Fri./Sat., April 1-2 Carnegie Science Center PRSEF Heinz Field Club (ACMSA Judges TBD)

Tue., April 14 Governing Board Meeting (ACMS)

Fri., April 15-17 Northeastern Regional Meeting – Hosted by PAMED Alliance, Gettysburg, Va., – Venue and Details TBD (ACMSA Reps and Gifting TBD; S. DaCosta; This meeting replaces Spring Confluence)

Tue., April 26 Past Presidents Luncheon (Leadership and Venue TBD)

Tue., May 3 Combined Board Meeting (ACMS)

Tue., May 17 Gen. Meeting III Annual Mtg. and Lnchn.; Confirm Leadership Appointments; PAMED Alliance President Visit; New Member Recognition (Leadership/Venue TBD)

Content anD text by Kathleen jenninGs Reshmi

iN mEmoriam


activitiEs & accoladEs

Gateway Medical Society receives awardGateway Medical Society has been selected as a 2015-

16 Jefferson Award recipient in recognition of its Journey to Medicine (JTM) program.

Gateway Medical Society volunteer members William Simmons, MD, president, Jan Madison, MD, and Anita Edwards, MD, are being honored for their work with the JTM program, which educates and mentors minority boys in grades 6-12 about the art and science of medicine.

Drs. Simmons, Madison and Edwards have volunteered 16 hours per month to provide instructional sessions; they also volunteer an additional 50 hours per year for mentoring, planning and enrichment program activities.

JTM currently has 85 students enrolled with many consis-tently earning 4.0 GPA on their academic reports. JTM was awarded partner status with the Pittsburgh Public School System in 2014. For more information about the JTM pro-gram, visit www.gatewaymedicalsociety.org.

ACMS member honored William Simmons, MD, was presented

with the Western Pennsylvania Execu-tive Humanitarian Award from Achieving Greatness, Inc. (AGI) at AGI’s Pittsburgh City League Hall of Fame awards banquet Jan. 2, 2016, at the Pittsburgh Athletic Club.

The event honors local sports heroes and those who started in Pittsburgh City Leagues and went pro, as well as many champions of local humanitarian efforts.

Dr. Simmons is currently the president and chairman of the Board of the Gateway Medical Society (GMS), as well as chair of the department’s Advisory Committee on Diversity and co-chair of the UPMC/University of Pittsburgh Physician Inclusion Council Retention Committee. In his spare time, he is a mentor for GMS’s academic mentorship program for African American males.

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matEria mEdica


Chemotherapy-induced nausea and vomiting, also known as CINV, is

a commonly feared adverse effect of patients undergoing chemotherapy. Without appropriate prophylaxis, 70 to 80 percent of patients undergoing che-motherapy experience vomiting, and historically, up to 20 percent of cancer patients would delay or discontinue po-tentially curative chemotherapy solely because they could not tolerate the nausea and vomiting that accompanied it.1,2 In addition, uncontrolled nausea or vomiting may result in metabolic im-balances, nutrient depletion, anorexia, wound dehiscence, esophageal tears, aspiration pneumonia or degeneration of self-care.3 However, great progress has been made in the last few de-cades, which has resulted in improved patient experiences and quality of life.1 New agents continue to be developed to further minimize both the frequency and complications of CINV.

Chemotherapy-induced nausea and vomiting

CINV is thought to be a complex process involving several sites within the medulla as well as multiple neu-rotransmitters. The proposed mecha-nism begins with contact between the antineoplastic agent and the gastro-intestinal tract, specifically the small intestine. This can occur either through

direct contact or delivery to the site by blood. Upon contact, enterochromaffin cells within the small intestine release serotonin (5-HT), which binds to 5-HT3 receptors on vagal afferent fibers. These receptors stimulate the chemo-therapy receptor trigger zone (CTZ) within the area postrema of the brain. The CTZ also can be stimulated to a lesser extent by dopamine and neuroki-nin-1 (NK-1). The CTZ then signals the central vomiting center to coordinate impulses sent to the salivation center, respiratory center and the pharyngeal, gastrointestinal and abdominal mus-cles that lead to vomiting.2,4 In summa-ry, activation of the vagal nerve and the release of neuroactive agents in the gastrointestinal tract, along with the dorsal vagal complex communicating with the vomiting center of the brain, causes the vomiting reflex.5, 6

The incidence and severity of CINV can be affected by several factors. These factors include the specific chemotherapy agents used, dose of the agents, route of the agents and indi-vidual patient characteristics such as female gender, younger age, a history of motion sickness and minimal alco-hol consumption.3 The most important and reliable factor among these is the specific chemotherapy agent(s) used.3 CINV can be classified into four levels according to the emetogenicity of the chemotherapy regimen, or the likelihood of experiencing emesis if the chemotherapy agent is administered without prophylaxis. These levels in-clude: (1) high emetic risk – 90 percent or more of patients experience acute

emesis; (2) moderate emetic risk – 30 percent to 90 percent of patients expe-rience acute emesis; (3) low emetic risk – 10 percent to 30 percent of patients experience acute emesis; and (4) mini-mal emetic risk – fewer than 10 percent of patients experience acute emesis.3 Examples of high risk agents include cisplatin, dacarbazine, high doses of cyclophosphamide and carmustine.6

CINV also can occur in phases. Acute CINV usually occurs within a few minutes to several hours after drug administration and commonly resolves within the first 24 hours, while delayed CINV develops in patients more than 24 hours after chemotherapy adminis-tration and can last six to seven days.3 Cisplatin, cyclophosphamide, carbopla-tin and anthracyclines are some of the agents that commonly cause delayed emesis.6 Acute CINV is mostly mediat-ed by 5-HT3 signaling, while NK-1 and substance P signaling is thought to play a larger role in delayed CINV.7,8

Prophylaxis of CINVThe optimal strategy for CINV pro-

phylaxis in patients at moderate or high risk currently includes a 5-HT3 receptor antagonist, dexamethasone and an NK-1 receptor antagonist.3 Agents that can be given as “rescue” therapy after unsuccessful prophylaxis include dopamine antagonists, lorazepam, metoclopramide and/or olanzapine.

Serotonin receptor antagonists are widely considered the most effective prophylactic agent for CINV during the acute setting.1 The introduction of selective 5-HT3 receptor antagonists in

bRent l. sCott KaRen m. FanCheR,

PhaRmD, bCoP

Rolapitant: Expanding the arsenal against chemotherapy-induced nausea and vomiting

matEria mEdica


the early 1990s, such as ondansetron, granisetron and dolasetron, revolution-ized the management of CINV. These agents now form the cornerstone of prophylaxis for chemotherapy with mod-erate to high emetogenic potential, and have greatly improved the quality of life of cancer patients undergoing chemo-therapy.6 They are extremely well-tol-erated, with the most frequent adverse effects including headache, constipation and diarrhea. Palonosetron, a second generation 5-HT3 receptor antagonist, has shown evidence in reducing both acute and delayed CINV episodes. Palonosetron has a half-life of 40 hours, is more potent and has a higher binding affinity than first-generation agents.5 Palonosetron is currently recommended as the preferred 5-HT3 receptor antago-nist for use with moderately emetogenic chemotherapy regimens.3, 9

The second agent used to prevent CINV is corticosteroids. The mecha-nism by which corticosteroids prevent emesis is poorly understood, but it is believed that corticosteroids may improve emetogenic control in a syn-ergistic manner with other antiemetic agents.10 Dexamethasone is commonly chosen and also is the most extensive-ly researched. Doses of dexametha-sone vary between 8 and 20mg per day depending on the emetic potential of the chemotherapy. Major side effects of steroids in this setting are hypergly-cemia and insomnia.1

Neurokinin-1 receptor antagonists exert their mechanism of action by inhibiting substance P from binding NK-1 receptors in the vagus and primarily from preventing activation of the vomiting center. The first agent in this therapeutic class was aprepitant (Emend®), and its prodrug fosaprep-itant. When combined with a 5-HT3

receptor antagonist and dexametha-sone, NK-1 receptor antagonists have shown improved acute CINV control when compared to a 5-HT3 recep-tor antagonist, dexamethasone and placebo. NK-1 receptor antagonists also have shown activity in preventing delayed CINV versus placebo. NK-1 inhibitors are usually tolerated quite well, but some cases of hiccups and fatigue have been reported.5 Aprep-itant is known to be metabolized by the cytochrome P-450 3A4 pathway, and caution should be advised when administering other drugs metabolized through this same pathway.6

A combination product of two anti-emetic agents has recently received Food and Drug Administration (FDA) approval. This product combines netu-pitant, an NK-1 receptor inhibitor, with palonosetron in an oral tablet known as NEPA (Akynzeo®). NEPA was studied in clinical trials in combination with dexamethasone versus palonosetron and dexamethasone. Patients who received NEPA experienced less CINV during the delayed phase compared to patients who received palonose-tron and dexamethasone.9 Adverse effects observed in these studies included headache, asthenia, fatigue and dyspepsia. Netupitant, similar to aprepitant, also is a known inhibitor of cytochrome P-450 3A4, and requires a dosage reduction of dexamethasone.1

The successful addition of NK-1 receptor antagonists to other agents for CINV prevention has prompted the development of a novel NK-1 receptor antagonist, rolapitant.

RolapitantRolapitant (Varubi®) exerts its mech-

anism of action in the same way as the other NK-1 receptor antagonists: by

inhibiting the binding of substance P to the neurokinin-1 receptors. Rolapitant is a unique agent due to its extended half-life of 180 hours, its lack of cytochrome P-450 CYP3A4 metabolism and its pro-longed receptor binding.11 The studied one-time dose of 180mg has shown the potential to prevent CINV throughout the highest risk period of 120 hours post chemotherapy.7

Rolapitant’s safety and efficacy were examined in two recently pub-lished phase III trials. The first trial examined rolapitant’s effectiveness and side effect profile pertaining to its use with moderately emetogenic chemotherapy or regimens containing an anthracycline and cyclophospha-mide in 1369 patients. This study was an international study that included patients over the age of 18, those who had not previously received moderate or high emetogenic chemotherapy, a Karnofsky performance score of 60 or greater, and a life expectancy of at least 4 months. The study was double-blind, and computer stratified randomization was used. All patients in the study received 2mg of granisetron and 20mg of dexamethasone, as well as either 180mg of rolapitant or placebo prior to chemotherapy. All patients then went on to receive 2mg of granisetron on days two and three. The study investigators could prescribe “rescue” medications at any time as medically indicated, and patients recorded all events of both vomiting and rescue medication use in a daily diary during the entire study period. The primary efficacy endpoint of the study was the proportion of patients achieving a complete response, which was defined as no emesis or use of rescue medication, in the delayed phase (>24-120 hours after the initiation


matEria mEdica


of chemotherapy) in cycle 1.7 In this study, patients who received

rolapitant experienced a 71 percent complete response in the delayed phase, as compared to 62 percent in the control group. This difference was statistically significant (odds ratio 1.6, 95 percent CI 1.2-2, p = 0.0002). Across the entire 120-hour risk period, significantly more patients treated with rolapitant had a complete response than did those patients receiving placebo (62 percent vs 53 percent, OR 1.4, 95 percent CI 1.2-1.8, p = 0.0012). Conversely, the results showed no difference between the groups in com-plete response during the acute phase only. Rolapitant was well-tolerated, and the incidence of adverse effects was similar between the groups, with fatigue, constipation and headache most frequently reported. The authors

concluded that adding rolapitant to a 5-HT3 antagonist plus dexamethasone improves CINV control in the delayed phase for patients treated with either moderately emetogenic chemotherapy or regimens that contain an anthracy-cline and cyclophosphamide.7

The second study examined the effectiveness and safety of rolapitant in preventing CINV with highly emetogen-ic, cisplatin-based chemotherapy in two global, randomized, placebo-controlled phase III trials. This study used the same inclusion criteria as the study previously discussed and enrolled 1,089 patients. All patients in the study received granisetron at 10mcg/kg and dexamethasone 20mg prior to cispla-tin-based chemotherapy, and were randomly assigned to receive either placebo or rolapitant 180mg. Dexa-methasone was then administered at

8mg twice daily on days two through four. Patients could be prescribed “res-cue” antiemetics at the study investiga-tor’s discretion, and patients recorded emetic episodes and use of rescue medication in a diary as discussed in the first study. The primary endpoint was the proportion of patients achiev-ing a complete response, which was defined as no emesis or use of rescue medication, in the delayed phase (>24-120 hours after the initiation of chemo-therapy) in cycle 1.8

The results of this study revealed that a significantly greater proportion of patients in the rolapitant group had a complete response in the delayed phase than did patients in the placebo group (pooled analysis 71 percent vs 60 percent, OR 1.6, 95 percent CI 1.3-2.1, p = 0.0001). Patients who received rolapitant also had a statistically greater

Table 1. Comparison of the currently available neurokinin-1 receptor antagonists.12-14

Aprepitant / Fosaprepitant(Emend®)

Netupitant(a component of the combination product Akynzeo®)

Rolapitant(Varubi®)

Dosage form OralIntravenous Oral Oral

Dosing

150 mg x1 or115 mg on day 1, 80 mg on days 2 and 3 or125 mg on day 1, 80 mg on days 2 and 3

300 mg/0.5 mg palonosetron x1 180 mg x1

Half-life 9-13 hours 80 hours 180 hours

MetabolismSubstrate of CYP3A4Inhibitor of CYP3A4Inducer of CYP2C9

Substrate of CYP3A4Inhibitor of CYP3A4

Moderate inhibitor of CYP2D6

Drug interactions

Numerous Numerous Few

Generic form Yes, but not yet available No No

From Page 25

matEria mEdica


complete response rate throughout the overall study period (69 percent vs 59 percent, OR 1.6, 95 percent CI 1.2-2.0, p = 0.0005). Adverse effects were min-imal in both groups, and were similar to those discussed in the first study. The results of this study suggest that rolapitant is effective in managing CINV in patients treated with highly emeto-genic, cisplatin-based chemotherapy at up to 120 hours after initiation of chemotherapy.8

Place in therapyThe potential advantages and

disadvantages of rolapitant compared to other NK-1 receptor antagonists are listed in Table 1.

The National Comprehensive Can-cer Network (NCCN) Clinical Practice Guidelines currently list rolapitant as a first-line agent for the prevention of CINV in highly emetic chemotherapy regimens, along with other NK-1 re-ceptor antagonists such as aprepitant and fosaprepitant. The guidelines state that an NK-1 antagonist, 5HT3 antag-

onist and corticosteroids should be used together as prophylaxis in highly emetogenic chemotherapy regimens. Rolapitant also is recommended as an optional third agent in combination with corticosteroids and 5-HT3 receptor an-tagonists as prophylaxis in moderately emetogenic chemotherapy regimens.3

Rolapitant’s specific place in therapy has yet to be determined, as it has not been directly compared to other NK-1 receptor antagonists or combined with any 5-HT3 antagonist other than palono-setron. Likewise, long-term safety data and robust clinical data are lacking. Finally, the cost of this new agent may be prohibitive, especially when com-pared to the anticipated availability of a generic form of aprepitant.

ConclusionRolapitant is a novel NK-1 receptor

antagonist that adds an additional op-tion for the prevention of chemothera-py-induced nausea and vomiting. In two clinical trials, the combination of a 5-HT3 receptor antagonist, dexamethasone

and rolapitant demonstrated superior efficacy in the control of delayed CINV and overall CINV. Its long half-life and prolonged receptor binding means that only a single dose is necessary during each chemotherapy cycle, and its lack of cytochrome P-450 3A4 drug inter-actions offer an advantage to patients on potentially interacting medications.11 Rolapitant already has been incorporat-ed into national guidelines, but further studies and more clinical experience will be necessary to clearly define the most effective use of this new agent.

Mr. Scott is a doctor of pharmacy candidate at Duquense University My-lan School of Pharmacy. Dr. Fancher is an assistant professor of pharmacy practice at Duquesne University Mylan School of Pharmacy. She also serves as a clinical pharmacy specialist in oncology at the University of Pittsburgh Medical Center at Passavant Hospital. She can be reached at [email protected] or (412) 396-5485.

References1. Jordan K, Jahn F and Aapro M. Recent

developments in the prevention of chemo-therapy-induced nausea and vomiting (cinv): A comprehensive review. Ann Oncol. 2015; 26(6): 1081-90.

2. Navari RM. Prevention of emesis from multiple-day and high-dose chemotherapy regimens. J Natl Compr Canc Netw. 2007; 5(1): 51-9.

3. National Comprehensive Cancer Net-work Clinical Practice Guidelines in Oncology. Antiemesis v2.2015. Available at www.nccn.org. Accessed December 9, 2015.

4. Wilhelm S. Nausea and vomiting. In: Chisholm-Burns MST, Wells BG, et al (eds). Pharmacotheray Principles and Practice, Second Edition. New York: McGraw-Hill Companies, Inc.; 2010.

5. Navari RM. Pharmacological manage-

ment of chemotherapy-induced nausea and vomiting: Focus on recent developments. Drugs. 2009; 69(5): 515-33.

6. Hesketh PJ. Chemotherapy-induced nausea and vomiting. N Engl J Med. 2008; 358(23): 2482-94.

7. Schwartzberg LS, Modiano MR, Rapoport BL et al. Safety and efficacy of rolapitant for prevention of chemotherapy-in-duced nausea and vomiting after administra-tion of moderately emetogenic chemotherapy or anthracycline and cyclophosphamide reg-imens in patients with cancer: A randomised, active-controlled, double-blind, phase 3 trial. Lancet Oncol. 2015; 16(9): 1071-8.

8. Rapoport BL, Chasen MR, Gridelli C et al. Safety and efficacy of rolapitant for prevention of chemotherapy-induced nausea and vomiting after administration of cispla-tin-based highly emetogenic chemotherapy

in patients with cancer: Two randomised, active-controlled, double-blind, phase 3 trials. Lancet Oncol. 2015; 16(9): 1079-89.

9. Hesketh PJ, Bohlke K, Lyman GH et al. Antiemetics: American society of clinical oncology focused guideline update. J Clin Oncol. 2015.

10. Barbour SY. Corticosteroids in the treatment of chemotherapy-induced nausea and vomiting. J Natl Compr Canc Netw. 2012; 10(4): 493-9.

11. Olver I. Role of rolapitant in chemo-therapy-induced emesis. Lancet Oncol. 2015; 16(9): 1006-7.

12. Emend [prescribing information]. White-house Station, NJ; Merck & Co., Inc: 2015.

13. Akynzeo [prescribing information]. Woodcliff Lake, NJ; Eisai Inc.: 2015.

14. Varubi [prescribing information]. Waltham, MA; TESARO, Inc.: 2015.

PracticE maNagEmENt


“How are things?” you ask.“Good,” she replies. Then silence.“So … what’s the biggest challenge

you’re facing here at work?”“Normal stuff, I guess.” More

silence.“Like what? What are the kinds of

things demanding your attention and effort these days?”

“Nothing out of the ordinary.”Does this exchange sound familiar?

If you hold regular one-on-one meet-ings with employees (and research in employee engagement makes it clear you should), then you’ve probably gone up against the no-talker. Or the one-word-answer-giver. What’s a dedicated, invested leader like yourself to do? You genuinely care about your employees’ ideas, opinions and challenges. How can you involve and engage them if they won’t talk? Here are nine strate-gies to get the conversation going in one-on-one meetings:

Ask Why or How questions. Open-ended questions (not “Yes”/“No” questions) are the lifeblood of any conversation. Questions that start with “Why” or “How” by their nature require an explanation. Plan to have several ready to go – the more specific the better. If it helps, make a list that you keep handy.

Wait. Silence is uncomfortable for some. Get over that. Don’t give in to the compulsion to fill the space. If you ask a legitimate, sophisticated ques-tion, and get a one-word answer, stay silent. You’ll be surprised how often the employee will start talking again. Often

what comes next is the kind of meaty answer you desired initially.

Start by asking for advice. Try opening with this: “Hey, I’m really glad we were scheduled to meet today. I’d love to get your advice on some-thing. I’m trying to figure out …” Then describe a challenge you’re facing, a question you’re pondering, or any other issue in which employee perspective could be helpful.

Share a personal story. If you open with some variation of “How are you?” most of the time your counterpart will ask a similar, general question. Answer it by sharing something you did that weekend or that happened that morning, then use it to pivot back to them. Like this: “I’m good … I’m tired, though. My daughter has been sick and I was up with her several times last night. She insists that she’ll only get better if she can sleep in her bed with ALL of her Barbies. At 3 a.m., I finally gave in! What’s the cold and flu season been like in your house?” The personal story fosters a more human connection between the two of you, and the pivot to asking about their circumstance gives them a low-risk way to ease into the conversation.

Ask for specific feedback. Ask about processes, systems, atmo-sphere, or even your performance.

Some questions can be broad (for example: “If you could change anything about the way things work at the front desk, what would it be?”), while others can be very specific: “How can we tweak our holiday scheduling process to make it fairer to everyone here?”

Offer a different communications vehicle. People who prefer introver-sion – people who prefer to take in and process information before responding or deciding – will often shine when given just a bit of space to ruminate. If you’re not getting much from someone during your meetings, restate how much you value their thoughts/feed-back/ideas/opinions, then invite them to follow-up via email, text, leaving a note, or “dropping in.”

Thank and tell after. Any time one of your reluctant participants DOES give you advice, feedback, or an opin-ion, be sure to circle back to them later (perhaps a few days after your meet-ing) to thank them and explain how it helped you. This is the “I was thinking about what you said; here’s how it real-ly helped me” strategy. Do this with all employees, as it is proof of their value and influence.

Ask for more. Despite your best efforts, you may have to come right out and ask the employee to get more verbally involved. Example: “Jim, I really value your insight, but I’m not getting much from you when I bring up things to discuss. Can you give me a little more?”

Be ok with it. Not every one-on-one has to be a profound, in-depth, profes-sionally satisfying discussion. In fact,

Nine strategies to get employees talking during one-on-ones

joe mull, meD


some people just aren’t talkers. Assess your approach. If you’re asking thoughtful questions, are demonstrating a sincere interest in the person across from you, and if they appear engaged in all other parts of their job, then accept that this person is just less verbal than others.

And a BONUS strategy (which actually brings our total to 10):

Give out a question or two ahead of time. Giving employees a heads up on something you plan to ask at a one-on-one may result in a more robust conversation.

Research suggests the most effective one-on-ones are those in which the agenda is set and led by employ-ees. That doesn’t relieve you of the responsibility to plan and prepare for one-on-one meetings. In some cases, you have to work a little harder to create an easygoing dialogue. Try out the strategies listed here and there’s a pretty good chance you’ll get the gab going.

Joe Mull, MEd, is president of Ally Training & Develop-ment. He teaches front-line health care leaders how to be better bosses. He can be reached at [email protected].

PracticE maNagEmENt

Anton Y. Plakseychuk, MD, PhDOrthopaedic Surgery

Dr. Plakseychuk received his medical degree from the Kazan State Medical University, Russia. He completed orthopaedic surgery residencies and fellowships at the University of Pittsburgh School of Medicine, Carnegie Mellon University, and the Kazan branch of Illizaov Center in Russia. Dr. Plakseychuk is board-certifi ed and an expert in hip arthroscopy (labral repairs), hip resurfacing, hip replacements (minimally invasive direct anterior approach), partial and full replacements of knee, shoulder, and ankle, and revision surgeries in diffi cult cases.

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For information or to schedule an appointment, call 412-641-8609. Dr. Plakseychuk sees patients

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lEgal rEPort

When a patient dies unexpectedly in a hospital setting, and there

may be some indication of negligence by a physician, plaintiffs’ lawyers try to target as many deep pockets as possible. Not only will they sue the physician responsible for the patient’s care, but increasingly they also will sue the hospital itself. This is even more likely if the lawyer failed to identify and name the responsible physician within the two-year statute of limitations. If the physician is directly employed by the hospital, there could be separate liability under the doctrine of respon-deat superior (Latin for “let the master answer”) which makes an employer re-sponsible for the actions of its employ-ees performed within the scope of their employment. But what happens when the physician is not an employee?

A recent Pennsylvania Supreme Court case overturned a lower court decision and held that a hospital could be separately liable for medical errors made by a non-employed physician staff member who was called to respond to a medical crisis. In Green v. Pennsylvania Hospital, the patient, Joseph Fusco, came to the hospital’s emergency department with shortness of breath, rapid breathing and wheez-ing. He spent 10 days in the ICU on a ventilator. In an effort to wean Fusco from the ventilator, he was given a tracheotomy. Later that day, a nurse noticed he was bleeding from the tra-cheotomy site and an emergency team

was called to attempt to identify the cause and restore his airway. Among the team was an independent otolar-yngologist, Dr. Nora Malaisrie, who allegedly misplaced a breathing tube into his thorax instead of his trachea. The error was corrected, but not in time to save Fusco.

Fusco’s estate brought a malprac-tice suit against the hospital, the nurse and the anesthesiologist, but not Dr. Malaisrie, the ear, nose and throat (ENT) specialist. Court filings indicate that the estate’s medical experts did not identify Dr. Malaisrie’s negligence as the cause of Fusco’s injuries until after the statute of limitations had ex-pired, which is the reason Dr. Malaisrie was not named individually as a defen-dant. As a result, the estate sought to hold the hospital vicariously liable for Dr. Malaisrie’s alleged negligence. The trial court tossed the vicarious liability count, and concluded that no reason-ably prudent person in Fusco’s position would be justified in believing that the care he was receiving from Dr. Malais-rie was being rendered by the hospital or its agents. This holding was upheld by the Superior Court, leading to the appeal to the state Supreme Court.

This counter-intuitive result was based on an interpretation of the Penn-sylvania Mcare Act, which the state Supreme Court has rejected in favor of a more common-sense approach. The Mcare Act states that a hospital may be held vicariously liable for the acts of another health care provider through principles of ostensible agency only if the evidence shows that “(1) a reasonably prudent person in the patient’s position would be justified in the belief that the care in question was being rendered by the hospital or its agents; or (2) the care in question was advertised or otherwise represented to the patient as care being rendered by the hospital or its agents.” The law specifically states that evidence that a physician holds staff privileges at a hospital shall be insufficient alone to establish vicarious liability.

The lower courts placed the burden of proving “agency” on the plaintiffs. The trial court noted that the estate did not present any witnesses to testify regarding “how the agency structure of the hospital was set up regarding ENT physicians . . . in the Hospital’s facili-ties,” and did not present any testimony “as to how Dr. Malaisrie presented herself as to agency, or whether a reasonable patient would believe she was an agent of the hospital.”

The Pennsylvania Supreme Court took a different approach. Citing its own opinion in the landmark case of Thompson v. Nason Hospital (which

William h. maRuCa, esq.

When is a physician an ‘agent’ of a hospital?


is well-known for establishing hospital liability for negligent credentialing), the court quoted: “hospitals have evolved into highly sophisticated corporations operating primarily on a fee-for-service basis. The corporate hospital of today has assumed the role of a comprehen-sive health center with responsibility for arranging and coordinating the total health care of its patients.”

The Supreme Court rejected the hospital’s reliance on the limitations of the Mcare Act and concluded that there was sufficient evidence to create a jury question concerning whether a reason-ably prudent person in Fusco’s position would be justified in the belief that Dr. Malaisrie was acting as the hospital’s agent when she provided care to him.

The court relied in part on the estate’s contention that Dr. Malaisrie first became involved in treating Fusco as part of an emergency response team at the hospital; Dr. Malaisrie had no prior doctor/patient relationship with Fusco; and Dr. Malaisrie rendered emergency treatment to Fusco at the request of the hospital, and not at the request of Fusco or his family.

The hospital did not dispute that upon discovering unexplained bleed-ing, the nurse (a hospital employee) paged anesthesia and ENT to come to the ICU. In such situations, the Su-preme Court held that when a hospital patient experiences an acute medical emergency, and an attending nurse or other medical staff issues an emergen-

cy request or page for additional help, it is more than reasonable for the patient, who is in the throes of medical distress, to believe that such emergency care is being rendered by the hospital or its agents, and that the determination of whether there is an agency relationship should be for the jury to decide.

Notably, the Pennsylvania Medical Society (PAMED) and the Pennsylva-nia Defense Institute filed a joint amic-us brief, and the Hospital & Healthsys-tem Association of Pennsylvania (HAP) filed a separate amicus (“friend of the court”) brief, in support of the hospital, to no avail. While the Green decision appears to extend vicarious liability to

lEgal rEPort

Responding to an

Industry in Transition

Fox Rothschild’s Health Law Practice reflects an intimate knowledge of the special needs, circumstances and sensitivities of physicians in the constantly changing world of health care. With significant experience and a comprehensive, proactive approach to issues, we successfully meet the challenges faced by health care providers in this competitive, highly regulated environment.

After all, we’re not your ordinary health care attorneys.

BNY Mellon Center | 500 Grant Street, Suite 2500 | Pittsburgh, PA 15219 | 412.391.1334 | www.foxrothschild.com

Seth I. Corbin 412.394.5530

[email protected]

Edward J. Kabala 412.394.5599

[email protected]

William H. Maruca 412.394.5575

[email protected]

William L. Stang 412.394.5522

[email protected]

Michael G. Wiethorn 412.394.5537

[email protected]

Visit our HIPAA, HITECH & HIT Blog at http://hipaahealthlaw.foxrothschild.com



FiNaNcial HEaltH

The goal of many investors and professional money managers is

to “beat the market” by earning higher returns than the Standard & Poor’s (S&P) 500 index. Most well-structured portfolios, however, are not limited to large capitalization U.S. equities. They also include international stocks, real estate investment trusts (REITs) and bond indexes that affect total return. While a portfolio’s U.S. equity returns should match the market, adding fixed income (bond) investments usually lowers return when stocks rise and vice versa.

The S&P 500 consists of the 500 largest publicly traded U.S. companies based on market capitalization (total shares X price) and is most commonly used as a proxy for the market return. It encompasses 80 percent of the total market and its three largest holdings are Apple Inc. (3.7 percent); Microsoft Corp. (2.4 percent); and ExxonMo-bil Corp. (1.8 percent). Small and mid-capitalization (cap) companies are excluded.

Although the Dow Jones Indus-trial average (the “Dow”) is widely reported, it consists of only 30 large company stocks chosen by committee. The average is calculated by dividing the sum of the 30 stock prices by 0.14967727343149. The denominator is changed annually and not adjusted for inflation. The small sample size and idiosyncratic calculation limit its useful-ness as a market proxy.

Investors can purchase stock indexes as mutual fund shares or exchange-traded funds (ETFs). Mutual fund shares are priced daily at the

market close (net asset value) and include embedded capital gains. The funds can retain those gains or distrib-ute them to shareholders as taxable capital gains. Investors can automate savings by electing to reinvest divi-dends and capital gain distributions in additional shares. For most portfolios, it is better to decline automatic rein-vestment and reinvest cash proceeds in portfolio indexes that have fallen in value.

In contrast to mutual funds, ETFs trade like stocks and are priced intraday. Commissions must be paid on each purchase, and dividends and capital gains cannot be automatically reinvested. There are no embedded capital gains, however, and the basis and purchase prices are the same. For equivalent indexes, consider choosing the share type with the lowest cost. A good rule of thumb is to only purchase well-established indexes sold by large reputable fund companies.

“Total” market indexes provide greater diversification and tax efficien-cy than owning a combination of large (S&P 500), small and mid cap indexes. They shield investors from paying capi-tal gains taxes when small and mid cap stocks increase in size and graduate to mid and large cap indexes. Unlike total market indexes, smaller indexes are required to sell stocks no longer meet-

ing its capitalization criteria, triggering capital gains taxes for the investor.

Some active managers repack-age their funds and market them as “indexes.” They select stocks based on criteria such as earnings, dividend yield, momentum, sales growth or price to earning (P/E) ratios. Not consid-ering market capitalization tilts these portfolios toward smaller companies. Compared to passive indexes like the S&P 500, active ones have higher expense ratios (up to 2 percent), less tax efficiency and lower returns.

All diversified portfolios are subject to “tracking error,” which is the differ-ence in return between a portfolio and its underlying index. Money managers and endowments with a mix of asset classes often report beating the S&P 500. A more honest way to evaluate performance is to compare each asset class to its underlying passive index. For example, a 50 percent large cap equity fund and 50 percent fixed income portfolio should be compared to 50 percent S&P 500 index and 50 percent fixed income of similar credit quality and maturity. If the S&P 500 returns 10 percent and the equivalent bond holdings return 2 percent, the weighted return should be 6 percent (50 percent of 10 percent + 50 percent of 2 percent) minus the funds’ expense ratios.

Investors seeking high short-term gains often invest “hot money” with high-priced funds and managers follow-ing recent market beating performance. Because excess return is frequently random, yesterday’s winners often underperform and “revert to the mean.”

Don’t try to ‘beat the market!’GaRy s. Weinstein, mD, FaCs


Disappointed investors dump their shares and switch to new funds and managers who also subsequently under-perform. Repeating the cycle increases transaction costs and capital gains taxes while lowering returns.

The goal of every prudent investor should be to achieve financial security rather than beating others or the market. This is best accomplished with a reasonable asset allocation and a diversified mix of low cost total market indexes. If you think you can beat the market by choosing tomorrow’s winners, realize that the odds of consistently doing so are extremely low. The more pru-dent strategy is to not even try!

Dr. Weinstein practiced oculoplastic surgery in Pitts-burgh for 25 years. He taught investing at Carnegie Mellon University’s Osher program and the American Academy of Ophthalmology. He co-authored a Retire-ment Planning chapter in J.K. Lasser’s Expert Financial Planning and lectures on investing and financial planning to physician groups.

FiNaNcial HEaltH

lEgal rEPort

hospitals for the negligence of their non-employed med-ical staff members, it is consistent with trends emerging in other states. The impact on physicians may be limited since physicians remain liable for their own clinical care decisions (provided they are named in a lawsuit within the two-year statute of limitations), but the impact on hospi-tals will increase their exposure. I predict that hospitals will increase the use of liability disclaimers in admission forms, signage and elsewhere to undercut any patient expectations of vicarious liability. Although patients in acute distress may not have the reasonable opportunity to select which physicians intervene in an emergency, juries will now get to decide whether such patients reasonably believe the physicians providing their care are doing so as hospital agents, and whether to hold hospitals responsible for their mistakes.

Mr. Maruca is a health care partner with the Pittsburgh office of the national law firm of Fox Rothschild LLP. He can be reached at [email protected] or (412) 394-5575.

From Page 31

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Allegheny MedcareHenry Schein, a Fortune 500 Company

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Mike isn’t just a “sales rep.” Mikeis a professional consultant withan MBA and 30 years experienceserving physicians.

Mike will find the best solution toyour medical supply needs, notjust the “product of the month”that others are pushing.

Allegheny Medicare is endorsedby the Allegheny County MedicalSociety—the only medical supplycompany that is!

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ALLEGHENYCOUNTYMEDICALSOCIETY

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Mike isn’t just a “sales rep.” Mikeis a professional consultant withan MBA and 30 years experienceserving physicians.

Mike will find the best solution toyour medical supply needs, notjust the “product of the month”that others are pushing.

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sPEcial rEPort


Health care providers’ meaningful use of Health Informa-tion Technology (HIT) can be a key driving force behind

making health care more patient-centered and improving overall quality. HIT also presents opportunities to strengthen infrastructure and data systems, enable local innovations, foster learning organizations and eliminate disparities.

Quality Insights Quality Innovation Network is collabo-rating with health information technology (HIT) Regional Extension Centers (RECs) to build on the successes RECs have achieved, including providing services to more than 100,000 primary care providers nationwide. We provide tools and resources, email alerts and educational opportuni-ties to participating practices. Our goals include:

• Improving EHR adoption rates, workflows, practice transformation, achieving meaningful use and attestation

• Increasing eligible professionals and eligible hospitals screening and delivery of preventive services for Medicare beneficiaries

• Improving care access and coordination for Medicare beneficiaries

• Reducing disparities in access and utilization of health care services for Medicare beneficiaries

Under a charter with the Centers for Medicare & Medic-aid Services (CMS) to serve as a resource for health care

providers in Pennsylvania, all of Quality Insights’ services are provided free of charge to participating providers.

Learn more about how Quality Insights can help your practice optimize its EHR. Contact Lisa Sagwitz at [email protected] or (877) 725-9998, ext. 7714, or (412) 655-7356 to get started.

About Quality InsightsAs the Quality Innovation Network-Quality Improvement

Organization (QIN-QIO) for Pennsylvania, New Jersey, Delaware, West Virginia and Louisiana, Quality Insights is committed to collaborating with providers and the communi-ty on the Centers for Medicare & Medicaid Services’ goals of better health, smarter spending and healthier people. Our data-driven quality initiatives improve patient safety, reduce harm and improve clinical care locally and across the network. To learn about Quality Insights’ health care quality improvement initiatives, visit www.qualityinsights-qin.org.

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Social Media and HIPAA: Can They Coexist Successfully in Your Practice?

by: Sherry Migliore, MPA, FACMPE, FACHE

Medical practices and other healthcare organizations are faced with a dilemma when it comes to the use of social media and potential violation of HIPAA regulations. Consider the following scenarios:

A medical practice’s employees took pictures of each other to post on social media. In the background of one of the pictures was a patient in the waiting area to be checked in. The patient found out about this from a friend’s daughter and filed a HIPAA violation complaint. The practice was fined $50,000 for violating the patient’s privacy.

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A physician who became annoyed with a chronically late patient used her Facebook page to vent her complaints. Other physicians also weighed in and provided sympathetic comments. The physician had not used the patient’s name but had mentioned personal information that could help identify the patient. An online debate ensued. An investigation was completed and ultimately it was determined that the physician’s statements did not represent a breach of privacy laws. However, her actions caused a large public relations problem for the hospital and she was disciplined by the state medical board for unprofessional behavior.

One need only go to the U.S. Department of Health and Human Services’ website to find numerous examples of violations of health information privacy by healthcare organizations, including medical practices. Social media is increasingly being utilized by hospitals and other healthcare organizations, and surveys have shown that the use of social media by medical practices is also increasing. Its use presents both opportunities as well as challenges. As noted by the Journal of the American Hospital Association, “social media has changed our interactions with others, and by direct consequence, our relationships.”

Medical practices use social media for a variety of purposes. Some are using it to improve communication with patients and to engage them by providing educational information and health monitoring. Portals are being used for this purpose as are other types of social media. The goal is to help patients make behavioral changes that will increase compliance and ultimately improve outcomes.

A subsidiary of the Pennsylvania Medical Society

There is currently an opening on the Bulletin Editorial Board for an ASSOCIATE EDITOR. The position requires basic writing skills and the willingness to

contribute an editorial column of 500-900 words at least once or twice per year. Associate editor terms are for two years; they may serve three consecutive terms.

Selection of the final candidate will be made by the Editorial Board and the ACMS Board of Directors. If you are interested, please email or fax a short letter and a writing sample to Bulletin Managing Editor Meagan Welling at [email protected], or fax (412) 321-5323.

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Social media is also being used by practices and other healthcare organizations for marketing and promotional purposes.

Physician-only social networks are being used to find and share health information, communicate with other physicians, or to disseminate their research.

Another type of social media, physician blogs, are becoming popular, but can be troublesome due to concerns about proper de-identification of individual patients.

For the medical community, one of the most controversial uses of social media in healthcare is physician rating sites. While they can be helpful in helping patients select physicians, they have also been misused.

No matter how social media is being used, it’s critically important to incorporate specific policies and procedures on this subject as part of a medical practice’s HIPAA compliance plan. The policies should address the following issues:

Definitions of the various types of social media being used by the practice and its staff Identification of who has permission to access social media from the practice’s network Definitions of what consists of inappropriate use of social media on practice and personal devices, both while at work as well as outside of the realm of employment Identification of the responsibilities of employees that witness inappropriate use of social mediaDescription of the penalties associated with various violations

A resource that provides examples of social media policy guidelines of healthcare and other types of organizations can be found at http://socialmediagovernance.com/policies. The American Medical Association has also developed guidelines for the ethical use of social media by physicians.

Training employees on the appropriate use of social media is an important part of the practice’s overall HIPAA training policies and procedures. There’s no point in writing policies if they’re not reinforced and followed by the practice. Because social media, like all technology, is continuously changing, practices should conduct security risk assessments to ensure that their policies and procedures reflect its current use in their organizations.

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This year marks the 25th anniversary of the Americans with Disabilities

Act. The most recent census data from 2010 revealed that 1.2 million adults had an intellectual disability and approximately 944,000 adults had other developmental disabilities, such as autism and cerebral palsy (Brault, 2010). According to the Arc of the Unit-ed States, an organization advocating equal opportunities for people with intellectual and developmental disabil-ities (I/DD) in all aspects of life, people with I/DD often encounter barriers to health care not experienced by others. The Arc reports the barriers include:

“Access – Underinvestment in public health and wellness targeted to people with I/DD results in preventable health care disparities and poorer health outcomes.

Discrimination – Health care pro-viders sometimes provide inadequate or inappropriate interventions and treatments or deny appropriate care for people with I/DD because of profes-sional ignorance as well as personal and/or societal bias.

Affordability – People with I/DD are more likely to live in poverty and can-not afford cost-sharing. For cost con-tainment purposes, many public and private health care plans limit access to specialists and critical services.

Communication and personal de-cision making – People with I/DD may have difficulties communicating their

needs and making health care deci-sions without support. Their decisions may not be respected and implement-ed by health care providers and, where applicable, surrogate decision makers” (Life in the Community, n.d.).

Pennsylvania regulationsMany people with I/DD live in

community residential group homes governed by Pennsylvania regulations. The capabilities for providing health care in these group homes differ from those in nursing homes or private homes. It is important for health care professionals developing in-home treatment plans to recognize the capabilities of provider agencies and understand the rules by which they are governed.

Medical knowledgeIn many cases, people providing

care in residential provider settings do not hold professional licenses or certif-icates; they generally learn caregiving skills on the job. Furthermore, most community homes do not have nursing services or oversight. A nurse at a pro-vider agency is generally considered a coordinator of care and may or may not provide direct care to the individual, based on agency practices. Contact the agency representative regarding the ability of nursing to provide direct care. If nursing care is required, a re-ferral to home care may be necessary.

HIPAAHIPAA regulations allow the disclo-

sure of protected health information to provider agency staff for the purpose of treatment – the provision, coordination,

or management of health care and related services among health care providers. HIPAA compliance educa-tion is provided to provider agency staff upon hire and annually.

Insulin administrationBy regulatory requirement, group

home caregivers are not permitted to administer insulin without training from a Certified Diabetic Educator. If insulin is required, alert the provider agency ASAP to determine if staff has had proper training.

Medications Group home caregivers are not

permitted to administer any other injections, IV fluids, or IV medications. Contact the agency representative concerning such medications and the availability of nursing staff to perform these procedures. Also, all OTC medi-cations and treatments (e.g., moisturiz-ing agents) require a written physician order with specific instructions for use.

Physician orders for PRN medica-tions must include specific dosages (not a range) for specific symptoms, to be administered within a specific time. Provider caregivers cannot choose when to administer medications for orders reading “every 4-6 hours.” Like-wise, they cannot choose how much medication to administer for orders reading “between 10-20 ml.” Group homes cannot accept orders for PRN psychotropic medications.

Tube feedingsGroup home caregivers are not

permitted to administer or maintain tube feedings without prior education. Contact agency representative regard-

Supporting quality health care for people with intellectual, developmental disabilities

CheRyl PuRsley, Rn, CDDn

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ing tube feedings and the availability of nursing staff to perform these proce-dures if caregivers have not received required education. If possible, care-givers should receive instruction during the individual’s hospitalization, prior to discharge.

Medical suppliesContact the person’s insurance

company or homecare agency to ar-range for medical supplies required to continue a person’s care at home (e.g., dressing supplies, catheters, bedside commode, oxygen, etc.). Note: Group homes are not equipped with wall suction or oxygen.

ComplianceA person with an intellectual and

developmental disability maintains the right to refuse treatment. Caregivers in provider agencies cannot compel a person to comply with treatment; they are not permitted to restrain a person for the purpose of medical treatment.

ToolsSpecialists in the I/DD field have

developed tools to assist health care professionals to provide quality care for people with I/DD.

The Developmental Disabilities Health Care E-Toolkit (http://vkc.mc.vanderbilt.edu/etoolkit/) is a project of the Vanderbilt Kennedy Center for Research on Human Development, the University of Tennessee Boling Center for Developmental Disabilities, and the Tennessee Department of Intellectual and Developmental Disabilities. The toolkit includes forms and information that address health care issues specific to people with I/DD, such as:

• Cumulative Patient Profile (http://vkc.mc.vanderbilt.edu/etoolkit/wp-con-tent/uploads/CumPatientProfile.pdf) – This form is to be completed at the

initial visit and updated at subsequent visits to document relevant information, such as decision-making capacity, special needs and communication, current concerns, and current and past medication records.

• Today’s Visit Form (http://vkc.mc.vanderbilt.edu/etoolkit/wp-content/uploads/TodaysVisit.pdf) – This form includes a checklist for changes noted in the individual, such as swallowing, mobility, or bowel routine. Sections of this form (e.g., Caregiver Needs and Advice to Patient and Caregivers) pro-mote dialogue between the physician and the caregivers.

• The Behavioral and Mental Health Issues section (http://vkc.mc.vanderbilt.edu/etoolkit/mental-and-behavior-al-health/) provides information on pos-sible triggers for behaviors displayed by people with I/DD and whether psychotropic medications should be prescribed.

• Other information about commu-nicating effectively, informed consent, specific syndromes and disorders specific to people with I/DD also is available.

An article from the World Psychiatry Journal entitled “International guide to prescribing psychotropic medica-tion for the management of problem behaviours in adults with intellectual disabilities” (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758582/) is an evidenced-based international guide providing guidance for prescribing psy-chotropic medications and assessing their effects in adults with intellectual disabilities.

A 2008 joint position statement of American Association on Intellectual and Developmental Disabilities (AA-IDD) and The Arc affirmed, “For the first time in history, Americans living

in the 21st century will experience millions of people with intellectual and/or developmental disabilities living into their ‘senior’ years.” In 2010, the National Task Group on Intellectual Disabilities and Dementia Practices (NTG) was formed to examine infor-mation specific to people with I/DD and dementia, their families, caregivers and organizations supporting them, to develop recommendations for services and practices for better support (Back-ground and History of the NTG, n.d.).

The NTG is comprised of experts in the field of intellectual disability, with members from the American Acade-my of Developmental Medicine and Dentistry (AADMD), the Rehabilitation Research and Training Center on Aging with Developmental Disabilities and the American Association on Intellectual and Developmental Disabilities (AAIDD).

In April 2013, the NTG published “Guidelines for Structuring Community Care and Supports for People with Intellectual Disabilities Affected by Dementia,” reflecting the developing nature of dementia and defining actions that should be implemented. The NTG embraces the staging model accepted for practice among general dementia supports. The staging model describes dementia in stages – from the pre-diag-nosis stage (early signs of cognitive de-cline recognized) through the early, mid and late stages (Guidelines, 2013). The NTG developed the Early Detection Screening for Dementia (NTG-EDSD), a tool to assess changes in cognition and functional abilities in people with I/DD. The NTG-EDSD is available at www.aadmd.org/ntg/screening.

Special Needs Units (SNU)Many individuals with I/DD living


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in southwestern PA have insurance coverage through one of four Managed Care Organizations (MCOs). Each MCO health care plan has a Special Needs Unit (SNU) to assist members with I/DD, providers, nurses, and/or caregivers to resolve issues or con-cerns involving a plan of care pre-scribed by a physician, such as obtain-ing approval for equipment or required medications not covered by insurance plans and addressing concerns with health care providers or entities.

SNU contact information for Man-aged Care Organizations in SW PA:

• Coventry Cares Health Plan SNU: (866) 427-9721

• Gateway Health Plan SNU: (800) 642-3550

• United Healthcare Community Plan of PA SNU: (877) 844-8844

• UPMC Health Plan/UPMC for You SNU: (800) 463-1462

Educating individuals with I/DDEducating individuals with I/DD

about their health care may require specialized support to reinforce under-standing. Methods for effective com-munication include:

• Teach the information in a quiet room; minimize distractions.

• Speak directly to the individual while caregivers observe.

• Speak clearly and slowly.• Be patient; only raise voice if the

person has a hearing impairment.• Allow 15-20 seconds for absorp-

tion and comprehension of information.• If no response, call the person by

name and repeat the information.• Rephrase information to reinforce

understanding.• Divide information into easy-to-un-

derstand segments, and teach one segment at a time.

• Ask for a return demonstration to confirm comprehension.

Closing thoughtI/DD can present unique challenges

for health care professionals. Actions that address those challenges can enhance the health and lives of people with I/DD.

Ms. Pursley is a health professional with APS Healthcare, Southwestern Pennsylvania Healthcare Quality Unit (HCQU). She can be reached at [email protected].

From Page 39

References1. Brault, M. (2012). Americans with Disabilities

2010. Retrieved 2015, from http://www.census.gov/prod/2012pubs/p70-131.pdf.

2. Life in the Community: Health Care. (n.d.). Retrieved 2015, from http://www.thearc.org/who-we-are/position-statements/life-in-the-community/health-care.

3. Health Care for Adults with Intellectual and Developmental Disabilities: Toolkit for Primary Care Providers. (n.d.) Retrieved 2015 from http://vkc.mc.vanderbilt.edu/etoolkit/.

4. Aging: Joint Position Statement of AAIDD and The Arc. (2008). Retrieved 2015 from http://aaidd.org/news-policy/policy/position-statements/aging.

5. Background and History of the NTG. (n.d.). Retrieved 2015 from http://aadmd.org/NTG/history.

6. Jokinen, N., Janicki, M.P., Keller, S.M., Mc-Callion, P., Force, L.T., and the National Task Group on Intellectual Disabilities and Dementia Practices. (2013). Guidelines for Structuring Community Care and Supports for People With Intellectual Disabil-ities Affected by Dementia. Albany NY: NTGIDDP & Center for Excellence in Aging & Community Wellness. Retrieved 2015 from http://aadmd.org/sites/default/files/NTG-communitycareguidelines-Fi-nal.pdf.

Humanities in Health Conference University of Pittsburgh, April 7, 2016, University Club

Organizing Committee: Abdesalam Soudi, PhD; Judy Chang, MD; Shelome Gooden, PhD; Scott Kiesling, PhD; Jeannette E South-Paul, MD

Hosted by: Departments of Linguistics; Family Medicine; Obstetrics, Gynecology, &

Reproductive Services

The humanities are vital to an informed and engaged society. We must value their impact and embrace their role in other disciplines. As part of the Provost’s year of the humani-ties initiative, this one day conference on humanities in health will: serve to enhance the visibility of

humanities in medicine

highlight teaching & research collabora-tions between the humanities & health

discuss opportunities to allow the conversation to continue past the end of the conference

Contact: Dr. Soudi at [email protected] Or visit : http://www.linguistics.pitt.edu/humanitiesinhealth/

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The final rule detailing how Medicare will reimburse physicians in 2016

was issued by the Centers for Medi-care and Medicaid Services (CMS) on Oct. 30, 2015. With your practice and family responsibilities, we know you don’t have time to read and analyze the 1,358-pages to figure out how your reimbursement may be impact-ed next year. That’s another value of your Pennsylvania Medical Society (PAMED) membership. We have you covered with what you need to know.

PAMED’s experts are continuing to analyze the final rule, but, at first glance, here are some of the items that may be of particular interest to physicians:

Advance Care Planning – The rule finalizes a proposal for separate pay-ment for two advance care planning services provided to Medicare benefi-ciaries by physicians and other practi-tioners. The Medicare statute currently provides coverage for advance care planning under the “Welcome to Medi-care” visit available to all Medicare beneficiaries, but they may not need these services when they first enroll. Establishing separate payment offers providers and beneficiaries greater flexibility in using these services.

Incident-To – In an effort to clarify “incident to” requirements, CMS re-iterates the supervising physician is

the physician who bills for “incident to” services. In a conversation with CMS’ subject matter expert, PAMED was told the rule “is intended to clarify that the ordering physician or other prac-

titioner and the supervising physician or other practitioner DO NOT need to be one and the same. Rather, the proposal is intended to clarify that the

2016 Medicare fee schedule: Here’s what you need to know

Pennsylvania meDiCal soCiety


More on Advance Care PlanningAdvance Care Planning Services

The 2016 Medicare Fee Schedule allows for payment for Advance Care Planning Services. Although advance care planning was available in the past, it was only covered when included with the IPPE. Most beneficiaries were not likely to discuss advance care planning at the time of that visit. This enhance-ment will allow for greater flexibility for scheduling advance care planning services for both beneficiaries and providers.

CMS defines advance care planning as a face-to-face meeting with the pa-tient, family members, and/or surrogate for “the explanation and discussion of advance directives such as standard forms (with the completion of such forms, when performed), by the physician or other qualified health professional.” CPT code 99497 is used for the first 30 minutes, and then add-on CPT code 99498 for 30 minute increments thereafter.

An advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time. Some examples of written advance directives include, but are not limited to, Health Care Proxy, Durable Power of Attorney for Health Care, Living Will and Medical Orders for Life-Sustaining Treatment.

CODING AND 2016 REIMBURSEMENT RATESName Code Philadelphia

AreaRest of Pennsylvania

Advance care planning; first 30 minutes

99497 $90.56 $83.91

Each additional 30 minutes

99498 $78.72 $73.33

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physician or other practitioner who bills for the ‘incident to’ services must always be the supervising physician or other practitioner.”

Modifications to Physician Qual-ity Reporting System (PQRS) – If an individual eligible professional (EP) or group practice does not satisfactorily report or satisfactorily participate in PQRS for 2016, a 2 percent negative payment adjustment will apply to covered professional services fur-nished by that individual EP or group practice during 2018. There will be 281 measures in the PQRS measure set and 18 measures in the GPRO Web Interface for 2016. Also, as recently authorized under the Medicare Ac-cess and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA), CMS is adding a reporting option that will allow group practices to report quality measure data using a Qualified Clinical Data Registry (QCDR). The 2018 PQRS payment adjustment is the last adjustment that will be issued under the PQRS. Start-ing in 2019, adjustments to payment for quality reporting and other factors will be made under the Merit-Based Incentive Payment System (MIPS), as required by MACRA.

Physician Value-Based Payment Modifier – In the final rule, CMS finalized the following provisions related to the value-modifier:

• To apply the Value Modifier to non-physician EPs who are Physician Assistants (PAs), Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs) and Certified Nurse Anesthe-tists (CRNAs)

• To use CY 2016 as the perfor-mance period for the CY 2018 Value

Modifier and continue to apply the CY 2018 Value Modifier based on partic-ipation in the PQRS by groups and solo practitioners

• For groups of ten or more EPs – Continue with maximum upward ad-justment of +4.0 to be multiplied by an adjustment factor (to be determined at conclusion of the performance period) and a maximum downward adjustment of -4.0 in CY 2018

• For groups of two to nine EPs and solo practitioners – upward adjustment of +2.0 multiplied by an adjustment factor and a maximum downward adjustment of -2.0 in CY 2018

Physician Compare – The final rule continues the phased approach to public reporting on Physician Com-pare. CMS will continue to make all 2016 individual EP and group practice PQRS measures available for public reporting. All CAHPS for PQRS mea-sures for groups of two or more EPs who meet the specified sample size requirements and collect data via a CMS-specified certified Consumer As-sessment of Healthcare Providers and Systems (CAHPS) vendor are avail-able for public reporting. In addition, all Accountable Care Organization (ACO) measures, including CAHPS for ACOs, are available for public reporting. CMS also is finalizing the following propos-als:

• To include Certifying Board, and specifically add American Board of Optometry (ABO) Board Certification and American Osteopathic Association (AOA) Board Certification.

• To include an indicator on profile pages for individual EPs who satisfac-torily report the new PQRS Cardiovas-cular Prevention measures group in support of the Million Hearts initiative

• To continue making individual-lev-el QCDR measures available for public reporting, and, new to 2016, to publicly report group-level QCDR measures

• To publicly report an item (or mea-sure)-level benchmark derived using the Achievable Benchmark of Care (ABC™) methodology.

• To include in the downloadable database the Value Modifier tiers for cost and quality, noting if the group practice or EP is high, low, or neutral on cost and quality; a notation of the payment adjustment received based on the cost and quality tiers; and an indication if the individual EP or group practice was eligible to but did not report quality measures to CMS

• To publicly report in the down-loadable database utilization data for individual EPs.

CMS is not finalizing the proposal to include a visual indicator on profile pages for group practices and individu-al EPs who receive an upward ad-justment for the Value Modifier. CMS is, however, finalizing its proposal to publicly report an item-level bench-mark for group practice and individual EP PQRS measures using the ABC methodology. The benchmark will be stratified by reporting mechanism to ensure comparability and reduce the interpretation burden for consumers. The benchmark will be displayed as a five-star rating on Physician Com-pare. CMS will conduct analysis and stakeholder outreach around the star attribution methodology prior to public reporting in 2017.

PAMED will monitor any develop-ments and will continue to review the final rule and provide information on any changes that could impact your reimbursement.

From Page 41

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