memphis medical news march 2016

Healthcare Marketing Becoming More of an Exact Science As social networks continue to grow in popularity and instant information – or misinformation – is merely a click away, Mid-South communications experts agree that providing accurate and engaging content is more important than ever for healthcare organizations ... 5

Sleep Disorder Treatments Still Face ChallengesDespite Advances, Insurance Restrictions Remain an ObstacleMid-South sleep specialists are able to treat patients more effectively than ever due to technological advances and a collaborative approach, yet according to two local physicians, challenges still remain in diagnosing and treating patients ... 6

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BY JUDY OTTO

His 10-year commitment to a dangerous and demanding job as a paramedic with the Los Angeles Fire Department says a lot about West Cancer Center CEO Erich Mounce. It also helps explain the inner fi re that drives him

toward achieving his goal of offering the best care possible for Mid-South cancer patients.

That fi re, along with his early determi-nation to make a difference, forged a char-acter that seems custom-made for the role that awaited him at The West Clinic in 2010.

(CONTINUED ON PAGE 9)

Former Paramedic Erich Mounce Ignites Ideas, Growth at West Cancer Center

CON Program Debate Continues Between THA and Beacon CenterBoth Sides Can Point to Academic Studies

BY PEGGY BURCH

Some state legislators hope to perform surgery this year on Tennessee’s certifi cate of need (CON) program for healthcare facilities and services, and their proposed legislation to cut back the regulations animated both supporters and oppo-nents.

The Tennessee Hospital Asso-ciation (THA) wants to keep regu-lations, which require healthcare providers to go to the Tennessee Health Services and Development Agency (THSDA) for a certifi cate of need when they want to build new facilities or offer new services. THA president and CEO Craig Becker said hospitals are not competing on a level playing fi eld with other healthcare businesses.

“We operate 24/7. We have emergency rooms. We have to take all comers whether they have insurance or not. Not everybody has to do that,” Becker said. “Sixty percent of our revenues are

already dictated by the federal and state government. Medi-care and Medicaid tell us how much they’re going to pay us, period, end

of story. “On top of that,

close to 14 percent of the folks who come

through our doors are unin-sured. So they obviously dic-

tate how much they’re going to pay us, which generally is not much.”

Among outspoken opponents of CON regulations is the Beacon Center of Tennessee, the free-trade-oriented nonprofi t based in Nashville that played an active role in last year’s defeat of Gov. Bill Haslam’s Insure Tennessee proposal to expand the state’s health insurance to nearly 300,000 uninsured residents.

Lindsay Boyd, the Beacon Center’s director of policy, calls (CONTINUED ON PAGE 8)

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PHYSICIANSPOTLIGHT

M.K. Jenny Tibbs, MD

ON ROUNDS

FOCUS TOPICS ONCOLOGY • HEALTHCARE MARKETING TRENDS • SLEEP DISORDERS

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m e m p h i s m e d i c a l n e w s . c o m MARCH 2016 > 3

Stars Were Aligned for Radiation OncologistJenny Tibbs Originally Wanted to Follow Father into Surgery

BY RON COBB

The best-laid plans of mice, men and medical students often go awry, as evi-denced by the career path of M.K. Jenny Tibbs, MD, medical director of radiation oncology at Saint Francis Hospital.

Tibbs grew up in Memphis, the daughter of a mother who taught math and science and a father who was a gen-eral surgeon in the Mississippi Delta. As a teenager, Tibbs worked with her father and even scrubbed into surgery with him, and she could see that he loved what he did.

“He’s passed now,” she said, “and he always said when he got to heaven he didn’t have to come out of the OR … he could stay in the OR.”

Coming out of Hutchison School as valedictorian and National Merit Scholar, Tibbs attended Princeton and then Co-lumbia University College of Physicians and Surgeons, having decided to follow in her father’s footsteps. But the deter-mination to be a surgeon was never rock solid, and an interest in radiation oncology slowly took hold.

First, she was infl uenced by what had happened earlier after her grandfather was diagnosed with a cancerous lymph node in his neck.

“I was in college at the time and he underwent radiation, and it was pretty gru-eling,” she said. “It’s a very diffi cult form of radiation, but he was completely cured. And so I think I had it in the back of my mind that this is an interesting fi eld. It’s a good fi eld – it saved my grandfather.”

When she was in medical school, Tibbs took a year off to go to New Zea-land, where she encountered a number of people who were radiation oncologists or children of radiation oncologists.

“And so I thought, ‘Well, God and the universe are telling me something, and I need to take a look at this fi eld.’”

The switch to radiation oncology

was all but complete, and she moved on to Harvard Medical School and became chief resident at Massachusetts General Hospital. While she was in Boston, a mu-tual friend who also was in training was doing a rotation at Boston Children’s Hospital. There she met a young doc-tor, Thomas Merchant, who was doing his residency at Sloan-Kettering but also spending time on a fellowship at Boston Children’s.

The friend set up Tibbs and Merchant on a blind date, and they clicked. Merchant eventually moved on to Memphis, where he is now chair of the Radiation Oncol-ogy Department at St. Jude’s. During his fi rst year in Memphis, he and Tibbs were married, and within a short time Tibbs ac-

cepted a job offer at Saint Francis.“Once I left Memphis and explored a

bit of the East Coast and had an opportu-nity to travel more,” she said, “I started to really appreciate the things that are here in Memphis. I can’t really say if I would have moved back if I hadn’t been engaged to Tom because there were offers in other places.

“But I can say that when I was offered a position at Saint Francis and Tom’s posi-tion was at St. Jude, and my mother was here, and then at that time my brother was moving back, literally all the puzzle pieces fell into place. I realized I could never or-chestrate that myself, and this is what I’m supposed to do.”

Now, after nearly two decades at Saint Francis, Tibbs is delighted with the way things turned out, particularly with her specialty.

“I like so many things about it,” she said. “It’s a team effort, and we have a fantastic team here, a very seasoned team in terms of physics and therapy. Our fi eld combines medicine, a little bit of surgery, some psychiatry, so it’s got a lot of aspects to it that you can wrap into one to try to take the best care of a patient.”

She enjoys helping patients at what she describes as a meaningful time in their lives, developing a patient-oncologist rela-tionship that she says is “fairly intense, at least early on.”

When technological advances help improve patients’ outcomes, that’s all the better.

“One of the things I also like about radiation is that when new technology comes along, oftentimes we’re able to

take advantage of it,” she said. “We have a CyberKnife at Saint Francis that is a dedicated linear accelerator that delivers stereotactic treatments. It’s very focused treatment with precise imaging.”

The imaging allows the doctors to track tumors as they move.

“We can track them very precisely and target them with a very high dose of radiation,” she said. “We’ve had it about 3½ years, and I still get excited when I get to treat patients with it because it’s so effec-tive. I think we’ve treated between 500 and 600 patients over the last 3½ years with that particular machine.”

Tibbs, who has a special interest in prostate cancer and sarcoma, made it a point to express gratitude to the Hope Lodge, affording patients who come in from Arkansas, Mississippi and other parts of Tennessee a place to stay while they get treatment.

At home, the conversation between wife and husband sometimes turns to ra-diation oncology, but maybe not as much as one might expect.

“We will defi nitely bounce cases off of each other,” Tibbs said. “However, the kinds of tumors that children get and the kinds of tumors that adults get are very dif-ferent and the treatments that they get are also a bit different. … But sometimes dur-ing the day I’ll get a call from him or I’ll call him. So if I have a nuanced question, he will provide a good sounding board for me.”

Tibbs and Merchant like to travel and expose their three daughters to other cul-tures, and they enjoy activities such as hik-ing, skiing and kayaking.

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BY CINDY SANDERS

When it comes to reducing cancer mortality in America, there is no question the nation has seen steady improvement with the death rate down 23 percent in just over two decades. Yet, it is also abun-dantly clear more work remains with cancer supplanting heart disease as the number one cause of death in 21 states. Drilling deeper, it’s also apparent not all cancer care is created equal.

Otis Brawley, MD, MACP, chief medical officer for the American Cancer Society (ACS), shared insights from Cancer Sta-tistics 2016. Released in January, the new report analyzes information through 2012, the most recent year for which data is available.

“I think the take-away is that we’ve had a 23 percent decline in the cancer mortality rate from 1991 through 2012,” he said. “That translates into 1.7 million cancer deaths averted from 1991 onward.”

Projecting out to 2016, Brawley said the drop in the mortality rate was ex-pected to be about 25 percent. The ACS projects a total of 1,685,210 new cancer cases and 595,690 deaths from cancer this year.

Looking at the four most recent years of data (2009-2012), men have enjoyed a 3.1 percent decrease in new cancer diag-noses, while the rate for women has stayed steady over the same time period. Some of the decline in male diagnoses is believed to be linked to changes in screening recom-mendations for prostate cancer (see below).

Brawley noted cancer mortality rates rose for most of the 20th century, peaking in the early 1990s. Since 1991, however, mortality rates have declined every year. While the 23 percent overall decline is good news, some types of cancer have en-joyed even greater progress over the past 21 years.

The Big FourIn 2016, the ACS expects 44 percent

of all newly diagnosed cancer cases in men to be attributable to lung, prostate or colon cancer with prostate cancer accounting for about 1 in 5 cases. For women, the most common new cancer diagnoses will be lung, breast or colon cancer with breast cancer accounting for 29 percent of those new cancer cases.

Lung, colon, breast and prostate can-

cers also continue to be the most common causes of cancer death with lung cancer leading the way. However, the big four have also have seen significant decreases in death rates as resources, research, and education have been applied to preven-tion, early detection and treatment.

“The death rate in lung cancer dropped 38 percent from 1991-2012 in men, and 13 percent from 2002-2012 among females,” Brawley said. He ex-plained lung cancer death rates for women actually continued to rise until 2002, which aligns with historical smok-ing patterns where women did not begin to widely use tobacco products until much later than men. “The decline for men started in 1955, and it’s gone from a 55 percent prevalence of cigarette smoking to 20 percent today. Women went from a 35 percent prevalence in 1965 to about a 16 percent prevalence today,” Brawley said.

“The death rate in colorectal cancer and breast cancer declined by nearly 40 percent,” he continued. Brawley added colorectal screening has significantly im-pacted prevention by allowing for the re-moval of pre-cancerous polyps. Among adults ages 50 to 75, colonoscopy use has increased from 19 percent in 2000 to 55 percent in 2013. Colon cancer incidence and mortality rates have declined about 3 percent a year for both sexes over the last decade.

However, not all screening is created equal. Prostate cancer, Brawley added, is a bit trickier to judge. “We’ve had a decline in prostate cancer … and we hope that’s a good thing,” he said. “On paper, our pros-tate cancer mortality rate has declined by nearly 50 percent.”

As for why mortality rates are down so much, Brawley said there are multiple theories. Some of the decline could be linked to accounting issues. Some could be due to improved treatments in regional and metastatic prostate cancer. Some re-searchers have published data suggesting certain treatments might have led to an increase in cardiac deaths. And, Brawley

added, another theory is that screening might actually work.

In addition to the United States, the prostate cancer death rate has gone down in 20 other countries. It should be noted, Brawley stated, that 17 of those 21 coun-tries do not screen for prostate cancer. Furthermore, he continued, “The pros-tate cancer rate went down in the United States before we started screening.”

Calling mass screenings a ‘mistake,’ he noted, “We had an epidemic of pros-tate cancer screening before any research showed any efficacy.” In fact, the latest edition of the ACS report states about half of the overall decline in new cancer cases for men is because of the recent rapid de-cline in prostate cancer over-diagnoses since routine screening with the PSA test is no longer recommended.

Brawley continued, “Currently, no professional organization in the United States, Canada or Europe says men should be screened for prostate cancer.” He added there are several organizations, including the ACS, that say men should be told about the potential risks and ben-efits and should be allowed to make an informed decision about screening in con-cert with their healthcare provider.

Some Cancers on the RiseUnfortunately, not all forms of can-

cer have shown decreases in incidence and mortality rates. Incidence rates in-creased from 2003 to 2012 among both men and women for tongue, tonsil, small intestine, liver, pancreas, kidney, and thy-roid cancers and some types of leukemia. Additionally, men saw increased incidence rates for melanoma, multiple myeloma, male breast cancer, testicular cancer and throat cancer. For women, incidence rates increased for anal, vulvar, and endome-trial cancers.

Brawley said some pancreatic, uter-ine, endometrial and liver cancers are linked to the increase in obesity. In the case of throat cancer, he noted there have been huge decreases in cases linked to

smoking and drinking but big increases in throat cancer tied to HPV.

“The leading cause of cancer in the United States is still tobacco smoking,” Brawley said. “About 30 percent of all cancers are correlated to obesity, lack of physical activity and high caloric intake,” he added. “It’s fair to say 40-50 percent of all cancers are preventable due to lifestyle change.”

Unequal OpportunityBrawley said another issue of key con-

cern is care disparity. “It correlates with socioeconomic status more than anything else and then with geographical status.”

He added the uninsured, underin-sured, and those without financial means receive less than optimal care. “We’ve got data to show in the United States, as a whole, you are better off having stage 2 colon cancer with insurance as opposed to stage 1 colon cancer without insur-ance.” Brawley added the data showed a 10 percent difference in five-year survival in favor of the group with more advanced cancer and insurance.

Similarly, there are regional dispari-ties in care. “There is a huge geographical disparity,” Brawley stated. “While you’ve had a 40 percent decline in colorectal and breast cancer death rates, there are some states with less than a 10 percent decline.” Alabama, Arkansas, Louisiana, Mississippi, and Missouri are among the 14 states that have seen the much smaller decrease in mortality rates.

Brawley added the findings super-sede race. “There is this fallacy that race defines biology,” he said. “I don’t think anyone thinks the biology is different for a white woman living in Mississippi or Ala-bama versus a white woman living in Ohio or Indiana, yet we see drastic difference in breast cancer rates.”

He also noted the racial disparities in breast cancer deaths have become more pronounced in the wake of major treat-ment improvements that occurred in the 1970s. “The disparities have increased every year since 1980 … and they are more in 2012 than in 2000,” he said, add-ing the gap has continued to widen as newer, more expensive treatments have become available. “Socioeconomics and education are a far greater driver of this than anything else.”

The Bottom LineBrawley said he thinks one of the most

important byproducts of the American Cancer Society’s annual statistical analysis is that it helps define the problems, which opens the door to meaningful dialogue.

“If access to appropriate care is a problem in the United States, then we need to figure out how to overcome that problem,” he stated. Brawley added the detailed data also highlights gaps in care to help guide decisions about allocation of resources.

By the Numbers: The Latest Cancer Stats & Facts

Dr. Otis Brawley

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@memphismednews


BY JAMES DOWD

As social networks continue to grow in popularity and instant information – or misinformation – is merely a click away, Mid-South communications experts agree that providing accurate and engaging con-tent is more important than ever for health-care organizations.

And as myriad media platforms vie for increasingly limited attention spans, provid-ing relevant information that increases effi-ciency and enhances user experience is key.

“The first thing healthcare market-ers, or any marketers for that matter, have to consider is their audience,” said Dave Chaney, director of communications for the Tennessee Medical Association. “We must consider their perspective when craft-ing our message. In Memphis, for example, there is a robust medical device sector and marketing messages to that community may be different, say, from marketing messages to pharmaceutical companies in Nashville.”

Stinson Liles, a principal of Memphis-based Red Deluxe Brand Development, agreed.

“So much of marketing now is target-ing,” said Liles, whose firm serves a number of healthcare clients, including Baptist Me-morial Health Care and the national ALS Association headquarters in Washington, D.C. “It’s amazing how specific you can get in choosing exactly who gets your mes-saging in digital now. And when you build a program that combines that with your social media and email strategy, it can be really powerful.”

For Chaney, a significant market-ing push for his 8,500-member associa-tion is recruitment. Shelby County boasts the largest county medical society in the state (there are 2,234 TMA members in Shelby County) and developing marketing messages that appeal to specific areas and demographics has become standard proce-dure.

“In the last few years we’ve seen health care reform and everyone is now looking to increase quality of care and efficiency and reduce cost,” Chaney said. “This is a dramatic change from 10 or even five years ago in terms of marketing and messaging. The convergence of different stakeholders, from physicians to health care professionals to patients to insurance companies, has led to more specific and detailed marketing.”

This is where accurate, easily accessed content comes in. Healthcare organizations and professionals must realize that the prolif-eration of online searches means an increas-ingly large number of patients are getting their initial medical information online. And marketing efforts must capitalize on that.

A study by the Pew Research Center found that more than 70 percent of Inter-net users have searched online for health information. And nearly 80 percent began those information-seeking journeys by uti-lizing search engines such as Google or Bing or Yahoo.

Marketing to online audiences there-fore takes on greater significance and may yield tremendous results, Liles said.

“Imagine you’re an endocrinologist looking to build market share. Mass media was once your only option, but today you can create some premium content — maybe a weight loss guide for women with hyperthyroidism — put it on your site, and advertise it in digital ads that are shown only to women in their 30s and 40s,” Liles said. “Better still, you can require an email address to get the content and then set up

periodic emails to that person about thy-roid issues. It’s a cost-efficient, high-ROI set of tools that didn’t exist before.”

And while marketing efforts are being developed with online audiences in mind, attention must also be paid to how such campaigns are discovered and consumed.

That strategy has been confirmed by the Local Search Association (LSA), a not-for-profit industry association of media companies, agencies and technology pro-viders with some 300 members in 19 coun-tries who help businesses market to local consumers.

Last year the LSA released a study that revealed mobile devices are now used more often than PCs to find information on local products and services. The study reported that 60 percent of adults use smart phones or tablets rather than laptops or desktops to access information before purchasing products or services offline. “The shift from PCs to mobile for local search, and smart phones in particular, is partly the result of the emergence of a new segment of ‘Mobile Fanatics.’ These heavy mobile users conduct at least 10 searches per week on at least two devices from multiple

locations,” Neg Norton, LSA president said in a release. “Mobile Fanatics are a new and growing consumer segment. Under-standing where and how these consumers find information is critical to make sense out of the new path to purchase. The challenge becomes delivering relevant and engaging content when they pick up their devices.”

Looking ahead at 2016 and beyond, healthcare marketing trends will continue to revolve around development of informa-tion-rich content that is easily searchable and viewable, experts agree. But even as marketing efforts expand in an effort to target narrow audiences with specific con-tent, careful planning must precede broad execution.

“Every day there is something new. I saw a cool platform recently that offers employees redeemable points as they post company social content to their personal social media channels, but none of this novelty is a silver bullet,” Liles said. “Suc-cessful marketers are still the ones who understand their audiences and plan clear and focused programs for reaching them. Technology is great, but it’s no substitute for strategy.”

BY MELANIE KILGORE-HILL

Medical News tapped into the expertise of three leading healthcare marketing pros to ask about some of the do’s and don’ts of hospital marketing.

What’s the worst thing you’ve seen in a hospital/healthcare website?

If a person is visiting a hospital website, it’s because they have a need – a need to find out pa-tient visitation hours, an address, emergency num-bers or something of that nature. Any website that buries this information is doing their visitor a disservice. So many hospitals want to market their services or talk about their latest technologies from a branding perspective. That is important but should not be front and center on a website. Who cares about your latest bariatric treatment when I am trying to find the emergency room address? – Todd Smith, President & CEO, Deane/Smith

The worst thing I’ve seen is, honestly, stagnation. In a lot of ways, having a really outdated website is worse than not having one at all. A website doesn’t have to be splashy, but it does have to be reasonably current. Features about the swine flu outbreak and a news section in which a 2012 press release is the most recent item just sends a terrible message and does not instill confidence in patients, employees or partners. – Nicole Cottrill, Partner, DVL Seigenthaler, A Finn Partners Company

The worst are hospital websites that provide no ways for view-ers to interact and learn more, engage with the content, or help them further down the care pathway (i.e. make an appointment). People don’t come to hospital websites for fun. They are there for a purpose. If the site doesn’t support that purpose, it’s a horrible experience. One specific worst thing – a hospital website home page that had 241 links on it. We did a study of hospital and health system website navigation five years ago and looked specifically at

home page navigation, which when handled poorly is a demonstra-tion of a lack of marketing discipline and an inability to effectively prioritize audiences. As a benchmark, the average hospital website home page had 57 links leading away from it. – Brandon Edwards, CEO, ReviveHealth, A Weber Shandwick Company

What are the best features you’ve seen in a healthcare website?

I love the hospital sites that allow a person to “get in line” while I am on the way to the hos-pital. It cuts down on wait time and really moves the process for one of the most painful experiences of a hospital ... waiting! – Smith

This is a harder question because I think there are a lot of healthcare companies doing great things on the web. I love the many creative ways so many in the healthcare sector are engaging and educating people of all ages and doing so much to reach peo-ple wherever they are and however they need – from video and apps to games and online communities. We are learning so much about tools and information individuals can use to take better con-trol of and more effectively manage their health. – Cottrill

The best are hospital websites that are engaging with content (multimedia, interactive content) that is emotionally engaging, using language that is clear and concise, and the site is responsive (designed to be accessed from multiple screens: phone, tablet, etc.) and usable (easy to navigate and useful). One specific best thing – a hospital website with a pricing calculator that provided actual costs of services based not only on a patient’s insurance company but based on the specific plan and the specific employer version of that plan. This was the first and, to my knowledge, only example of a community hospital providing that level of price transparency to its patients. – Edwards

The Do’s and Don’ts of Hospital Marketing

Healthcare Marketing Becoming More of an Exact Science

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BY BETH SIMKANIN

Mid-South sleep specialists are able to treat patients more effectively than ever due to technological advances and a col-laborative approach, yet according to two local physicians, challenges still remain in diagnosing and treating patients.

The medical community is more aware of sleep disorders, and physicians are more likely to refer a pa-tient to a sleep specialist now than a decade ago, according to Neal Aguil-lard, MD, pulmonologist and medical director for Methodist Healthcare Sleep Disorders Center.

“The evolution of sleep medicine has changed drastically,” Aguillard said. “It is stressed more in medical school and through continuing education. Also, the patient teaches the physician. If a patient spends seven to eight hours in bed each night and is still sleepy, then something is wrong and the physician will refer the pa-tient to us.”

As awareness of sleep disorders has in-creased, so has the demand for testing and treatment. Patients with suspected sleep apnea, which is the most commonly diag-nosed sleep disorder, are sent to accredited

sleep centers, where they are interviewed and evaluated overnight in a sleep labora-tory. In the past decade, the number of ac-credited sleep centers has grown nationally from 566 to 2,258, according to the Ameri-can Academy of Sleep Medicine.

The Methodist Healthcare Sleep Dis-orders Center read 4,000 sleep studies last year, Aguillard said. The center has seven specialists on staff certified to read sleep studies.

One of the largest hospital-based sleep disorder centers in the country, it treats various types of sleep disorders and sees patients from newborns to advanced age. The center is unique in that there is a pedi-atric neurologist on staff who sees current and former cancer patients from St. Jude Children’s Research Hospital through a partnership between the two hospitals. Ac-cording to Aguillard, 80 percent of patients treated at the center have some form of sleep apnea, which is when a patient pauses in breathing during sleep.

Aguillard’s team collaborates inter-nally and meets weekly to go over patient cases anonymously to better service a pa-tient’s needs.

“As physicians, we take a multi-disci-plinary, team-based approach to diagnosis and treatment,” Aguillard said. “For in-stance, our neurologist could recommend a certain medicine for a neurological prob-

lem a patient may have. We may discover that we need to swap patients depending on the physician’s level of expertise. Each case is unique.”

It is not uncommon that a sleep spe-cialist discovers that a patient has other health issues resulting from sleep deficiency, according to Amado Freire, MD, professor and chief of the University of Tennessee Health Science Center’s division of pul-monary, critical care and sleep medicine.

Additionally, Freire is the program director for the UTHSC fellow-ship program for sleep medicine. The fellows in the program train in sleep medicine at the Memphis VA Medi-cal Center and Le Bonheur Children’s Hospital.

“We can sometimes find other po-tential issues when we treat a patient,” Freire said. “Patients who experience sleep deficiency are more likely to suffer from chronic diseases such as hypertension, dia-betes, depression and obesity.”

Regarding other health issues discov-ered during a sleep study, Aguillard said, “For instance, we could determine through a sleep test that a patient has an arrhyth-mia and refer the patient to a cardiologist. It could be an incidental finding.”

In addition to physicians working to-gether, technological advances have aided in the treatment in sleep disorders.

Typically, a patient who is diag-nosed with obstructive sleep apnea must use a continuous positive airway pressure therapy (CPAP) machine to breathe more easily during sleep. A CPAP machine is a mask that covers the nose and mouth. It in-creases air pressure in a patient’s throat so the airway doesn’t collapse when a patient breathes. A patient must use the machine every night during sleep and is an effective, noninvasive way to treat sleep apnea.

“CPAP machines are very sophis-ticated now, “Aguillard said. “A decade ago when a patient used it at home, it gave the highest pressure for air flow no mat-ter what. Now CPAP machines can sense

when the air pressure should be higher or lower as the patient moves in his or her sleep. They allow us to download informa-tion to find out if the patient is using the machine every night at home and if the air pressure is varying. The patient doesn’t have to be seen in the office as much any-more. There is a transfer of data directly to the physician.”

However, insurance restrictions can be an issue for doctors wanting to perform sleep studies inside a sleep center laboratory.

“An overnight sleep study performed in a lab is very expensive and can cost around $3,000 to perform,” Aguillard said. “Commercial insurance won’t always cover it and will opt to cover a home sleep study instead. Sometimes a home screening isn’t always enough or as comprehensive.”

Monitoring patient’s sleep at home in-volves measuring a patient’s oxygen level, heartbeat, air flow and chest movement. In addition to these measurements, an over-night sleep study performed in a sleep cen-ter records and monitors a patient’s brain waves.

“A patient’s brain activity is monitored in a lab, and we can see what goes on inside a patient’s brain when asleep,” Freire said. “For example, a patient may only have sei-zures while he or she is asleep. We can ob-serve and monitor this carefully in the lab. It’s highly effective.”

Aguillard points out that a technician observes the patient the entire time he or she is asleep when the study is performed inside a sleep center.

“At home, machines can be discon-nected when a patient sleeps, and we don’t get as accurate data as we do inside a lab,” Aguillard said. “Someone is there constantly monitoring the patient and can adjust the equipment as needed.”

According to Freire, the Mid-South area is underserved due to a shortage of trained sleep specialists.

“There is an insufficient number of physicians to service the Mid-South com-munity in sleep medicine,” Freire said. “The fellows we train are the next genera-tion of providers. We hope they will stay in the area and practice here.”

Sleep Disorder Treatments Still Face ChallengesDespite Advances, Insurance Restrictions Remain an Obstacle

Dr. Neal Aguillard

Dr. Amado Freire

m e m p h i s m e d i c a l n e w s . c o m FEBRUARY 2016 > 7

BY SCOTT SHANKER AND

KATE MARA DOWD

Although the charge of hospitals acquiring physician practices appears to have slowed during the last 12 months, the healthcare field has seen a renewed interest in contractual integration models between hospitals and physicians. As hospi-tals continue to seek ways to enhance patient care, improve operational ef-ficiencies and reduce costs, service line co-management arrange-ments have regained traction as a popular and productive method of clinical integration. Ser-vice line co-management arrangements pose significant benefits for hospitals and physicians alike by aligning clinical and financial interests.

Overview of Service Line Co-Management Arrangements

Service line co-management arrange-ments are a model of clinical integration

between physicians and hospitals in which physician members of a hospital’s medi-cal staff oversee and manage day-to-day operations of a hospital department or service line (e.g., cardiology, radiology, oncology, orthopedics, urology, etc.). These arrangements are separate from, and may incorporate certain aspects of, an on-call or medical director arrange-ment.

Under a service line co-management arrangement, the hospital and partici-pating physicians collaborate to design strategies and establish goals to enhance a service line’s quality of care and opera-tional efficiencies while decreasing the service line’s overall costs. The model further unites hospitals and physicians with respect to service line improvements and provides financial incentives for phy-sicians to satisfy pre-established perfor-mance metrics.

Commitments & Compensation: What does a Co-Management Arrangement Involve?

Structure: Co-management arrange-ments can take several forms, ranging from a direct contract to a hospital-phy-sician joint venture. While the contract model is the simplest to implement, al-

ternate co-management models generally require the formation of a new legal entity as the management company.

Written Agreement: Regardless of their structure, all co-management arrange-ments require a written agreement that specifies each party’s responsibilities and the mechanics of integration, governance and compensation. Key contract terms include: (1) A thorough description of services the physicians will perform; (2) careful attention to each party’s rights, duties, and authority to make service line decisions; (3) designation of performance metrics to measure improvements in quality of patient care and operational ef-ficiencies; and (4) compensation terms (as further described below).

Compensation: Physician compensation under a co-management arrangement typically has two elements:

Fixed Compensation: Physicians are paid a pre-established flat rate for their daily work in overseeing and managing the service line. Compensation can be paid hourly, monthly or on a task-based model.

Variable / Incentive Compensation: Physi-cians typically receive incentive payments for achieving designated performance metrics. Incentive payments can be paid

in whole or in part to the extent that such performance metrics are satisfied.

All compensation must be consistent with fair market value (“FMV”) and can-not take into account or vary with the vol-ume or value of referrals or other business generated between the parties.

Services: Service line co-management arrangements may cover a broad array of services, including inpatient, outpatient, ancillary and / or multi-site services. Examples of management duties may in-clude, without limitation:

• Managing staff (e.g., hire, fire, train, direct, schedule, manage per-formance and supervise)

• Developing and implementing poli-cies, procedures, clinical protocols and operational protocols

• Evaluating patient, staff and physi-cian satisfaction

• Overseeing research activities• Support medical education for

medical students, residents, fellows and other practitioners

• Monitoring and providing recom-mendations regarding annual bud-gets

• Evaluate and manage relationships with key vendors (e.g., technolo-

Service Line Co-Management Arrangements on the Rise

(CONTINUED ON PAGE 10)

3150 Stage Post Drive # 103, Bartlett, TN 38133

Scott Shanker

Kate Mara Dowd


CON laws “antiquated” and says they limit op-tions for consumers, es-pecially low-income and rural patients. She says the federal government and some states repealed CON laws more than 25 years ago because they weren’t having the intended effect of controlling healthcare costs.

“Healthcare continues to be a com-modity that is constantly increasing in price, and the amount of healthcare pro-viders out there is diminishing,” Boyd said. “We believe it’s time that Tennessee reforms these laws so that we create more space in the healthcare market and more providers for those most in need.”

Magnetic resonance imaging, with expensive equipment that requires a large physical space for operation, is among the services that require a state certificate of need. In 2013, TennCare reported that if state legislators decided to end the CON process for imaging services, it would cost the state nearly $1.6 million a year. “We have conservatively estimated a 5 percent

increase of $1,590,757 in the first year for MRIs and PET scans,” the report said.

“Diagnostic imaging utilization increases significantly when there is a greater supply available and especially when the service provider is owned by physicians who self-refer. Despite current CON requirements, Tennessee with 275 has more MRIs than New York, Ken-tucky or Michigan.”

At THA, Becker echoed that opinion. “If you buy one of these machines,

you’re going to make it hum to make sure it pays itself off and you get your return on it,” he said. “From our perspective, one, it’s not necessarily the best quality of care. If you don’t need an MRI, you shouldn’t get one. Sec-ondly, it doesn’t make a whole lot of sense to have a lot of MRIs out there. There are more MRIs in Nashville than there are in most of the provinces of Canada. Not say-ing that we want to be like Canada, but I think there’s some happy medium in there. We’re probably at it right now.”

At Beacon Center, Boyd counters that the number of MRIs in the state should be determined by businesses, not government.

“If businesses believe that it’s ju-dicious for them to purchase an MRI machine because they have the patient demand to justify that, then they should be free to make that decision,” she said. “If they make that decision and it’s an error, or they find that they don’t have the patient demand to justify that cost, then that’s a decision that they’re going to have to be held accountable for to their board members and their investors.”

Becker said imaging services may be one income source that keeps rural hospi-tals afloat. “If a local physician gets a hold of an MRI, they can pretty much put a hospital out of business with that alone,” he said. “If they’re an entrepreneur, they are not going to take uncompensated care and they’re more than likely not going to take Tenncare patients. A lot of times they sign things that say they will, but we know they don’t.”

Jim Christoffersen, THSDA legal counsel and legislative liaison for the agency that issues certificates of need, said the process was overhauled in 2002. “We think the process is strong and the statute is good, that it’s important health planning, but there’s always room for im-provement,” he said.

Both sides of the discussion can point to academic studies that back them up.

At Vanderbilt University Medical Center, a study framed the CON issue in terms of quality of care, and reported that medical outcomes improved when patient volumes at a hospital increased, permit-ting the facility to become more proficient at specific services.

“One of the goals of the original 1974 federal CON legislation was to improve the outcome of medical care by increasing the volume of patients at any one given hospital,” the report said. The Vanderbilt analysts said a review of medical literature

“shows that patients have lower death rates in hospitals/medical centers that have high volumes of certain services.”

The services cited were surgery, in-cluding open heart surgery and cardiac catheterization; burn care; neonatal inten-sive care; and organ transplants. “Medical literature also shows that patients under-going CABG (coronary artery bypass graft) surgery in states with CON have lower death rates than those in states with-out a CON,” the Vanderbilt study said.

The points against CON made by Boyd of the Beacon Center were similar to those outlined in a study at George Mason University’s Mercatus Center, which noted that Tennessee was among states with the seventh most restrictive CON process of the 36 states that have the programs.

“Since 1973, Tennessee has been among the states that restrict the supply of healthcare in this way, with 20 devices and services — ranging from acute hos-pital beds to magnetic resonance imaging scanners to psychiatric services — requir-ing a certificate of need from the state be-fore the device may be purchased or the service offered,” the report said.

The report said that in Tennessee, the CON program may have resulted in 8,500 fewer hospital beds and 32 fewer hospitals offering MRI services. In opposition to the TennCare study, the Mercatus study said strict CON programs may “increase costs by 5 percent” because they limit the num-ber of service providers, who then are “able to charge higher prices than would be pos-sible under truly competitive conditions.”

Said Boyd: “The best thing for the patient is to be able to have choices. The reason why healthcare costs are so astro-nomically high these days is because no-body knows the real cost of their care. You can’t get a transparent, forward-thinking diagnosis and assessment from the hos-pital prior to treatment. You’re only told after the fact what the actual costs are when you receive a bill.”

While Vanderbilt’s study supported CON regulation, it also called for changes in parts of the process, such as dollar thresholds for construction and equip-ment and fees for CON applications.

The final version of legislation to alter CON regulations in Tennessee is still being created. The bill’s Senate spon-sor, Todd Gardenhire, R-Chattanooga, is leading a group of senators in a sum-mer review of the program. The sponsor of the companion bill in the House, Rep. Cameron Sexton, R-Crossville, told The Tennessean in January that he hopes CON changes will lead to “as much free market as we can potentially have.”

CON Program Debate Continues, continued from page 1

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Under his helmsmanship, the clinic grew and blossomed into the West Cancer Center, a collaborative partnership with Methodist Healthcare and the University of Tennessee Health Science Center.

His success to date is represented in part by the newly opened West Cancer Center facility on Wolf River Boulevard, with its state-of-the-art approach to can-cer treatment, as well as to design and equipment.

Mounce, who holds a master’s degree in health administration from California State University, left his fi rst-responder role to hone his management skills during a 14-year term as CEO for a privately owned company that operated hospitals in St. Louis, Chicago, Washing-ton, D.C., and Los Angeles. He was later invited by a former physician mentor to serve as CEO for Lakeside Comprehen-sive Healthcare in Glendale, Calif., a community healthcare organization that included a 105-physician multispecialty medical group, a 2,000-member IPA (independent practice association) and a Medicare Advantage Plan.

When his mentor succumbed to can-cer and the organization was dissolved, Mounce was left jobless — and with pain-ful memories of a meaningful life lost to cancer.

When the invitation came to lead The West Clinic in its plan to create a better way to care for cancer patients, “I knew it was fate,” Mounce said. “The timing was right; cancer was fresh on my mind.”

He was also impressed by what he heard.

“Dr. (Lee) Schwartzberg and Dr. (Kurt) Tauer didn’t talk about money or income at all during our fi rst meeting,” he said. “They didn’t look toward a vision of how to create a better income for them and their doctors; they worked toward creating a better cancer program and a better delivery model in the community that they served. Having worked in so many different places where the reverse was true, it was very eye-opening and made the decision for me.”

(To this day, Mounce reportedly re-minds people at every meeting and every opportunity, “Remember, guys, it’s all about our patients. That’s why we all are here, and that’s the most important thing.”)

Where the traditional medical refer-ral method of cancer care had sent pa-tients ping-ponging around town from one specialist to another, each with po-tentially different processes and billing methodologies, Mounce’s mission was to create a comprehensive care center where patients’ needs for all services, including medical, surgical and radiation oncology, increased clinical trials and more, could be met under one roof with minimum delay and maximum communication, in-cluding 25 monthly meetings of multidis-ciplinary minds concerning each patient’s care. The conferences ensure that every-one involved in each patient’s treatment remains on the same page.

“Creating a better journey allows us

to eliminate some of the barriers to that care,” he said, “and hopefully start to make a dent in that unbelievably sad dis-parity we have in Memphis and Shelby County, where an African-American woman with breast cancer is twice as likely to die as a Caucasian woman — that’s just a tragedy.”

The toughest challenge he faced was getting disparate cultures to work together — academic cultures, community, physi-cians — and to believe it would succeed. “It’s taken us fi ve years to get there, be-cause it was such a fundamental change for this marketplace,” he said.

Along the way, Mounce has fostered community outreach efforts such as a mo-bile center that provided more than 500 free screening mammograms to the un-derserved last year and successfully iden-tifi ed cancers that might otherwise have gone undetected.

He has overseen the recent devel-opment of the University of Tennessee/West Institute for Cancer Research, a 501 (c) 3 entity with West Clinic founder Dr. William West serving as volunteer chair-man of the philanthropic effort. The re-search foundation was kick-started by a $2.25 million donation of their own funds from West Clinic physicians dedicated to their mission.

He is also involved in Methodist’s ex-pansion plans, including its $300 million investment in a new facility on the cam-pus of the University hospital — 70,000 square feet of which “will be dedicated to creating the same kind of outpatient on-cology journey that we’ve done in Ger-mantown,” Mounce said. “We will be running it as our part of the collabora-tion.”

Still in early stages, the project has a target opening date of January 2019.

His short-term goals involve conver-sion to a new electronic medical record system this year, building a mid-level management team equipped with more tools and training to help provide “really great patient journeys” and constantly re-viewing and improving operations.

“Change will always happen,” he cautions healthcare professionals. “If you don’t facilitate change, it will change you.”

Mounce credits his roots for the ser-vant leader management philosophy he embraces: “I was a fi refi ghter-paramedic because I wanted to develop a career of service. I think that really good leaders enjoy the service they’re doing. They’re not doing it to be the boss or the leader.”

He takes pride in changing the way cancer care is being delivered in Mem-phis — and in surviving as a Los Angeles fi refi ghter-paramedic, which left him with great respect for police and fi refi ghters. “I know what they go through!”

He’s also proud that he and wife Marla have raised fi ve amazing children, the youngest of whom is graduating from Lausanne this year.

In his leisure time he loves to travel, enjoys red wine and is an avid, lifelong skier.

Former Paramedic, continued from page 1

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gies, equipment, services)• Collaborating with hospital leader-

ship • Recommending selection and pri-

oritization for equipment• Serving as a community liaison Performance Metrics: The hospital and

physicians collaborate to develop specific service line performance metrics that will be used to measure improvement. Per-formance targets are used to calculate incentive compensation and are typically subject to change annually. Examples of service line performance metrics may in-clude, without limitation:

• On-time starts • Completion of pre-operative evalu-

ation and examinations• Readmission, complication and

mortality rates following admission• Appropriate clinical documenta-

tion and accurate coding• Patient and staff satisfaction scores• Cost reductions• Legal, Regulatory and Other Con-

siderations for Developing Co-Management Arrangements

The Federal Anti-kickback Statute (“AKS”): Co-management arrangements should comply to the greatest extent pos-sible with an applicable AKS safe harbor and guidance issued by the Office of In-spector General (“OIG”). The OIG has previously approved a co-management arrangement between a hospital and a

cardiology group in which the group received incentive compensation based on satisfaction of pre-established perfor-mance metrics (the “Proposed Arrange-ment”) (see OIG Advisory Opinion 12-22). Although the Proposed Arrangement would not meet the AKS safe harbor for Personal Services and Management Con-tracts because aggregate payment was not set in advance within the “four corners” of the written contract, the OIG con-cluded that the Proposed Arrangement would not violate the AKS for several reasons, including: (1) Payment was con-sistent with FMV and the group would provide substantial services; (2) compen-sation did not vary with the number of patients treated; (3) the compensation was not likely offered to induce referrals under the circumstances; (4) the incentive com-pensation was tied to performance metrics developed based on nationally recognized standards; and (5) the Proposed Arrange-ment was set forth in a written agreement with a limited, three year term.

The Federal Civil Money Penalty Statute (“CMP Statute”): Co-management ar-rangements should implement safeguards in accordance with applicable OIG Ad-visory Opinions. In OIG Advisory Opin-ion 12-22, the OIG further concluded that the Proposed Arrangement would not violate the federal CMP Statute for several reasons, including: (1) it did not adversely affect patient care; (2) appropri-ate monitoring procedures were in place and an independent third party reviewed the Proposed Arrangement annually; (3) the Proposed Arrangement did not apply to specific cost saving measures and physi-cians were not prohibited from using cer-tain devices or supplies; (4) the financial incentive was “reasonably limited in du-ration and amount” with an annual cap

and a limited term; and (5) payment was conditioned on the physicians not (i) stint-ing on care, (ii) increasing referrals, (iii) cherry-picking patients or (iv) accelerating discharges.

The Federal Stark Law: Co-manage-ment arrangements must be structured to comply with an applicable exception to the federal Stark Law (if it applies). This might be a reason to consider a joint ven-ture or separate management company, rather than an agreement directly be-tween the hospital and physician group.

HIPAA: Ensure the arrangement complies with applicable HIPAA require-ments, including execution of a Business Associate Agreement, when appropriate and necessary.

Medical Director / Service Line Adminis-trator: Eliminate any overlap between the co-management arrangement and any pre-existing medical director or service line administrator. If the medical director or service line administrator is retained to perform administrative services, he or she should generally receive compensation through the co-management arrange-ment.

Periodic Review: Review the co-man-agement arrangement on a periodic basis (e.g., annually) to ensure that all duties and performance metrics are appropri-ate. Compensation should be adjusted ac-cordingly to remain consistent with FMV.

FMV Considerations: Consider engag-ing an independent valuation firm to pro-vide an FMV appraisal to support and place parameters around the compensa-tion terms.

While service line co-management arrangements are not new, they seem to be making a comeback since they present significant potential benefits for both hos-pitals and physicians. A key to successfully implementing co-management arrange-ments is advance business planning and careful legal construction. Determining the optimal structure and performance metrics for effective co-management ar-rangements requires a careful review of the facts and circumstances specific to a hospital and its participating physicians, as well as an in-depth legal analysis to en-sure compliance.

Service Line Co-Management, continued from page 7

Debra Coplon Opens Practice in East Memphis

Dr. Debra Coplon, DNP, DCC has opened her own practice in East Mem-phis at 5658 South Rex Road, Suite 200 and is currently accepting new patients, including those with Medicare.

Coplon has served the Memphis and Mid-South medical community since 1987 and now is offering profes-sional healthcare for the entire fam-ily. She said the mission of Hope Pri-mary Care is to provide a wide range of medical services at affordable prices and does not participate in any health-care plans or file insurance claims, other than Medicare. The practice will provide

a printed summary of services rendered upon completion of a visit.

Patients with insurance may file the claim with their insurance provider or keep it as a record for the purpose of meeting their deductibles.

Baptist Names Vice President of Revenue Cycle

Baptist Memorial Health Care has named Keith A. Siddel as vice president of revenue cycle.

Siddel will be responsible for the overall Baptist revenue cycle and will provide leadership for both hospital and physician-owned services to in-clude patient access, health information

management, coding and transcription, patient financial services, revenue audit, managed care finance, Chargemaster, clinical documentation, denial mitiga-tion and payer enrollment.

Siddel has worked as a consultant and healthcare financial expert for na-tional healthcare providers, including hospitals, physician practices, surgery centers, clinics and fully integrated health care providers.

Siddel holds a bachelor of science, master in business administration and a juris doctorate of law. He was licensed as a nurse and served in the United States military.

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GrandRounds

Martin Willoughby Jr.

Emergency Mobile Health Care Names New CEO

Martin Willoughby Jr. has been named CEO of Emergency Mobile Health Care (EMHC).

A native of Jackson, Mississippi, Willoughby brings 25 years of legal and corporate experi-ence to the company. He previously owned Wil-loughby

Law Firm and later was a Principal with Butler Snow Advi-sory Services, LLC. He has written three books with a fourth, Intentional Lead-ership, scheduled to be released this spring.

Gregory Fink, MD, Joins the Cardiovascular Center

Dr. Gregory Fink, MD, has joined The Cardiovascular Center, a Method-ist Healthcare-affi liated physician practice spe-cializing in thoracic and cardiovascular surgery.

Fink earned his medi-cal degree from Jefferson Medical College in Phila-delphia, Pennsylvania. He completed his residency in general surgery at the University of Florida in Tampa and a residency in tho-racic surgery at State University of New York in Syracuse.

He is certifi ed by the American Board of Thoracic Surgery, American Board of Surgery, and the National Board of Medical Examiners.

Total Health Medical Clinic Opens in Collierville

Total Health Medical Clinic, which offers same-day visits for primary care, sick visits, and minor inju-ries, has opened in Col-lierville at 1204 West Pop-lar Avenue, Suite 102.

The clinic, which also offers wellness programs and provides injections for energy, illness pre-vention and hormone therapies, is owned by Candace Harris, a nurse practitioner with more than a decade of nursing experience. Dr. Cas-sandra Hawkins, MD is the supervising physician.

Harris, whose prior experience is predominantly in acute, intensive care, and family practice, said a major reason

she opened the clinic is to serve adults and children who seek same-day treat-ment, but do not want to wait for long periods in emergency rooms.

Hours for the clinic are 9 am to 6 pm, Monday through Friday and 9 am to 1 pm on Saturday.

Christ Community Health Services Opens Raleigh Health Center

Christ Community Health Services has a new location in Raleigh.

The Raleigh facility, which opened

last month at 3481 Austin Peay, offers medical and dental care.

Brian McKinnon Named to Memphis Medical Society Board

Brian J. McKinnon, MD, FACS, who specializes in neurotology with Shea Ear Clinic, has been named to the board of the Memphis Medical Society.

McKinnon has a distinguished clinical, research, and teaching practice focused on hearing and balance dis-orders, with particular specialties in im-

plantable hearing devices and cochlear implants. A recognized lecturer, author and presenter McKinnon is widely pub-lished in peer review publications. He is currently completing his Masters in Pub-lic Health at the University of Memphis.

McKinnon’s newly published book, Life Is Worth Hearing! can serve as a guide to patients and caregivers in re-gard to hearing loss prevention and hearing recovery. The book is available at no charge for medical and healthcare practices for use in waiting rooms or for distribution to visiting patients.

Dr. Gregory Fink

Candace Harris

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non profi ts ... check the online calendar for healthcare happenings.


Relentlessly progressive cancer care and research since 1979. Visit WestCancerCenter.org.

PERCENTof West Cancer Center patients with new metastatic cancer have the opportunity to receive extensive molecular testing.

memphis medical news march 2016

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