KEEPING THE PUBLIC IN THE DARK

By John Norris, Managing Director, and the Head of Wealth Management at Oakworth Capital Bank in Birmingham

Our elected politicians are currently sparring over tax rates and spending cuts to avoid something popularly called “the fiscal cliff,” as we head into 2013. If the two sides can’t reach a conclusion, all the so-called Bush tax cuts expire, as does the Administration’s payroll tax break. Further, the Congress will have to start cutting spending, or at least cut the growth of deficit spending moving forward.

When combined, the US economy is presumably facing a sudden loss in liquidity, or government largesse if you will. While experts can’t reach a unanimous conclusion as to the outcome, they are in agreement it won’t be positive for the economy. Frankly, that probably isn’t very likely.

The reason is pretty simple: either party’s proposal is preferable to letting everything expire, no matter what the media leads you to believe. Further, Washington’s concept of spending cuts is much different than yours or mine. When we cut spending, we reduce the absolute number of dollars going out the door. When the Federal government does it, it simply reduces the projected amount of deficit spending over the next 10 years.

As a result, the biggest problem with the fiscal cliff is psychological, in so many ways. Yes, your tax bill is likely going to go up no matter what happens, but the end result is probably not going to be as bad as you currently think. Once you accept this, the only thing left is for Washington to quit the fooling around, and set the rules moving forward. After all, knowing what the rules are is arguably more important than the rules themselves.

What is more concerning is the public’s basic illiteracy regarding what has become known as Obamacare.

I admit I haven’t taken the time to read the entire 2000 page healthcare bill. So, I don’t know all the nuances and the like. Does anyone, really?

Obviously, the problem with predicting the future is things can change. I have seen the numbers Washington is throwing around in regards to associated costs, and think you can throw them out the window. They are estimates about something that has never happened from people who have never had to make them. Were the original 10-year estimates for Social Security, Medicaid, and Medicare accurate? You know, who cares? What good is a 5-10 year guesstimate when you are talking about a perpetual entitlement/program?

Now, throw political ideology out the window, and look at the issue in terms of basic economics. What ultimately determines the price of a good or service in a competitive market? Perhaps it has something to do with the level of consumer demand relative to the supply, you think? If demand is greater than the available supply, prices go up. If it is less, they go down. This makes sense.

For all the hand-wringing in Washington, I still can’t figure out where the increase in supply is going to come from in order to drive down the price of healthcare. Oh, I understand forcing people to buy insurance policies and the like, and there might even be a public option. Who knows? But that isn’t the same thing as increasing the supply of healthcare, is it? Wouldn’t that actually be increasing the number of people demanding it? Hmm.

Think of it this way. From what I have read, the new Birmingham Barons stadium, Regions Field, is estimated to have a seating capacity of around 8,500. Now, what if the Yankees come to town to play an exhibition against the Barons, and I stand outside the stadium selling $5 general admission tickets to everyone who walks up? If I sell 20,000, how many people will be able to get inside to watch the game? What? 8,500? Maybe 10,000 if you use a shoehorn? What about the other 10,000?

Hey, you might not get to see the Yankees play, but you would have an affordable ticket to watch them, wouldn’t you? As such, you should be happy and thank me.

The only real way to have a meaningful decrease in healthcare costs is to increase the number of trained medical professionals and decrease our demand for them. It is kind of like losing weight. You won’t keep the weight off for good unless you fundamentally change your eating habits and get some exercise. Everyone thing else is just pushing string, wasting time, and spending someone else’s money. 

So which is it? Forcing people to buy insurance will increase demand, but what about supply? Well, cutting Medicare payments 21%, tacking an additional $2 billion tax on medical device companies, and forcing states to pick up more of Medicaid at first blush don’t look like good attempts to increase the supply of healthcare. In fact, you could even argue these things might actually decrease the supply. Hey, you seniors on Medicare, the doctor won’t be taking on anymore Medicare patients this year! If they do, they make less money, and making less money isn’t what most people go into medicine to do. 

In the end, from what I have seen thus far, healthcare reform, at this stage, proves to be a costly endeavor, for someone, which won’t be able to deliver as promised. Still, there are people who honestly believe Obamacare is going to provide “free healthcare” and the same measure of care to everyone. That is very frustrating, because it simply isn’t going to happen.

Where the rubber meets the road, between the fiscal cliff and Obamacare, the American public gets bombarded with a lot of talk and not a lot of useful information. If Washington’s end aim is to frustrate and confuse the medical industry and the rest of us, it seems to be doing a good job. If it is to rapidly expand the economy and increase the supply of healthcare in the country, I am afraid its current actions and game plan are, well, ironic.

John Norris is a Managing Director, and the Head of Wealth Management at Oakworth Capital Bank in Birmingham. He can be reached at john.norris@oakworthcapital.com.

The opinions expressed within this report are those of John Norris as of the initial publication of this blog. They are subject to change without notice, and do not necessarily reflect the views of Oakworth Capital Bank, its directors, shareholders, and employees.       

Retrieving Data When and How You Need It

Written by Emily Jones, Senior Manager of Jackson Thornton Technologies



We all know how much we depend upon our business’ data to be able to make accurate decisions.  However, most businesses struggle with retrieving and utilizing their information.  It can prove to be a daunting task to gather information from various electronic applications only to end up manually combining all that information to finally have the data you need.

You may have heard the buzz word - Business Intelligence (BI) – and wondered what it is.  BI is somewhat self-explanatory in that it is a way to make your business more intelligent.  Business Intelligence streamlines the day-to-day processes and procedures of data management.  It is a method of looking at data to make better business decisions both for today and into the future. 

One of the most common uses of BI addresses the issue of retrieving information in an automatic, accurate, and easy to understand format.  This allows you as a business manager to easily spend your time running your business rather than combining your business information.  BI can consolidate, normalize, and analyze the data from various sources that your organization has been collecting.  Business Intelligence is an integral piece that joins business activities and the information technology necessary for those activities. 

Many have thought that BI was only needed by mega corporations and that they were the only ones that could afford to use it.  With today’s technology, this is false.  Over the last several years, BI has moved into mainstream usage for mid-size and small businesses alike.  Companies such as IBM have products like Insight and Cognos Express that fit well in this arena by providing mid and small sized companies with excellent BI tools that are both easy to use and affordable.  Business Intelligence solutions give your company the ability to track, analyze, and manage its internal information more efficiently.  And, we all know that an increase in efficiency has a direct correlation on overall profits.

We’ve all been saving our data in various methods, and for what reason?  If you cannot quickly and easily access the data to make knowledgeable business decisions, you need to check into what a good BI system can do for you.  Implementing a Business Intelligence strategy is a great way to keep your company as efficient as possible to consistently stay competitive in today’s business environment.

Bad to the Bone

By Ryan Cordry, DO, MBA with Medical West

Did you know that bone is a living tissue? It's true. During our lives, bone is being continually replaced by new bone. But what happens when you don't produce enough new bone to replace the old? Then you have osteoporosis.

In its most basic terms, osteoporosis is when you are losing density in your bones. This loss of density makes your bones more susceptible to breaking. It is the most common bone disease, and prevalent among women. Around 50 percent of all women over 50 years old will fracture a wrist, hip, or a vertebra.

If you've ever broken a bone, you know what a pain it is and how difficult it can make life. It causes you to adjust the way you do things - from not being able to hold a cup of coffee to wearing a boot or having to use a wheelchair.

Osteoporosis can have a major effect on how you live your life. It's important to know how you get it, and how you manage it so you can live comfortably. While there are occasions when bone loss occurs with no explanation, there are a several factors that can put a person more at risk.  

  

Risk Factors

 For women - a significant drop in estrogen (often triggered at menopause) and a long period of time without menstrual periods

 For men - a drop in testosterone

 A low body weight increases risk

 Smokers have a higher risk of osteoporosis

 Consuming heavy amounts of alcohol

 Osteoporosis presence in family history

 Some medications can reduce bone density

When it comes to risk, the older you are - the more likely. And older white women are at the top of the osteoporosis totem pole.

Diagnosing can be tough, as there are many times when people don't realize they have osteoporosis until they actually break a bone and it is discovered.

Often times a Dexa Scan (a bone mineral density test) will be conducted to gauge the density of your bones and how much bone loss is present. It can also help determine just how likely you are to break more bones.

Treatment of Osteoporosis

Lifestyle changes are often recommended. Diet and exercise can help maintain bone strength. Stopping smoking and drinking less alcohol may also be recommended.

Calcium and vitamin D. Milk does a body good? The right amount does. Calcium is an important mineral in bone formation. You could just be deficient here. Ask your doctor what the right amount of calcium is for you.

There are medications for osteoporosis that are often used when a deficiency in bone density is revealed. Depending on your sex and situation, your doctor will know best.

Hormonal replacement is also an option - estrogen or testosterone enhancements can get the body jolted back to a healthier bone production level.

Quick Tips to Prevent Falling, If You Have Osteoporosis

 Stay on stable ground - avoid icy sidewalks, slick surfaces

 Use the handles on stairs, to get out of bathtubs

 Leave a few lights on at night - if you can't see where you are going or what you are stepping on, you're asking for a problem

 Don't exercise or go on a walk alone - if you do fall, you need someone there to help

As stated above, osteoporosis is extremely prevalent. Do your best to live a lifestyle that puts your body at less risk. It's about living healthy to live happily.

Hyperbaric Oxygen use in Delayed Radiation Injuries

By Jeff Rickert, M.D.

Board Certified, Internal Medicine

Director, Hyperbaric Oxygen Department, Princeton Baptist Medical Center

Many patients receiving treatment for various types of cancer undergo radiation therapy either alone or in combination with surgery and/or chemotherapy. Although the benefits of radiation therapy are widely known, one potential side effect is Delayed Radiation Injury to hard or soft tissues of the body. This unfortunate side effect can have a significant impact on the quality of life for the brave patients battling cancer. 

Symptoms of injury to irradiated tissues can occur at any point after exposure -- sometimes years after radiation therapy is finished. Delayed Radiation Injury is usually seen at least six months after therapy is complete and can involve both soft tissues, such as the lining of the bladder or intestines, or hard tissues like bone.

The causes of Delayed Radiation Injury result from the release of inflammatory substances after exposure to radiation. These inflammatory markers, called cytokines, are involved in the formation of fibrosis, scar tissue, and damage to small blood vessels that supply oxygen to tissues. This results in compromised delivery of oxygen, or hypoxia, to these vital tissues which can lead to chronic inflammation, bleeding, ulcer formation, delayed healing and even severe infection.

A disruption in the normal framework of these blood vessels and local cell structure can cause severe tissue inflammation seen in proctitis (with colorectal cancers), cystitis (with bladder cancer), and bone necrosis (especially in those patients with oral cancer and radiation to the neck or jaw). With radiation injury to the jaw, patients often experience loss of teeth or require tooth extraction due to extensive bone damage.

For patients suffering from Delayed Radiation Injury, Hyperbaric Oxygen therapy has been shown to provide significant benefit in tissue healing. Hyperbaric Oxygen therapy involves breathing 100% oxygen under pressure which dramatically increases the amount of oxygen circulating in our blood, thus improving oxygen delivery to damaged bone or soft tissues.

Hyperbaric Oxygen therapy has been used in Delayed Radiation Injury since the 1980s.  This treatment has been shown to (a) enhance new blood vessel growth into the irradiated areas (b) improve the local tissue framework that was previously damaged to promote healing and (c) reduce fibrosis and scarring.

As one of only two Hyperbaric Oxygen departments in Alabama with accreditation by the Undersea & Hyperbaric Medical Society (UHMS), the Princeton Baptist Hyperbaric Oxygen Department has broad experience in treating these types of Delayed Radiation Injuries. This accreditation demonstrates a commitment to patient care and facility safety by meeting benchmarks of excellence & adherence to the standards of care set forth by the UHMS.

For more information, please contact the Princeton Baptist Hyperbaric Oxygen & Wound Care Center at (205) 783-3727.

TRINITY MEDICAL CENTER WINS. RELOCATION MOVES FORWARD

The Alabama Court of Civil Appeals has unanimously overturned a lower court ruling, finding that Montgomery District Court Judge Jimmy Pool erred in his July ruling against Trinity and ordering him to enter a judgment in favor of the hospital’s relocation.

In issuing their ruling, the five-judge panel reinstated the Certificate of Need Trinity was awarded in September of 2010 and paved the way for the hospital’s relocation to Highway 280.

“We are delighted to take this important step forward with our relocation project and we appreciate the Court’s direction on this matter,” said Trinity President and Chief Executive Officer Keith Granger. “With expedited action from Judge Pool as requested by the Court, we hope to have this matter resolved within a few months so we can move forward with planning and construction as soon as possible.

The appellate court’s ruling is the sixth legal victory Trinity has achieved in the four years since the medical center first announced plans to relocate. The only decisions against Trinity came from Montgomery County District Judge Jimmy Pool, who twice ruled against Trinity and now twice has been overturned by a higher court.

“Today’s ruling is affirming not only for the thousands of area residents who need improved access to care, but also for the Trinity physicians and employees who consistently raise the bar in patient satisfaction, quality care, infection reduction and many other measures despite the limitations of our 45-year-old facility,” added Granger. 

Barring further legal delays, Trinity intends to complete planning efforts for the 280 facility within the next few months. Construction could begin as early as mid-2013.

Alabama Supreme Court Announces Modified Four-Part Test for Application of the Physician Office Exemption Under CON Rules

By Jennifer H. Clark
Bradley Arant Boult Cummings LLP

On November 21, 2012, the Alabama Supreme Court announced a modification of the Physician Office Exemption (“POE”) to Alabama’s Certificate of Need (“CON”) rules and regulations. In Ex parte Sacred Heart Health System, Inc. (In re: “Infirmary Health System and South Baldwin Regional Medical Center v. Sacred Heart Health System, Inc.”), the court withdrew its March 2, 2012, opinion that had crafted a new test adding a fifth part, and, instead, modified the original four-part test, referred to as “the POE Application Test.” The Court indicated that the modified POE Application Test will “provide an objective standard that can be used to determine whether the POE applies to any medical practice, whether the practice is solo or group, large or small, specialized or general.”

            This case arose when Infirmary Health System and South Baldwin Regional Medical Center filed an action seeking a declaratory ruling that Sacred Heart Health System was required to obtain a certificate of need in order to develop a medical building that would accommodate physician offices, an outpatient surgery center, a diagnostic center, a laboratory, and a rehabilitation center. (The surgery center and rehabilitation center were later dropped from the project.)

            The trial court held that the part of the building that was to be occupied by Sacred Heart Medical Group physicians qualified for the POE and did not require a CON. The court later amended its judgment to hold that the exemption applied only to the part of the building to which three physicians had previously located their practices. On appeal, the Court of Civil Appeals reversed and remanded, holding that none of the building qualified for the exemption.

            The Alabama Supreme Court granted certiorari and, in its opinion, noted that the CON Review Board had previously formulated a four-part test to determine whether a proposed project qualifies for the POE. While determining that the four-part test used by the CON Review Board is still substantially sound, the court made minor modifications to the test, specifically to the second and third factors of the test. In doing so, the court reversed the judgment of the Court of Civil Appeals and remanded the case for analysis under the new POE Application Test.

            Under the current form of the POE Application Test, all four criteria must be satisfied in order to qualify for the Physician Office Exemption from CON review. The modified POE Application Test is as follows:

1.  The proposed services are to be provided, and related equipment used, exclusively by the physicians identified as owners or employees of the physicians’ practice for the care of their patients.

2.  The proposed services are to be provided, and related equipment used, at any office of such physicians.

3.  All patient billings related to such services are through, or expressly on behalf of, the physicians’ practice.

4.  The equipment shall not be used for inpatient care, nor by, through, or on behalf of a health care facility.

Patients Benefit From Princeton BMC’s Newest, Most State-of-the-Art Operating Rooms in the City

By Stan Hewlett, MD, FACS, General Surgeon

Alabama is home to sixteen new operating rooms bursting with industry leading technology. You will not be surprised to learn that they are located at Princeton Baptist Medical Center, which has a long history of quiet, groundbreaking innovations. The new fifty seven million dollar east expansion houses the newest, most advanced operating rooms in Birmingham.

There is no other facility in the region currently using the technology that my patients are treated with at Princeton. Complex foregut, pancreatic, hepato-biliary, intestinal, colorectal, and retroperitoneal diseases are treated with “state of the art” robotic technology and integrated complex intra-operative imaging.

The da Vinci surgical robot helps in cases not amenable to laparoscopic techniques such as Whipple, hepatectomy, esophagectomy, and others. These patients benefit from less pain and less pain medicine, less blood loss, shorter hospital stay and quicker recovery. Single site robotic cholecystectomy leaves an invisible scar, less pain, and excellent patient satisfaction.

The Artis Zeego Robotic radiographic imaging system by Siemens, the only one currently in the state,  is housed in the three million dollar futuristic ‘multi-use’ angiographic and advanced endoscopic OR suite. The Artis Zeego system utilizes Robotic fluoroscopy and intra-operative computerized axial tomography using automotive assembly line precision robotic technology. This, combined with 3-D software, allows unprecedented intra-operative imaging. It is used for angiography, ERCP, cholangioscopy, PTC and ablative techniques such as RFA. On-table, intra-operative 3-D reconstruction with real time CT or previously acquired CT/MRI overlay provides the stereo tactic targeting previously only dreamed of. The surgical applications are being expanded daily.

Fluorescence imaging using indocyanine green (ICG) angiography has applications in lymphatic, tumoral, and conduit perfusion. It is useful in liver resection, esophagectomy, bowel resection, and promises to replace second look surgery in cases of questionable bowel viability.

Access to the newest, most advanced OR’s in town must be combined with the training and experience that allows adoption of these techniques and realization of their benefits. Fellowships in Laparoscopy, Surgical Endoscopy & ERCP and over a decade of experience at Bethesda and Princeton have provided me the privilege of offering the most advanced robotic and endoscopic options to every patient, no matter how complex the disease.  

HAVE YOU SEEN MY HIPAA REGULATIONS?

By Judd A. Harwood
Bradley Arant Boult Cummings, LLP

Another month has gone by without the publication of the final Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH Act) regulations (referred to as the HIPAA Omnibus Final Rule). The HIPAA Omnibus Final Rule is expected to include modifications to HIPAA privacy and security rules required under the HITECH Act; data breach enforcement and penalty requirements; regulations related to the HITECH Act’s breach notification rule; and changes to HIPAA to incorporate the Genetic Information Nondiscrimination Act (GINA). The HIPAA Omnibus Final Rule is also expected to extend HIPAA liability and obligations directly to business associates and their subcontractors. 

By way of background, on March 24, 2012 the Office of Civil Rights (OCR) sent a final HIPAA Omnibus Final Rule to the Office of Management and Budget (OMB) for review before publication in the Federal Register. Despite indications from the Director of the OCR late this summer that the Omnibus Final Rule was extremely close to publication, the OMB elected to extend its review of the rule under Executive Order 12866. Under Executive Order 12866, OMB is given ninety (90) days to review most proposed and final rules. However, the Executive Order permits OMB to extend the review period for an additional thirty (30) calendar days on its own, and, with the agreement of the agency head, for longer periods of time. 

It has now been over three and a half years since the HITECH Act was passed and almost two and a half years since the proposed HITECH Act regulations were published in July of 2010. As autumn gives way to winter and proceed past the election season, there’s no sign of the HIPAA Omnibus Final Rule yet. Healthcare attorneys and compliance specialists have been left to speculate about what the hold-up is and to eagerly wait for the issuance of the final rule.

Chronic Obstructive Pulmonary Disease (COPD)

By Sandra Gilley, MD

Pulmonary Associates of the Southeast

COPD refers to two lung diseases, chronic bronchitis and emphysema, that cause airflow obstruction that interferes with normal  breathing. Asthma is not included in COPD, but people with asthma  may develop COPD over time. The incidence of COPD among adults in the US in 2008 was 12.1million people. COPD is the fourth leading cause of death in the US.

Tobacco use is the key factor in the development of COPD in the US. Approximately 80 to 90 percent of COPD deaths are caused by smoking. But air pollution in the home and work place, second-hand smoke, and genetic factors also play a role. In developing countries the use of indoor wood-burning cook stoves is thought to play a much larger role in the development and progression of COPD, especially among women. Thus, COPD is a largely preventable disease and early detection  might change its course.

The diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum  production and/or a history of exposure to risk factors for the disease. Spirometry is required  to make the diagnosis. The severity of the disease is assessed based on the patient's symptoms, risk of exacerbations, degree of spirometric abnormality, and the identification of comorbidities.

The most important step to preventing COPD and slowing its progression is to stop smoking.  Treatment of COPD is based on the symptoms  and disease severity. Pharmacologic therapy included bronchodilators, steroids,  and other medications. These can reduce COPD symptoms, reduce the frequency  and severity of exacerbations, and improve health status and exercise tolerance. Vaccinations for Influenza and Pneumococcal pneumonia  can reduce serious  illness and death in COPD patients. All patients with COPD appear to benefit from rehabilitiation and maintenance of physical activity. Supplemental oxygen therapy improves  exercise tolerance and reduces  mortality.

World COPD Day is an annual event organized  by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) to improve awareness and care of COPD. This year, the event took place on November 14th, with this year's theme being "It's Not Too Late." As part of World COPD Day, Pulmonary Associates of the Southeast hosted a COPD fair in the 1st floor lobby at 880 Montclair Road.

Hunger, Satiety and Obesity; what exactly regulates our appetite?

By Robert A. Shaffer M.D., Medical Director

Denise Biro, Weight Loss Coordinator

Shaffer Weight Loss Center at Gastroenterology Associates, N.A.P.C.

                                                                                                                 

     Our body naturally tells us when to eat and when to stop by hormones and neurons: ghrelen, neuropeptied Y, cholecystokinin, peptide YY, insulin, leptin and melanocortin. Problems begin when we do not listen to the signaling of our body. As we continue to consume more calories than needed without expending them, we start to develop excess fat and over time this can lead to health problems due to an erroneous message sent by the hormone leptin. Our appetite; hunger and satiety are regulated by the endocrine system that communicates with the hypothalamus and is controlled by a negative feedback system which can be disrupted by an improper diet leading to obesity.

   The stomach secretes a hunger hormone that sends a message to the brain to tell us it is time to eat. When our stomach is empty it produces the hormone ghrelin. Ghrelin sends a message from the epithelial cells of the the gastric fundus to the arcuate nucleus of the hypothalamous; the center for appetite regulation in the brain.  Ghrelin then stimulates the neuropeptide Y secreting neurons in the brain to increase hunger.

      Upon consuming food our stomach stretches and hormones start communicating with the appetite control center to signal satiety. Ghrelin concentrations decrease due to the release of the hormone cholecystokinin (CCK) from the enteroendocrine cells of the small intestine. Cholecystokinin then works together with another hormone called Peptide YY from the large and small intestine in a negative feedback cycle to control the appetite over a period of time.

      Another hormone that controls our appetite is insulin. Insulin is released from the beta cells of the pancreas to indicate that your body is metabolizing and not to consume anymore food.  Insulin regulates our fat stores by stimulating adiposytes (fat cells) to take up glucose and store as fat to use as energy at a later time.  As we eat, adiposcytes are stimulated to secrete leptin which stimulates melanocortin secretion in the arcuate nucleus of the hypothalamus signaling satiety; preventing the continued release of neuropeptide Y.

     Improper diet can lead the accumulation of excess adipose tissue and cause disruption in signaling of leptin secretion.  A person with a higher body fat mass will secrete an excess of leptin by the adipose cells. Here is the problem: over a long period of time this excess secretion of leptin can cause a disturbance in our negative feedback system. This causes our feedback system to become unresponsive to leptin or to have a receptor defect on the target cells in the hypothalamus.

     This disruptive signal of leptin signaling sends a message to the brain that we are hungry even after we just ate a big meal.  This could be a contributing factor that leads to obesity and other health disorders like fatty liver and insulin resistance. The best way to these issues is to follow a healthy nutrition plan and exercise. For more information on nutrition, exercise and diet please call 205-397-1448. 

       Shaffer Weight Loss Center at Gastroenterology Associates, N.A.P.C.

       100 Pilot Medical Drive

       Suite 250

       Birmingham AL 35235

      (p) 205 397 1448

      (w) gastrodocs.info

      (e) weightloss@ganapc.net                                                                           

      facebook.com/ shafferweightlosscenter.com

Resources:

http://www.ncbi.nlm.nih.gov/books/NBK22251/

http://www.jci.org/articles/view/36284

http://www.cdc.gov/pcd/issues/2009/jul/pdf/09_0011.pdf http://circres.ahajournals.org/content/101/6/545.full

WHY MAMMOGRAPHY IS NOT PERFECT

By Caroline A. Reich, MD, PhD

Women’s Imaging Associates

Birmingham, Alabama

Without a doubt, mammography is the most sensitive screening test developed for the early detection of breast cancer. Many lives have been saved because cancers have been caught when they are small and treatment is most likely to lead to a cure. However, like any screening test, the sensitivity (the ability to detect cancer) is not perfect. Some studies suggest that up to 20% of breast cancers may not be detected on mammography.

Several factors limit the sensitivity of mammography. First, not all breast cancers are the same. Some cancers like Ductal Carcinoma in Situ (DCIS) are often detected because of tiny, irregular calcifications that are deposited within the tumor and then seen on the mammographic images. Other cancers such as Invasive Ductal Carcinoma often cause distortion within the tissue, showing up as a mass with irregular margins.  Invasive Lobular Carcinoma is a particularly aggressive cancer that may grow quite large before distorting the normal tissue enough to be visible.

Just as breast cancers differ, the density of each woman’s breast tissue is variable and is a factor that can affect the sensitivity of the exam. Normal breast tissue ranges from being primarily fatty in composition to dense with fibroglandular elements. The density of the breast parenchyma will affect the appearance of the mammogram. A breast that is composed primarily of fat will be gray on the mammogram. A breast with dense tissue will be much whiter. Unfortunately, the signs of malignancy such as calcifications and tissue distortion are also white and can be obscured at times by the white tissue in a dense breast.

What can you do to increase your chances of detecting breast cancer as early as possible?

     1.       Most importantly, get a yearly mammogram once you turn forty! While mammography is not perfect, it remains the best screening tool we have, even in dense breasts. Tiny, irregular calcifications are a common sign of cancer. These suspicious calcifications are usually invisible on ultrasound or breast MRI.

      2.       Do NOT skip monthly breast self-exams! There are some cancers that are apparent as a breast lump before being visible on mammography. 

      3.       Know your breast density. Every mammography report includes a statement describing the relative density of the breast tissue. If you have dense breasts and have an increased risk for breast cancer such as a mother, sister or daughter with breast cancer, discuss with your healthcare provider your options for additional screening with breast ultrasound.

Be Strategic in Growing Your Medical Practice

By Matt Mettry, Director of Medical Professional Services

Brookwood Medical Center

If you’re involved in running a medical practice as a doctor, nurse or administrator, chances are that you know you need to think ahead. But do you know how important it is to be strategic about how you grow the practice?

There’s a lot of overhead when it comes to practicing medicine, and planning ahead will not only help your bottom line, but also help you provide high quality services to your patients.

You need to plan as far ahead as possible, which in most cases means 3-5 years. Look at the ages of your physicians and think about when they might retire. Succession planning is so important because it can take 12 months to 3 years to find physicians in certain specialties. The more time you have to interview candidates, find the right fit and get that new partner on board, the better.

Also think about whether or not aligning with a hospital is something you want to see in the practice’s future. Interests like autonomy, control, being part of a small organization and being your own boss are often reasons to start a private practice. Are you willing to give those up?

When you join forces with a hospital, you become part of a much bigger organization. You’ll still have control over the way you practice medicine, but there may be some changes, like requirements to use electronic health records and receiving input on hiring decisions.

Being a part of a hospital run medical practice will also introduce expectations of net revenue and volume. These are things you need to be comfortable with because it takes a lot of patient volume to have a really successful medical practice.

Whether aligning with a hospital is in your future or not, here are some action items you can take now to help grow your medical practice:

Introduce yourself to the community with speaking engagements and community education.

Consider opportunities to get involved in the community through business and civic clubs, church, social clubs, professional associations, chamber of commerce, rotary, etc.

Print welcome flyers and cards with name, photo, location, bio, availability and website.

Meet and greet other physician office staffs to create referral base.

Develop a list of targeted local schools and employers for introductions, screenings and events.

Create customized appointment cards, business cards, letterhead and envelopes.

·      

OIG and DOJ Take Increasingly Aggressive Fraud and Abuse Enforcement Posture

By Daniel Murphy

Bradley Arant Boult Cummings

If you have been following recent Department of Justice (DOJ) and Department of Health and Human Services (HHS) fraud and abuse enforcement efforts, you will be forgiven if you thought you had mistakenly tuned in to a 1980’s Chuck Norris film or an installment of professional wrestling’s Friday Night SmackDown.

Chuck Norris and Lee Marvin starred in the 1986 classic “The Delta Force”, while the DOJ and HHS jointly launched a “Medicare fraud strike force”, known as the “H.E.A.T. Task Force”, in 2009.  “H.E.A.T” stands for health care fraud prevention and enforcement action team.

In the 1980s, the World Wrestling Federation’s Jimmy “Superfly” Snuka and Junk Yard Dog delivered numerous smackdowns against their opponents, while the HEAT Task Force recently executed a large-scale, coordinated series of health care fraud and abuse charges against nearly one hundred individuals and billed it as a “takedown.”

On October 4, 2012, the DOJ and HHS announced that the HEAT Task Force had charged 91 individuals in seven cities with various criminal Medicare fraud violations that resulted in $429.2 million in improper Medicare payments.  The individuals charged in the task force operation included physicians, nurses and other licensed health care professionals.  The DOJ press release regarding this operation can be accessed here:  http://www.justice.gov/opa/pr/2012/October/12-ag-1205.html.

In addition to numerous individual charges and arrests, the HEAT Task Force has carried out other multi-jurisdictional, multi-agency raids like the most recent one on October 4.  In 2010, for example, the HEAT Task Force charged or arrested 94 physicians, health care company owners, and other for fraudulent Medicare claims worth $251 million.

The October HEAT Task Force raids came on the heels of a Government Accountability Office (GAO) report released in September 2012 (http://www.gao.gov/products/GAO-12-820) that detailed the scope and types of fraud identified by HHS and other agencies during the year 2010.  According to the GAO report, the DOJ and HHS investigated 10,187 cases of fraud against the Medicare, Medicaid and CHIP programs.  Of these cases, 7,848 involved criminal health care fraud and 2,339 were civil matters.  The cases described in the GAO involved every type of health care provider, located all across the country, and included a broad array of activity.

The GAO report is notable not only for the vast scale of fraudulent activity it documents, but also for the massive amount of government investigatory and prosecutorial resources that have been deployed to combat this activity.

One of the few areas of bipartisan agreement that existing during the policy debates leading up to the passage of the Affordable Care Act (ACA) was the need to reduce fraud, waste and abuse in Medicare and other federal health care programs.  Prior to the passage of the ACA, Congress passed the Fraud Enforcement and Recovery Act (FERA) in 2009.  In addition to many other enforcement tools FERA gave the federal government, the law included hundreds of millions of dollars in appropriations to fund fraud and abuse enforcement.

The developing track record of the HEAT Task Force and recent DOJ and HHS enforcement efforts suggests that these federal appropriations are now translating into action and large recoveries of improper federal health program payments.  With a continuing public appetite for federal deficit control, especially in the arena of health care spending, don’t expect the aggressive fraud and abuse enforcement stance of the DOJ and HHS to relax any time soon.

   

Important Upcoming Oral Argument and Decision for “Trinity on 280”

By Colin Luke
Bradley Arant Boult Cummings

Finally, the residents on the 280 corridor may get some relief and obtain their long-awaited medical center!  

The long-running battle by Brookwood and St. Vincents to stop a competing hospital from relocating to the half completed former HealthSouth Hospital on Highway 280 is in its final chapter. The Alabama Court of Civil Appeals has scheduled oral arguments on October 23 to hear the appeal by the State Health Planning & Development Agency (“SHPDA”) and Trinity Medical Center from Montgomery District Judge’s reversal of SHPDA’s unanimous decision approving this project. This appeal was joined by the Business Council of Alabama, Greystone Residential Association and the Shelby County Economic & Industrial Authority when they filed amicus briefs in support of Trinity and SHPDA’s position.

Trinity’s relocation efforts were approved by Administrative Law Judge James Hampton after the longest certificate of need hearing in Alabama’s history. Trinity received support from over 110 physicians (including many who work at Brookwood and St. Vincents) and numerous business leaders in and around the Birmingham, Jefferson County, and Shelby County areas. Importantly, many residents and emergency medical personnel testified about the dire need for a hospital on the 280 corridor and life-threatening drives down 280 past the proposed Trinity site to other hospitals. Trinity filed its CON application for this project in December of 2008.

Birmingham area contractors and subs are anxiously awaiting approval for this massive construction project which is described by noted economist Keivan Deravi as having the impact of a major automobile plant in the Birmingham area.  Completion of the 60% finished state-of-the art hospital for Trinity’s relocation will keep hundreds of construction workers busy for up to eighteen months. Trinity’s relocation will also cause the construction of a large professional office building next to the new hospital as well as an upscale hotel above the Cahaba Grand conference center.

Brookwood and St. Vincents oppose Trinity’s relocation for competitive reasons and are not confident in their ability to convince patients and physicians to choose Brookwood and St. Vincents after Trinity’s relocation. Brookwood has historically opposed any significant effort by Trinity (formerly Baptist Montclair) to update or relocate its current campus.

The Court of Civil Appeals has expedited its consideration of this important decision and should issue an opinion by the end of the year. 

State May Get Its First Freestanding Emergency Department

By Kelli F. Robinson, Sirote & Permutt, PC

In 2008, Brookwood Medical Center filed a Certificate of Need (CON) Application with the State Health Planning and Development Agency (SHPDA) to build a $19 million, 19,598-square foot freestanding emergency department on U.S. 280 in Shelby County. A freestanding emergency department is a fully functioning emergency department separately located from its hospital. Currently, there are no freestanding emergency departments in Alabama. The freestanding emergency department proposed by Brookwood will be located approximately eight miles from the hospital it owns and operates in Homewood.

Both Trinity and St. Vincent’s Health Systems intervened in opposition to Brookwood’s CON Application.  Trinity and St. Vincent’s requested a contested case hearing, and SHPDA appointed an administrative law judge (ALJ) to conduct the contested case hearing. Trinity moved the ALJ to dismiss Brookwood’s CON Application on the ground that Brookwood had failed to comply with SHPDA’s publication rule. Under SHPDA’s rules in effect at the time Brookwood’s CON Application was filed, an applicant was required to provide to SHPDA, within thirty days of filing the CON Application, proof of publication of notice of the CON Application for two consecutive weeks in a newspaper of general circulation in the areas affected.    

The ALJ denied Trinity’s motion to dismiss Brookwood’s CON Application and a contested case hearing was subsequently held. Following the hearing, the ALJ issued a recommended order concluding that Brookwood should be granted the CON. SHPDA’s CON Review Board adopted the ALJ’s recommended order and issued the CON to Brookwood. Trinity appealed to the Montgomery Circuit Court.

On June 3, 2011, the circuit court ruled that Brookwood committed a “fatal flaw” when it failed to comply with SHPDA’s publication rule and reversed the CON Review Board’s decision to issue Brookwood the CON. Brookwood appealed to the Alabama Court of Civil Appeals.  Trinity filed a cross-appeal, challenging the circuit court’s judgment insofar as it purported to affirm the CON Review Board’s decision “with respect to the merits” of the CON Application.

After hearing oral arguments in July 2012, the Court unanimously decided that Brookwood’s failure to publish notice of the CON Application in a newspaper of general circulation was harmless error. The Court found no indication that Brookwood’s noncompliance with the publication rule had the effect of silencing opposition to the CON Application from any member of the general public. The Court also concluded that Trinity was not prejudiced by Brookwood’s noncompliance because Trinity automatically received notice of Brookwood’s CON Application from SHPDA as an affected party providing similar services in the same area where the project was proposed to be located. 

Hence, the Court reversed the circuit court’s judgment reversing the CON Review Board’s decision to issue Brookwood the CON and remanded the case back to the circuit court for further consideration of Trinity’s appeal from the decision to issue the CON to Brookwood. The court also dismissed the cross-appeal filed by Trinity regarding the statement in the circuit court’s decision indicating that the Brookwood CON Application was valid on its merits. On remand, the circuit court was instructed to enter a judgment regarding the merits of the decision to issue Brookwood the CON. 

On September 12, 2012, the circuit court issued its opinion affirming the CON Review Board’s decision to issue Brookwood the CON which will allow Brookwood to build the first freestanding emergency department in Alabama. Trinity, however, could still appeal the circuit court’s ruling.

In addition, two more freestanding emergency department projects were approved by the CON Review Board on September 19, 2012. CON Applications filed by Princeton Baptist Medical Center and Medical West, an affiliate of UAB Health System, which would allow both hospitals to build freestanding emergency departments in Hoover, were approved despite an ALJ’s recommended order that only Princeton Baptist’s CON Application be approved. Both hospitals have until November 3, 2012, to appeal the rulings of the CON Review Board.