Thursday, April 23, 2015

Good Heavens! Another banker on Line 3??

By: Patrick S. Carlton, Senior Vice President at National Bank of Commerce

 For all the obvious reasons, medical practices and their physicians are excellent banking prospects. As such, practice administrators likely hear from bankers on a regular basis, and with each call probably wonder if it’s worth the time away from billing and personnel issues to take the call. In our years of banking this business segment, we have uncovered several reasons why it just might make sense to talk to another banker.

  • Fees - A fee to view this online? A fee for that module? Sometimes you feel like you are getting fee’d to death, or at least to extreme discomfort. Experience shows that a regular review of existing banking products and services will often reveal opportunities for savings - both money and time. Maybe that extra account no longer makes sense or that sweep really isn’t earning the interest you thought. While choosing your bank, just like selecting your physician, should never be about finding the low-cost provider, cost certainly plays a factor into whether you are getting the most bang for your buck.

  • Access - Do you know who to call when your large insurance deposit has not posted, or your payroll didn’t process correctly, or you need to move quickly on a big purchase? Nothing can be more frustrating than not being able to reach someone in a time of need, especially your banker. Some practices never hear from their banker and some don’t even know who their banker is! Quite simply, your banker should be accessible.

• Technology - Are you using all of the technology tools available to create efficiencies, improve internal controls, and make your life easier? Whether it’s using remote deposit capture, which allows you to make deposits directly from your office, or receiving detailed information associated with electronic transactions (think EOBs for insurance deposits!), your banker should offer solutions on how to enhance your banking experience so you can focus on the other needs of the practice.

• Experience – You won’t find a banker who understands your business as thoroughly as you do, but you can find one who understands most of the issues you face every day and who has recommendations for making life easier. It shouldn’t take more than a few questions aimed in the direction of that banker on the other end of the line to see if he or she knows enough to help, or is just dialing for dollars.

It goes without saying that there are a lot of challenges and worries in healthcare today--margins are lower, risks are higher, and regulations continue to grow (sounds a lot like the banking industry). However, having a great banker as an “off-balance sheet” asset can only help improve your bottom line.

Thursday, April 16, 2015

The SGR Is Dead!!!!! Long live the???????



By: Bill Cockrell, President - Cockrell, Egeland and Associates, LLC

Anyone who has been in healthcare management for any length of time knows the issues caused by the constant battle over the Sustainable Growth Rate (SGR). For those of us who have been around for a while, we are so used to the annual battle over fixes / patches / cuts related to the SGR I wonder what we’ll worry about at next year-end. With few exceptions (primarily those asking how this gets paid for), the repeal of the SGR is viewed as a major, positive development. It’s also significant that the primary parts of this legislation were proposed last year so the fact that they survived for a year in Washington is somewhat remarkable. Now, though, we have to figure out what this three part permanent fix really means.

Part one is relatively straight forward, at least in the short run. We now know that Medicare payments will increase by 0.5% for the next few years. However small and below the inflation rate this is, it’s still better than fretting over a cut. Then,we see a freeze for the next six years and .0.25% increases after that. Of course, if any of use believe this won’t change, probably before the first four year phase is over, it’s time for a visit to our friendly neighborhood, at least in Colorado and Washington, dispensary of calming medication.

Part two is a little more challenging. It is difficult to project our ability to participate and be rewarded. In this section, a two tiered payment is established where there is the base model and a second model that provides incentives for doctors to participate more in Alternative Payment Models (APM) which will include accountable care organizations, bundled payment arrangements and, probably more achievable than the first two, medical homes. To qualify for the 5% bonuses tied to these incentives, things have to be in place before 2020 as these bonuses will occur each year from 2020 to 2024.. That sounds like a long way away but there is a lot of work to be done to allow physicians to meet the 25% participation level by 2019 and the 75% level in 2023. Again, there will undoubtedly be some changes but the road map is there.

Finally, part three of the bill creates the Merit-based Incentive Payment System (MIPS), which, in addition to giving us a new acronym, gives incentives to move into a value-based system. Incorporating existing quality reporting programs and meaningful use requirements, this part includes elements of the value-based system that was part of the Affordable Care Act (ACA). Under this section, penalties and rewards range from -4% to +4% in 2018 to -9% to +9% by 2012. A significant date is 2018, 2 ½ years from now. This is also tied to the stated Medicare goal of having 50% of Medicare spending tied to value based payment models by 2018.

Now, for those holding out hope that the ACA will be repealed returning us to the “good old days”, note that this legislation has nothing to do with the ACA and had broad bi-partisan support ( for example, a 92 – 8 vote to pass it in the Senate). Then there’s that point that some of the ACA value based programs were included in this bill. The bottom line here is that the ACA is here to stay. We need to work to fix the many problems with it but planning on its repeal to fix all issues is probably not a good approach to prepare for the future.

So, in summary, we need to find something else to think about each year in December, need to not spend the big annual increase too quickly, be getting our data tracking aligned while we establish our Patient Centered Medical Homes (PCMH), and be sure we are able to track the data required by the value based elements. Yes, the physician contact with the patient will remain very important but these other elements have to be factored in to any plan for the future. The dates sound far away, but waiting until 2018 to get ready is not a good idea for doctors who see Medicare patients and wish to practice for several more years.

What is Pollen? (Part II)

By H. Wayne Shew, Ph.D.
*in conjunction with Alabama Allergy & Asthma Center  

In part I of this discussion about pollen I talked about wind-pollinated plants versus animal-pollinated plants with reference to the number of pollen grains produced by the plants and indicated that wind-pollinated plants produce greater numbers of pollen grains. In addition to the number of grains produced by different plants there is often a difference in the size and external appearance of the pollen grains as well. The size and appearance of pollen grains is extremely varied, with a range in size from very small (5-7 microns*) to quite large (over 200 microns), and wide variation in shape and ornamentation also. Most pollen grains probably fall in the size range of 30-40 microns. Most wind-borne pollens are small to medium in size with a common size range of approximately 15-35 microns. There are some larger types of pollen that are transported by wind but these grains are typically modified to have air bladders which make them more buoyant in the air. (See figures below of some of these typical air-borne pollen grains.)

Pollen grains are composed of two layers, an inner layer called the intine and an outer layer called the exine. The intine is composed of “normal” cell-wall material; substances such as cellulose and pectic compounds. Internal to the intine is the cytoplasm of the pollen grain which includes the nuclei formed from the meiotic and mitotic divisions that were required to produce the mature pollen grain.

The outer layer of the cell wall of pollen grains is called the exine. The exine is composed principally of a material called sporopollenin. The exact composition of sporopollenin isn’t known but it is extremely resistant to decay, being generally insensitive to enzymatic activity and chemical degradation. The exine layer is initiated while the grain is still present in the group of four cells called the tetrad which is formed following meiosis in the anthers, but most of its thickness is added after the pollen grains separate from one another. The exine is often sculptured in various ways to produce intricate and beautiful patterns. (See figures below.) Most pollen grains have openings in the exine through which the pollen tube grows following germination of the pollen. The pollen tube then grows down the style and makes its way to the ovule present in the ovary. Openings in the pollen grains may be pores or furrows (called colpi) or pores within furrows. Pollen grains with pores are said to be porate, those with furrows are described as colpate, and those having pores in the furrows are referred to as colporate. Some pollen grains have no openings in the exine and are labeled as inaperturatepollen.   

Sweetgum – many pores in exine

Red cedar – no pores or furrows

Ragweed – small grain and tricolporate

  Long-leaf pine – “Mickey Mouse” ears are air bladders – large pollen grain

Pollen grains vary in shape. Some grains when viewed with a light microscope have contours that appear triangular, or circular, or oval, while others have modifications of these basic shapes. The surfaces of pollen grains vary greatly in their appearance as well. Some appear almost smooth while others are fine to coarsely granulate. Some have distinct striations and others appear to have wrinkles on their surfaces. Pollen grains produced by plants in the sunflower family have pollen grains that possess spines.

All of these variations in pollen grain shape, size, and ornamentation permit the identification of the species or family of plants which produces the pollen. Knowing which plants are producing pollen at a particular time is important for allergy sufferers. It means that if these individuals stay aware of when particular plants are releasing their pollen, they can take added precautions and reduce the likelihood of a major bout with allergic rhinitis or asthma.

  * A micron is one millionth of a meter or a thousandth of a millimeter. For comparison, the thickness of a piece of typical printing paper is approximately 0.1 millimeter which is 100 microns.

H. Wayne Shew, Ph.D. NAB certified counter BSC/AAAC Collection Station—Birmingham, Alabama

Alabama Allergy & Asthma Center

Wednesday, April 15, 2015

Anterior Total Hip Arthroplasty

By: James A. Flanagan, Jr., M.D. Andrews Sports Medicine and Orthopaedic Center

Making the decision to have a total joint replacement is a life-changing decision for all involved. In the past 40 years, millions of people have suffered from arthritic hip pain and experienced relief through total hip replacement and restored mobility. Most patients report that pain experienced after surgery pales in comparison to the pain they were living with on a daily basis.

What is Anterior Total Hip Arthroplasty?

The anterior arthroplasty approach to a total hip replacement is a muscle-sparing procedure that allows the surgeon to access the hip joint without disrupting the stability ligaments, thus making the hip significantly less likely to dislocate in the future. To the patient, this means there are no positional restrictions after the initial 6-week, post-op healing period.

Our surgical team’s approach is through a minimally invasive incision which allows for accelerated recovery time, reduced pain & scarring, shorter hospital stay, smaller chance of infection, and more rapid stability of the hip - compared to the traditional posterior approach.

What type of implant is used?

Our surgical team uses a prosthesis manufactured by Zimmer. There is no cement involved or metal-on-metal. The implant is a porous-coated metal implant that is press-fitted into the bone that allows the bone to grow into the implant itself. The metal is composed of a combination of cobalt chrome and titanium. A polyethylene liner is used to “cushion” the hip and allow for an easy-gliding motion of the joint. How long an implant will last varies from patient to patient depending on physical condition, activity level and body weight.

What is the hospital stay and typical recovery time?

Having a total joint replacement requires general anesthesia and typically a 2-3 day stay in the hospital. Once a surgery date is chosen, the patient is scheduled for pre-op registration at the hospital and lab work, which includes basic blood work, EKG and a possible chest x-ray.

The surgery itself takes approximately 1 hour to perform. During surgery, we utilize a multimodal pain management regimen – that includes EXPAREL. This new approach reduces pain and lessens patient recovery time. In addition, the utilization of tranexamic acid is used to better control surgery blood loss, keep the blood pressure low and lessen the likelihood of a blood transfusion.

A few hours following surgery, physical therapy - with assistance - gets the patient up and moving. PT visits twice a day during their hospital stay is crucial. Once the patient is fairly independent with a walker and able to meet discharge requirements, they are discharged either home with home physical therapy or to a skilled nursing facility. The patient can expect to walk approximately 1-2 weeks on a walker, 1-2 weeks with a cane, then eventually without assistance at all. Usually, outpatient physical therapy will be arranged upon their 1st post-op visit through our office at a facility of the patient’s choice. The patient can expect a total of 6-8 weeks of formal PT following a total hip replacement.

What are patients’ restrictions?

There are very little restrictions with the anterior approach compared to the traditional posterior approach of replacing a hip. For the first 6 weeks following surgery, each patient is limited to crossing one leg over the other and extending the operative leg behind them. Once the soft tissue is healed, the hip is considered stable and the restrictions are lifted. I do require antibiotics to be taken by mouth prior to any minor surgical procedure or dental work, including dental cleaning, to prevent bacteria from entering the blood stream and traveling to the prosthetic joint. This is required for the life of the prosthesis.

James A. Flanagan, Jr. M.D. is an orthopaedic surgeon at Andrews Sports Medicine and Orthopaedic Center in Birmingham, AL. Dr. Flanagan specializes in joint replacement and has been performing direct anterior total hip arthroplasty for the past 9 years, giving patients a more rapid recovery and less post-operative restrictions. He is also skilled in total knee, shoulder and wrist replacement.

For more information, contact Andrews Sports Medicine and Orthopaedic Center at 205.939.3699 or visit  

Dance medicine a growing specialty at Children’s of Alabama

By: Dr. Reed Estes is the Chief of UAB Sports Medicine at Children’s of Alabama and an Assistant Professor at UAB. He treats young athletes, and has developed a growing specialty in dance medicine. He has worked with performers in the Boston Ballet and many other professional and amateur dance companies.

Dance, like any other physical activity, produces its share of injuries, particularly in children and teenagers. There are sprains, strains, broken bones, bumps and bruises. The more serious injuries often require specialized care and rehabilitation aimed at getting dancers back on their feet and toes. It’s important to understand when and why this specialized care is needed.

Dance injuries account for a steadily increasing volume of my sports medicine practice at Children’s of Alabama. We provide and coordinate care across the many specialties at Children’s, and we work closely with Agile Physical Therapy, which greatly enhances our ability to serve dancers. We conduct clinics at dance studios, and see patients from throughout the southeastern U.S.

Dance injuries are fairly common. On average, 23 children are treated every day in U.S. emergency rooms for some type of dance-related injury, according to a recent study published in the Journal of Physical Activity and Health. That same study also found that the number of serious, dance-related injuries increased 37 percent from 1991 to 2007, climbing from 6,175 to 8,477 annually.

Some dancers come to us just to be checked when approaching a new, more difficult level of performance, such as beginning pre-pointe participation with ballet. Others have been injured, and come to us for specialized care. We understand the mentality of dancers and the things they need to prepare for. It’s considerably different than the way we treat our football players or soccer players.

For example, when a football player tears his anterior cruciate ligament, or ACL, we focus rehabilitation on strengthening his core movements to get him back on the field, specifically to the demands required of a contact athlete. In dance, there are different requirements. A dancer must not only be limber and able to accomplish difficult tasks in an aesthetically pleasing manner, but also maintain full stamina. Rehabilitation for a dancer focuses on that.

Not all injuries require a dance medicine specialist. I tell patients and families to watch for pain that is ongoing, persistent and may be causing disability. Pain that is present with one particular activity, every time it occurs, may indicate a need for medical intervention. Likewise, pain that progresses with a decreasing level of activity often poses a warning sign.

Of course, the best medicine is prevention, and there are things that parents can do with a child who is a dancer. Watch for fatigue, monitor dietary habits, ensure that sleep is sufficient and know when a child or teenager is under stress with projects at school. Understand how that affects them when they are in the dance studio, when they are under duress and fatigued. Young dancers tend to eat poorly and not get enough sleep before performances when life becomes stressful. There’s only so much time in the day to practice and do homework.

Many times, teenage dancers will remain silent when they are injured. There is often a fear that their instructor may be upset with them, their classmates may lose faith in them, or they may lose their roles in performances. Oftentimes, it requires the parent watching closely and saying, “I noticed my daughter was icing down her ankle or rubbing down her knee.” Parents should be mindful of those things.

Also, we encourage parents to watch for the level of pain after dance. We usually advise that a low level of pain is acceptable some of the time. That’s a 4 or 5 out of 10, on occasion, and is often a symptom of soreness, as opposed to something that is more persistent.

Remember, most sports are seasonal, but dance is a year-round pursuit with little downtime. Thus, my mentality has to change when treating a dancer.

Friday, April 10, 2015

Using Technology to Remove Barriers in Productivity

By Ryan McGinty, President / CEO at OCERIS, Inc.

Running a business is no trivial task. There is no shortage of mind-numbingly repetitive tasks that need to be done on a routine basis. The reality is that complicated or mundane tasks often get put on the backburner until the last minute. As someone who designs workflow solutions for healthcare, as well as running a business, I’ve seen and had my fair share of challenges in efficiency. Making the best use of technology is the number one thing you can do to improve your productivity and maintain your sanity.

The first thing to do is to evaluate your current situation and determine what barriers are in your way. Look at every task that is done more than one time, determine how many resources and how much time is required to accomplish the task, then look for ways to make this task more efficient. You may already have tools that can help you, but you may also need to consult with someone who specializes in the task in question. While many consider the fees charged by consultants to be expensive, this must be weighed against the true cost the task incurs on the business. For instance, freeing a mere hour a week adds up to 52 hours, or more than a full work week, over a year. Think about what you do in a week – that’s a lot of time.

The goal will ultimately be to get as much data digital as possible – and that’s where technology solutions come into play. Digital information can be shared, searched, accessed off-site, and backed up. Paper locks your data into a format that is not conducive to collaboration and often times is misplaced or misfiled resulting in hours of lost time. Choose a solution that best holds the data you are working with, for example, accounting software, document management solutions, or an EHR. For other types of data, look for ways to share it, such as cloud drive solution – just make sure it is HIPAA compliant.

If you implement a new product, or have one already in place, the next step is to make sure that you know how to use it. Today’s software is ever increasing in capabilities and complexity. Most people don’t even know the capabilities of products they already own. These capabilities could save countless hours and reduce frustration. Many products have free resources such as webinars and help files to help you better understand the capabilities of the product. If these resources aren’t available, or a hands-on approach is more appealing to you, see if the vendor offers one-on-one training. As with consultants, the cost of the training is usually justifiable when compared to the amount of resources and time saved.

Lastly, for processes that can’t be easily automated, use collaborative technology to document and share the steps to complete the process. Working a complicated task from a checklist is much easier than rediscovering the process each and every time. Often the process is already documented, but locked on a sheet of paper in someone’s desk. Having this information shareable will prevent disruption when an employee is inevitably unavailable and another needs to handle their responsibilities.

Today’s technology offerings can significantly streamline any business and greatly increase the quantity and quality of work that a single person can handle, making your business more efficient, and therefore, more profitable. Embrace it, make sure you know how to use it, and enjoy more profit and time.

Monday, April 6, 2015

Focus on Men’s Health

by: Jack L. Zaremba, M.D. Internal Medicine at TRINITY MEDICAL CLINICS at Trussville

Although we are focusing on men's health issues, this topic is also for the ladies in their lives who often are instrumental in noting men's problems and encouraging them to seek medical evaluation. Also a wife's participation in healthy behaviors has been shown to improve the outcome of both partners.

There are obvious differences between men and women not just with respect to their relative risk of certain diseases but with their participation in periodic health screenings. Women, perhaps due to their role in child bearing and nurturing, are more likely to participate in periodic health examinations than men. Men, on the other hand, may have an attitude that if it's not broken, don't fix it. Some men may give more attention to the preventive maintenance of their trucks, boats and lawn mowers than their own body. Men would not fail to give attention to a check engine light but they may have a tendency to continue to drive on ignoring certain health warning signs.

Certain medical conditions could be detected earlier and have more effective treatment if men would take advantage of periodic health examinations and preventive medicine screenings, as appropriate to their age and risk factors. Delay can lead to serious difficulties or even disaster. The emphasis now is not just to cure disease but to try to prevent its occurrence or to mitigate its consequences. This is the case where an ounce of prevention may be worth a pound of cure. Men should consider a periodic examination every 1 to 3 years starting at about age 18-25 and then yearly after age 50 depending on risk factors.

Let's turn our attention to some of the mile markers on a man's road of health. Consider these as guidelines, and for further direction I would encourage discussions with your physician. Men at age 18 to 24 could focus on accident prevention, seat belt usage, tobacco abstinence, alcohol moderation and incorporating healthy life styles such as aerobic exercise for approximately 150 minutes per week, weight reduction to a BMI of Iess than 25, decreasing waist circumference and a heathy diet. This may reduce premature cardiovascular related deaths by up to 40%. Also, perform screening for hypertension which is the most common chronic disease. The goal is to keep the systolic pressure less than 140 mm and the diastolic less than 89 mm.

Screening for testicular cancer by monthly self-exams is prudent, particularly if there is a history of undescended testes as a child.

Promote skin health through avoidance of UV light exposure and the use of sun screen is appropriate at any age However, those with a positive family history of melanoma should be cautious and have their skin checked - particularly those areas that are not sun exposed.

At age 25 - 44 consider screening for fasting lipid profile to achieve a target LDL (bad cholesterol) lower than 100 and HDL (good cholesterol) higher than 40 as well as triglycerides less than 150. Diabetes Mellitus Type 2 can have a prolonged asymptomatic period before one develops weight loss with frequency of urination and thirst. Those at higher risk have one positive family history of diabetes as well as those with Metabolic Syndrome consisting of hypertension, dyslipidemia, increased triglycerides and central obesity. We can't affect our age or family history but we can improve our diet, exercise and weight reduction.

At age 40-45 consider having a prostate evaluation depending on symptoms, age and family history. It is said that there are two types of men. One type has prostate problems and the other type will develop prostate problems if he lives long enough. Benign prostate hypertrophy is the enlargement of the prostate gland that may cause symptoms of urinary frequency and urgency, as well as hesitancy and nocturia. A Digital Rectal Examination can evaluate size and consistency of the prostate. Interventions include diet modification to reduce caffeine and alcohol and treatment with medications such as alpha blockers.

At age 45-64, having a prostate cancer screen to include a Prostate Specific Antigen (PSA) and a complementary digital rectal examination is prudent for men with a first degree relative with prostate cancer and also African American men who are at higher risk. It is important to know your risk and to know your PSA number - particularly when your PSA number is elevated. The natural history of prostate cancer is variable. Early detection may have a beneficial effect on treatment, although there is conflicting data on mortality from prostate cancer and PSA screening. Know your risk and consult with your physician if you are over 70 years of age.

At age 50 it is time for men to perform a "gut” check. A screening colonoscopy is recommended. This could be performed earlier if there is a family history of colon cancer or symptoms. Colon cancer is preventable if detected early by colonoscopy.

A periodic chest X-ray and pulmonary function test for smokers may be indicated depending upon their risk. Cardiovascular screening may be indicated depending on symptoms, age and risk factors. An ophthalmological exam, at about age 50, for glaucoma followed by yearly exams thereafter is recommended.

Erectile Dysfunction can have multifactorial causes. Encourage life style changes such as weight loss, regular exercise, moderate alcohol consumption, correct any sleep disorders and rule out organic causes, as well as medication side effects, stress and psychogenic causes. Treatment with oral Phosphodiesterase 5 inhibitors can be effective. However, they can affect blood pressure and should not be used with nitroglycerine. Those with cardiovascular disorders should check to see if they are “safe” for sex using these medications.

Low testerone level - or low T- can often be seen in direct consumer marketing. Low T can be related to delayed sexual development, Kleinfelter's Syndrome, sexual dysfunction, infertility, decreased muscle mass, obesity, bone fractures, depressed mood and decreased stamina. Yet, many of these symptoms are non-specific and could be related to other causes. An association between two things does not mean that one causes the other. Age related decrease in testerone may begin in the 40s. One must document the early morning low T level in the presence of symptoms and in the absence of other causes. There is increasing interest in normalizing low T levels through testerone replacement therapy. Many studies indicate the normalization of low T levels can promote cardiovascular health, decrease obesity, improve glycemic control, and improve libido, lean muscle mass and quality of life. Recently a study indicated that testerone replacement may increase the risk of cardiovascular events. However, this study is inconclusive. Therefore, you should discuss the risks and benefits of testosterone replacement therapy with your physician. Treatment should be accompanied by surveillance of PSA, HCT, OSA symptoms as well as risk of DVT

At age 65, consider screening for Abdominal Aortic Aneurysm particularly for men who are, or have a history of, smoking.

Consider recommended immunizations for disease prevention such as Influenza, Pneumococcal, Shingles Vaccine and Tdap.

There are some warning signs or red flags that could alert us to potential problems ahead.

These include:

• Vision changes in one or both eyes

• Oral lesions or sores that don't heal particularly in smokers or smokeless tobacco users

• Hoarseness that is persistent

• Difficulty swallowing

• Chronic cough

• Chest pain or Dyspnea on exertion or atypical exertional pain such as in the arm or jaw

• Unusual bleeding such as nose bleeds

• Change in bowel or bladder function or blood in the stool or urine

• Chronic indigestion

• Lumps on the body or breasts (male breast cancer is relatively rare but does occur)

• Change in the color, size or shape of a wart or mole

• Confusion, difficulty with speech, vision or use of an arm or leg could be a symptom of impending

• Sleep disturbance such as excessive snoring or apneic pauses in breathing- particularly in a man
whose neck size is greater than 17 and/or BMI greater than 30

• Consider family CPR training to intervene early and save lives in a cardiac arrest situation. The life saved may be yours.

• Also attention to disaster preparedness and dangerous weather preparation.

Perhaps two-thirds of our ailments could be related to our life style. The foundation for health is healthy habits of diet, exercise and weight reduction as well as optimizing our lipid profile and reversing other risk factors. Know your risks and change your direction accordingly, as well as participate in appropriate periodic medical health screening examinations.

Here’s looking forward to your life's road being long and healthy.