Monday, July 25, 2016

How the Alabama Medicaid Cut to Physicians Will Endanger Patient Care

The Alabama Medicaid Agency and Gov. Robert Bentley announced a devastating cut to primary care physicians (pediatricians, family physicians, and other physicians) effective Aug. 1, which will make access to care more difficult for Medicaid patients and could force them to leave the program. The proposed cuts translate to an average of 30 percent reduction in payment for basic care.

According to Medicaid Commissioner Stephanie Azar and Gov. Bentley, this will be the first of many cuts to Medicaid fees and services unless additional funding is found to fill the $85 million budget gap left by the Alabama Legislature during its Regular Session.

The announced cut would eliminate the primary care “bump,” which was originally a provision of the Affordable Care Act requiring states to raise Medicaid primary care payments to make them comparable with those of Medicare. The provision was implemented to increase access to primary care services. The federal government subsidized the increase in 2013 and 2014, and Alabama was one of 16 states to continue the fee increase…until now.

Sacrificing Physicians to Save the RCOs?

“Alabama already runs the most bare-bones Medicaid program in the country,” said Medical Association Executive Director Mark Jackson. “This cut is more than disappointing. It’s dangerous. With more than half the births in Alabama and 47 percent of our children covered by Medicaid, as well as 60 percent of Alabama’s nursing home residents, Alabama’s Medicaid program could easily collapse, leaving these individuals without coverage. I noticed in his statement, the governor said his goal was to save the Regional Care Organizations. However, I feel as though this logic is backwards. This cut will most likely perpetuate the demise of the RCOs by inhibiting their ability to get physicians to participate in the Medicaid program.”

While cutting the primary care bump is expected to save Alabama Medicaid $14.7 million, Alabama’s physicians are looking to Gov. Bentley and the Legislature to solve this problem for the sake of their patients.

“The Medicaid program takes care of children, the elderly and the disabled, and the program itself is sorely misunderstood,” said Montgomery pediatrician Cathy Wood, M.D, president of the Alabama Chapter-American Academy of Pediatrics. “I look at these families, and I know what’s going to happen next. It’s not good. It’s like having a car with no gas. Our legislators need to understand that every one of their districts will be impacted by these cuts.”

According to Dr. Wood, Medicaid’s cuts will be felt across the board, not only in the health of the patients, but also with the staff employed by the physician. She stated that in a survey of Alabama pediatricians close to 30 percent of respondents said they would have to lay off staff members should this cut became reality.

“We practice medicine with an altruistic heart because the rewards are tremendous,” Dr. Wood said. “No price tag can be placed on that. However, this cut will make it extremely difficult to keep the doors of many practices open. With Medicaid funding, physicians provide jobs for individuals in our communities. If we cannot sustain our community health care systems, we’re going to be in serious trouble in areas where access to care is already a tenuous situation at best.”

Childersburg family physician Jarod Speer, M.D., president of the Alabama Chapter of the American Academy of Family Physicians, agreed with Dr. Wood that the announced cut will make the practice of medicine in rural settings even more challenging, possibly forcing practices to close under the overwhelming financial burdens caused by the cut.

“I don’t want to stop taking Medicaid because I have an obligation to my community,” Dr. Speer said. “I still want to see my patients, so I’ll have to find other ways to make cuts in my practice. I’ve been here for eight years, and I appreciate that my patients have put their trust in me. I just wish Medicaid would make it easier for me to see my patients.”

Dr. Speer said that some of his fellow family physicians will be forced to stop seeing Medicaid patients or limit the number of patients they see.

“Obviously that’s going to limit access to health care in our rural areas where we already have a physician shortage,” Dr. Speer added. “We don’t need any more barriers to health care.”

How Physicians Contribute to Alabama’s Economy

Alabama’s physicians fulfill a vital role in the state’s economy by supporting 83,095 jobs and generating $11.2 billion in economic activity, according to a joint report by the Medical Association and the American Medical Association.

Alabama’s physicians are major economic engines in their communities. Urban or rural, large group or solo practitioner, Alabama physicians can improve both patient health and the economy.

With the changing health care environment, it is increasingly important to quantify the economic impact physicians have on our society. To provide lawmakers, regulators and policymakers with reliable information, the report measured the economic impact of Alabama’s physicians according to four key economic barometers. The overall findings in Alabama include:

• Jobs: Each physician supports an average of 9.5 jobs, including his/her own, and contributed to a total of 83,095 jobs statewide.

• Output: Each physician supports an average of $1.3 million in economic output and contributed to a total of $11.2 billion in economic output statewide.

• Wages and Benefits: Each physician supports an average of $758,744 in total wages and benefits and contributed to a total of $6.7 billion in wages and benefits statewide.

• Tax Revenues: Each physician supports $46,148 in local and state tax revenues and contributes to a total of $404.9 million in local and state tax revenues statewide.

The study found, in comparison to other industries, patient care physicians contribute as much or more to the state economy than higher education, home health care, legal services, nursing and residential care.

Alabama’s more than 11,200 licensed, practicing physicians have called upon Gov. Bentley to use whatever means at his disposal to find a permanent revenue solution to fully fund Medicaid and ensure no further cuts are made to the Medicaid program.

Physician practices, nursing homes and hospitals are among the economic engines driving many Alabama communities. Closure of these health care providers will have a devastating impact on the State of Alabama and the health and prosperity of its citizens. The ripple effect will be felt statewide.

We strongly believe that Medicaid matters … to all Alabamians. No resident should be without access to health care.

Lori M. Quiller, APR
Director, Communications and Social Media
Medical Association of the State of Alabama

Thursday, July 7, 2016

The Ministry of Rural Medicine

Physicians Giving Back – Dr. Roseanne Cook

The town of Pine Apple lies about 20 minutes off I-65 South tucked in the southeast corner of Wilcox County along Alabama’s Black Belt. Driving through this farming community, you quickly notice the picturesque countryside dotted with the occasional farm house and antebellum home. This is an old and settled community with a population of around 150 residents.

However, Pine Apple is nestled into one of the poorest counties in the country with a population of about 12,000 residents and few physicians to make the rounds. Roseanne Cook, M.D., is one of a handful of physicians serving the county. The Pine Apple Clinic is a community health center with its business center in Selma. The clinic receives some federal funding, and Dr. Cook has taken care of patients there since 1986. The clinic isn’t the average medical clinic, and Dr. Cook isn’t the average rural physician.

Dr. Cook is a Roman Catholic nun, a sister of St. Joseph out of St. Louis, MO.

In 1979 working as a biology professor, Dr. Cook said she felt her life had another mission. So, at age 40, she entered medical school, and her life’s work was about to fully take shape with the intent of delving even deeper into her ability to help our country’s poor residents.

“I loved teaching, but I knew the Lord wanted me to do more. When I first went to my major superior about going to medical school, I wasn’t sure what that answer would be!” she laughed. “The answer was if it’s the Lord’s inspiration, you’ll get in, if not, you won’t get in. And, I got in at age 40…the age of most of my student colleagues’ mothers.”

After medical school, Dr. Cook had planned to follow her order to Peru, but the nurse practitioner from her order was already in Pine Apple and convinced her to come to Wilcox County instead to join the practice.

Now as a family physician serving many counties, not just her own due to a shortage of family physicians in rural areas, she has more than her hands full of patients. But, she and her staff always make the best of the situation.

“I’ve been in this area since 1986, and it’s poverty stricken…actually it’s beyond poverty stricken,” Dr. Cook said. “These residents work hard, and because they work, they don’t qualify for Medicaid or subsidies, so we do everything we can to make their lives a little better.”

Wilcox County has a recorded median income for a household in the county is around $16,646, and the median income for a family is about $22,200. According to the last census, about 36 percent of families and 39 percent of the population were below the poverty line, including 32 percent of those age 65 or over.

Dr. Cook’s clinic is a small community unto itself and eagerly accepts donations to continue some of the services the surrounding residents have come to depend upon. The medical clinic building is flanked by an adult care building and learning center building. At the end of the square lies a thrift store-style facility. Unfortunately, due to lack of funding, the adult care and learning center has closed. Yet, the medical clinic building almost doubled in size due to a private donation in 1991.

“We do the best we can with what we have,” Dr. Cook said. “Sometimes we have more. Sometimes less. But we always make it work here.”

Working in a rural setting presents unique challenges for any physician. But in 2001, Dr. Cook was faced with one of her most challenging moments when she stopped to help a vehicle of stranded motorists just outside of town.

She was on her way to the clinic when she spotted the car on the side of the road. It needed a jump, so she pulled up and got out of her vehicle with her jumper cables. Ready to deliver roadside aide, Dr. Cook wasn’t prepared for what happened next.

She was knocked unconscious and tossed into the trunk of her vehicle. Driven down a desolate road deep into the county and only partially conscious, she wasn’t sure what was happening until shots were fired into the trunk. Five shots rang out. Four missed. One grazed her cheek.

“God didn’t want me to die that day,” she said. Today, she can look back on the incident with an ease that she surely didn’t have 15 years ago. It’s part of Dr. Cook’s character, woven into every fiber of her soul that keeps her soldiering on every day to treat the patients she’s grown to call members of her extended family.

And…she still makes the occasional house call.

Tuesday, July 5, 2016

Benefits of CO2 Angiography

By: James Trimm, M.D. Interventional Cardiologist at Birmingham Heart Clinic

Many patients with PAD have issues such as diabetes mellitus which can lead to kidney dysfunction. These patients are at risk to develop a condition known as contrast-induced nephropathy after being exposed to standard contrast agents during angiograms and interventions. This condition can lead to renal failure, short term dialysis, or even permanent dialysis. Many PAD patients already suffer from impaired kidney function and until now, they could not have potentially limb-saving procedures for the fear of being placed on dialysis. The use of CO2 angiography has changed this way of thinking and opened doors to treatment options not previously available.

Carbon dioxide is a non-toxic, compressible gas that has been available since the early 1900s. It has many advantages when compared to commonly used agents. Unlike iodinated contrast medium, there is no risk for allergic reaction. This makes CO2 an ideal adjunct to iodinated contrast medium for patients who have a history of allergic reactions. In addition, CO2 causes no renal toxicity. Studies indicate that the selective injection of CO2 is safe, even in patients with diabetes or compromised renal function. This makes it ideal for use in renal artery angioplasty and stent placement.

Furthermore, CO2 does not cause liver toxicity. CO2 has been used successfully as a contrast agent for celiac, splenic, superior mesenteric, and hepatic arteriograms for patients with a variety of disorders.

Overall, CO2 is a great option for patients with compromised renal function who need complex, peripheral vascular interventions, and we at BHC are proud to offer this expertise to our patients.

Birmingham Heart Clinic, in conjunction with St. Vincent’s East Hospital, is the first and only practice in Birmingham to use CO2 angiography in the treatment of peripheral arterial disease or PAD. 

Why Recommendation of the USPSTF Not to Perform PSA Based Screening, Even in High Risk Individuals is a Mistake.

By: Brian A. Stone MD, FACS with Jasper Urology Associates Brookwood Baptist Health

Prostate cancer will be diagnosed in 180,890 men in 2016 and will likely cause the deaths of another 26,120 men in the United States. It is estimated that there are over 2.8 million men living with prostate cancer in the US (2013 data). The likely unintended consequence of the United States Preventative Services Task Force has been the presentation of men in our office with higher PSA levels and more advanced prostate cancer when it is found. More alarming was the fact that this recommendation included high-risk men who have a strong family history of prostate cancer and African American men. This negative recommendation has created a dilemma for the urologist who must manage reluctant patients and prostate cancer. Even more concerning is the potential reluctance of the “gate keeper” physician to perform the PSA test in the appropriate age group or to not respect a rising PSA.

Fact: The leading cause of malpractice claims against urologists is the failure to diagnose and treat prostate cancer in a timely manner. Primary care physicians are being increasingly held liable for failing to obtain PSA testing and failure to refer patients to an urologist.

PSA or “prostate specific antigen” is a serine protease that is produced by the cells of the prostate. Both normal and cancerous cells of the prostate produce PSA. Elevated levels of PSA are “suggestive” of prostate cancer risk and are the trigger for prostate biopsies. However, PSA levels can also rise from inflammatory processes (prostatitis, instrumentation and trauma) and benign prostatic hyperplasia (BPH). PSA is also a good marker for prostatic volume. The PSA blood test is not the perfect screening tool for prostate cancer, but it is the only marker that we have for this disease.

Fact: PSA is found primarily in the epithelial cells of the prostate and semen. Low concentrations of PSA have been found in urethral glands, endometrium, normal breast tissue, breast milk, salivary glands and urine (males & females).

The goal of prostate cancer early detection has always been to detect potentially aggressive and lethal forms prostate cancer at its earliest stages when treatment can mitigate the morbidity and mortality from the disease. However, it has become evident that “blanket” screening does detect non-lethal cancers and the treatments are not without potential side effects. Prostate biopsy also carries a very low, but real, risk of sepsis requiring in-patient treatment. It is clear that common sense use of PSA and shared decision making with the patient can be useful in protecting those patients who are at high risk of being diagnosed with prostate cancer.

Fact: Since PSA was introduced, 75% of men diagnosed with prostate cancer have non-palpable disease.

The USPSTF recommendation is based on one study, the PLCO trial (Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial), whose methodology was severely flawed. Over 90% of the men in the control group (allegedly not screened) had indeed been screened contaminating the data. Additionally, African American men only represented 4% of the cohort in this pivotal study. This was a critical flaw in a study that has been used to make a negative determination about a test that has saved so many lives. I base this statement on the fact that mortality had steadily declined since the introduction of PSA testing in 1992 based on SEER mortality statistics.

Fact: Prior to the introduction of PSA 70% of men with prostate cancer presented with extraprostatic or metastatic disease. Since the introduction of PSA, fewer that 3% of men have metastasis at diagnosis.

In March of this year, the Centers for Medicare and Medicaid Services temporarily suspended development of a proposed “non-recommended PSA based screening” measure that would have discouraged PSA screening in all men. USPSTF is currently in the process of updating its recommendations for prostate cancer screening. The decision makers (both in policy and the insurance side) must make very well educated and thoughtful considerations about the fate of the PSA blood test, particularly with the available data that is highly supportive of intermittent PSA testing. This reduces the costs and harms of screening while preserving the benefits of yearly testing (based on the AUA guideline for early detection of prostate cancer).

Fact: Men who begin PSA testing and digital rectal examinations at the recommended age (depending on risk factors) and are eventually diagnosed with prostate cancer and treated, have a 5-year survival of 100% and 10-year survival of over 90%.

Physicians have sworn the Hippocratic oath, which states that above all things “do no harm”. It is obvious to me that the blanket denial of educated, patient involved prostate cancer screening in high risk populations would be a violation of our oath.

Men's Health

By: Michael Bivins, MD 

As doctors and caregivers we can play a big role in improving men's health and wellness.

Today, men are more willing then ever to talk about their health. As a urologist, specializing in the treatment of advanced prostate cancer at Urology Centers of Alabama, I offer a holistic approach to cancer care. This approach also makes sense for the man who is healthy today and wants to stay healthy. Let's remind our male patients of the basics during Men's Health Week:

• Get good sleep;

• Avoid excessive alcohol use;

• Toss out the tobacco;

• Move more;

• Eat healthy;

• Reduce stress;

• Have regular checkups; and

• Maintain a spiritual purpose.

These guidelines from the CDC are not only good for our male patients; the guidelines are equally as relevant to physicians and caregivers.

Dr. Michael Bivins is a member of the American Urological Association, American Medical Association and the Medical Association of the State of Alabama. He received his board certification from the American Board of Urology in 2004