Nashville Medical News Nov 2013

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Meharry Medical College Celebrates 138th Annual ConvocationCivil Rights Pioneer Andrew Young Headlines Event

On Oct. 14, Meharry Medical College held its 138th Annual Convocation with civil rights leader Ambassador Andrew J. Young as keynote speaker and recipient of an honorary doctorate degree ... 4

Tennessee Hospital AssociationReinventing Tomorrow’s Healthcare Every Day for 75 Years

Established in 1938, the Tennessee Hospital Association has adopted the tagline “reinventing tomorrow’s healthcare every day for 75 years” as an ongoing theme for 2013 ... 18

November 2013 >> $5

FOCUS TOPICS DIABETES & COMORBIDITIES REIMBURSEMENT

Craig Wierum, MD

PAGE 3

PHYSICIAN SPOTLIGHT

ONLINE:NASHVILLEMEDICALNEWS.COMNEWS.COM

Tax Planning with Rates on the Rise

Preventing Type 1 DiabetesBy CINDy SANDERS

What year did researchers discover the cure for polio? Trick question … a cure wasn’t discovered,

but Jonas Salk, MD, developed a highly effective vaccine to prevent polio that was fi rst tested in 1952 and widely introduced in 1955. As a result, the devastating disease has been nearly eradicated worldwide.

Calling upon that same ‘ounce of prevention’ spirit, researchers participating in the international TrialNet studies hope to achieve a similar victory by preventing type 1 diabetes (T1D).

While only about 5 percent of diabetes cases in America are type 1, the Juvenile Diabetes Re-search Foundation estimates as many as 3 million Americans have T1D. The latest data from the National Institute of Diabetes and Digestive and Kidney Diseases fi nds more than 30,000 children and adults — approximately 80 people a day — are diagnosed with T1D each year in the United States. Furthermore, the Centers for Disease Con-trol and Prevention identifi ed a 23 percent jump in T1D prevalence rates among Americans under age

(CONTINUED ON PAGE 6)

Dr. William Russell talks with participant Ric Hudgins at the Vanderbilt Eskind Diabetes Clinic about a new study examining the ability of the drug abatacept to prevent type 1 diabetes. Hudgins, whose 13-year-old son has type 1 diabetes, noted, “Hopefully trials like these can help researchers fi nd ways to prevent other children from receiving a type 1 diabetes diagnosis.”

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By JERRy MOSS, CPA & DAVID LISTER, CPA

Your 2013 tax bill might come as an unwelcomed surprise if you haven’t been paying attention to the tax changes that took effect for 2013. Increased tax rates, brand new taxes and phase-outs of both itemized de-ductions and personal exemptions hit taxpayers this year. Depending on your income level, each of these changes could take its own bite out of your disposable income.

ATRA Increased Rates & Phase-Outs The good news is that the 2012 American Taxpayer Relief Act (ATRA)

extended the Bush-era tax cuts for most Americans. For the past decade under these rules, the top individual income tax rate was 35 percent. The bad news is that, starting in 2013, there will be a new 39.6 percent top individual income tax rate applicable to individuals with adjusted gross income (AGI) over $400,000 and married couples whose AGI is over $450,000.


Saint Thomas Heart to Offer New Alternative to Open-Heart SurgeryLearn more on page 5

2 > NOVEMBER 2013 n a s h v i l l e m e d i c a l n e w s . c o m

PROMPT AND PERSONAL – IT’S HOW REGIONS KEEPS THE WHEELS OF PROGRESS TURNING FOR SMALL BUSINESS. Dr. Susana Leal-Khouri began her relationship with Regions in 1996 at the suggestion of her personal accountant. She was just starting her private practice, the Miami Dermatology Center, and needed to furnish the offi ces. “Regions has been very helpful in allowing us to be able to start and grow the practice. They’ve also helped make it possible for us to hire the right people,” says Dr. Leal-Khouri.

“Regions is always there when I have questions. My relationship with my Regions banker is personal and I have her on my speed dial.”

What started as a single location has grown to three with a full-time staff of 17 employees. These days, the Miami Dermatology Center utilizes a wide range of Regions banking tools, from Business Analyzed Checking and Treasury Management to loans and lines of credit.Dr. Leal-Khouri plans to expand parking at her Coral Gables location, and Regions is part of those plans too. To learn more about the Miami Dermatology Center and how Regions can assist your business, visit regions.com/success.

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By KELLy PRICE

Lala salama means “sleep well” in Swa-hili.

This was just one of many things that Craig Wierum, MD, learned while living with a Maasai tribe during a junior year abroad program in which he participated as an undergraduate at Duke University.

The other semester of that year was spent in Great Britain studying literature and theater. Wierum even appeared on a London stage, sporting a British accent, in the lead role in a Tom Stoppard play produced by the college.

International relations have al-ways been part of Wierum’s DNA. He grew up just outside New York City in Demarest, N.J. with a father who was an internal medicine physician and a mother who hailed from New Zealand. Wierum’s Kiwi heritage gives him dual citizenship.

Throughout his schooling, he excelled in science and math. Although initially pursuing a college path towards literature and theater, he ended up focused on medi-cine. After graduating magna cum laude from Duke, Wierum chose a career with specific interests in neuroscience at the University of North Carolina School of Medicine. In 1990, he came to Nashville for internship and residency at Vanderbilt University School of Medicine and served as chief resident for the University of Tennessee Residency Program at Baptist Hospital (now Saint Thomas Midtown).

Upon completion of his training in endocrinology, diabetes and metabolism, Wierum was appointed director of the Baptist Diabetes Center and hired as a full-time faculty member for the UT Resi-dency program, where he taught and prac-ticed for nine years.

In 2004, Wierum moved into private practice with Heritage Medical Associates and now serves as director of the Heritage Diabetes Center. His focus is on one of this nation’s most troubling health dilemmas — the epidemic proportions of the growth in the incidence of diabetes in this country.

Wierum noted the increase in the di-agnosis of diabetes directly parallels the nation’s obesity epidemic. Currently, it is estimated that more than 26 million peo-ple in the U.S. have diabetes, and another 80 million are on the cusp of developing the disease.

Wierum observed, “The reasons are multifactorial but center mostly around three major factors: decreased physical activity, a high carb diet, and epigenetics. This latter phenomenon is the most alarm-ing. It means that an obese mother with

insulin resistance will actually program her unborn child to become insulin resistant, overweight and diabetic.”

He continued, “If the same woman delivers a second child after 50-100 pounds of weight loss, she will deliver a child with normal glucose tolerance and a much lower risk of diabetes. In other words, this epidemic is actually feeding itself.”

Wierum added, “This is one of the reasons we are witnessing such an epi-demic of ‘adult’ diabetes presenting in children.”

Since he began practicing, the arma-mentarium to fight diabetes has increased. “When I started, we had only two classes of drugs, insulin and sulfonylureas. There are now 12 classes of drugs for the treat-ment of diabetes,” Wierum said.

He added. “The Heritage Diabetes Center uses state-of-the-art technology to help our patients trace and treat their diabetes.” Technology to assist patients includes the use of implantable glucose sensors, insulin pumps, disposable insulin pumps, insulin pens, and a large variety of glucose meter devices. Advances in drug therapy and device technology have dra-matically enhanced the quality of life for diabetic patients by helping to minimize injection discomfort, minimize weight gain associated with older therapies, and prevent life-threatening low blood sugars, Wierum noted.

“For the Heritage Diabetes Center, the continuous glucose monitoring system (CGMS) has been one of the most helpful tools in our management of patients on in-sulin. It has allowed us to monitor glucose levels every few minutes, 24 hours a day. This has taught us a tremendous amount of information about the effect on blood sugar that is caused by various meals, ex-ercise routines, alcohol and sleep. We have discovered that some patients were having severe low blood sugars overnight that might have led to coma, seizures, or even death if left unrecognized and untreated,” he said.

“Changing human behavior is the hardest thing we attempt to do every day.

Fortunately recent advances in drugs, technology and laparoscopic obesity sur-gery have allowed us to help many patients who struggle to change their behavior. Meanwhile, we have also learned that fear of complications is rarely the best motiva-tion for many patients. On the contrary,

we have been able to motivate patients by taking the time to make sure they under-stand that we care about them … not just their labs or their numbers. It is repeated often and understood by all my staff that the greatest service we provide to our pa-tients is to make them feel cared for,” he stressed.

Wierum observed, “Today’s resi-dents, interns and students work shorter hours than they did during my training in the 1980s and 1990s. As a result, they are often unprepared for the reality of medical practice, which has no such restrictions.” His advice to young doctors is to “always make the patient feel cared for … even if you are tired, frustrated, and irritated by non-compliance.” He added, “Always be kind and always be fair to your patients and your staff. Nobody wants to be sick, and not everyone deals with it gracefully.”

When he isn’t caring for patients, Wierum loves spending time with his wife and two busy, beautiful daughters, ages 12 and 14. He also heeds his own advice to patients about finding balance and good health. His personal prescription is to carve out time for reading, running, bik-ing, and woodworking.

On the Frontline of the Diabetes EpidemicCraig Wierum, MD: Director of Heritage Diabetes Center

PhysicianSpotlight

Wierum with Maasai friends during his junior year abroad.


On Oct. 14, Meharry Medical Col-lege held its 138th Annual Convocation with civil rights leader Ambassador An-drew J. Young as keynote speaker and recipient of an honorary doctorate degree.

“Andrew Young is one of the fin-est public servants this country has ever known,” said A. Cherrie Epps, PhD, presi-dent and CEO of Meharry Medical Col-lege. “We are honored to have him join us to formally launch our new school year and welcome students to this new aca-demic year.”

Under President Jimmy Carter, Young became the 14th U.S. Ambassador to the United Nations and the first Afri-can-American to hold that post. He also served two terms as a U.S. Congressman from Georgia and eight years as mayor of Atlanta. Young, alongside Dr. Martin Luther King, Jr., played a major role in the Civil Rights Act of 1964 and in the passage of the Voting Rights Act of 1965.

Reminding Meharry students of their call to the medical profession and their abil-ity to bring about change, he said, “You’re in one of the most exciting professions on the face of the planet. God has blessed you to be born at such a time as this.”

The son and brother of dentists, Young told Meharry’s dental students that the U.S. Congress should have addressed dentistry in the Affordable Care Act. “But it’s not too late,” he said. “The fun hasn’t started yet. Nobody ever thought that President Obama could get that (ACA) passed … and then when he got it passed, they never thought that he could get re-elected, and he’s done that … and they can’t figure out what to do next.”

During the ceremony, a formal por-trait was unveiled to honor the presidency

of Henry Wendell Foster Jr., MD, whose career has been dedicated to fighting for healthcare equality for disadvantaged populations and to improving the quality of life for women and children. Foster is pro-fessor emeritus of the Department of Ob-stetrics and Gynecology and former dean of the Meharry School of Medicine. Addi-tionally, five prominent leaders who have helped promote quality healthcare, espe-cially for the underserved, were honored.

Rueben C. Warren, DDS, MPH,

DrPH, MDiv, professor and director of the National Center for Bioethics in Re-search and Health Care at Tuskegee Uni-versity and the former dean and associate professor of the Meharry School of Den-tistry, received an honorary degree.

Dorothy Burton Berry, the first African-American female to hold the of-fices of assistant commissioner, deputy commissioner and commissioner of the Department of Personnel for the State of Tennessee, was awarded the Presidential

Distinguished Service Medal.Arikana Chihombori, MD,

FAFP, president and CEO of Bell Fam-ily Medical Centers, received the Axel C. Hansen, MD, ’44 Distinguished Physician Award.

William B. Butler, DDS, MS, FACP, former dean of the Meharry School of Dentistry received the Fred. C. Fielder, DDS, ’60 Distinguished Dentist Award.

Byron Ford, PhD, professor in the Department of Neurobiology and the director of the Neuroprotection, Neuro-repair and Stroke Program at the More-house School of Medicine, received the Harold D. West, PhD, Distinguished Bio-medical Scientist Award.

Following the convocation, Meharry marked the rededication ribbon-cutting ceremony and open house of Hulda Mar-garet Lyttle Hall, which served as a home to Meharry’s School of Nursing until its closing in 1962. One of the oldest build-ings on Meharry’s campus, Lyttle Hall was built in 1930. In 1998, the structure was listed on the National Register of Historic Places. The building, which now houses office space, has been recently renovated.

“Meharry is an institution growing to better serve the city of Nashville and com-munities across our nation,” concluded Epps. “Our students, faculty and alumni share a dedication to serving and treating those whom no one else will. Convocation is a time for us to recognize their dedica-tion and accomplishments and demon-strate our appreciation for their service to their communities.”

Meharry Medical College Celebrates 138th Annual ConvocationCivil Rights Pioneer Andrew Young Headlines Event

(Left): Andrew Young addresses the 138th Annual Meharry Convocation.

(Below left): Dr. Henry Wendell Foster admires his portrait.

(Below center): Dr. Byron Ford accepts his award for distinction in the biomedical sciences.

(Below right): Dr. Charles Mouton (L), dean of the School of Medicine, presents Dr. Arikana Chihombori with the award for distinguished physician.

Call For Nominations!Our annual Women to Watch

issue and event is coming in April 2014, and we want your input on women in Middle Tennessee that are impacting healthcare on a local, state or national level.

Clinicians, researchers, administrators, policy makers and allied industry suppliers who are changing the way we deliver care are all eligible.

To nominate, please go online to: nashvillemedicalnews.com and click

the Women to Watch icon.

NOMINATION DEADLINE:FEBRUARY 10, 2014

For advertising and event sponsorship opportunities, please contact Tori Hughes, 615.844.9410 or [email protected]

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omenW to WATCH2014


Saint Thomas Heart has become the first center in TN to have the MitraClip available, as part of a national clinical trial, for patients with congestive heart failure (CHF) and mitral regurgitation (MR). MR is the most common type of heart-valve insufficiency in the United States, affecting approximately 4 million people.

The MitraClip is a small metal clip that helps patients with mitral regurgitation (MR), a condition in which the heart’s mitral valve leaflets do not close tightly, causing blood to leak into the heart’s left atrium. The condition can lead to advanced heart failure.

This new treatment expands the options for selected patients with MR, especially those who are not candidates for invasive open-heart surgery. The procedure allows doctors to use catheter-based technology to repair the mitral valve via a groin puncture without requiring patients to undergo cardiopulmonary bypass or the need for traditional chest incisions.

The MitraClip procedure shortens recovery time and ultimately improves quality of life for those experiencing life-altering symptoms like fatigue and shortness of breath.

With MitraClip and the recently introduced transcatheter aortic valve replacement (TAVR) procedure, Saint Thomas Heart’s Cardiac Team is now able to treat a number of serious heart conditions using the least invasive techniques available.

“This is the first time that we’ve had the ability to manage these very complex patients who are too ill to undergo open heart surgery,” said Dr. Evelio

Rodriguez, Director of Minimally Invasive and Robotic Cardiac Surgery at Saint Thomas Heart. “In the past, the only option to help patients with congestive heart failure was to band-aid the symptoms with medication. This is a huge opportunity to increase the health and quality of life for many patients.”

During the MitraClip procedure, our interventional cardiologists use traditional catheter methods to guide the clip into the left atrium. The clip is lowered and attached to the valve to repair or reduce MR. Before final placement, the clip can be moved and rotated to ensure optimal fit.

The new MitraClip trial is a great complement to Saint Thomas Heart’s ongoing transcatheter aortic valve replacement (TAVR) program, which helps patients with severe aortic stenosis, narrowing of the opening of the aortic valve in the heart. During this procedure, a replacement valve is inserted through a catheter and implanted within a diseased aortic valve, allowing for valve replacement without traditional open-heart surgery and while the heart is beating, therefore also avoiding cardiopulmonary bypass.

It is the only valve replacement option for patients with severe aortic stenosis who are not well enough to undergo traditional open-heart surgery. Without surgery, 50 percent of symptomatic patients with severe aortic stenosis will die within an average of two years if untreated.

For more information about transcatheter aortic valve replacement (TAVR) or the MitraClip national clinical trial at Saint Thomas Heart, call the Saint Thomas Heart Valve Center at 855.789.2593.

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20 between 2001 and 2009. Whereas type 2 diabetes can often

be prevented, delayed or even reversed through behavioral modifications in diet and exercise, T1D is an autoimmune dis-order that doesn’t fundamentally respond to the same types of external interventions (although nutrition and exercise still play a critical role in disease management). In type 1 diabetes, the body’s immune sys-tem destroys the insulin-making beta cells in the pancreatic islets.

William E. Russell, MD, director of Pediatric Endocrinology & Diabetes for the Monroe Carell Jr. Children’s Hospi-tal, directs they Type 1 Diabetes TrialNet program at Vanderbilt Eskind Diabetes Clinic, which is one of 14 North Ameri-can clinical center sites. He also is protocol chair for the latest international TrialNet T1D prevention study on abatacept, which will soon include sites in Australia, England, Finland and Italy. In addition to the 18 clinical centers worldwide, more than 150 physician offices and medical centers are part of the larger screening ef-fort and TrialNet consortium.

“The mission of TrialNet is to find ways to prevent type 1 diabetes,” stated Russell. “It starts as an immune system problem. The endocrine system is one of its targets,” he continued. “We’re looking at how to turn off the immune attack on the beta cells in the pancreas.”

Russell noted, “People often think that screening for type 1 diabetes risk factors is unimportant because there is

currently nothing that can be done to mitigate their risk level for type 1 diabe-tes.” However, he continued, TrialNet provides hope that researchers might one day find the right mechanism to prevent, or at least significantly delay, T1D in high risk populations.

Pathway to PreventionThere are three major T1D preven-

tion studies that are part of TrialNet. The entry point to all three begins with a T1D autoantibody screening panel in the Pathway to Prevention study. Qualified participants must be between the ages of one and 45 and have a blood relative with T1D. From ages one to 20, it can be any blood relative with the disorder. From 21-45, participants must have a first degree relative with T1D.

After meeting the initial inclusion cri-teria, Russell said clinicians draw blood from potential participants and screen for five different antibodies, which can be present in the blood up to a decade be-fore diabetes is diagnosed. A positive result for any one of the five antibodies signifi-cantly increases the chance of developing T1D, and Russell said the more positive responses, the quicker the progression to the autoimmune disorder.

“People with two or more (autoanti-bodies) have close to 100 percent lifetime risk of developing type 1 diabetes,” he said. ”And if you have three or four, it’s going to be a more rapid progression to diabetes.”

For those who test positive, the next step is a confirmatory lab test where the autoantibody screening panel is repeated. Clinicians also run a number of other tests including hemoglobin A1C, oral glucose tolerance and HLA (human leukocyte an-tigen) typing.

“At that point, we’ve identified mul-tiple people who had type 1 diabetes and didn’t know they had it,” Russell said, not-ing those patients were then immediately referred to a physician for active disease management. “Several have been the parent of a child with T1D and were well outside the traditional age range thought to be vulnerable to developing type 1 dia-betes. This study is helping redefine the profile of the ‘typical’ T1D patient,” he continued.

Those with only one autoantibody are monitored annually or semi-annually, depending on the results of the additional screening tests. For those who tested posi-tive for two or more antibodies but did not yet have T1D, the potential participants have several options: opt not to participate in a trial but be followed and monitored every six months, drop out of the study completely, or enter one of the three trials based on which entrance criteria was met.

“Two of the three trials are aimed at antibody-positive individuals with normal glucose tolerance, indicating there has been no significant pancreatic damage yet,” said Russell. “The third one is for people who have two or more antibodies and abnormal glucose tolerance but are not yet in the diabetic diagnostic range. This is a particularly high-risk group. The glucose tolerance abnormalities reflect significant beta cell loss, and these indi-viduals have an 85 percent likelihood of developing T1D in the next five years.”

All three studies are placebo-con-trolled and double blinded, and all of the trials are still recruiting participants.

Oral Insulin TrialThe longest-running trial, which

launched in 2002, is the oral insulin trial. “We’re testing the hypothesis that if you deliver insulin by mouth you might make the body more tolerant of insulin and turn down the attack on the beta cells,” Rus-sell explained. He added the idea of taking insulin in a capsule form, which is broken down in the stomach, is that the body will view it more like food rather than as a for-eign substance to defend against.

“To qualify, one of the five antibod-ies tested positive for must be the antibody against insulin,” he noted. Russell added this trial is for those who still have normal glucose tolerance.

Half the patients receive the insulin capsule and half a placebo powder. Pa-tients are then followed until they develop diabetes. Russell said the trial’s endpoint will be when the statisticians, who are the only ones who know which patients are in the active arm, determine the oral in-sulin demonstrates a statistical difference in developing or delaying T1D … or not. However, he added, pilot human studies and mouse model studies have suggested oral insulin might make a difference in

delaying onset.

Abatacept TrialInclusion criteria for this trial include

the presence of at least two autoantibodies and a normal glucose tolerance. However, the potential participant cannot be posi-tive for the insulin autoantibody. In that case, the individual would be referred to the oral insulin trial.

The abatacept (brand name Oren-cia®) trial is the newest one for TrialNet and rolled out this summer. Also known as CTLA-4 Ig, abatacept was first approved by the Food and Drug Administration in 2005 for treatment of other autoimmune disorders, chiefly rheumatoid arthritis.

“It’s a molecule that has been en-gineered and blocks the activation of T lymphocytes … the T cells are the ones that do the dirty work,” Russell said of CTLA-4 Ig.

Because T cells are critical to those fighting certain viral diseases including HIV, hepatitis and Epstein-Barr, poten-tial participants are carefully screened for the presence of such conditions before being approved for the study. Safety labs and continual monitoring for diseases that compromise the immune system occur throughout the active portion of the trial.

Participants are given abatacept or placebo intravenously for 14 treatments over a year’s time. Those who pass the safety screens are given an infusion on the first day of their regimen, a second infu-sion two weeks later, a third one two weeks after that, and then monthly infusions for the balance of the year. After the active treatment phase is completed, participants are followed every six months with safety labs and an oral glucose test.

Russell said the trial design is a bit different for this arm of TrialNet. “In the abatacept study, we said, ‘Let’s not make diabetes our endpoint. Let’s make abnor-mal glucose tolerance our endpoint,’” he noted. “Once you have abnormal glucose tolerance, you have an 85 percent chance of progressing to type 1 diabetes within five years. This will shorten the duration of the study considerably,” Russell contin-ued of the surrogate marker.

Anti-CD3 mAB TrialThe third trial is for those who have

two autoantibodies of any kind and an abnormal glucose tolerance. In July 2011, Vanderbilt became the first to enroll a patient in the teplizumab TrialNet pre-vention study. However, Russell noted, the drug has been studied in conjunction with diabetes in other trials since the early 2000’s.

He added both abatacept and tepli-zumab have been used in active interven-tion trials for those newly diagnosed with T1D. “Both of these drugs have been shown to be effective at slowing down the further loss of beta cells even when the damage has been great enough to cause diabetes.”

Teplizumab, which is not currently on the market for any other medical dis-order, is a monoclonal antibody that at-

Preventing Type 1 Diabetes, continued from page 1



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What if a simple blood test could pro-vide information that your patient had a significantly elevated risk of developing diabetes within the next decade? What might that mean from the standpoint of early intervention and prevention? While it’s much too soon for this type of clinical application, researchers at the Vander-bilt Heart and Vascular Institute (VHVI) and Massachusetts General Hospital have identified a novel biomarker that lends it-self to such intriguing questions.

Led by Thomas J. Wang, MD, direc-tor of the Division of Cardiovascular Med-icine at Vanderbilt and physician-in-chief for VHVI, the team recently published re-sults of their discovery of elevated 2-aminoadipic acid (2-AAA) as a pre-cursor to diabetes in The Journal of Clinical Inves-tigation. Tapping into the rich data source of the Framingham Heart Study, which is now fol-lowing its third generation of participants, the Wang research team studied blood samples gathered more than a decade ago from 188 individuals who ultimately de-veloped type 2 diabetes and 188 who did not develop diabetes.

Using these blood samples, the in-

vestigators were able to compare levels of metabolites to see if there were any differ-ences between the group that went on to develop diabetes and the group who did not. Wang noted newer technology now makes it possible to profile hundreds of metabolites at one time.

“One of the things that really lit up when we looked at the people who devel-oped diabetes was 2-aminoadipic acid,” he said. “Having elevated levels of 2-AAA predicted risk above and beyond their blood sugar at baseline, their body weight, or other characteristics that put them at risk.” Wang added there doesn’t appear to be a specific threshold of risk at this point … the higher the levels of 2-AAA, the higher the risk of developing diabetes. In fact, those in the top quartile of 2-AAA concentrations had up to a fourfold risk of developing diabetes during the 12-year follow-up period compared to those in the lowest quartile.

Interestingly, the researchers found 2-AAA might not be just a passive marker. As part of the same study, the team con-ducted mouse model testing and discov-ered giving 2-AAA to the mice actually altered the way the animals metabolized glucose.

“It suggests the molecules might be playing a direct role in how the body pro-cesses glucose rather than being an inno-cent bystander in the process,” Wang said.

He added that elevated levels of 2-AAA don’t necessarily mean the molecule is bad for the body. Instead, it could be a defense mechanism where the body is producing higher levels to fight risk from another, as yet unknown, source.

Figuring out the metabolite’s exact role in the functioning of pancreatic cells is one area for future research. If, indeed, 2-AAA turns out to be a defense mecha-nism to stave off diabetes, the good news is that the metabolite could be given to humans in the form of nutritional supple-ments. On the other hand, if 2-AAA turns out to be harmful to the body’s glucose regulation system, further research could reveal methods to lower the metabolite’s presence.

Wang was quick to say the next step is to conduct additional research to mea-sure 2-AAA in other human populations outside of the Framingham study through both retrospective and prospective stud-ies. More in depth animal model studies are also in the pipeline. “A lot of the effort will be focused on trying to understand the biologic effect of 2-AAA in develop-ing diabetes,” he said of the work going forward.

However, Wang said the current re-search results at least raise the possibility

that somewhere in the future knowing how high a person’s circulating 2-AAA levels are could impact clinical practice by allowing providers to adopt a more ag-gressive intervention posture among those at highest risk, whether that be through exercise, weight loss or pharmacologic measures. It is conceivable that 2-AAA might be the type of red flag for diabetes that high cholesterol is for heart disease.

“Understanding why diabetes occurs and how it might be prevented is a very intense area of investigation because of the serious consequences of having the disease,” Wang said. “Down the road, this might be one part of the armamen-tarium of tests that could be considered. If this were proven useful in further studies and could be used clinically, it would be an easy test to administer.”

As for the impact of the findings right now, Wang added, “In 2013, it highlights a specific pathway that might be related to diabetes risk that we previously didn’t know about.”

Considering the prevalence of type 2 diabetes and growing obesity epidemic in the United States, that is an important lead for researchers working to develop strategies to interrupt the disease progres-sion and stop risk from becoming a reality.

Early Warning System: Researchers Identify Diabetes Risk Biomarker

Dr. Thomas J. Wang

taches to the CD3-epsilon chain that is expressed in mature T lymphocytes. The T lymphocytes monitor the destruction of the insulin-producing beta cells. The hy-pothesis is that teplizumab might modu-late the immune response by inhibiting unwanted beta cell destruction.

“This drug transiently depletes the recipient of T lymphocytes,” explained Russell, who added that potential partici-pants are closely screened for conditions that would make it dangerous for the par-ticipant to receive teplizumab.

For those who meet the screening cri-teria, half receive the anti-CD3 drug and half placebo in the form of 14 IV infusions

on 14 successive days. Because of the need to perform safety labs before each infusion and the time required for the treatment protocol, it isn’t unusual for these partici-pants to stay overnight in the clinical re-search center for two weeks.

The End Game“I explain to families that their par-

ticipation in a study may not prevent their family member from developing diabetes … but that they have an opportunity to be part of the solution so when their children become parents of the next generation, T1D may be eliminated,” Russell said. “That, to me, is the homerun … no more type 1.”

He continued, “I’ve been treating pa-tients for many years. My goal is to help put an end to type 1 diabetes in my life-time.” However, Russell added, he isn’t planning on slowing down any time soon. “I’ve got plenty of energy left for this.”

While he and TrialNet colleagues continue striving for the ‘homerun,’ Rus-sell is quick to admit that significantly de-laying the onset of T1D would be a big win, too.

“It would be a really, really good first step,” he concluded.

Preventing Type 1, continued from page 6

TrialNet at VanderbiltType 1 Diabetes TrialNet is

funded by the National Institutes of Health. For more information about TrialNet and the international consortium, contact the Vanderbilt team or visit the website.

By Phone: (888) 884-8638By Email: diabetesresearch@

vanderbilt.eduBy Website: www.

vanderbiltdiabetesresearch.com


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By CINDy SANDERS

As if trying to manage diabetes isn’t diffi cult enough, patients and physicians must also be alert to the comorbid condi-tions that, if left unchecked, can be as dan-gerous and deadly as the primary diagnosis.

Michael G. Carlson, MD, FACE, a board-certifi ed endocrinologist with the Frist Clinic, said physicians … both pri-mary care providers and specialists … must be aware of the numerous complications associated with diabetes and look for red fl ags that can signal a looming issue.

Retinopathy, ne-phropathy and neuropa-thy are three of the key comorbidities that plague patients who have a diffi cult time with glucose control. “High blood sugar, over time, damages the eyes, the kidneys and the nerve endings,” said Carlson.

The vascular damage to the venules, capillaries and arterioles in patients with diabetes has long been documented. In a 1954 presentation during the American Medical Association annual meeting, How-ard F. Root, MD, of Boston; William H. Pote, Jr., MD, of Los Angeles; and Hans Frehner, MD, of Switzerland used the term “triopathy” to describe diabetic patients

who fi rst showed clinical evidence of neu-ropathy, then diabetic retinitis and fi nally, nephropathy.

Carlson said there are some new treat-ments for the various conditions. For ex-ample, intraocular injections of Avastin®

(bevacizumab) are a relatively new option for the treatment of diabetic retinopathy. “Ophthalmologists can now inject medi-cine into the eye to control the formation of fragile blood vessels that can leak or bleed and lead to a detached retina or blind-ness,” Carlson said of the anti-angiogenic therapy fi rst used in certain cancers to con-trol blood vessels in tumors by blocking the VEGF (vascular endothelial growth factor) protein.

With nephropathy, he continued, “High glucose damages the part of the kid-ney that fi lters the waste products.”

Two classes of medications used to control blood pressure — angiotensin-con-verting enzyme (ACE) inhibitors and an-giotensin receptor blockers (ARBs) — have both been shown in clinical studies to pre-vent or slow progression in those with early renal disease. Carlson said it is important for primary care providers and endocrinol-ogists to be aware of even slight elevations in a diabetic patient’s blood pressure and to routinely check for albumin in the urine. In addition to kidney disease, those with dia-betes have a signifi cantly elevated risk for hypertension and cardiovascular disease.

Carlson said with diabetic neuropa-thy, “The typical early symptoms would be numbness or tingling in the feet. It typically starts in the feet and moves up the legs. Less commonly it affects the hands. He added patients might feel the occasional sharp pain and are at increased risk of develop-ing ulcers that can be diffi cult to heal.

He continued, “Diabetic neuropathy is the most common complication of dia-betes. About half of all diabetics will go on to develop diabetic neuropathy.”

However, Carlson continued, only a small portion of those patients progress to painful diabetic neuropathy. For those who do, a number of medicines are used to con-trol the pain including antidepressants and anti-seizure medications such as Lyrica® (pregabalin) and Neurotin® (gabapentin). Carlson noted a high potency B-complex vitamin preparation, Metanx, is another possible therapy. “It can heal some of the nerve damage and improve sensation in the feet,” he explained.

However, Carlson stressed, at every turn the best option is glucose control. Unfortunately, he said, too many patients don’t truly understand how diet impacts their diabetes.

“Many people think that if they just avoid sugar, that’s what they need to do. We stress to them it’s carbohydrates that need to be looked at in general,” Carlson said.

“The main issue that we see that is overlooked by primary care providers is referring them (newly-diagnosed diabetic patients) for nutrition counseling,” he con-tinued. “Following a healthier diet plan is half the battle in controlling diabetes.” Carlson added it is also extremely benefi -cial for patients to see a certifi ed diabetes educator to learn as much as possible about the disease.

Of course the fi rst step in controlling diabetes is to be aware that you have it. “We can certainly do a better job of screen-ing people at risk to allow early interven-tion to prevent complications,” Carlson concluded.

InCharge HealtHCare 2013

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Nashville is a city where thought leaders are always willing to make strategic moves, groom the next generation of leaders, and help ensure our city’s

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In December 2013, the 2014 edition of InCharge Healthcare will showcase theleaders who have risen to the top of one of Nashville’s most lucrative industries.This is Nashville’s resource guide for who’s who in the healthcare sector and provides a strategic opportunity for your brand to align itself among the healthcare elite who subscribe to Nashville Medical News.

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Ads due: Friday, November 15Materials due: Wednesday, November 20

Controlling Diabetic Comorbidities

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DIABETES AND CLINICAL PRACTICE: YESTERDAY, TODAY, TOMORROW

Andrea Hayes MD

November, deemed “National Diabetes Month,” is a perfect time to examine diabetes as both a national and local healthcare crisis. It is also apropos to review advances in treatment options and our understanding of this complex disease state.

In 2010 The Institute for Alternative Futures was commissioned to model the spread of diabetes over the next 15 years.Current and future trends were examined nationally and on a state-by-state basis. This model estimates that by the year 2025, the number of people in the United States living with diabetes will increase 64 percent from a total of 32.3 million today to 53.1 million. These are staggering statistics to say the least. Tennessee boasted a 15 percent prevalence of diabetes in 2010 affecting nearly 1 million lives and costing our local economy $8.2 billion. Estimates of currents trends predict a 40 percent increase by 2025 leading to a total of 1.3 million affected Tennesseans.

For those of us involved in diabetes care, the above statistics certainly bode well for job security. Although this spiralingepidemic appears quite dismal, we now have a vast armamentarium of treatment options for this common disease state. We have certainly come a long way from the days of Banting and Best who so eloquently discovered insulin thanks to theisolation of insulin-producing beta cells from a dog named Marjorie. I have witnessed the explosion of new pharmaceutical agents and technology over the last 20 years (I can’t believe I am that old!). As I started my fellowship at Vanderbilt, our “tools” for the treatment of diabetes included cumbersome insulins and sulfonylureas. Metformin represented the new “blockbuster” drug introduced to market after having been available in Europe for many years. When I developed Type 1 diabetes at the tender age of 15, blood glucose monitoring was not even available thus necessitating the use of such crude technology as urine glucose dipsticks!

Well, today, we have available pharmaceutical agents aimed at treating many of the underlying metabolic defects that occur in diabetes including insulin resistance, insulin deficiency, unrestrained hepatic glucose output, the intestinal incretin system, fat metabolism, glucose absorption, gastric emptying, satiety, and urine glucose excretion … just to name a few. Some of these newer drugs have distinct advantages with regards to weight control, hypoglycemia, beta cell preservation and durability. Available insulin analogs have been engineered to more closely mimic normal physiologic insulin secretion so that we now have insulins that treat both prandial and basal needs thus mitigating the risk of dangerous hypoglycemia. Each patient must, of course, be treated individually taking into account many factors such as age, BMI, co-morbidities, acceptance, and A1C, not to mention COST and formulary availability.

Further emphasizing the technology front, we now have vastly improved insulin pump technology as well as “continuous glucose monitoring” devices (CGMS). CGMSallows for a small cannula to be placed in subcutaneous tissue thus measuring levels of glucose in the interstitial fluid. The data is transmitted to a hand held receiver, and a new glucose measurement occurs every 5 minutes. Imagine how many finger sticks it would take to measure this many values! High and low blood sugar settings will provoke the device to alarm, allowing the patient to respond quickly to blood glucose trends. This information is downloaded and the data presented in most any fashion one couldpossibly imagine. Of course, the utility of this information is dependent upon accurate patient data entry including carbohydrate intake, exercise, and medicationadministration.

Now, turning to the challenge of outpatient medicine, I find myself frequentlyfraternizing with other clinicians regarding their unique experiences in both the clinical and administrative aspects of running a practice. A common challenge that many physicians face is the implementation of electronic medical record (EMR) technology. I keenly remember the painful six months that ensued after purchasing and implementing our EMR in 2004. It was hard to imagine at the time that this technology would ever be my friend. But I am now happy to report that this toolallows much greater ease in charting, coding, billing, documentation and dataanalysis. As our patient outcome data lies shyly in the future as our link between a grade of a job well done and our financial remuneration, we must all get comfortable quickly with the idea of reporting our numbers. I am pleased to report that I have not laid eyes on a paper chart in years, and our days of dictation, searching for lost charts and crinkled sticky notes are a distant memory.

I have long believed in the idea of “physician extenders” as a vital component to the treatment of patients with chronic disease states such as diabetes. A physician can quickly grow weary in trying to treat a large number of patients single handedly. Lack of job satisfaction and waning personal reward are natural consequences of this physician-centric approach. So the days of a patient seeing “the doctor” every time he or she visits a medical facility are over. Maybe the traditionalists do not agree

with this concept, but in the field of diabetes, where the number of practicing endocrinologists is rapidly dwindling, I find that having well trained, energetic nursepractitioners allows me to treat a much larger population of patients than I could ever see alone. Embracing the realities of cultural diversity, I am thrilled that one of my NPs speaks fluent Spanish, as this alleviates my need to speak very loudly and perform sign language. As I represent an example of a nearly extinct species, that of a solo practitioner, I am comforted by the fact that I am not really “solo” at all.

Attesting to another lesson learned, after having experienced the devastation of employee embezzlement, I have transformed my previous persona of indifference to thefinancial aspects of running a practice to one who meticulously analyzes excel spreadsheets and bank accounts on a daily basis. I have made it my goal to becoming a diligent bookkeeper/financial analyst/accountant/detective in my spare time! I fully believe that we, as physicians, should be as familiar with QuickBooks as we are with our patient’s A1Cs.

The most successful practices will be those whose physicians embrace technology and take a “hands-on” approach to the administrative aspects of office management. We must dismiss the days when all any of us ever wanted to do was “practice medicine!”

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Hayes Endocrine and Diabetes Center501 28th Avenue North, Nashville, TN 37209 • 615-320-1620

Dr. Hayes welcomes new patients with diabetes, thyroid disease and other endocrine disorders.


MGMA Reports Costs, Revenues Higher with PCMH

According to the Medical Group Management Association’s Cost Survey for Primary Care Practices: 2013 Report Based on 2012 Data, practices adopting the patient-centered medical home (PCMH) model incurred higher costs but also enjoyed higher revenues.

In comparison to practices that that were not operating as a PCMH, those that embraced the delivery care model saw an increase in operating costs per patient but also reported higher total medical revenue per patient. The median total operating cost per patient in a PCMH practice was $245.79. In the non-PCMH practice, the cost came in at $177.11 per patient.

The national survey, which included data on 969 groups, found increased per-patient cost were due, in part, to the greater number of staff and providers required to optimize the delivery model. PCMH’s reported a median of 29 total full-time-equivalent (FTE) support staff per 10,000 patients compared to 18.5 FTE support staff per 10,000 patients in non-PCMH practices. Similarly, PCMH practices also reported a higher number of FTE providers. Increased costs of medi-cal equipment and supplies also added to costs in the PCMH practice.

“It’s possible to be truly patient-centered in any model of delivering care,” said Susan L. Turney, MD, MS, FACMPE, FACP, president and CEO of MGMA-ACMPE. “Re-gardless of model, it re-quires a proper structure and foundation — the right providers and staff — to truly provide quality and cost-effec-tive care to patients.”

She continued, “It’s encouraging that physician practices are working to care and support their patients in new and in-novative ways, even if it means a greater investment up front.”

Turney added it’s heartening that doing what is best for the patient remains a top priority even in an environment of fiscal uncertainty.

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These same AGI thresholds of ATRA also trigger a 20 percent top capital gain rate applicable to qualified dividend in-come and gain on the sale of capital as-sets for individuals. This rate had been 15 percent for the past decade. It should be noted that this 20 percent top rate does not include the new 3.8 percent Medicare tax on unearned income, as explained below.

In recent years phase-outs of item-ized deductions and personal exemptions haven’t been a concern. For 2013 and beyond, these rules have resurfaced for individuals with AGI over $250,000 and married couples with AGI over $300,000. These limitations can reduce otherwise al-lowable itemized deductions by up to 80 percent of their face amount.

ACA New TaxesIn addition to the new rates out-

lined above, individuals with AGI over $200,000 and married couples with AGI over $250,000 should also expect a new 3.8 percent Medicare tax on unearned in-come and an additional 0.9 percent tax on earned income.

The new 3.8 percent Medicare tax on unearned income will apply to the lesser of your “net investment income” (NII) or your AGI over the appropriate threshold amount. Generally, interest, dividends, annuities, royalties, rents and capital gains are all considered NII and are subject to this tax. Income from a passive, flow-through entity is also subject to the new NII tax. Thankfully, there are exceptions for tax-exempt bond interest and distri-butions from qualified retirement plans. But, taxable distributions from retirement plans do serve to drive up your AGI that could cause you to be subject to this tax.

The additional 0.9 percent Medicare tax on earned income applies to wages and self-employment income of taxpayers in excess of the $200,000/$250,000 thresh-olds noted above.

Year-end Tax Planning Strategies

As you can see from the various threshold amounts noted above, the days of tax planners being able to “roughly esti-mate” clients’ tax liabilities are over. With calculations for regular tax, alternative minimum tax, net investment income tax and the additional Medicare tax, there are at least four separate but interdependent calculations to be made to determine a tax-payer’s tax liability.

In order to minimize current year tax liability, most tax planning revolves around opportunities to defer income and accelerate deductions.

One of the simplest ways for individu-als to defer income is through contribu-tions to qualified retirement accounts. Workers are allowed to defer up to $17,500 through a 401(k) for 2013. Those over 50 can contribute an additional $5,500 catch-up amount.

If you’re a healthy individual, con-sider a high deductible health plan that al-lows for tax deductible contributions to a related health savings account (HSA). Indi-viduals can contribute up to $3,250 annu-ally and up to $6,450 for family coverage. Individuals age 55 or older can contribute an additional $1,000. Unused amounts left in an HSA account can accumulate and grow on a tax-free basis if ultimately used for qualified medical expenses.

While itemized deductions of high-income taxpayers may be phased out, opportunity exists for others to “bunch” multi-year deductions within the same tax year. This strategy can be used for:

• Two years of property tax. • an extra payment on home mort-

gage to get additional mortgage interest, and

• grouping of charitable contributions.Also, don’t miss the opportunity to

use expiring tax breaks. While Congress could extend these options, it is uncertain whether or not they will do so.

For individual taxpayers, the option to deduct state and local sales and use taxes (instead of state and local income taxes) is set to expire at the end of 2013. If you know you’re going to make a major purchase in the next few months — a boat or new car for example — it would be wise to do so before year-end to lock in this expiring de-duction.

Likewise, individuals age 70-½ or older have the option to make tax-free dis-tributions from their IRAs for charitable purposes. This option is also set to expire at the end of 2013. Individuals who buy qualified small business stock before Jan. 1, 2014 will be able to exclude 100 percent of the gain on the sale if they hold the stock for more than five years. This exclusion is also set to expire unless Congress acts.

Business owners should: • Look for opportunities to maximize

accelerated depreciation allowances for tax purposes. The Section 179 expensing elec-tion allows for current deduction of up to $500,000 of fixed asset additions. Bonus de-preciation remains allowable at 50 percent for newly manufactured business property.

• Review their accounting methods to make sure income recognition is timed as late as possible and deductions are recog-nized as early as possible

• Consider whether a pension or profit-sharing plan may benefit both the business owner and employees.

We encourage taxpayers to make some estimation of their 2013 income and resulting tax before year-end so they are not surprised to see their liability next spring. While tax rates are going up and deductions are being limited, there is still time before year-end to take action and manage your 2013 tax liability.

Tax Planning with Rates on the Rise, continued from page 1

Jerry Moss is a member and David Lister is a tax manager with Nashville-based KraftCPAs PLLC. You may contact them via email: [email protected] or [email protected]

Dr. Susan L. Turney


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Meet Jeremy Conner 615.309.2217 (direct) / [email protected] Senior Manager – Accounting and Assurance Services

Jeremy, a Certified Public Accountant, has been practicing accounting for eleven years, the last eight years in public accounting. Jeremy has spent the last six years serving the healthcare industry and is a senior manager in the Accounting and Assurance practice. He manages a number of healthcare engagements, including profit and not-for-profit hospitals, behavioral hospitals, surgery and imaging centers, continuing care retirement communities, pathology labs, urinalysis providers, fertility clinics, pharmacy and home health care companies. Jeremy is a graduate of Belmont University, and obtained his Bachelor of Business Administration in accounting in 2000. He is also actively involved in the Tennessee Society of Certified Public Accountants (TSCPA)- Health Care Conference Committee Member, Kentucky Society of Certified Public Accountants, Nashville Health Care Council, Leadership Health Care and the University of Kentucky Alumni Association.

Britt Cumbie

By CINDy SANDERS

With shrinking margins, grow-ing demand for technology investment, mounting fines for regulatory missteps, and increasing expectations of pay-for-performance and coordinated care, it has become difficult for many hospitals to op-erate independently. For small community hospitals, ‘going it alone’ and ‘surviving’ are often mutually exclusive concepts.

Certainly the economies-of-scale mindset has been good for the multiple investor-owned hospital operations com-panies based in Middle Tennessee includ-ing HCA, Community Health Systems, RegionalCare Hospital Partners, IASIS, Ardent Health, Capella Healthcare, and LifePoint Hospitals. In fact, rumors began earlier this fall that the M&A trend might make Capella ripe for purchase by a larger hospital owner/operator … perhaps a nearby neighbor.

What’s good for the hospital com-panies is often good for the community hospitals, as well, depending on how agreements are laid out and whether or not the new partner is sensitive to the community’s needs, character and expec-tations. In the best scenarios, a struggling hospital doesn’t simply find a way to sur-

vive but actually to grow and flourish. Jeff Seraphine, president of Life-

Point Hospitals Eastern Group, said his company knows a thing or two about turn-ing around struggling hospitals. After all, the company was founded on that concept in 1999. With 23 underperform-ing hospitals in non-urban markets spun off from HCA, Seraphine said the first few years of LifePoint was fo-cused on honing the core strategies to re-vitalize the rural facilities … most of which were the only hospital in the community.

In the early years, Seraphine noted, “Our largest creation of value was helping those hospitals reach their full potential.” He continued, “What we do well is under-standing the needs in a non-urban hospital environment and creating value in those non-urban environments.”

Beginning with the mission of making communities healthier, LifePoint crafted five guiding principles: deliver high qual-ity patient care, support physicians, cre-ate excellent workplaces for employees, strengthen the hospital’s role in its com-munity and ensure fiscal responsibility.

Seraphine said the first four principles are what make the fifth one possible.

In the ensuing 14 years, LifePoint has almost tripled in size, growing from 23 hospitals to 60 facilities in three opera-tional groups across the nation by year’s end, pending approvals by state attorney generals on the company’s three latest acquisitions in Virginia and Michigan. Seraphine’s operational group covers Tennessee, North Carolina, Virginia and Michigan and includes the Duke LifePoint partnership.

Seraphine said it is getting harder for small hospitals to operate in isolation. “That’s one of the reasons we’ve seen an increased pace in mergers and acquisition activity,” he noted. “What we’ve been suc-cessful in doing is creating scale for them that they cannot create on their own.”

The list of requirements for finan-cial success is long and growing in an environment where the majority of reim-bursement still comes from fee-for-service activities but is shifting to value-based payments and population health. The fi-nancial health of a hospital is impacted by operational efficiency, meeting quality benchmarks, securing needed capital to invest in key growth areas, having the right medical staff in place to offer services, of-

fering those services in the appropriate set-ting, and avoiding federal penalties while taking advantage of incentives, among other functions.

Seraphine said it’s difficult for a small staff to effectively manage all the opera-tional issues that affect the bottom line. “Do they have the resources to enroll people in the health exchange? Do they have the resources to recruit physicians in an environment where physician supply is going down not up?” he questioned. In fact, he continued, today’s environment is challenging even for large hospital compa-nies and systems. “We’re having to create value and economies of scale from every direction we can,” he said.

He was quick to add it really is a mat-ter of scale and resources as opposed to a lack of understanding about the complex healthcare landscape for most non-urban facilities. “They’re looking out and saying, ‘We have a pretty good idea of where we need to go … and even how to get there, but we don’t have the necessary organi-zational resources, expertise and access to capital,’” Seraphine pointed out.

“They know they need to get more efficient, but they don’t have access to the subject matter resources,” Seraph-

Corporate Owners & Operators Help Rural Facilities, Small Hospitals Find Financial Security

Jeff Seraphine



13-378

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By CINDy SANDERS

To see something in a different light often requires a shift in perspective. David A. Williams, CPA, MPH, FHFMA, leader of healthcare reimburse-ment and advisory ser-vices for HORNE LLP, believes this certainly holds true for practices and facilities facing ever-increasing budget pressures.

Glass Half EmptyWilliams, a partner in HORNE’s

Ridgeland, Miss. office, noted for many healthcare providers, any incremental increase in revenue is eaten up by rising costs — from increased wages to higher prices for supplies to hikes in rent and utilities.

He pointed out that for hospitals, the largest revenue stream is for inpatient stays, and the largest single payer is Medi-care, which can represent from the low 40s to the high 60s in terms of percent-age of patients. “There has been a market basket update, but for the last couple of years, it’s been less than 2 percent,” he

said. Williams noted the government

puts in the full market basket update but then begins reducing the rate by looking at adjustments tied to value-based pur-chasing, readmission rates and acquired conditions, in addition to other factors. “Normally you’re seeing very minimal increases. It’s caused a flattening of rev-enue per patient,” he said. Then, Wil-liams continued, after payment increases are netted out, “Medicare is subject to a 2 percent reduction to fulfill the sequestra-tion order.”

He added that Medicaid, which typi-cally covers anywhere from 5-15 percent of patients … or higher depending on lo-cation and a hospital’s safety net status, is not currently subjected to sequestra-tion. Yet, he said, hospitals are faced with mounting concerns about Medicaid ex-pansion, uncompensated care, and cuts to disproportionate share hospital payments.

For hospitals in states that didn’t opt to expand Medicaid rolls, administrators are worried about rising levels of uncom-pensated care for those that fall into the gap in the Affordable Care Act between traditional Medicaid eligibility and quali-fying for federal subsidies on the health-care exchange. Even for providers who

are in states that did expand Medicaid, Williams said uncertainty still exists about how reimbursement will actually net out.

Traditionally, Medicaid has reim-bursed providers at a set match rate for direct patient services and a 50 percent rate for the administrative portion of the episode of care. Although the ACA Med-icaid expansion plan covers 100 percent of patient services for three years and then rolls down incrementally to 90 percent over subsequent years, the administrative match remains at 50 percent so the state does incur additional cost by expanding rolls. Additionally, Williams said certain provisions of the ACA require mandatory changes for states regardless of expan-sion, including: welcome mat population or those who were eligible for Medicaid but had not enrolled previously, foster children expansion to age 26, expanded eligibility for children, primary care phy-sician fee increase, and health insurer fee. In Mississippi, a non-expansion state, the estimated amount of the mandatory changes is between a $272 - $436 million increase in spending. With this amount of growth, the state is not expected to in-crease the reimbursement rate for a full episode of care.

Medicare DSH payments also are

causing administrators to lose sleep at night. Initially, the ACA plan called for a 75 percent reduction in Medicare DSH payments. However, Williams said part of the final regulation that went into ef-fect Oct. 1 of this year moderated that number a bit by moving to an empirical DSH payment for uncompensated costs … a complex, calculated cut that softens the blow some by looking at a hospital’s relative share of Medicaid inpatient uti-lization as a proxy for uncompensated patients.

Williams said that for one hospital in the Mississippi Delta, the original Medi-care DSH reduction would have meant a loss of $5.6 million. “But,” he continued, “because of the additional payment to fund the uncompensated cost, it was ac-tually a reduction of $2 million.” While that is still a significant loss, “It could have been worse,” Williams noted.

Still, he continued, “You’re faced with the fact your revenue isn’t growing as fast as your expenses. It’s very concern-ing to most every healthcare organization around.”

Glass Half FullSo if revenue isn’t going up, the logi-

Gaining Perspective on the Reimbursement Landscape: Glass Half Empty … or Half Full

David A. Williams



TreatmentTreatment of NETs is highly dependent on the overall biology of the tumor.3 A multidisciplinary approach is critical because of the complexity of their presentation. At Vanderbilt, multiple specialties contribute to the diagnosis and treatment of patients, including: • Surgery•Oncology• Endocrinology• Pathology•Gastroenterology

An important part of comprehensive care is symptom management. In general, surgical treatment with tumor resection and debulking is the frontline therapy for NETs. With more advanced disease or recurrence, resection is still indicated. Given theslow nature of these tumors, complications from the tumors can affect quality of life and can be well treated surgically.

Hormone therapy with somatostatin analogues still remains the foundation for managing neuroendocrine tumors. In addition to controlling symptoms such as the diarrhea and flushing from carcinoid, clinical data have shown these therapies to have anti-tumor effects such as slower growth in metastatic midgut carcinoid.4 Targeted chemotherapy is also an important treatment; two medications, everolimus and sunitinib, were approved in 2011 for the treatment of advanced pancreatic neuroendocrine tumors. For more aggressive high-grade neuroendocrine carcinoma, cytotoxic chemotherapy is still the frontline treatment.

For more local regional disease in the liver, embolization techniques are proving to be very effective. The growing field of interventional oncology encompasses the treatment of many types of malignancies, with NETs an important population. Radioembolization with 90Y microspheres is effective at controlling symptoms and can have some tumor growth effects. Bland and chemoembolization also have an important role.

An important new therapy in testing now is Peptide Receptor Radiotherapy(PRRT).A treatment first developed and administered in Europe, it uses thesomatostatin analogue octreotide and chelates a beta-emitting isotope, 177Lu, to deliver the radiation in a systemic but targeted fashion directly to tumors. This therapy is being evaluated in a multinational, randomized clinical trial, NETTER-1, for patients with metastatic, non-resectable midgut carcinoid. FourteencentersareparticipatingintheU.S.anditisopenhereatVanderbilt.

There are many new and exciting changes in the world of NETs. While the therapies are novel and interesting, the most important part of improving patient outcomes is still awareness and early diagnosis.

R E F E R ENC E S :1.Yao, J.C., et al.One hundred years after “carcinoid”: epidemiology of and prognostic factors forneuroendocrinetumorsin35,825casesintheUnitedStates.JournalofClinicalOncology:OfficialJournaloftheAmericanSocietyofClinicalOncology26,3063-3072(2008).

2.Vinik, A.I., et al. NANETS consensus guidelines for the diagnosis of neuroendocrine tumor.Pancreas39,713-734(2010).

3.Kunz, P.L., et al. Consensus guidelines for the management and treatment of neuroendocrinetumors.Pancreas42,557-577(2013).

4.Rinke,A.,etal.Placebo-controlled,double-blind,prospective, randomizedstudyon theeffectofoctreotide LAR in the control of tumor growth in patients with metastatic neuroendocrine midgut tumors:areportfromthePROMIDStudyGroup.JournalofClinicalOncology:OfficialJournaloftheAmericanSocietyofClinicalOncology27,4656-4663(2009).

Neuroendocrine tumors (NETs) are unusualmalignancies that most commonly arise from the respiratory and digestive tracts. The prevalence of the disease is higher than other more well-knownmalignancies (>100,000cases) in theU.S.with an incidence of 5/100,000.1 Unfortunately, neuroendocrinetumorscanbedifficulttodiagnoseand the average time of symptom onset to diagnosis ranges from 5-7 years.

NomenclaturePreviously,theterminologyofthediseasecausedafair amount of confusion. They went by the terms carcinoid, islet cell tumors, or APUDomas. Theterm neuroendocrine tumor is now the overarching name for most carcinoids originating from the luminal digestive tract and the lungs. Endocrine tumors of the pancreas are now called pancreatic neuroendocrine tumors.

PresentationOne of the most challenging aspects of neuro-endocrine tumors is the variety in presentation and the complexityof tumorbehavior.Manyof the tumors arehormonally activeand can produce classical syndromes such as carcinoid syndrome (flushing and diarrhea), Whipple’s Triad (hyperinsulinemia), Zollinger-Ellison Syndrome(gastrinoma),orWerner-MorrisonSyndrome(profusediarrheafromvasoactiveintestinalpeptidetumors).Clinicalsuspicionisthemostimportantelementofmaking the diagnosis. Frequently, biochemical markers are indicative of tumor activity.However,about50%ofthetumorsare“non-functional”inthesensethatthey do not produce any syndrome. They may cause subtle symptoms depending on their location, or be completely asymptomatic.

DiagnosisDiagnosisisthefirststepincaringforpatientswithNETs.2 Hormone and tumor markers are very useful, including: • ChromograninA• Pancreastatin• Gastrin• Insulin• Glucagon

Imaging and biopsy, however, are the cornerstones of diagnosis. Frequently, CT of the chest, abdomen or pelvis is enough to identify the disease, though depending on the site, special protocols may be required (e.g. triple phase liver orpancreasprotocol).

To definitively make the diagnosis, tissue biopsy must be performed. Fine needle aspirationmay be sufficient to provide a diagnosis, but core biopsy ismore informative as neuroendocrine tumors have a characteristic pathological appearance.MRIoftheliverwithhepaticenhancementisanespeciallyusefultoolindetectingsmalllesions.MRIissuperiortoCTbecausemanyneuroendocrinetumors can only be seen on CT with specific contrast enhanced phases that may not be routinely performed. Functional imaging of neuroendocrine tumors includesOctreoscan,aSPECT-basedimagingtestthatisspecificforsomatostatinreceptor expressing neuroendocrine tumors.

ThenextgenerationoffunctionalimagingforneuroendocrinetumorswillbePETbased.Vanderbiltwasthefirstcentertointroducetheuseof68Ga-DOTATATEPET/CTimagingofNETstotheU.S.(Figure).Thestudyhasimprovedsensitivityand resolution. We are currently working with other centers to provide this advanced imaging to patients across the country and developing a multi-center clinical trial.

Best Practices

Neuroendocrine and Carcinoid TumorsBy Eric H. Liu, M.D., FACS

All source data for this article has been provided by

Evidence-Based Standards of Care

• Interventionalradiology• Pulmonology• Radiology• Nuclearmedicine• Nursing

• ACTH• 5-HIAA• Serotonin• Pancreaticpolypeptide

Figure – Two images of the same patient with metastatic neuroendocrine tumor with Octreoscan

(left) and 68Ga-DOTATATE PET/CT (right)


ine continued. “So they spend signifi cant resources to hire consultants, and when those consultants walk out the door, the knowledge goes with them.”

Having access to the 10,000-foot view is a huge value. Companies like LifePoint, CHS, Ardent and others have the benefi t of fi rsthand knowledge of what will work … or not work … in a struggling facility in a small Midwestern town because they have experience with 30 other similar facili-ties. “We have the resources to create data-driven strategic plans and the resources to

execute them,” Seraphine pointed out. Going back to his company’s guid-

ing principles, Seraphine said LifePoint’s attention immediately goes to four areas when partnering with a new hospital. First, he noted, attention is given to qual-ity and service lines to meet the expecta-tions of patients, payers, providers and the community. Next is building an infra-structure for effective collaboration and to manage a growing employee/physician enterprise. Equally important is allocat-ing resources for operational effi ciency

Corporate Owners & Operators Help Rural Facilities, continued from page 11

From the Provider PerspectiveThe Benefi t of Being Part of a Big Family

By CINDY SANDERS

Small pond, big ripples.As CEO of HighPoint Health System, part of LifePoint Hospitals, Susan

Peach, RN, MBA, has the interesting viewpoint of operating both suburban and rural facilities. She has oversight of four hospitals, home health and hospice services, and a number of outpatient facilities spanning several counties in Middle Tennessee. The fl agship hospital in the system is the 155-bed Sumner Regional Medical Center in Gallatin, part of the Nashville MSA. Livingston Regional Hospital near Cookeville just came under the HighPoint umbrella last month, and the system is rounded out by two critical access hospitals in Trousdale and Smith counties.

“There are some similarities in the challenges they face, and then there are some pretty big differences between the smaller and larger hospitals,” Peach noted. Bigger facilities, she continued, are better able to weather the ebb and fl ow of patient volumes and staffi ng that can throw a wrench into operations in smaller facilities.

It’s also harder to weather fi nancial storms. Over the past few years, Peach said hospitals of all sizes have faced an escalating rate of bad debt and increased number of denials from payers. “Bad debt is a signifi cant problem for all hospitals, but a bigger problem for smaller hospitals because their margins are so tight,” Peach said.

The bad debt, she noted, comes from two buckets — those with no health coverage and those with coverage that comes with such high co-pays that the insured cannot cover the out-of-pocket cost. “The second one is rising at a faster rate. That’s the hidden secret that is overwhelming many families,” she added of the increasing fi nancial responsibility for individuals.

Payment denials can stem from a variety of issues ranging from poor documentation to a difference of opinion about clinical necessity. “We are writing off increasing numbers of bills where the payers … the insurers … are refusing to pay, and most of these are managed Medicare payers,” she said.

To combat the problem, Peach said hospitals are increasing functions that address payer criteria. “In almost all our facilities, we’ve added nurses with case management experience in our Emergency Room. They work with the physicians to make sure the documentation meets the requirements,” she said.

“There’s an enormous value in being part of a larger system,” Peach continued. She said the LifePoint Hospital Support Center provides resources that might otherwise be out of reach … at least in an affordable manner. Tapping into expertise on health reform, case management, technology, and marketing can help minimize the fi nancial hits. Legal and regulatory advice is also critical to avoid fi nes and penalties.

For all the supports available from LifePoint, Peach noted, “Probably the one I rely on the most is the support we get from our strategy group.” She noted the demographic information, usage patterns and population trends are invaluable in planning growth.

Peach said benchmarking data and survey information is also key to growing the bottom line. She noted patient satisfaction scores will begin playing into reimbursement rates next year. In addition to that overt impact, quality and satisfaction also play a subtler role in future income.

Peach said in a series of focus groups and studies from last year, they found a patient’s experience in the Emergency Room determined whether or not that person would use or recommend the hospital later for other services.

“Door to doctor … we have a 15 minute promise,” she said of cutting ER wait times. By eliminating non-essential steps and conducting some registration functions in the room while the doctor has begun the patient exam, Sumner Regional has sustained their short wait time for more than 18 months. Peach said the process is now beginning at Livingston and launching in the critical access hospitals in early 2014.

“It took a lot of culture change because our staff grew up thinking all those steps were necessary, but now they wouldn’t do it any other way. Our Emergency Room volume is up signifi cantly over the last three years. Our volume is up almost 30 percent … so that’s how it impacts the bottom line,” she stated.

Susan Peach

and growth. Fourth is truly becoming part of the

community and investing in it. “We make these commitments on the front end, and they know we’re going to invest in their communities,” Seraphine said. “We feel healthcare is local.” By becoming part of

the community, he noted, “We create hos-pitals where patients want to go for care, where physicians want to practice and where employees want to go to work.”

He concluded, “When we do all the things we’ve talked about, we fi nd the fi -nancial results come with that.”

cal place to increase margins is to decrease costs. Yet, healthcare providers want to make sure they provide the best care pos-sible without sacrifi cing a patient’s well being simply to save a few dollars.

“A lot of people equate higher quality with higher cost, but that’s not necessar-ily true,” Williams pointed out. In fact, he said, doing the right thing in the right way is often signifi cantly more cost effi cient.

“A major cost in providing care to patients is variation in the clinical process of care,” Williams said. He added it is easy to fi nd real world examples of this type of variation where one hospital’s cost for an average hip replacement is $45,000, yet another one might have an average cost of $22,000. “What’s the disconnect?” he asked of the two cost scenarios. “A lack of standardization of using evidence-based protocols,” he answered.

By using data available through elec-tronic health records coupled with a part-nership with technology company Health Catalyst, Williams said HORNE is able to mine the available information to look at clinical pathways and search out de-viation from standard protocols that adds to the cost of care. He was quick to add that the technology doesn’t seek to stop physicians from exercising their medical judgment but does highlight where there are outliers when it comes to following clinical protocols. “Best practices and ev-idence-based medicine say that these are the best protocols out there,” he pointed out.

Following those protocols not only saves money, but also should optimize quality. With increased transparency, payers and patients will have access to information regarding those positive out-comes and lower costs, which could ulti-mately drive volume.

A Foot in Both BoatsAdministrators and chief fi nancial

offi cers are caught between the fee-for-service and value-based payment worlds right now. Williams said they are trying to keep their heads above water in the current payment system … and now re-imbursement experts want them to shift their focus to population management. Although making the move is understand-ably frustrating, Williams believes it is also the best option to ultimately improve the bottom line.

“There has to be a change in cul-ture from what it’s been in the past,” he noted. “We tell them, ‘Let’s prepare for it by being the most effi cient, effective deliverer of care and eliminating patient waste.’ That puts you in a competitive ad-vantage over those providers that have a higher cost structure.”

It is a different mindset, Williams continued, to stop attacking reimburse-ment from the top and instead improve revenue by cutting costs. “If you deliver high quality at a lower cost, then your margins are going to be greater. We see opportunities,” he concluded.

Gaining Perspective, continued from page 13

Nov. 23-24 • Total Health Fest • A Game Sportsplex • 11 am-7 pm

Nashville’s fi rst annual Total Health Fest sets the stage for a healthy holiday season. Focused on health, fi tness and wellness, the expo will feature the latest information on get-ting – and staying –healthy and happy. Attendees of all ages, from toddlers to seniors, will be able to interact with expert exhibitors to learn more about fi tness, health and wellness services. The event also offers activities for the whole family – a toddler zone, ice skating, fi tness sessions, basketball, volley-ball and football throwing contests and laser chase. Proceeds benefi t the local Alzheimer’s Association chapter. Tickets are $10 at door, $7 advance; children under 10 and senior are free. www.totalhealthfest-nashville.com.

Dec. 3-4 • TAMHO Annual Conference • Embassy Suites Hotel & Convention Center • Murfreesboro

The Tennessee Association of Mental Health Organizations will host its an-nual meeting next month with a focus on integrated care. Regional and national keynote speakers will address the growing healthcare delivery model. Providers and administrators from all healthcare disciplines are welcome to attend. For information and registration, www.tamho.org.

ting – and staying –healthy and happy. Attendees of all ages, from


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By CINDy SANDERS

Most innovators don’t want to be put in a box … unless of course it’s Healthbox.

Launched in Chicago in January 2012 by founder and CEO Nina Nashif, this business accelerator, which is focused on healthcare technology and technology-enabled companies, quickly differentiated itself from other incubators and accel-erators. Nashif, who was named a ‘2013 Young Global Leader’ by the World Eco-nomic Forum, envisioned a collaborative environment to help nurture healthcare entrepreneurs with ideas to address some of the industry’s most vexing challenges.

“Traditionally, accelerators have been focused on companies that fi t into that unique stage of development — post-prototype development and pre-seed funding,” Nashif noted. “As we continue conversations in the market though, we realize that innovative providers want to source and collaborate with the best solutions overall … regardless of funding and revenue,” she continued of Healthbox’s decision to accept companies at varying stages of devel-opment into the four-month program.

In less than two years, Healthbox has launched seven accelerator programs — two in Chicago (the second one rolling out this month); two in Boston; London; Jacksonville, Fla.; and Nashville. In each community, Healthbox has reached out to members of the established industry to form strategic partnerships and tap into expertise to help their portfolio companies achieve rapid development and growth. In Nashville, those strategic community partners are BlueCross BlueShield of Ten-nessee, HCA, the Entrepreneur Center and the Nashville Health Care Council.

“We started out knowing entrepre-neurs needed funding, as well as knowl-edge, to carve out a space in healthcare,” Amy Len explained of the initial purpose behind launching the accelerators. Len, a company director who leads operations for Healthbox Nashville, continued, “But then we quickly realized it’s a dual mis-sion. The second part of our mission is really to bring industry partners together into a collaborative ecosystem to enable and to support entrepreneurship.”

She added, “We’re really at a turning point in our industry. Innovation has al-ways been critical … now more than ever. Innovation is all well and good, but it’s re-ally hard to go it alone.”

Not only does Healthbox help nur-ture young portfolio companies but established community partners also ap-preciate and recognize the need to drive innovation through collaboration. From the large stack of applicants seeking to

be included in the Nashville accelerator, Healthbox and its local partners brought in more than two dozen startups for a panel of interviews before winnowing that group to the fi nal seven selected. While the local partners are on hand to support the growth and development of the young companies, the industry veterans also ap-preciate the mutually benefi cial relation-ship.

“It was a unique opportunity for us to sit at the same table with provid-ers and entrepreneurs to discuss ways to better healthcare delivery,” Sherri Zink, vice president of Medical Informatics for BCBST, said of the selection process. “We walked away with an increased un-derstanding of the needs and pain points of our counterparts in other industry seg-ments.” She added, “This initial collabo-ration is the start to leaders from across the continuum working in tandem, rather than in the traditional silos, to solve criti-cal challenges.”

In discussing the diffi cult task of nar-rowing the fi eld, Len noted, “First and foremost, we look for solutions that ad-dress key challenges in healthcare.” Then, she added, the panel looks for that some-thing extra … that “spark in the eyes” … that signifi es the entrepreneurs are pas-sionate about what they are doing and ca-pable of executing their visions. The third key is having a prototype. “We fi nd we can provide value if they are past the idea phase,” she said.

Len added Healthbox portfolio com-panies typically sit at the intersection of healthcare and technology. “That’s our sweet spot,” she said of the role technology plays in bringing about innovation across the healthcare spectrum.

Selection, of course, is just the fi rst step in the process for the portfolio com-panies. “The most intense portion of our relationship is the four months of the ac-celerator whey they are under one roof,” said Len. “But,” she continued, “that’s just phase one … we continue to work with the

companies to grow them post-program.”Success is measured by a number

of metrics. Len noted that in their other markets, the portfolio companies have been very successful in securing capital, with seven out of 10 companies that have actively sought outside funding receiving it. “We think of it as more than just fund-ing, though,” she said. “It’s about making a real difference. The Healthbox compa-nies, through their products and services, will touch a million lives in 2013.” Of

course, Len added with a laugh, the fund-ing is key, too.

Even after portfolio companies leave the accelerator, Healthbox continues to provide strategic guidance and advice, as well as to help entrepreneurs make valu-able connections. Market traction for the young companies is another indicator of the program’s success.

The seven Nashville portfolio com-panies (see box) are in the middle of their intensive accelerator experience leading up to Healthbox Nashville 2013 Innova-tion Day on Dec. 10. The event brings together innovators and investors as the accelerator companies prepare for the next phase of development.

Len certainly doesn’t think this fi rst Nashville program will be the last. “The entrepreneurial scene is rich and vibrant,” she said of the city and its well-established healthcare industry. “We think Nashville was a fantastic location for us. We do plan to grow our network, and we do plan to continue to establish our presence here.”

HealthcareEnterprise

Thinking Inside the BoxHealthbox Helps Entrepreneurs Build Sustainable Success

Entrepreneurs representing seven portfolio companies make up the Nashville Healthbox team. On the fi rst row, the innovators are pictured here with Healthbox CEO Nina Nashif (2nd from L), Healthbox Director Amy Len (2nd from R), and BCBST sponsor represen-tative David Criswell (far R).

Nina Nashif

The Nashville ClassHealthbox Selects Seven Companies for the Nashville Accelerator

On Sept. 19, Healthbox announced the companies selected for the four-month Nashville accelerator program. Although the “Nashville” class could be a bit misleading as companies in the local accelerator could originate anywhere, six of the seven selected companies are actually rooted in Middle Tennessee. The seventh company in the program came from Raleigh, N.C.

“We were extremely impressed with the applicant pool for this program. Many of them were already well connected within Nashville’s healthcare ecosystem and founded by seasoned professionals and serial entrepreneurs,” Nina Nashif, Healthbox founder and CEO, said in announcing the inaugural accelerator group.

Atlas Health: provides a cloud-based platform that helps HIT organizations launch new solutions and exchange data with partners while staying compliant with federal HIPAA and HITECH regulations.

Axial Healthcare: automates evidence-based decision support for chronic pain therapy to reduce variability in interventional procedures, opiate prescribing and spine surgeries.

Clariture: helps providers communicate the right message to the right person at the right time in order to drive patient volume, improve payer mix, and keep patients both loyal and healthy.

eClinic Healthcare: allows providers to use two-way video, voice and secure messaging to deliver consultative healthcare to their patients within a web-based and HIPAA-compliant environment.

Gema Touch: offers a patent-pending product linked to a cloud-based service that improves mobile patient engagement and remote monitoring.

PRSM Healthcare: features a seamless solution for managing gastroenterology patient follow-up, cancellation and no-show needs by identifying and engaging patients regarding follow-up care events.

Remedify: has created cloud-based software that takes the guesswork out of sterile processing at hospitals and surgery centers.


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6:30a.m.

already behind schedule6:30

already behind schedule6:30

Lunch Skipped.and a late-night urgent call

a downed computer server.

about the one thing your practice cannot heal ––

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By CINDy SANDERS

Established in 1938, the Tennessee Hospital Association has adopted the ta-gline “reinventing tomorrow’s healthcare every day for 75 years” as an ongoing theme for 2013.

Over the years, the staff of the THA might have had many days … often stretching into many months … to help members prepare for and implement change. However, in the face of industry-wide transformation, being nimble enough to reinvent the hospital’s role in healthcare delivery on a daily … if not hourly … basis has become the norm. Helping its mem-bership navigate the challenges that come with sweeping reform is a central theme of the programming at the THA Annual Meeting, held Oct. 31-Nov. 1 at Gaylord Opryland Resort and Convention Center.

“I’ve always said healthcare moves glacially, but we’re getting up to lighten-ing speed now,” THA President Craig Becker said with a rueful laugh. “It has been a tough road to hoe right now for our members.” Yet, Becker continued, he ulti-mately views the transformation process as ‘constructive deconstruction.’

Going into 2014, he continued, “Our number one issue is the Affordable Care Act and trying to get people enrolled …

not only the ones that are eligible through the federal exchange but to try to convince the gov-ernor and Legislature to expand TennCare to in-clude the poorest of the poor.”

Becker added there are approximately 500,000 Tennesseans who should be eligible for enrollment through the federal exchange. However, there are another 400,000 currently left out of coverage opportunities unless Gov. Haslam and the Centers for Medicare and Medicaid Services can come to an agree-ment about expanding TennCare rolls, and the Tennessee Legislature approves the plan.

“We’re having a hard time getting the Legislature to separate this from Obam-acare,” Becker said. However, he noted negotiations with CMS are ongoing, which he said was an encouraging sign.

“We’ve got $5.4 billion worth of cuts over 10 years under the Affordable Care Act,” Becker pointed out. Those cuts were more palatable when hospitals thought Medicaid rolls would be expanded. When the individual mandate was upheld but not the Medicaid expansion, anticipated coverage for large chunks of the popula-

tion evaporated. “I’m really concerned about my rural

hospitals. They don’t have the reserves some of the bigger hospitals do,” Becker said. However, he added no facility is im-mune to the looming financial stressors. Addressing the key point of coverage for the 400,000 left out, Becker stated, “If we don’t get it, some of our hospitals cannot make it. I guarantee that.”

Three hospitals have recently shut down operations in Tennessee. While two in West Tennessee probably had more to do with the number of facilities in comparison to the population, one in East Tennessee simply couldn’t make it in healthcare’s new financial reality. Scott County residents now have to go else-where for care. “The hospital was strug-gling. When the (ACA) cuts came, it was the death nail for them,” Becker said.

The Tennessee Hospital Association is also focused on the Tennessee Payment Reform Initiative, which is initially slated to be rolled out for the TennCare and state employee populations. Tennessee has received a CMS grant to transform the state’s healthcare payment system. While details are still being ironed out, the governor’s vision is to incentivize ‘quarter-backs’ (typically physicians) to provide the highest quality, least costly care. As part of

that plan, the quarterbacks would receive a bonus for sending patients to facilities with the best quality and lowest prices.

However, Becker said there are con-cerns arising from geographic location and from skewed price comparisons. He pointed out large academic medical cen-ters with high-cost service lines including trauma centers and burn units and other unusual expenses such as graduate medi-cal education cannot fairly be compared to community hospitals without those same factors. In areas with only one nearby hos-pital, referring patients to a facility farther away that has a better cost structure might not be feasible … or desirable … depend-ing on the urgency of the situation.

Becker noted, “Seventy-five percent of physicians admit to one hospital only so I’m not sure it makes a lot of sense. I’m not sure that this will change physician admitting patterns.” However, he contin-ued, the general consensus is that the plan will move forward so THA staff is prepar-ing for implementation while addressing their issues with government and provider stakeholders in an effort to design a work-able plan.

Despite any reservations about the plan’s mechanics, Becker applauded the general concept of shared information. “I

Tennessee Hospital AssociationReinventing Tomorrow’s Healthcare Every Day for 75 Years


Craig Becker


On Oct. 1, the federal Health Insurance Marketplace, commonly referred to as the health ex-change, offi cially opened for business. A new tool to help the uninsured get covered and those with insurance shop around to see if other options might better suit their needs, the exchange helps people meet the individual coverage man-date that is part of the Affordable Care Act.

With a few exceptions, most individu-als must have health coverage in 2014 or pay a fee. The penalty in 2014 is typically $95 per adult, $47.50 per child or 1 per-cent of a family’s income (whichever is higher). The fee for non-coverage will in-crease each year.

Major technical glitches have plagued the federal exchange since the launch. The president, who was clearly displeased by the website issues, reminded Americans they still have fi ve months to enroll. At press time, the administration had not changed the March 31, 2014 deadline for enroll-ing but did clarify that insurance coverage didn’t actually have to begin on that date as long as a person had completed the enroll-ment process by then.

To assist patients who turn to you as a healthcare provider or executive with questions about the Health Insurance Marketplace, the following is a synopsis of several resources and notes surrounding this new venture.

General NotesThe main online site for help is www.

healthcare.gov. Questions can also be answered via phone 24 hours a day by calling toll free 800-318-2596 (TTY: 855-889-4325). The ‘one page guide’ online is a quick primer with links to more detailed information.

There are fi ve types of plans:• Catastrophic: less than 60 percent of

the total average cost of care,• Bronze: 60 percent of the total aver-

age cost of care,• Silver: 70 percent of the total average

cost of care,• Gold: 80 percent of the total average

cost of care,• Platinum: 90 percent of the total av-

erage cost of care.

Signing Up in TennesseeTennessee did not opt to run a state-

wide exchange so individuals must use the federal marketplace. However, individuals will be asked to answer a few questions, including state and county, before being directed to plans specifi c to Tennessee.

There are four ways to apply:• Paper application, available to

download at the healthcare.gov site.• Online application, available at the

healthcare.gov site.• Phone application, available

through the toll free number.

think the more transparent and the more information you get in the hands of our physicians and hospitals, the better off we are,” he said.

While the immediate future brings many challenges, Becker said the message of the annual meeting is a hopeful one. “This is the constructive destruction of the health system as we knew it. It will be very different going forward.”

As for the THA’s role in helping hospitals shift to population manage-ment models, Becker succinctly noted, “It’s coming, and we’re here to help you do it.” He continued, “We’ve really put an increased emphasis on quality. We’ve put an increased emphasis on education and on sharing best practices and process improvement data. Our data is all geared toward giving transparent information to our members so they understand how they stack up against others.”

He added the THA has also been hands-on in helping hospitals help their

patients. In a move unique among hospi-tal associations, Becker said, “We actually took $3 million out of reserves and put it aside for grants for hospitals to enroll people in the exchange.”

He continued, “We touch 350,000 uninsured people every year in our emergency rooms.” Becker noted iden-tifying those who qualify for the federal exchanges and getting them covered is a win/win for families and facilities. Hos-pitals have until the end of November to apply for the grants.

“We’re excited to have a good oppor-tunity to give back to our members and hopefully help our hospitals get ahead of the curve in signing people up,” he said.

Despite the obvious pain points that come with transformational change, Becker and his staff are keeping an eye on the prize. “We’ll have a far better health-care system once we get to the other side,” he concluded.

Exchange News & Notes

THA’s New Board Chair

Before the fi nal bell sounds on the Tennessee Hospital Association’s 2013 annual meeting, an important transition of power will take place. Joe Landsman, president and CEO of the University of Tennessee Medical Center in Knoxville, will pass the gavel to new board chair Reginald Coopwood, MD, president and CEO of Regional Medical Center at Memphis.

A graduate of Meharry Medical College, Coopwood practiced in Nashville as a general surgeon and served as chief medical offi cer for Nashville General Hospital. In 2005, he was named CEO of the Metropolitan Nashville Hospital Authority. In March 2010, he made the move to Memphis to take the top position at The Med. In addition to his role with THA, Coopwood also serves on the boards of several nonprofi t organizations including March of Dimes, Leadership Academy, QSource and MidSouth eHealth Alliance.

Dr. Reginald Coopwood

Tennessee Hospital continued from page 18

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• In-person assistance, avail-able through navigators, state

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dates to help explain the exchanges and implications for hospitals. Go online to www.advisory.com/Research/Financial-

Leadership-Council.Baptist Healing Trust oversees “Get

Covered Tennessee,” a private collabo-ration to help uninsured Tennesseans understand and enroll in new healthcare coverage options. Information on Get Covered Tennessee, is available at http://healingtrust.org under the “Programs” tab.

The Tennessee Hospital Association provides information and links to out-reach and enrollment resources through the THA site at www.tha.com/?pid=150.

The Tennessee Medical Association offers a similar resource with the option to subscribe to health system reform news updates. The TMA site includes links to ad-ditional resources including “10 things pro-viders need to know” and “10 things to tell your patients” about the Health Insurance Marketplace. To access the information or signup for updates, go to www.tnmed.org/for-physicians/health-system-reform.

GrandRounds

Mid-Tennessee Bone and Joint Welcomes Dr. Cason Shirley

Mid-Tennessee Bone and Joint Clinic recently welcomed W. Cason Shirley, MD, to the prac-tice. He received degrees in biology and chemis-try from David Lipscomb University and his medical degree with highest hon-ors from the University of Tennessee Health Science Center. Shirley completed his orthopedic surgery residency at the University of Tennessee – Campbell Clinic in Memphis.

NHC-Tullahoma: Construction Complete, Opening Slated for Nov. 4

Construction is now complete on National HealthCare Corp.’s new skilled nursing facility in Tullahoma, and it is expected to open to residents on Nov. 4. The 90-bed skilled nursing and reha-bilitation facility, located on Cedar Lane in Tullahoma’s emerging medical zone, represents an $11 million investment by NHC and will employ approximately 100 people. Veteran administrator Jaine Colley, who has worked as a healthcare administrator for NHC since 1998, will serve as the center’s director.

Sumner Regional Adds Third Ob/GYN in 2013

Sumner Regional Medical Center (SRMC) recently announced Suzanna Chatterjee, MD, has joined the medical staff and will be offering obstetrics and gynecology services to patients through-out Gallatin and the surrounding commu-nities.

Chatterjee graduated from Vander-bilt University and attended medical school at the Medical University of Lu-blin in Poland, where she was the class ambassador and a top fi ve student. She completed her residency at Oakwood Hospital and Medical Center in Dear-born, Mich.

Feather Takes AHA National Role

Nashvillian Paula Feather has been promoted to national program manager for Mission: Lifeline for the American Heart Associa-tion, directing the national effort to improve health-care system readiness and response to acute STEMI heart attacks, and improv-ing quality of care and pa-tient outcomes. Previously, she served as the program’s regional director for Tennessee and Mississippi.

Dr. W. Cason Shirley

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GrandRounds

New Imaging Tool Tracks Breast Cancer Therapy Effectiveness in Days

A group of Vanderbilt University re-searchers has used laser technology and a custom-built multiphoton microscope to distinguish breast cancer subtypes and determine if specific therapies are working against the cancer cells in as little as two days. The technology al-lows investigators to see how molecules “light up” through autofluorescence and to measure the molecules’ activity.

The study, led by Vanderbilt PhD candi-date Alex Walsh, was published in the AACR journal Cancer Research.

The new optical metabolic imaging (OMI) measures the metabolic activ-ity in cells. “By looking at the different ways the cells are metabolizing glu-cose we’ve been able to differentiate the different subtypes of breast cancer and also see how anticancer drugs are affecting the metabolism,” said Walsh, who works in the Department of Bio-medical Engineering.

The technology Walsh and her col-leagues used to study the metabolic ac-tivity of cells involved the multiphoton microscope and a titanium-sapphire laser. They used special filters to see the fluorescence emitted by two mol-ecules — NADH (nicotinamide adenine dinucleotide) and FAD (flavin adenine dinucleotide).

“NADH and FAD are molecules that are present in every cell in the body, and when these molecules are excited with laser light, electrons jump to higher

orbital levels,” said Walsh. “When they return to the normal states, instead of releasing the energy as heat, they emit fluorescent light.”

Using OMI, the investigators were able to capture images of cellular me-tabolism and to differentiate between estrogen receptor positive or negative breast cancer cells and HER2 positive or negative cells. The investigators also used the technology to test the effects of anti-HER2 therapy trastuzumab in breast cancer cell lines, then grew hu-man breast tumors in mice and treated some of the mice with trastuzumab. They were able to image the tumors in live mice and see a difference in re-sponse between trastuzumab-sensitive or resistant tumors as early as two days after the first dose of the cancer therapy.

TDH, Meharry Partner to Provide Dental Services

Tennessee Health Commissioner John Dreyzehner, MD, MPH, joined offi-cials from Meharry Medical College and other state and local officials on Oct. 22, for an open house at the Maury Coun-ty Health Department Dental Clinic in Columbia. TDH is partnering with the Meharry School of Dentistry to enhance provision of comprehensive dental care for children and targeted populations of uninsured adults at the facility and at the Montgomery County Health De-partment Dental Clinic in Clarksville.

Fourth-year students at the Meharry Medical College School of Dentistry in Nashville provide services in two-week rotations at the Maury clinic, as part of a new partnership with the college. Me-harry students are also serving rotations at the Montgomery County Health De-partment Dental Clinic in Clarksville.

Recent Certifications, Accreditations & Commendations

RJ Young Chief Financial Officer Sam Shallenberger recently earned the Certified Lease Professional (CLP) designation from the Certified Lease Professional Foundation. Shallenberger is now one of only 186 Certified Leasing Professionals worldwide.

Let’s Give Them Something to Talk About!Awards, Honors, Recognitions

Keith B. Churchwell, MD has been named president of the Ameri-can Heart Association’s Greater Southeast Affili-ate board of directors for the 2013-2014 fiscal year. Churchwell, the executive director and chief medical officer for the Vanderbilt Heart and Vascular Insti-tute, has been affiliated with the AHA for a decade and recent-ly served as president of the Greater Nashville board. The Greater Southeast Affiliate services the region covering

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Frank Knobbe, partner with LBMC Security & Risk Services, has been named a Fellow of the Information Sys-tems & Security Associa-tion.

Susan Alcorn, se-nior vice president with Jarrard Phillips Cate & Hancock, Inc. was announced as the re-cipient of the 2013 Award for Individual Professional Excellence from the Soci-ety for Healthcare Strategy & Market Development (SHSMD) of the American Hospital Association. SHSMD’s Award for Individual Professional Excellence is the highest honor the Society can be-stow on one of its members.

Gina Pruitt, CPA, CISA, CGMA, CRISC, CQA, CITP, the member in charge of KraftCPAs’ in-formation systems assur-ance and consulting prac-tice, has been appointed as a member of the Amer-ican Institute of Certified Public Accountants Board of Examiners (BOE) for the 2013-2014 term.

LBMC Technologies LLC has been selected for the 2013 Tennessee Excel-lence Award amongst all its peers and competitors by the Small Business In-stitute for Excellence in Commerce (SBIEC). The consulting firm has also been recognized as one of the top ac-counting technology value-added re-sellers (VAR) in North America in a spe-cial report from ACCOUNTING TODAY entitled VAR 100.

Wishes Granted

UnitedHealthcare has announced the company is providing $600,000 in support of Healthier Tennessee, the inaugural initiative of the Governor’s Foundation for Health and Wellness.

Lipscomb University’s School of TransformAging has been contracted by Princeton to provide technical as-sistance to the Bureau of TennCare through a grant from the Robert Wood Johnson Foundation as part of the state’s Quality Improvement in Long-Term Services and Supports (QUILTSS)

values-based purchasing initiative for nursing facility and home and commu-nity-based services.

Vanderbilt University Medical Center has received a five-year, $1.2 million grant from the National Insti-tutes of Health (NIH) to develop “bold and innovative approaches to broaden graduate and postdoctoral training.” Vanderbilt is one of 10 academic medi-cal centers in the country to receive “BEST” (Broadening Experiences in Scientific Training) grants from the NIH’s Common Fund, which has a goal of helping train U.S. scientists for today’s more diverse array of employment op-portunities. The Vanderbilt program is called ASPIRE (Augmenting Scholar Preparation and Integration with Re-search-Related Endeavors).

UnitedHealthcare Community Plan of Tennessee is allocating $1 mil-lion in grant funding to increase hous-ing options available for Tennesseans who suffer from mental illness. The funding will help support development of appropriate housing for people who need a place to live after having been discharged from a mental health facility. The Tennessee Department of Mental Health and Substance Abuse’s Creating Homes Initiative estimates that nearly 190,000 Tennesseans with mental illness are in need of some sort of housing as-sistance.

The Vanderbilt Vaccine Research Program (VVRP) has received a contract from the National Institutes of Health to continue its work as one of the nation’s Vaccine and Treatment Evaluation Units (VTEU). Vanderbilt is one of nine institu-tions that have the potential to receive funding up to $135 million per year from the National Institute of Allergy and In-fectious Diseases (NIAID), part of the NIH, over a seven-year period.

St. Thomas Medical Group Launches ACO PAC

St. Thomas Medical Group, a 28-phy-sician, multi-specialty practice, recently achieved Level 3 NCQA certification and has launched a Patient Advisory Council for their Accountable Care Organization. Seven patients from within the group will serve in advising STMG on its perfor-mance-improving activities and alignment with the ACO’s goals of delivering care in a safe, effective, efficient, patient-centered manner while preserving the dignity of

patients and their families at all times. The PAC will have an active role in the patient care experience by identifying opportuni-ties, gathering and sharing feedback and perspectives on plans and programming related to patient-centered health.

Elections were held at the inaugural meeting in late September. George Bo-swell was named chair; Gwen McKinney, co-chair; and Jane Boram, secretary. Mary Arnold, JoAnne Hill, Theresa Park and Barbara Hornal round out the PAC.

Huddleston Takes on Tech Council

Bryan Huddleston has been named president and CEO of the Nashville Technology Council. Hud-dleston, a technology veteran, has been with Microsoft Corporation for the past eight years in the Nashville office. Prior to that, he worked with Ingram Industries as a micro systems specialist.

NorthCrest Names New CEORandy Davis has been tapped to

lead NorthCrest Medical Center as president and chief exec-utive officer. He has been part of the senior leader-ship team at the Spring-field hospital since 2008, most recently serving as senior vice president and chief operating officer. He has also served as vice president and chief information officer.

Davis received his undergraduate degree from Vanderbilt and holds an MBA with a healthcare management concentration from Lipscomb Univer-sity. The hospital board selected Davis after a nationwide search.

GrandRounds

UNHS Opens New ClinicLast month, United Neighborhood

Health Services opened a new clinic in-side Casa Azafran Community Center. The new Unity Family Clinic, located on Nolensville Pike, will serve patients from the surrounding community including a diverse group of immigrants and refu-gees. The clinic is utilizing about 1,500 square feet of the community center and expects to serve close to 25 people a day.

Cutting the ribbon on Unity Family Clinic are: (L-R, front row) Mayor Dean, Renata Soto, UNHS CEO Mary Bufwack, Councilwoman Sandra Moore (L-R, back row) Rep. Jason Powell and Metro Health Director Dr. Bill Paul.

Gina Pruitt

Frank Knobbe

Bryan Huddleston

Randy Davis


TriStar StoneCrest Names Tyrer COO

Drew Tyrer has assumed the role of chief operating officer for TriStar Stone-Crest Medical Center in Smyrna.

Most recently, he served as associate chief operating officer of East-side Medical Center in Snellville, Ga. Tyrer earned his bachelor’s degree in sport administration from University of Dayton in Ohio and his master’s of sport administration from the University of Louisville in Kentucky. He later earned a master’s degree in healthcare administration and a mas-ter’s degree in business administration from Xavier University in Cincinnati, Ohio. He is also a graduate of HCA’s Chief Operating Officer Development Program.

HCA, Jason Foundation Partner to Prevent Youth Suicide

The Jason Foundation, Inc. (JFI), a youth suicide prevention and aware-ness organization, and Hospital Cor-poration of America (HCA) announced this fall that HCA has become a JFI National Community Affiliate and will establish Community Resource Centers at 10 hospitals that provide adolescent behavioral health services. The Com-munity Resource Centers will serve as hubs where parents, teachers, guidance counselors, students, churches and other community organizations can get educational materials and learn about training programs available through JFI. According to the Centers for Dis-ease Control and Prevention, suicide is the second-leading cause of death for youth between the ages of 10 and 24, resulting in approximately 4,800 lives lost each year.

Seebach Joins TriStar Southern Hills Medical Staff

Jeff Seebach, MD, has joined the medical team at TriStar Southern Hills Medical Center. The gen-eral surgeon received his medical degree from University of Kentucky College of Medicine in Lexington. He then com-pleted a general surgery residency at Walter Reed Army Medical Center in Washington, D.C. Seebach is board certified with the American Board of Surgery.

Amplion Taps Grant as New Chief Sales & Marketing Officer

Nashville-based Amplion Clinical Communications recently announced Frank Grant has been named chief sales and marketing officer. In his role, Grant will oversee the company’s sales, busi-ness development and marketing ef-forts. Grant brings more than 30 years of integrated sales and marketing expe-rience in the healthcare and technology industries, and has a strong history of growing businesses. Previously, Grant held the same position for Adreima, a Phoenix-based company providing rev-enue cycle and reimbursement services to hospitals. He also spent more than a decade with technology juggernaut, Cisco Systems.

Jeff Gould, who previously served in this position, has transitioned to chief strategy officer for Amplion.

McDonough Named Optimal Radiology CEO

Joe McDonough has been named CEO of Optimal Radiology, the national imaging company that moved its home office to Nashville from Birmingham this summer.

An industry veteran, McDonough

comes to Optimal having led Soteria Imaging Services from 2007 until ear-lier this year and before that working as president and CEO of IRG/American Imaging Management for four years. He takes the top spot at Optimal from Jon Grimes, who has moved over to lead the company’s business development efforts.

Aegis Adds TwoNashville-based Aegis Sciences

Corporation, a leading forensic toxicol-ogy and healthcare sciences laborato-ries, recently announced two additions to the team.

Adam Meyer, MD, has been named medical director, overseeing laboratory medicine operations, devel-opment, regulatory requirements, di-rect strategic operations of Aegis tech-nologies and applications, and assisting in client and management relations. Previously, he was a clinical pathology resident at Vanderbilt and before that at Saint Louis University (SLU) School of Medicine, where he worked in the forensic toxicology lab. Meyer received his medical degree from SLU and his master’s in organic chemistry from Washington University in Saint Louis.

Ali Roberts, PharmD, has joined the company as clinical scientist of healthcare services. She will assist in the growth of service lines by offering guidance on healthcare research and outcomes, answering pain manage-ment and toxicology-related questions that arise during patient treatment, and providing continuing education related to healthcare and drug testing practic-es. Previously, Roberts was a pharmacy resident at Memorial Hospital. She re-ceived her undergraduate degree in chemistry from Middle Tennessee State University and her pharmacy degree from Belmont University.

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Myers Takes the Helm at Corizon

Last month, officials with Brentwood-based corrections healthcare compa-ny Corizon announced Woodrow Myers, Jr., MD, has been named CEO. Since 2011, the physician has been a member of the board for Valitas, Corizon’s parent company.

Previously, he served as executive vice president and chief medical officer of WellPoint. Prior experience also includes a stint as director of healthcare management for Ford Motor Co. and as health commis-sioner for the city of New York and state of Indiana. Myers received his undergrad-uate degree from Stanford and medical degree from Harvard. He also holds an MBA from Stanford’s Graduate School of Business. He is a diplomat of the Ameri-can Board of Internal Medicine and Mas-ter in the American College of Physicians.

Burden Named VP Human Resources for TriStar Centennial

TriStar Centennial Medical Center recently announced Jennifer Burden has been named vice president of Human Resources. She joins the TriStar Centen-nial leadership team with over 20 years of human re-source experience. Burden has held positions within the discipline in the TriStar Health network since 2004, serving most recently as the vice president of human resources for TriStar Hendersonville Med-ical Center.

She earned her undergraduate de-gree from Belmont University and an-ticipates completion of her master’s of Professional Studies in Human Resources Leadership from Austin Peay State Uni-versity in May 2014.

Banick Named Market Medical Director for UnitedHealthcare

Paul D. Banick, MD, PhD, MBA has been named market medical director for UnitedHealthcare’s Mid-South Health Plan. He will provide leadership for shaping the benefits and services UnitedHealth-care provides to employer and individual health plan members in Arkansas and Tennessee.

Banick joined the company in 2008 as an associate medical director for Unit-edHealthcare Community Plan of Ten-nessee and most recently served as the inpatient medical director for Tennessee and Arkansas. He earned undergradu-ate degrees in chemistry and humani-ties from Villanova University, a medical degree and doctorate from Georgetown University, and an MBA from the Univer-sity of Tennessee, Knoxville.

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