VOL. 103, NO. 9 | OCTOBER 2010 Ask TM A: SpaBotox I njections Inactivty inTens Smoking Cesation

Volume 103, Number 9 + October 2010 President’s Comments

5 “It’s The Cost, Stupid!”—B W. Ruffner, Jr., MD, FACP CONTENTS Ask TMA

11 Are Medical Spas Violating the Practice of Medicine Statute with Botox Injections? Member News

15 UHG Settlement Claims Deadline; TMA Elections: How They Work; Online Membership Renewal; ICD-10 Transactions Testing; Claims Process Checkup in November; First EHR Certification Bodies Named; TMA Photo Gallery; Member Notes Practicing Medicine

31 Health System Improvement: Developing Regional Capacity across Tennessee—Jill D. Nault; James E. Bailey, MD, MPH, FACP 35 Loss Prevention Case of the Month—“My Stomach Hurts”—J. Kelley Avery, MD Special Feature 23 39 Saving Money on Supplies – A GPO Strategy—Kathy Spratt Cover Story The Journal Get Off the Couch! Tennessee Wages a Battle to Become a 41 Original Contribution—Correlates and Predictors of Physical Inac - Healthier State—Brenda Williams tivity among Tennessee Adults—Peter D. Hart, MA; Tiago V. Barreira, PhD; Minsoo Kang, PhD 45 Original Contribution—Smoking Cessation: Barriers to Success and 7 Readiness to Change—Alexander B. Guirguis, PharmD, BCPS; Editorial Shaunta’ M. Ray, PharmD, BCPS; Michelle M. Zingone, PharmD, Why Aren’t Doctors Allowed to Care about Money? BCPS, CDE; Anita Airee, PharmD, BCPS; Andrea S. Franks, PharmD, —David G. Gerkin, MD BCPS; Amy J. Keenum, PharmD, DO 37 For the Record Special Feature 50 TMA Alliance Report—Alliance Works to Help the Health of Tennessee—Gail Brabson Plan Your Steps to a Smooth ICD-10-CM Transition New Members —Ken Bradley 51 53 In Memoriam 54 Statement of Ownership; Advertisers in this Issue; WWW.TNMED.ORG Instructions for Authors Tennessee Medicine communications submitted to Tennessee Medicine Copyright 2010, Tennessee Medical Association. All Journal of the Tennessee Medical Association for publication. The author or communicant shall be material subject to this copyright appearing in (ISSN 1088-6222) held entirely responsible. Advertisers must conform Tennessee Medicine may be photocopied for noncom - Published monthly under the direction of the Board of to the policies and regulations established by the mercial scientific or educational use only. Trustees for members of the Tennessee Medical Board of Trustees of the Tennessee Medical Periodicals postage paid at Nashville, TN, and at Association, a nonprofit organization with a definite Association. additional mailing offices. membership for scientific and educational purposes, Subscriptions (nonmembers) $30 per year for US, devoted to the interests of the medical profession of $36 for Canada and foreign. Single copy $2.50. POSTMASTER: Send address changes to: Tennessee. Payment of Tennessee Medical Association member - Tennesssee Medicine This Association is not responsible for the authen - ship dues includes the subscription price of PO Box 120909, Nashville, TN 37212-0909 ticity of opinion or statements made by authors or in Tennessee Medicine. In Canada: Station A, PO Box 54, Windsor, Ontario N9A 6J5

President Office of Publication Editor Editorial Board B W. Ruffner, Jr., MD 2301 21st Avenue South David G. Gerkin, MD Loren Crown, MD Greg Phelps, MD PO Box 120909 James Ferguson, MD Bradley Smith, MD Chief Executive Officer Nashville, TN 37212-0909 Editor Emeritus Ronald Johnson, MD Jonathan Sowell, MD Donald H. Alexander, MPH Phone: (615) 385-2100 John B. Thomison, MD Robert D. Kirkpatrick, MD Jim Talmage, MD Sr. Vice President Fax (615) 312-1908 Managing Editor Karl Misulis, MD Russ Miller, CAE [email protected] Brenda Williams

Advertising Representative: Beth McDaniels – (615) 385-2100 or [email protected] Graphic Design: Aaron & Michelle Grayum / The Gray Umbrella PRESIDENT’S COMMENTS

“It’s The Cost, Stupid!” 1

By B W. Ruffner, Jr., MD, FACP President e have all heard that healthcare costs are going up ONE NEUTRAL ISSUE: W faster than growth of the economy. The article referred • Comparative Effectiveness Research. This effort began in to in my title is a summary of the reality that one way the stimulus bill last year and received substantial funding in or another, costs have to be controlled. The issue goes beyond the ACA. As a result of aggressive lobbying (including by the Medicare and TennCare. Employers respond to increasing premi - AMA) the Act explicitly states the research cannot focus on ums by buying policies that shift more of their cost to their em - the comparative cost of treatments and cannot be used for ployees. With wages stagnating, workers are unhappy about coverage decisions. Even without these restrictions it would covering the extra cost. probably take 10 years to plan, initiate, complete, interpret Even most liberals agree the Patient Protection and Affordable and incorporate the results of CER into patient care. Care Act (ACA) does not do enough to constructively control costs. On the conservative side, the “tea partiers” want to decrease the size TWO POTENTIAL LANDMINES: of government but they have not acknowledged that Medicare would • Bundled payments . Some hospitals already offer a fixed be one of the targets. Medicare and Medicaid combined consume price for discrete services like coronary artery surgery. These about 19 percent of the federal budget. efforts will expand but seem unlikely to ever constitute a sig - The ACA does include some token benefits that physicians must nificant part of overall expenses. These payments would be be aware of. These include: controlled by hospitals and could not be easily expanded to • Funds to study tort reform. There is no question that de - outpatient care of chronic diseases. fensive medicine leads to waste but reform in this area alone • The Independent Payment Advisory Board (IPAB). The won’t solve the problem. The ACA includes only token IPAB has been strongly opposed by the AMA. It is the result of amounts of money to “study” the problem. Congress’ desire to insulate itself from the overwhelming po - • Medical homes . Again, the ACA includes money to fund litical pressures that will come to bear if draconian measures demonstrations but no commitment that would subsidize are necessary to finally “bend the curve.” In any year that development on a large scale. A medical home requires Medicare expenditures exceed a defined target, the IPAB investment in electronic health records and increased use would submit a resolution to Congress to effect the necessary of mid-level providers to coordinate care and expand serv - expense reductions. Congress must either accept the proposal ices in the physician’s office. A significant capitation will be or pass a substitute which accomplishes the reduction, in - necessary to recover the cost. Studies today show clear cluding a three-fifths vote of the Senate. If Congress’ alterna - benefit to the patients but only modest overall savings to tive does not pass, the IPAB resolution becomes law. the system. In my view, primary care should be the foun - Beginning in 2015, the spending rate reduction must be 0.5 dation of our system and anything that strengthens it is percent, rising to a 1.5-percent reduction in 2018. After that, valuable. Medical homes alone, however, will not control the target will be the rate of increase in the GNP (gross na - healthcare inflation. tional product) plus one percent. • Electronic Health Records. This initiative also began last The law puts limits on how the reductions can be achieved. year, with the HITECH Act. I believe EHRs will transform There can be no rationing of care and reduced benefits, eligi - healthcare as dramatically as cell phones and the internet bility or increased cost sharing cannot occur. Clearly the re - have transformed our daily lives. They will make health care ductions will come from providers, and hospitals are exempt better and more efficient but may not have much effect on from the cost reductions until 2020. Physicians, watch out! the overall cost. (Continued on page 12)

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 5

EDITORIALS CCOOMMMMEENNTTAARRY Y Why Aren’t Doctors Allowed to Care about Money?

By David G. Gerkin, MD Editor

few days ago I was skimming the medical blogs and came Aacross an article with the same title as my editorial subject. I Whenever it is in any way possible, thought back to my first days in practice to how uncomfort - able I was when patients broached the topic of my fee for various “every boy and girl should choose as his life treatments or procedures. My usual response was to “punt” the pa - work some occupation which he should like to tient to my assistant or business office after saying my escape com - ment, that it varies and I don’t “keep up” with such things. Back do anyhow, even if he did not need the money. then I just accepted my reticence to discuss money as being a new --William Lyon Phelps in practice; a product of the stance that medicine is one of most eth - ical professions, not to be tainted by any evidence of fiscal limita - ” tions; and my starting and current belief that health care is a basic are not gods, nor even divinities, but are human. They are subject to human right. the same frailties and errors of all humans. Then trial lawyers entered Many years ago doctors were considered members of one of the the picture in an aggressive way and patients begin to sue doctors for most trusted and admired groups in America, right up there with even frivolous reasons since contingency cases ruled. Driven by the ministers and bankers and well ahead of lawyers. They lived in nice publicity and by a few huge verdicts, lawsuits multiplied. Almost every homes in good neighborhoods and drove great cars. Older doctors doctor engaged in an active practice has been sued drove Cadillacs and younger doctors drove sports cars. Their incomes haven't been increasing lately. They still have to Most people thought doctors deserved their positions in the work just as hard, if not harder, to become doctors. The technology community. They had worked hard to get there, through long years involved has become infinitely more sophisticated and substantially of education. Most worked hard, had long hours, were called out in more expensive Doctors know there's not much sympathy out there the middle of the night to care for emergencies such as automobile for declining physician incomes. There are a couple of reasons peo - accidents, and made critical decisions on treating disease and sav - ple feel doctors should not be concerned about income at this time: ing lives. Their incomes seemed to increase every year. As a child I people seem to have a sense of how much money they think is remember how revered, loved and respected the doctors in our enough for someone else to make. Second, and as I referenced in community were and how pleased we were that they had nice homes, my difficulty discussing “money,” people in helping professions are drove new Hudsons and, yes, were humans who cared about our not supposed to care about money. lives and futures. We expected their best for us but realized they had Also, the public usually thinks if you're in a serving profession, limitations – human frailties, fears and needs – just like the rest of you should care only about others and not about yourself. Patients us. What has happened? see their doctors as good people and find it difficult to believe this I often wonder whether it was society or our profession that ethical person could place financial self-interest equal to or perhaps changed or perhaps a combination of both. As the art of medicine ahead of helping others. Even with today’s patient/physician part - progressed rapidly and technology and research led to “wonder” nership risk or diminution, the doctor is still an authority figure who treatments and operations and the profession’s ability to cure dis - gives life-changing treatment and advice. Patients want to believe this eases that were the scourge of humankind, doctors reached, I use beneficent authority figure cares deeply about their welfare and noth - the phrase cautiously, a “godlike” aura of success, or godlike sagac - ing else. Believing otherwise could be distressing. Of course, some ity. As R. H. Rovere said, “Man must play God for he has acquired understand our dilemma. I've heard many patients say, in effect, that certain godlike powers." for what doctors do and what they put up with, they should be re - The decrease of income probably started with the fact that doctors imbursed reasonably.

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 7 EDITORIALS

Now some facts to bring us back to reality and why we can still main - decisions. They want to be paid fairly but they also want to recover tain our ethical stance, care of humanity, and live a reasonable and their decision-making power, their pride and prestige. deserved lifestyle for ourselves, our families and our employees. Finally, I got good night’s sleep last night. It is not because I no First, physicians are only 10 percent of the healthcare dollar. We longer see patients on a full-time basis, since I still work in the pro - could all work for free and it would make barely a dent. All the focus fession full time, but for a strange compelling sense I cannot ex - is on ending the insurance antitrust protection to make them com - plain. Some of my non-medical friends and colleagues might think pete on price and service. Second, what is wrong with allowing MDs I suffer from “Stockholm Syndrome,” a term used to describe a par - and hospitals to deduct from their respective incomes the loss for adoxical psychological phenomenon wherein hostages express adu - seeing uninsured patients? The physicians and hospitals in the re - lation and have positive feelings towards their captors that appear spective local areas would see all patients, the insured and unin - irrational in light of the danger or risk endured by the victims. Even sured; the payer mix would work out to make a good living for the though it appears we have accepted our future as doctors being held doctor and their family. hostage by political forces, most of us still do our work, try our best Third, do we deserve the apparent rewards for our work? Let us to succeed, and are optimistic for our future. It is probably because look at the average physician's "life plan"... 12 years of elementary, most of us have a small part left in us that believes in the Hippo - middle and high school. There is an average of four years of college, cratic Oath … or is it just because we have bills to pay that we con - followed by four years of medical school—often with student loans tinue our work? Maybe we are like soldiers in the field who fight for in excess of $100,000; three to seven years of residency—during their units, determining we will “leave no one behind” as we serve which you are paid just over minimum wage when you consider the to protect our colleagues. I would like to think the latter. 80-hour work week. The average age when beginning a practice life: I am trying to understand why many of my fellow physicians keep 31-35. Now add the competition to enter college, medical school and going back to work, day after day. For me, I believe I have a re - residency. Add the fact that most physicians are paying for their edu - sponsibility to do whatever I can to make this a better and safer na - cations after this fierce competition. Then add in the life cost of de - tion. I believe that 37+ million people need access to health care but laying entry into the workforce along with the cost of entering the the present system is so corrupt, some patients are so parasitic on workforce as a physician: malpractice insurance, overhead, travel the system, and special interests have turned healthcare reform into and moving expenses, family uprooting, etc. a legal morass of self-interest. Now, compare American professional athletes who have schol - I am looking for leadership in our community to face this im - arships through college, who enter professional sports with tremen - pending problem but there is none. I want to be heard but so far I dous contracts and who are revered by millions of fans. I understand feel like the fallen tree in the remote forest. Does it really make a and admire their skills but is their physical ability really worth more noise when it hits the ground if there is no one to hear? than the total package of our physicians? I think not. What really con - As the saying goes, I can only change myself ... and that has been cerns me most among people who are critics of physician salaries is difficult. The issue has no longer become financial or even cultural the notion that doctors shouldn't care about their incomes. This is a for me. I am proud to be a physician and will continue as long a disrespectful and ignorant view that serves only to dissuade capable people seek my service. + individuals from choosing a career as a doctor in the first place. Physicians are not, in most cases, an overpaid profession. Over the past 15 years I have seen colleagues work harder every single year and make less per patient. They are often physically unable to What really concerns me most among sustain their income due to falling reimbursements. Until the cul - ture supports physicians being rewarded for their extraordinary ef - “ people who are critics of physician forts to achieve their levels of ability, the problem will continue to salaries is the notion that doctors grow. When American Idol – and I do admire their talents –shapes our culture's values about who our real heroes are, what else can we shouldn't care about their incomes. expect? This is a disrespectful and ignorant view Keep in mind that all structures are unstable and I think we are witnessing the destruction of the modern U.S. medical system as we that serves only to dissuade capable know it. It's unlikely to ever return to what it was. Something differ - individuals from choosing a career ent will replace it. Will it be something that eventually serves our pa - tients well? I doubt it but none of us knows for sure. I also think as a doctor in the first place. people usually get what they pay for. Some will tire of it...when there is no one to handle the complex situation. Doctors think they know more about what patients need than the actuaries who are making ” 8 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 ”

Ask TMA A FORUM FOR QUESTIONS, ANSWERS AND COMMENTS

ARE MEDICAL SPAS VIOLATING THE PRACTICE OF MEDICINE STATUTE WITH BOTOX INJECTIONS?

Q: I recently learned of a day spa in my town that is owned by tical nurse (LPN) is governed by T.C.A. § 63-6-204(b). That statute an individual who does not have a license to practice medicine. requires that such delegation may take place if “such service is ren - This spa recently mentioned in an advertisement that it performs dered under the supervision, control, and responsibility of a licensed Botox injections. I don’t know if the spa has hired a physician to physician.” When delegating to a PA or NP, the appropriate protocols be its medical director. Even if it has, the physician is not on site and supervision requirements must be in place, as dictated by rules when these injections are performed. Isn’t this considered the of supervision promulgated by the Tennessee Board of Medical Ex - practice of medicine? aminers (BME). The TMA offers a resource for members to refer to when supervising PAs or NPs. The Supervising Physician Kit may be A: “Practice of medicine” is defined in statute at T.C.A. § 63-6- accessed on our web site at www.tnmed.org/legal. 204(a)(1) as follows: For all other supervisees, which would include any unlicensed persons such as medical assistants, the BME has adopted a policy for “Any person shall be regarded as practicing medicine, within supervision of services that are delegated pursuant to T.C.A. 63-6- the meaning of this chapter, who treats, or professes to diag - 204(b). The Policy of Supervision provides that: nose, treat, operates on or prescribes for any physical ailment or any physical injury to or deformity of another.” 1. The supervising physician must hold a Tennessee license to practice medicine. Clearly, the administration of Botox for treatment or cosmetic pur - 2. The supervising physician’s Tennessee license must not have poses is the practice of medicine. However, Tennessee law allows an encumbrance or restriction imposed after the date of this for some medical procedures to be delegated by a physician. The policy. delegation of medical services by a physician to a physician assistant 3. The supervising physician must be “on-site” at least four (4) (PA), registered nurse (RN or nurse practitioner) or licensed prac - hours per week. 4. The supervising physician and supervisee must compile pro - tocols to be used by the supervisee. TMA MEMBERS CAN “ASK TMA...” 5. The supervising physician must update the protocols at least annually. E-mail: [email protected] 6. The supervising physician must have a copy of the protocols Phone: 800-659-1-TMA + Fax: 615-312-1907 on site and must be produced upon demand if requested by Mail: P.O. Box 120909 + Nashville, TN 37212-0909 the appropriate authorities. ______7. The supervising physician may supervise in his/her area of Questions and comments will be answered expertise only (i.e. specialty board certification). 8. The supervising physician must be available at all times (e.g. personally and may appear in reprint telephone, pager, etc.) for communication and consultation. for the benefit of our members. 9. The supervising physician must sign all medical charts, after proper review, within seven (7) days.

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 11 ASK TMA

10. The back-up supervising physician(s) must be identified in would not delegate the procedure to an unlicensed person; others the protocols. might delegate the procedure but want to be near in case something goes wrong. If something goes wrong and the supervising physician Violations of the Medical Practice Act that reflect on the supervising is not close by then the emergency room must clean up the mess. physician’s competency and/or ability to provide adequate supervi - This increases the chance that litigation will result from the injured sion to the supervisee shall be grounds for suspension or revocation patient. of supervision privileges. The TMA Legal Department has received several complaints The nursing law in Tennessee allows for unlicensed persons in from physicians regarding administration of Botox and laser proce - a physician’s office to perform certain “nursing functions” without dures by unlicensed persons. In the absence of legislative or regu - a nursing license if they are employed by a physician or dentist. This latory fiat, medical communities and/or medical specialties having exception states that the person employed must be providing nurs - such concerns should seek to establish and promote the standard of ing care and there must be adequate medical or nursing supervi - care and the role of medical directors within establishments offer - sion (T.C.A. § 63-7-102(2)). This law applies only to nursing tasks, ing these services. not medical services like Botox injections. Botox injections are the practice of medicine and, therefore, Q: Does this spa violate the corporate practice of medicine governed by the community standard of care. This means physicians statute? who choose to delegate the function must be familiar with the stan - dard of care in their community about whether to delegate the ad - A: The corporate practice of medicine law only pertains to physi - ministration of Botox and, if so, whether to delegate to unlicensed cians (T.C.A. §63-6-204(c)). If the spa owner is not a licensed physi - persons or just to TCA § 63-6-204(b) professionals, assuming such cian, the law does not apply. If the non-physician day spa owner persons are trained and competent in the procedure. Another con - employs the physician, such physician would likely be in violation. sideration is whether the supervising physician should be in the same Most likely, there is an independent contractor relationship between room or same building if Botox is administered. Many physicians the spa owner and physician to supervise the Botox services. +

IT’S THE COST, STUPID! (Continued from page 5)

When I weigh the good and the bad parts of the ACA, I think the bad There are two ideas in the ACA that may be transformative. Ac - outweighs the good and it should be defeated. We must remember countable Care Organizations if structured properly give physicians that while President Obama is in the White House, efforts to repeal an opportunity to lead efforts to improve the efficiency of the sys - the Act would be vetoed. Some in Congress believe cutting off fund - tem. Insurance exchanges would bring free market forces into the ing needed to expand Medicaid and subsidize the exchanges would commercial world and give employees an opportunity to make in - be effective. However, repealing or neutering the ACA does not solve telligent choices of provider panels, benefits, etc. I will discuss these the problem I outlined at the beginning of this article. If we can work in my column next month. + together and focus on the big picture instead of just on what is best for our own specialty, doctors can fix the system. The citizenry is Reference: getting increasingly cynical with less confidence in the president, 1. Emmanuel EJ: The cost-coverage tradeoff: “It’s Health Care Costs, Stupid.” JAMA Congress and our industry. Nevertheless, the public has more trust 299:947-949, 2008. in us than in elected leaders and knows we would be better able to fix the current dilemma than anyone else. Share your thoughts with Dr. Ruffner at [email protected].

12 Tennessee Medicine + www.tnmed.org + OCTOBER 2010

Member News Visit www.tnmed.org for the latest TMA news, information and opportunities! Notice on October 5 UHG Settlement Claims Deadline Physician class members in the UnitedHealthGroup UCR lawsuit form, as well as to any Class Member whose submitted claim form have until Oct. 5, 2010 to file their claim form to be eligible to re - is deficient in some manner. The Deficiency Letter will notify the ceive monies from the Settlement Fund. Class Member of what has to be submitted, as well as a new due When Class Members submit requests for claims data from the date by which such new information must be supplied. All deficien - Claims Administrator or submit the claim information request form, cies in Class Members’ submissions to the Claims Administrator, in - as described in the Class Notice, they will be assigned an Initial cluding the lack of complete and signed claim forms for those class Claim Number which will satisfy the filing deadline. Once they re - members assigned an Initial Claim Number, and the absence of all ceive the requested claims data, they should submit their claim form necessary evidence, must be resolved by the due date set out in the directly to the Claims Administrator at the address shown, using the Deficiency Letter for Class Members to be eligible to receive their Initial Claim Number for identification purposes. Recognized Losses from the Settlement Fund. After the October 5 deadline, and after all requested claims data For more on the settlement, visit the UnitedUCR settlement web has been provided, the Claims Administrator will send a Deficiency site at www.uniteducrsettlement.com . For details and information Letter to any Class Member who has been assigned an Initial Claim on the TMA’s member benefit related to this settlement, visit Number but who has not yet submitted a complete and signed claim www.tnmed.org/uhc_mcag . +

TMA Elections: Here’s How They Work

The TMA’s annual elections are just around the corner and now is the Regional offices to be filled include: time to submit nominations for possible candidates for regional and • Board of Trustees (two seats, Re - statewide offices. gions 1 and 3) By November 14 , Component Medical Societies need to certify • Judicial Council (four seats, Regions their Society representative(s) to the Regional Nominating Commit - 2, 4, 6 and 8) tee. They should also provide a list of members interested in running • Young Physician Section (eight seats, one for regional and state offices to the Society’s RNC members and to the from each region TMA, to be relayed to the regional and state nominating committees. To find out what Region you are in, log on to www.tnmed.org/elections . ONLINE ELECTION RESOURCES All election-related materials are available online, including online sub - RUNNING FOR OFFICE mission of required forms for Regional and Statewide Nominating If you are interested in running for a TMA office or have questions re - Committees and candidates. Your TMA Election resource center is lo - garding the elections, let the officers of your medical society know, cated at www.tnmed.org/elections . Further questions can be submit - contact your regional TMA Board of Trustees member or Yarnell Beatty ted online or directed to the TMA at 800-659-1862. at [email protected] . BOT members are listed in the Leader - ship Directory on www.tnmed.org/about. + POSITIONS OPEN For 2011, the TMA is accepting nominations statewide for: • President-elect • AMA Delegation (12 seats) • Speaker/Vice-Speaker of the TMA House of Delegates

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 15 Member News

2011 Membership Renewal Offers Online Payment Option and Simplified Statement Renewing your TMA membership is now easier than ever, with a new online payment option and a simplified billing statement. Your membership is based on the calendar year; therefore, renewing your membership now will ensure that you receive member benefits in 2011.

ONLINE RENEWAL To renew your membership online, log on to www.tnmed.org , find the “Membership Renewal” image at the top of the front page and click on “Learn More.”

SIMPLIFIED STATEMENT You will also receive a streamlined membership statement in the mail. There are three sections for your convenience: • Top: should be returned with your dues payment. • Bottom: should be returned with your IMPACT contribu - tion. • Middle: keep as your receipt for tax purposes.

Tax calculations are available online at www.tnmed.org/taxes. If you choose to pay your dues and make a contribution to IMPACT, please use separate envelopes and note the payment options for each. Please note that AMA membership dues are not included in your 2011 TMA invoice. We encourage support of all levels of or - ganized medicine. If you wish to renew with or join the AMA, this is now a separate process, not included in renewal of your mem - bership in the TMA or your local medical society. If you have questions about membership dues, benefits and services, or if we can assist you in any way, please call 800-659- 1862 or email [email protected] .+

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16 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 Member News

CMS: Testing of ICD-10 Perform a Claims Transactions Should Process Check-Up Begin in Jan 2011 in November The Centers for Medicare & Medicaid Services (CMS) has issued a reminder to healthcare providers, health plans, clearinghouses and Learn how your practice can process claims right the first time, vendors about the approaching compliance dates for ICD-10, the every time. new generation of diagnosis and procedure codes and updated The American Medical Association’s “Heal the Claims standards for electronic health care transactions. Process” TM campaign offers physician practices useful tools— Beginning in January 2011, entities covered under the Health In - such as a physician claims process check-up—to help your surance Portability and Accountability Act (HIPAA) should be ready practice gain efficiencies and reduce claims processing costs. to test with their trading partners the functionality of the entities’ Join the campaign during this November’s “Heal that Claim” TM practice management and/or other related software featuring Ver - month, and learn how to save time fielding delayed, denied and sion 5010 standards. reduced claims payments. Use of the Version 5010 standards for HIPAA electronic health - Visit www.ama-assn.org/go/healthatclaim to pledge your care transactions, including claims, remittance advice, eligibility in - support and access resources to help your practice submit ac - quiries, referral authorization and other administrative curate claims the first time, and free up more time to devote to transactions, will be mandatory on Jan. 1, 2012. The Version 5010 patient care. Find additional resources in the AMA’s Practice standards also provide the framework needed for use of the revised Management Center at www.ama-assn.org/go/pmc .+ medical data code sets (ICD-10-CM and ICD-10-PCS), that must be implemented on Oct. 1, 2013. To help healthcare providers, health plans, clearinghouses and vendors work toward the compliance dates for Version 5010 and ICD-10 — and avoid delays in claims processing and payment — CMS has been conducting ongoing industry outreach and educa - tion, and, most notably, has revised its ICD-10 Web site. All the information is free and can be downloaded from www.cms.gov/ ICD10 .+

Initial EHR Certification Bodies Named The Certification Commission for Health Information Technology the national initiative to encourage adoption and effective use of (CCHIT) and the Drummond Group Inc. (DGI) have been named by the EHRs by America’s healthcare providers. Office of the National Coordinator for Health Information Technology To learn more about the ONC-ATCBs, visit www.cchit.org and (ONC) as the first technology review bodies authorized to test and cer - www.drummondgroup.com . tify electronic health record (EHR) systems for compliance with the For more information about the ONC certification programs visit standards and certification criteria issued by the U.S. Department of http://healthit.hhs.gov/certification. Health and Human Services earlier this year. For more information about other HHS Recovery Act Health In - This means EHR vendors can now begin to have their products formation Technology funding and programs, visit www.hhs.gov/re - certified as meeting criteria to support meaningful use, a key step in covery/programs/index.html#Health . +

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 17 Member News

TMA PHOTO GALLERY

TMA Legislative Committee Chairman Dr. Dr. Ken Holbert (left) and TMA President Dr. B W. Ruffner discuss Charles White, Jr. (left), poses with Knoxville possible legislation during the interactive “webinar” portion of Mayor and Tennessee gubernatorial candi - the TMA Legislative Committee meeting in August. Members date Bill Haslam during an August stopover were invited to attend the meeting or participate online to share at TMA headquarters in Nashville. their concerns and ideas for next year’s legislative agenda.

TMA Physician Leadership College scholars are led in a conflict resolution session by Dr. Larry Bridgesmith of Lipscomb University during their September training session in Nashville.

18 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 Member News

TMA PHOTO GALLERY

First-year medical students crowd display booths manned by staff members of the TMA and The Memphis Medical Soci - ety during orientation at the University of Tennessee Health Science Center in August; a total of 117 M1s were recruited as new members in the AMA, TMA and MMS.

Rain-soaked UTHSC students arrive for a welcome reception, held annually at the home of former TMA President Dr. Charles Handorf following new student orientation. Over 200 students and guests were treated to traditional Mem - phis barbecue and introduced to MMS and TMA physician leaders.

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 19 Member News

MEMBER NOTES

Ted L. Flickinger , of Maryville, has been re- Stephen D. Loyd, MD , , is the new associate elected to serve as vice president of the chief of staff for education at the VA Medical board of directors for Blount Memorial Hos - Center at Mountain Home. Dr. Loyd oversees pital; he has served on the board since 1998. academic and affiliation programs including A retired urologist, Dr. Flickinger is a member Graduate Medical Education and Associated of the hospital’s honorary medical staff. and Allied Health Education programs. He serves as liaison to the East Tennessee State David G. Gerkin, MD , a Knoxville ophthal - University Quillen College of Medicine for mologist, has been named president of the training issues and sits on committees relevant to residency edu - Interfaith Health Clinic for the next two years; cation, where he previously served as associate professor of in - he previously served as vice-president. Dr. ternal medicine and program director for internal medicine Gerkin is a former TMA president and Board residency. He has received numerous internal awards at Quillen of Trustees chairman, current AMA delegation College of Medicine. vice-chairman, and editor of Tennessee Med - icine , the Journal of the TMA. He serves as Robert J. Mandel, MD, MBA , senior vice pres - medical director of the Tennessee Valley Eye ident of Health Care Services for BlueCross Center. He was chief of staff, an associate clinical professor and BlueShield of Tennessee, has been elected chair of the ophthalmology section at the University of Tennessee board chairman for the Health Information Medical Center. Active in the military reserves until 1999, he is a Partnership for Tennessee (HIP-TN). The non- brigadier general in the Tennessee State Guard serving as state profit group is a collaborative effort of pa - surgeon. Dr. Gerkin is a 2010 recipient of the Prevent Blindness tients, providers, health insurers, self-insured Tennessee’s Lifetime of Service Award and serves on the board of employers, hospitals and pharmacies working directors for the Innovation Valley Health Information Network. to set up a statewide health information exchange to improve the quality of care. Previously with BlueCross BlueShield of Massa - Jeffrey J. Gleason, MD, FACOG , of Cookeville, chusetts, Dr. Mandel oversaw eHealth and ePrescribing technolo - has been appointed by the Cookeville City gies and led medical informatics initiatives. A licensed Council to a seven-year term on the ophthalmologist, Dr. Mandel is a fellow of the American College of Cookeville Regional Medical Center Board of Surgeons and a member of the American Academy of Ophthalmol - Directors. Active in organized medicine, Dr. ogy, as well as the American College of Physician Executives. Gleason has served the TMA as a member of the Medical Liability Reform Steering Com - Roger J. McSharry, MD ,of Bristol, has been mittee and in the Young Physician Section, named chief medical officer of Bristol Re - and is a TMA delegate representing the Putnam County Medical gional Medical Center. Currently Dr. McSharry Society. Board certified in obstetrics and gynecology, Dr. Gleason serves as medical director of BRMC’s respira - practices with OB/GYN Associates, and is a fellow of the American tory therapy department. He also serves on College of Obstetrics and Gynecology. the staff at The Rehabilitation Hospital of Southwest Virginia and Select Specialty Hos - Daniel S. Lewis, MD, of Greeneville, was se - pital. Board certified in pulmonary, critical lected by the American Academy of Family care and internal medicine, he is a clinical professor of medicine Physicians (AAFP) to receive a 2010 Pfizer at the James H. Quillen College of Medicine at East Tennessee State Teacher Development Award, recognizing his University. commitment to education in the field of fam - ily medicine. The award is based on his scholastic achievement, leadership qualities and dedication to teaching. A family physician with Takoma Medical Associates, Dr. Lewis sets aside a number of volunteer hours each month to train medical students and resident physicians. He was nominated for the award by the East Tennessee State University Department of Family Medicine.

20 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 Member News

MEMBER NOTES

Four TMA members were honored in August as Greater Knoxville Business Journal Health Care Heroes. H. Lynn Massingale, MD, chair - man and CEO of TeamHealth, won the Dr. Christensen Dr. Massingale Dr. Anderson Dr. Backlund Dr. Meador award for Administra - tive Excellence; Bergein Three TMA members were among those named Health Care Heroes F. “Gene” Overholt, MD, in October by the Nashville Business Journal . Clifton K. Meador, FACP, MACG , a principle MD , executive director of the Meharry-Vanderbilt Alliance, won the with Gastrointestinal As - Lifetime Achievement Award; Allen F. Anderson, MD , a surgeon sociates, PC, received with Tennessee Orthopaedic Alliance, was the Physician recipient; the award for Innova - and Dana C. Backlund, MD , assistant professor and medical on - tion; Lise M. Chris - cologist at the Vanderbilt-Ingram Cancer Center, won the Health - tensen, MD , pediatric care Newcomer award. + Dr. Leahy Dr. Overholt emergency specialist with Children’s Pediatric Group, and M. Douglas Leahy, MD , internist with Summit Medical Group, PLLC, were the Physician recipients.

Are you a member of the TMA who has been recognized for an honor, award, election, appointment, or other noteworthy achievement? Send items for consideration to Member Notes, Tennessee Medicine, 2301 21st Ave. South, PO Box 120909, Nashville, TN, 37212; fax 615-312-1908; e-mail brenda.williams@ tnmed.org. High resolution (300 dpi) digital (.jpg, .tif or .eps) or hard copy photos required.

21

PRACTICING MEDICINE

By Brenda Williams

By the numbers, Tennesseans are among the most overweight, under-nourished, inac$ve, over-medicated people in the na$on.

“When you look at the Behavioral Risk Factor Surveillance Survey data, we are 48th in the coun - try for obesity, 49th in ge1ng no exercise, 42nd in adults who are smokers,” said TennCare Med - ical Director Wendy Long, MD, adding it is no surprise that lifestyle-related diseases like diabetes, heart disease and cancer are seen in correspondingly high rates.

Tennessee’s health measures have long missed the mark in nearly every area – birth weight, child and infant mortality, child and adult obesity, tobacco use, cancer, heart disease, stroke, diabetes, life expectancy, and deaths resul/ng from preventable diseases (see “Tennessee Health Facts”). Studies show Tennessee has one of the highest diabetes rates in the country. Add to that more than one-third of Tennesseans with high blood pressure and another third with high cholesterol – a lethal and expensive mix.

“Tennessee is spending more on healthcare – 15.6 percent of the gross state product compared to 13.3 percent na/onally – but without the be0er health to show for it,” said the State Health - care Report Card, issued last month.

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 23 PRACTICING MEDICINE

even declined; and there are “significant declines” in the number of adults who re - port having Type II diabetes and in deaths from cardiovascular disease. But the Com - missioner said the numbers are far from where they need to be and the effort is just beginning.

The state’s Chief Medical Officer Veronica Gunn, MD, agreed, adding it requires a long-term commitment to policy change and education to transform the behavior and mindset of Tennesseans when it comes to their health … and it will not happen overnight. “It will take a signifi - cant period of time, generations perhaps, to change the culture to one of sustaining wellness,” said Dr. Gunn.

Tennessee Health Commissioner Susan Cooper addresses the crowd during the September State Health Plan 16th launch of the “Eat Well, Play More” Statewide Physical Activity and Nutrition Program. One step down the road to a healthier Ten - Photo: State of Tennessee Division of Photographic Services. nessee may be the 2010 State Health Plan – the blueprint for health policy, programs, and the allocation of state resources for health over the next decade. This year’s draft is currently wrap - ping up, with recommendations scheduled to be finalized this Moving the Needle month and presented to the Governor in November. State health officials don’t deny the statistics – but they don’t The Plan addresses five principles: dwell on them, either. 1. The purpose of the State Health Plan is to improve the health of Tennesseans; “We’re not really great fans of report cards,” said Commissioner 2. Every citizen should have reasonable access to health care; of Health Susan Cooper, RN. “When you have 50 states, some - 3. The state's healthcare resources should be developed to ad - one is always going to be first and someone is always going to be dress the needs of Tennesseans while encouraging competi - 50th.” She said Tennessee moved from 48th to 44th in overall tive markets, economic efficiencies, and the continued health status in 2007 but questions what the rankings really development of the state's healthcare system; mean without digging into the data. “We don’t want to move 4. Every citizen should have confidence that the quality of health up just because someone else got un healthy,” she said, adding care is continually monitored and standards are adhered to that, conversely, “we could be satisfied at 48 if the entire nation by healthcare providers; and moved in the right direction in all these metrics.” 5. The state should support the recruitment and retention of a sufficient and quality health care workforce. The preferred approach, Commissioner Cooper explained, is to assess where the state of Tennessee Through statewide regional meetings currently is and advance a compre - and public and professional surveys, hensive statewide effort to keep state Health Planning Division Direc - moving the needle forward. tor Jeff Ockerman, JD, said his team heard some recurring themes – the There has already been some need for more personal responsibil - progress. Tobacco use has dropped ity, the need for better communication nearly 10 percent from a decade ago; between healthcare professionals Tennessee is ranked number two in and patients, the link between a giving schoolchildren access to community’s health and its economic healthful foods; a just-passed law re - vitality. The goal now is to translate quires at least 90 minutes of physical those concerns and ideas into a sus - Dr. Gunn activity in a school week; child obe - tainable policy program that actually Mr. Ockerman sity appears to have plateaued and works on the local level.

24 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 PRACTICING MEDICINE

ACHIEVE Communities in TN In February, Jackson and McMinnville, TN, were among 38 ci/es na/onwide selected as ACHIEVE (Ac/on Communi/es for Health, Innova/on and Environmental Change) communi/es by the U.S. Centers for Disease Control. The program fosters col - labora/ve partnerships and provides funding and technical support for policy, systems, and environmental change strategies that will help prevent or manage health-risk factors for heart disease, stroke, diabetes, cancer, obesity and arthri/s. Specific ac/vi/es are directed toward reducing tobacco use and exposure, promo/ng physical ac/vity and healthy ea/ng, improv - ing access to quality preven/ve healthcare services, and elimina/ng health dispari/es.

“You can do significant things at the state level,” Ockerman said, treating the patient in a holistic manner, makes a lot of sense “and the importance of aligning state policies and programs can - and facilitates better care.” not be underestimated. But until you also help figure out how local communities can embrace a program and make it effective Lifestyle issues are also being tackled. Maternity and disease in their own way, you’re not getting the job done.” management programs offer coordinated care and patient edu - cation to encourage healthy choices; physicians are encouraged With a new focus on improving Tennessee’s health and looming to counsel their patients on smoking cessation, diet and physical federal health reform changes, one overarching concern is the activity. Drug over-utilization is less of a problem since TennCare shortage of primary care providers. “Primary care is such a critical rolled out restrictions in 2005; per-person prescriptions have component of any state health plan,” he said. “This document will since dropped from 36 to 14. “There are some who were pre - help us look down the road on these types of issues, help us pre - dicting doom and gloom when we moved to the prescription lim - pare for baby boomers as they age. They’re going to need more its; that really did not come to pass at all,” said Dr. Long. “In fact, care. We need to know: how do we make sure we’ve got the our quality indicators have improved.” She added that as en - healthcare workforce in place? So we’ll be raising that issue up and looking for the TMA to give us some guidance and input on that.” “Healthy Tennessee” Resources

TennCare Consor$um for Health Educa$on, Economic As the state’s largest insurer, TennCare has a vested interest in Empowerment and Research (CHEER) improving the health of its enrollees. Medical Director Dr. Long www.uthsc.edu/CHEER said the program is already making headway with some impor - tant initiatives. Get Fit Tennessee Since 2005, TennCare has required its www.ge"i$n.com managed care organizations (MCOs) to be accredited through the National Governor’s Council on Physical Fitness Committee on Quality Assurance & Health (NCQA) and submit Healthcare Effec - h$p://health.state.tn.us/governorscouncil tiveness Data and Information Set (HEDIS) data, which allows the pro - gram to track health improvements Project Diabetes from year to year. h$p://health.state.tn.us/projectdiabetes.htm

“We actually just completed our 2010 State Healthcare Report Card: Diabetes, Dr. Long HEDIS report and we have seen im - provements in a variety of really crit - Hypertension and Asthma ical indictors,” said Dr. Long, citing www.tn.gov/finance/healthplanning/ better immunization rates, access to primary care providers, lead Documents/HealthcareReportCard2010.pdf screenings, well child visits and adult diabetes care. Tennessee Prescrip$on Safety Program Having MCOs deliver both regular health care and mental health care was another important milestone. Since 2007, Dr. Long said www.tnrxsafety.org the integration has resulted in better care for mental illnesses, behavioral health issues and substance abuse treatment. “Physi - Tennessee Tobacco Quitline cians across the state really supported this move,” she said. h$p://health.state.tn.us/tobaccoquitline.htm “Physical health and behavioral health are very much interre - lated and being able to deliver them through a single provider,

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 25 PRACTICING MEDICINE

rollees get healthier, prescription drug use will decline further. birth and low birth weight, and develop best practices and system changes in the clinical realm. With input from regional advisory com - A new tool on the horizon for healthier TennCare patients is the mittees made up of families, insurance companies, health providers, electronic health record, she added. Officials anticipate that EHR institutions, data collectors, government and non-government ad - implementation and incentives over the next few years will lead to vocacy groups, TIPQC concentrates its efforts within the provider better follow-up, better case management and overall improve - setting: the obstetrician, the NICU, the pediatrician. It seeks out proj - ment in the quality of care. ects and best practices that have been effective for its members and votes on whether to adopt them statewide. The plus: these projects “We’re pleased with the trends we’re seeing,” said Dr. Long. are proven to work before they are put into place. “We’re going to continue to focus on these key areas, measure our performance with the tools available, like HEDIS, and believe we’re Current projects include initiatives to reduce central line blood stream moving in the right direction.” infections; raise the temperature of NICU infants; reduce elective de - liveries before 39 weeks; promote the use of human breast milk in the NICU for very low birthweight infants; promote breastfeeding in the obstetric community; prepare NICU parents for their baby’s re - Infant & Maternal Health lease; and improve NICU focus on the critical first hour of life. A healthy Tennessee begins with both mother and baby. Overall, Tennessee has spent more than $8.7 million since 2006 on health education, home visits and clinical care aimed at im - Facing a much-higher than average in - proving maternal health and reducing infant mortality. Dr. Grubb fant death rate, a statewide Infant Mor - said TIPQC is one small piece of that effort. tality Summit in April 2006 led to the hiring of infant mortality specialists for “We at TIPQC in no way can say this is the fix,” said Dr. Grubb. Tennessee’s three grand divisions and “What we can do is assemble the evidence, bring the data to - funding for women’s healthcare initia - gether, share the data and have a conversation. People share how tives in Memphis, where the infant mor - they’re implementing the evidence-based practices and what tality rate is the highest. Overseen by we’re striving to do is get the most efficient and effective imple - the Governor’s Office of Children’s Care mentation of what we know works.” Coordination (GOCCC), the programs have contributed to Tennessee’s move Dr. Grubb from 47th to 44th this year. In announc - ing additional funds for Memphis in July, Governor Phil Bredesen said parts of Obesity the state still resemble third-world countries when it comes to in - Body weight is probably the most visible symbol of Tennessee’s un - fant mortality. healthy state. More than 69 percent of us adults tip the scales at an unhealthy weight, and up to 51 percent of our children. Experts say The ranking is yet another report card that does not reveal the full, if we would just get off the couch, get moving and make some complicated picture. But the numbers are a mirror, according to lifestyle adjustments, we would reap a host of benefits. Peter Grubb, MD, medical director for the Tennessee Initiative for Perinatal Quality Care (TIPQC). The challenges are daunting. Tennessee’s agricultural roots lend to communities that are spread far apart with few opportunities “What it’s telling us is not just the health of our babies but the health for physical activity. Its southern roots lend to a diet steeped in of our mothers, and that really is a reflection of the health of our so - tradition and comfort – and high in fat and cholesterol. The grow - ciety,” he said. “It’s a mirror and the question’s up to us as to what are ing proliferation of fast food restaurants and “value menus” offer we going to do about what we see in the mirror.” less healthy but cheaper options, especially for those on a fixed income. There are a growing number of “food deserts” – commu - Funded by the state, TIPQC aims to establish a statewide perinatal nities or neighborhoods where fresh produce and healthy foods database, support quality initiatives aimed at reducing premature are inaccessible or too expensive.

2010 Shining Star Awards The Tennessee Governor’s Council on Physical Fitness and Health in August honored nine Tennessee programs and organiza/ons with the 2010 Shining Star Award. The program recognizes the contribu/ons of an individual or group for efforts to promote healthy lifestyles in areas where Tennesseans live, work and learn. Recipients: Where We Live – Giles County Health Council; City of Cookeville’s The Power of Ten; Wayne County Health Council. Where We Work – Freed Hardeman University Fitness for U Well - ness Program; McKee Foods Worksite Wellness Program; Lenoir City School Staff Wellness Program. Where We Learn – Lawrence County Health Council; Roane County TNCEP Coali/on Tasty Tuesday; Fit Kids Ready for Ac/on at East Tennessee State University.

26 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 PRACTICING MEDICINE

Members of the Tennessee Obesity Taskforce met in March with First Lady Andrea Conte to discuss childhood obesity efforts in Tennessee. (L-R): Susan White, Save the Children; Patty Clements, American Heart Association; First Lady Andrea Conte; Chastity Mitchell, American Heart Association; Joan Randall, Vanderbilt Institute for Obesity and Metabolism; Ted Cornelius, YMCA of Middle Tennessee; Julie Denney, Lipscomb University.

“One of the biggest challenges,” said Joan Randall, administra - That thought is echoed by pediatrician Nita Shumaker, MD, pres - tive director of the Vanderbilt Institute for Obesity and Metab - ident of the Chattanooga-Hamilton County Medical Society and olism and current chair of the Tennessee Obesity Taskforce a member of the TMA Strategic Planning Oversight Committee, (TOT), “is that many people don’t think of themselves or their who is currently helping to organize a comprehensive obesity children as overweight or obese. The norm is now to be over - project for her own community. “There are so many initiatives; weight rather than to be normal weight, so most people don’t I’m talking to everybody I can, whether it’s the PTA president or the perceive their weight as being a problem.” patients in my practice or state legislators to say there’s a lot every one of us can do to change this.” Which is precisely why the TOT avoided those words in the state’s new obesity plan, calling it instead the “ Eat Well, Play Dr. Shumaker said she sees young par - More Statewide Nutrition and Physical Activity Plan.” Funded by ents confused about healthy eating the Centers for Disease Control, the Plan sets out a sweeping list and how to instill that in their children. of actions and policy recommendations to be implemented over Her goal in the office is to talk with her the next five years in settings where Tennesseans live, play, patients and their parents at every learn, heal and work, and among vulnerable populations. visit about healthy lifestyles, diet, nu - trition and exercise, and outside the The Plan takes a long-term, comprehensive approach. “Over the office to encourage her colleagues to years the CDC has discovered that funding a bunch of individual do the same. programs and interventions is not successful long-term; there’s no sustainable change. So now they’re looking for plans that “Physicians need to be the loudest voice focus on policy and environmental change,” Randall explained. about what’s healthy and not healthy Dr. Shumaker for our patients,” she said. “Everybody Recommendations range from incentives for farmers and grocery else may have an agenda but we don’t. stores to bring their fresh goods to food desert areas or to Our only concern is for our patients, and physicians are uniquely schools, to new policies and programs that support and protect positioned to be the authoritative voice in this effort.” breastfeeding, to improving community access to health re - sources and physical activity. In the healthcare setting, it includes providing technical assistance, education and resources for healthcare providers to better counsel patients on healthy weight and lifestyle and screen for obesity, as well as insurance coverage Tobacco for obesity, breastfeeding and nutrition services and treatment. Fewer Tennesseans are lighting up these days, thanks to some changes many thought they would never see in a southern “to - Doctors are a key component in preventing obesity before it bacco state.” starts, Randall said. “In the past, physicians have been hesitant to bring it up. Now I think providers are coming to the realization A three-pronged approach – the Non-Smoker Protection Act, they can’t skirt around it anymore; they have to get in people’s higher tobacco taxes and investment in smoking cessation faces sometimes,” she said. strategies – has succeeded in bringing Tennessee’s tobacco use

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 27 PRACTICING MEDICINE

rate from 30 percent down to about 23 percent. State officials say that would not have been possible without policy change.

“There’s your stickiness factor – it stays regardless of who the administration is or what the legislature looks like, and that has contributed to the decline in tobacco use,” said Commissioner Cooper. “Now, are we at the 12 percent we would like to be at? No. But we will continue to decline as more folks are presented with the healthful choice.”

Groups like CHART (Campaign for a Healthy and Responsible Tennessee), which helped lead the charge to get Tennesseans to crush out their ciga - rettes, are pleased with the progress and say the work must continue. CHART board member Peggy Alsup, Dr. Roland Gray leads a class on proper prescribing for the MD, MPH, said her fellow physicians are uniquely positioned to help their Tennessee Prescription Safety Program. patients kick the habit but face a diffi - cult therapeutic challenge. Tennessee recently dropped from the number one prescriber in Dr. Alsup the nation to the number two spot. Dr. Gray credits two impor - “It’s tough to convince patients that this tant efforts: the creation of the state’s Controlled Substance is really the number one preventable Monitoring Database, an important tool in detecting and track - cause of death and they’re at high risk,” Dr. Alsup said. "Physicians, ing “doctor shopper” patients who obtain and abuse or sell I would suggest, have to think about a team approach that engages Schedule II drugs; and the implementation of the PSP’s Proper all kinds of healthcare professionals." She added, "Doctors will need Prescribing education courses, now required for a physician’s li - all the help they can get. The net benefit to the patient of physician cense renewal. intervention is so great that physicians must be supported in their efforts in every possible way. This support should include reim - Pill dependency remains a significant public health issue, com - bursement by third-party payors that is commensurate with the re - plicated by the fact that the drugs are obtained from legal source and labor intensive nature of physician intervention.” sources. Tennesseans cross state lines to get their meds at so- called “pain management” clinics, or find outliers who will pre - scribe for money, or do their best to fool their doctors and pharmacies to get the pills they seek. While the state tries to crack down on drivers impaired by their “legal” prescriptions, Drugs Dr. Gray said the medical community needs to step up and do a Over-medication is a big problem for the Volunteer State. “If better job: physicians need to use the monitoring database to more drugs made people more healthy, we’d be the healthiest help determine the use versus misuse by patients; medical state in the country – or the second healthiest,” said TennCare’s schools need to educate the next generation of doctors on Dr. Long. proper chronic pain management; and he personally favors more controls on both prescribers and patients when it comes Exacerbating the problem is the fact that many Tennesseans to opiates and narcotics. need their meds because of their obesity, inactivity, poor diet and tobacco use. “As long as we’re in the top five in the nation “The good news is – and I’ve talked to the Board of Pharmacy in in those categories, we’re going to be in the top five in the num - the last month – there has been a slow and steady decline in the ber of prescriptions per patient,” explained Roland Gray, MD, a prescribing of these drugs that have a potential for misuse, certified addiction medicine specialist and faculty member for abuse, addiction and overdose death,” Dr. Gray said, adding that the Tennessee Prescription Safety Program (PSP), a statewide ef - during a recent FDA subcommittee meeting in Washington, no fort launched by the TMA to address the state’s abuse and over- other state was able to report a similar decline. “I’m actually prescribing of prescription drugs. very proud of that,” he said. “While we are in no way declaring victory, we are moving in the right direction.”

TennCare Now Covers Smoking Cessation Effec/ve October 1, TennCare began paying for smoking cessa/on services for pregnant women, due to a mandate from Medicaid. Expectant mothers who want to quit smoking can now access free stop-smoking products, both prescribed and over-the-counter. In 2014, under federal health reform requirements, those services will be expanded to all TennCare enrollees.

28 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 PRACTICING MEDICINE

Get Off The Couch! the work we do in the healthcare setting; it’s critical. But our cur - At the end of the day, tackling Tennessee’s health problems may rent efforts at disease treatment and focusing on individual dis - seem overwhelming. Officials say it is important to do the work to ease maintenance cannot, has not, and will not work to improve a improve the health of our citizens, with a focus on the big picture population’s health.” Tennessee must have policy change and a and with policy initiatives at the center of the plan. comprehensive effort, she said, adding that doctors and other providers will make the biggest difference through prevention. “Individual health is important and options to support individual “What we do as clinical providers to facilitate behavior change, health, but at the end of the day that’s not going to drive our num - that’s really hard but it’s possible.” bers,” said Commissioner Cooper. “What’s going to drive our num - bers are those policies that affect the population as a whole.” Both agreed physicians could best serve their patients’ health by be - coming a healthy example. “Invest in your own health, take your own Citing a 2002 study, Dr. Gunn said it is sobering for physicians to advice,” said Commissioner Cooper, adding doctors would have read that clinical work by providers, having high quality care, access more impact if they would stop smoking, get fit, get a flu shot, etc. to care, insurance coverage and utilization only account for 10-15 “If we are holding ourselves out to be the healthcare experts, we percent of a population’s overall health. “That’s not to minimize need to expand that definition to become the health experts.” +

New IOM Guidelines Tennessee Health Facts* on Pregnancy Weight In 2009, the Ins/tute of Medicine MEASURE TN (US) published new weight gain guide - lines for expectant mothers. The Low birth weight 9.4% (8.2%) guidelines say women of normal Infant mortality 8.7 deaths per 1,000 live births (6.8) weight (BMI of 18-24) should gain 25-35 pounds during pregnancy; Childhood obesity 36.5% (31.6%) overweight women (BMI of 24- Child mortality 20 child deaths per 100,000 children (19) 29) should gain 15-25 pounds; obese women (BMI of 30+) Teen mortality 84 teen deaths per 100,000 teens (62) should gain 11-20 pounds. Alzheimer’s deaths 25.9 per 100,000 (22.7) Cancer incidence 467.4 per 100,000 (461.8) Cancer deaths 200.3 per 100,000 (178.4) Colorectal cancer deaths 19.4 per 100,000 (17.5) Diabetes 10.2% (8.3%) Diabetes deaths 26.2 per 100,000 (22.5) Heart disease 220.6 per 100,000 (190.9) Smoking adults 23.1% (18.3%) Overweight/obese adults 65.9% (60.8%) Adult physical ac/vity 35.9% (50.9%) Poor mental health 26.3% (33.3%) Stroke/cerebrovascular deaths 53.9 per 100,000 (42.2) Life expectancy 75.3 (78)

*State Health Facts, Kaiser Family Founda#on, 2007 (some 2005); h$p://www.statehealthfacts.org/profileglance.jsp?rgn=44

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 29

PRACTICING MEDICINE Health System Improvement: Developing Regional Capacity across Tennessee Ms. Nault Dr. Bailey

By Jill D. Nault and James E. Bailey, MD, MPH, FACP

INTRODUCTION THE “OTHER” HEALTH CARE RE - mation, improved care delivery and payment Rather than focus once again on the conse - FORM INITIATIVES reform. In addition, health information tech - quences of insurance coverage expansion National health reform has set the stage for nology is being leveraged throughout the sys - under the Affordable Care Act, this article de - innovation in reorganizing the healthcare sys - tem to improve patient care and eliminate scribes “other” national and regional health tem. The Affordable Care Act mandates de - administrative redundancy. A brief descrip - reform efforts and how they are likely to im - velopment of the Center for Medicare and tion of these “cornerstones” of value-driven pact providers and patients in the state of Ten - Medicaid Innovation, which will provide health care is provided below. nessee. Debate over expanding coverage has funding for testing new payment methods and overshadowed these other potentially more healthcare delivery systems that reduce cost Health Information Technology: Efforts important aspects of health reform activity. and improve the quality of care in communi - to use health information technology (HIT) This article reviews critical elements of health ties with established infrastructure. The Office to improve the value (quality and cost effi - system improvement within health reform that of the National Coordinator for Health Infor - ciency) of health care have focused on in - include: performance measurement and pub - mation Technology (ONCHIT) along with the creasing adoption of electronic health lic reporting, health information technology, Centers for Medicare & Medicaid Services records and sharing health information improved care delivery, and payment reform. (CMS) have created meaningful use and cer - through health information exchanges. Ini - Lessons learned from States that have made tification criteria to support provider adop - tially, meaningful use of HIT will focus on significant progress toward aligning these el - tion of electronic health records. The HITECH electronically capturing, tracking and report - ements are shared. (Health Information Technology for Eco - ing health and healthcare performance infor - The article also focuses on health system nomic and Clinical Health) Act leverages mation using standard measures and improvement in Tennessee. While Tennessee health information technology to improve practices. Later stages will focus on pro - has many assets that can be leveraged, im - healthcare delivery and patient care through gressing capacity for health information ex - plementation of reform activities must be con - specific programs including (but not limited change to coordinate care and drive quality sidered within a local context and will require to) the Beacon Communities, the State Health improvement efforts. Communities with ad - significant multi-stakeholder collaboration. A Information Exchange Cooperative Agree - vanced HIT infrastructure already have the ca - common vision of a healthcare system that ment Program, and the Health Information pacity and are demonstrating success in works for all who provide, pay for and use Technology Regional Extension Centers. From quality improvement and cost efficiency of health care is needed in order to positively Minnesota to Maine, communities are lever - health care. impact the health of Tennesseans. Reigning in aging these and other programs to transform healthcare costs by reducing administrative health systems. Performance Measurement and Pub - waste and unnecessary and expensive care is lic Reporting: Performance measurement essential. Furthermore, in order for all Ten - CORNERSTONES OF A VALUE-DRI - of the healthcare system is crucial to both nesseans to get the most “bang for their buck” VEN HEALTH SYSTEM quality improvement efforts as well as paying out of the health system, we have to ensure Successful communities recognized as lead - for value-based care (as opposed to volume that reducing cost does not occur at the ex - ers in health reform seem to have aligned crit - of care). The evidence is pretty clear that vari - pense of quality. ical elements required to create a healthcare ation in quality and cost of care occurs both system that works. (See “The Minnesota within a region as well as across the country. Story” sidebar) These elements include on - If you don’t know where the system is bro - going transparency of quality and cost infor - ken, it becomes pretty difficult to fix. How -

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 31 PRACTICING MEDICINE

ever, not all public reporting of performance tronic health records can be used to send however, all payers need to achieve consensus measurement initiatives have been well-coor - alerts to a provider who may not be aware that on what is to be incentivized. Consider the fol - dinated and often create confusion among his or her patient was seen in the emergency lowing simple scenario. Most providers see a providers, payers and consumers. The Na - room for a chronic disease complication. The mix of patients insured via Medicare, Medi - tional Quality Forum and Quality Alliance alert, in turn, can help to ensure the patient caid or commercial insurance. Creating prac - Steering Committee are spearheading an ini - receives follow-up in the ambulatory care set - tice-wide mechanisms to ensure all patient tiative designed to create standardized meas - ting and the provider develops a plan to im - subsets (based on insurance type) achieve ures and methodology for performance prove disease management. Both of these outcomes that qualify for payer-specific sup - measurement and public reporting. This is examples of leveraging HIT to provide team- plemental payments is immensely difficult. In essential to gaining stakeholder trust of data. based care and care coordination are part of order to receive the incentivized payments, a In addition, 17 communities across the coun - the activities inherent to medical homes. A provider must ensure that outcome X occurs try are being funded through the Robert practice that moves toward a medical home for one subset of patients, outcome Y for an - Wood Johnson other subset of pa - Foundation’s Align - tients, and outcome ing Forces for Z for still another Quality initiative to The Minnesota Story subset of patients. pave the way for ro - The alternative is bust public report - Over the past decade, various stakeholder groups in Minnesota have been actively pursuing health reform. that providers will ing of performance In 2008, the State passed legislation for a comprehensive health reform initiative that is changing the ways be paid for achieving measurement. in which health care is provided and reimbursed. Community stakeholders started by defining highest prior - health outcomes ity population health outcomes. Then they used these priorities to define “baskets of care” including all across their patient Improved Care health services (e.g., physicians, hospitals, pharmacy, ancillary) needed to achieve optimal patient out - population regard - Delivery: Focus - comes. The baskets cover a wide range of services including preventive (i.e., pre-diabetes, immunization), less of payer mix. ing on population chronic disease management (i.e., diabetes, asthma), and “high dollar” acute illness (i.e., acute low back While pay for per - health is part of the pain) services for which increased spending does not consistently achieve better patient outcomes. formance is one “triple aim” for im - Several system-level initiatives to redesign care delivery, like health care homes and chronic care coor - possible portion of proving health sys - dination, are incentivized by payment reform. One specific example of an innovative approach to create payment reform, it is tems. The redesign high-value, patient-centered care is an initiative that utilizes an electronic decision-making tool to be used at only complementary of care delivery the point of care between patient and provider to support more appropriate ordering of high-tech diagnostic to a base payment must be able to im - imaging scans. Cost savings demonstrated during a pilot phase of this initiative totaled $28 million with approach (i.e., fee pact all patients projected annual savings of $60 million (and 15 lives/year saved from radiation induced cancers) with for service). using the healthcare statewide rollout. Capitated pay - system. Hence many Performance measures tied to desired health outcomes are used to report quality, utilization and price ment (per person quality improve - data. Data sources in Minnesota include quality, cost and outcome data both submitted directly from per month) is an - providers via medical records and administrative data from health plans. Led by the nationally-renowned ment initiatives are other type of ap - Mathematica group, Minnesota uses peer provider grouping methodology to drive market volume toward system-level inter - proach. For higher quality, lower cost (high value) providers. ventions. At the example, patient- provider level, pa - centered medical tient registries are home payment ap - one tool to ensure that all individuals seen by model can improve the quality and efficiency proaches typically involve some type of up- a provider(s) with a common need receive of care to all of its patients. A system in which front lump sum or per-person-per-month recommended care on a regular basis. For medical home activities are incentivized payment that provides compensation for in - example, a provider can look at diabetes care (therefore, more likely to occur across mul - direct (e.g. “unbillable”) services. This pay - across all of his or her patients and initiate tiple practices) can improve the quality and ment usually covers care coordination follow up for those who have not received a efficiency of care to all patients. activities or pays for additional staff required test or service (for example, an annual LDL- for team-based care including outreach ac - C test), rather than relying on remembering to Payment Reform: Most experts agree pay - tivities, group education or case management. do the test the next time the patient comes in ment reform is essential to creating meaning - In order to qualify for a comprehensive pay - (or doesn’t). Likewise, immunization reg - ful change in the way care is provided and paid ment, some states require practices to istries can be an important tool to ensure all for in the U.S. healthcare market. These ex - demonstrate increases in their medical home children get the recommended immuniza - perts concur that payment reform is the most capacity (e.g., different levels of comprehen - tions, regardless of whether a well child visit important next step in health reform to help sive payment tied to achieving NCQA levels of occurs. control costs and improve quality. Payers can certification for patient centered medical At the system level, interoperable elec - incentivize high value health care differently; homes). The most likely approach to paying

32 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 PRACTICING MEDICINE

for primary care will include some type of hy - varying opinions of the root causes of poor which is slightly lower than the national aver - brid approach (i.e., FFS +/ PPPM +/ P4P) or health outcomes exist, we cannot ignore the age. Just over 50 percent are insured either a comprehensive payment for medical serv - fact that the current health system is not par - through employers or private insurance and ices and medical home activities. ticularly effective in improving population about 33 percent have public insurance. Ex - Many experts agree that providers can level health, and even less so among those in panded coverage will not create improved ac - expect to be paid through comprehensive racial and ethnic subgroups. cess for the many Tennesseans who live in payments, particularly for primary care, and What implications do poor health out - areas with insufficient primary care capacity. bundled payments for episodes of care. In - comes have for costs of care? It’s generally ac - In addition, racial and ethnic subgroups are creasingly, private and public payers will seek cepted that it is more expensive to treat a less likely to get needed care even if they have to contract with accountable care organiza - sicker population due to a greater reliance on insurance. Creating a health system that pro - tions (ACOs) or large physician and hospital inpatient vs. ambulatory care. Tennessee vides equal access to high-value health care groups that can take responsibility for con - Medicare data shows one-quarter of heart can improve health for all Tennesseans. trolling costs while maintaining quality for the failure patients are readmitted within 30 days. full range of healthcare services. ACOs enable Further, Tennessee regional health plan data BUILDING CAPACITY FOR HEALTH payers to bundle payments across provider shows only about one-third of patients with a SYSTEM IMPROVEMENT IN settings for episodes of care. hospitalization for an ambulatory sensitive TENNESSEE chronic condition (ASCC) like diabetes re - There are currently unprecedented oppor - HEALTH CHALLENGES ACROSS TEN - ceive outpatient follow-up within 60 days. Ad - tunities in Tennessee to improve our health NESSEE ditionally, at least 10 percent of all hospital systems. Some assets that can be leveraged Tennessee is the second fattest state in the expenditures fall into a category of potentially to improve health systems are listed in the country, setting the stage for high rates of avoidable, demonstrating that major savings Table below. chronic lifestyle-related diseases. About one- could easily be achieved by redirecting funds Many of these opportunities are the re - third of Tennesseans have hypertension and wasted on repeated episodes of rescue care sult of federal and state programs that have high cholesterol. It surprises no one that one- toward more effective chronic disease man - received bipartisan support from the past and quarter of all deaths across the state are due agement in the ambulatory care setting. An - current administration. The TnREC (Ten - to heart disease and that Tennessee has the other example of a potentially low-hanging nessee HIT Regional Extension Center) is al - third-highest cerebrovascular death rate fruit for cost savings focuses on over-reliance ready working to assist providers in adopting across the country. And while the prevalence on drug therapy. According to the National electronic health records (EHR) and achiev - of diabetes is over 10 percent statewide, we Health Expenditures Data Set, Tennessee’s ing meaningful use. Meaningful use criteria know its prevalence is even higher in select prescription drug use per capita is the sec - will help drive EHR vendors to provide reg - communities across the state – in some pri - ond highest in the nation with total retail sales istry and related functions physicians need to mary care practices 25 percent of patients are of $6 billion in 2009. In addition, despite a manage population health more effectively. diabetic. Tennessee citizens also suffer from rate of 62 percent generic drug use, 75 per - Regional and statewide health information ex - serious health disparities. Recent research cent of total pharmacy expenditures can be changes (HIEs) are being developed that will demonstrates a six-fold increased likelihood attributed to brand name drugs. interface with EHRs to allow providers to find that African-Americans with diabetes living in Simply expanding coverage will not im - the information they need to care for patients Shelby County will experience a leg amputa - prove health for Tennesseans. Less than 15 when they need it. Other state-level initiatives tion over the course of their lifetime. While percent of our state population is uninsured, (Continued on page 44)

TABLE. Assets for Health System Improvement.

Program Lead Organization Website

Regional Extension Center program for Tennessee (TnREC) QSource, the Quality Improvement Organization for Tennessee http://www.tnrec.org

Statewide Health Information Exchange for Tennessee Health Information Partnership for Tennessee and the Tennessee http://www.hiptn.org Office of eHealth Initiatives http://news.tnanytime.org/ehealth Aligning Forces for Quality Healthy Memphis Common Table with support from the Robert www.healthymemphis.org Wood Johnson Foundation Regional Health Information Exchanges CareSpark (East Tennessee) http://www.carespark.com/dev MidSouth eHealth Alliance (West Tennessee) http://www.midsoutheha.org/

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 33

PRACTICING MEDICINE LOSS PREVENTION CASE OF THE MONTH

“My Stomach Hurts”

By J. Kelley Avery, MD 70-year-old healthy appearing slen - stresses along with the names of her other patient complaining of chest pain. No EKG Ader woman presented to the emer - physicians, including her primary care was performed on either day. No lab was ob - gency room on Friday evening physician and cardiologist. Again the GI tained for the initial visit or on the second complaining of “indigestion” with abdom - cocktail was administered and she was dis - visit. However, when the patient presented inal pain, epigastic and neck pain, some charged with reduced pain. Her blood the third time in the ambulance, her enzyme shortness of breath, and a burning feeling pressure on this visit was 181/116. labs were elevated. The blood pressure on in her throat. She gave a history of a stom - About two hours later, EMT was called the second day was 181/116 and attributed ach ulcer in the past. She complained of to the patient’s home after the daughter to “stress.” nausea and diarrhea with anxiety because found her mother unresponsive and called Although the outcome might have been of a stressful living situation, with a hus - 911. The patient was transported to the the same, the delay in beginning appropriate band in declining health for whom she is hospital, stabilized and transferred to a ter - treatment made this a difficult case to the major caregiver. tiary center. She had a 100-percent oc - defend. This case was settled in the mid The patient was examined by the emer - cluded small right coronary artery and six-figures. + gency room physician. The woman had aggressive treatment was begun. The fam - been a patient in the facility on previous oc - ily agreed to the DNR and she was pro - The Case of the Month is taken from ac - casions and her medical records were re - nounced dead about two hours later. tual Tennessee closed claims. An attempt quested. A GI cocktail was ordered based is made to fictionalize the material in on the assumption the patient was having a LOSS PREVENTION COMMENTS order to make it less easy to identify. If flare-up of her ulcer and other gastric Looking back on this scenario, we asked you recognize your own case, please be problems. The patient was given the GI how could two separate skilled emergency assured it is presented solely for empha - cocktail with Pepcid, Reglan and Ativan and room physicians on two subsequent days sizing the issues in discussion. felt immediately better. The physician noted miss the possibility that this lady was having the patient was not complaining of chest a cardiac event? As we know, GERD may pain. The patient was discharged with in - cause chest pain. Anxiety and stress cause structions to see her GI physician for fol - abdominal pain and indigestion. Patients low-up as soon as possible and to add with ischemia heart symptoms might be re - Maalox to the medications if she felt symp - lieved with GERD treatment. Two different toms again. There is no notation about the days, two opportunities missed equaled one review of previous records. bad event. The patient returned on Saturday This case reminds us of the importance morning complaining again of the pain, of hearing the complaints of the patient with both back and epigastric, and stated the GI an open mind. This patient was focusing on cocktail from the previous day had relieved her indigestion problems. The patient ap - her symptoms. Since it was the weekend peared to be healthy with no underlying car - she would not be able to see her GI physi - diac problems other than the hypertension. cian until Monday or Tuesday. Her pain was The medical records that detailed previous described as a 10 out of 10. The patient treatment for aortic insufficiency were not was accompanied by her daughter on the immediately available and probably not re - second visit who gave additional history viewed. The hospital had a standing order about the patient’s anxiety and recent for the triage nurse to obtain an EKG on any

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 35

SPECIAL FEATURES

Plan Your Steps to a Smooth ICD-10-CM Transition

By Ken Bradley

dvance planning is the key to ensuring STEP 3: PREPARE A TIMELINE AND IMPLE - cific staff training in the actual use of ICD-10 Ayour practice will be ready to imple - MENTATION PLAN codes should be done closer to the imple - ment the ICD-10 code sets by October Once the team knows where and how diag - mentation date. 1, 2013. If your practice is among the many al - nosis codes are used within your operations, Given all the pressing needs in your prac - ready stretching resources thin, early prepara - they should document detailed ICD-10 edu - tice today, October 2013 probably seems too tion takes on even greater importance. cational requirements and prepare a plan to distant to worry about. But this is one compli - Undoubtedly, you are well aware of the ensure use of ICD-10 codes by the 2013 dead - ance deadline that is likely to stand firm, be - magnitude of the ICD-10 conversion. It is not line. Staff educational needs should be as - cause many healthcare reform initiatives just another annual diagnosis code update. Ap - sessed and high-level cost estimates depend on the level of detail found in the ICD- plications throughout clinical, practice man - determined. 10 codes. Also, the federal government origi - agement and claims management systems must nally supported ICD-10 implementation be altered to fit an entirely new data format. STEP 4: IMPLEMENT TRANSITION PLAN earlier than 2013; it already has granted a Failing to meet the compliance date will When the team feels confident it fully under - deadline “extension” of sorts. result in delayed or denied reimbursement— stands the impact of the ICD-10 conversion, it The transition will not be quick or easy. one excellent motive to start preparations now. can then move forward allocating necessary One study by the Workgroup for Electronic But there are clinical reasons as well: consider time, personnel and financial resources. That Data Interchange (WEDI) and the North Car - all the healthcare advancement efforts in Ten - includes ensuring that all manual, hardware olina Healthcare Information and Communi - nessee, nationwide and globally that rest on and software systems are appropriately up - cation Alliance (NCHICA) said practices would data compiled using diagnosis codes. dated or replaced to handle ICD-10 codes need nearly 1,286 business days to complete Still, the ICD-10 transition does not need to (and to continue handling ICD-9 codes for a it. That is roughly 4.9 years. be overwhelming if you take time now to plan time). Consider building ICD-10 requirements Those of us who remember the similarly your approach: into any technology upgrades you are propos - monumental transition to National Provider ing for electronic health records, practice Identifiers (NPIs) can pass along a couple of STEP 1: ASSEMBLE A TRANSITION TEAM management systems or revenue cycle man - lessons. First, communication is key. Keep in Even the smallest practice needs to select staff agement solutions. If you purchase an EMR contact with payers and vendors about their responsible for shepherding the ICD-10 con - before the deadline, make sure your vendor own implementation and testing timelines. version. A solid team will include representa - contracts have language warranting timely up - Second, do not delay. A smooth transition de - tives from practice management, clinical, and dates in preparation for ICD-10 conversion. pends in large part on advance planning. + administrative staffs—including billing, regis - Try to negotiate the necessary update fees with tration, information systems (administrative your vendor, if any, on the front end as part of Mr. Bradley is vice president of Strategic and clinical, if they’re separate), clinical maintenance. Planning for Navicure, Inc. To learn how processes, and finance. In small practices, the Most experts agree the lion’s share of time Navicure can help ease your ICD-10 transi - team might consist of one or two people wear - and expense will be consumed by educational tion, contact him at 770-342-0210 or ing multiple hats. efforts because this change requires a com - [email protected]. plete understanding of the medical and Navicure, Inc., is a TMA Corporate STEP 2: IDENTIFY IMPACT anatomical concepts used most frequently in Partner. This information was supplied by The transition team’s first job is to identify all your office. Then, along with the ICD-10 cod - Navicure exclusively and for the benefit of places where diagnosis codes are used or ref - ing documentation, clinical notes will more ef - our members. The TMA does not accept re - erenced within your practice. An impact as - fectively be translated into an accurate ICD-10 sponsibility for the information provided. sessment of all stakeholders—as well as code. I highly recommend that transition team information/technology systems—must be members attend conferences and webinars to conducted. understand the basic concepts of ICD-10. Spe -

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 37

SPECIAL FEATURES

Saving Money on Supplies – A GPO Strategy

By Kathy Spratt

hile few physician offices have price is loaded, it stays in place for an ex - how much we saved with medical gas, we Wa centralized purchasing effort tended period of time that can range from got to thinking about office supplies and similar to hospitals, it is still one to five years. There are also limits on we were able to get hand towels for 50 possible for a physician office to utilize a distributor markup on contracted items percent less….I wish I’d discovered all strategy that results in significant savings. based on your annual spending with that our GPO could do for us last year, we Few practices know that the same con - distributor, so savings can come not just could have saved a lot more money.” 1 tracts available to hospital purchasing de - from the discounted product cost but also partments are also available to them. A from lower distributor margin and, in WHAT DOES A GPO MEMBERSHIP COST? necessary part of this strategy is member - some cases, there are also rebates on se - GPO membership is easy to obtain but it ship in a Group Purchasing Organization lect items. does require a minimal investment of (GPO). Even if a GPO is already used in a your time. Once you join, remind your physician office, it is often the case that WHERE ARE THERE GPO SAVINGS? vendors (distributor or manufacturer) not all of its contracts are utilized to their GPO discount pricing affects every day which GPO you are with and don’t be full benefit.every impermissible use or clinical purchases along with capital afraid to ask your vendors for GPO pric - disclosure. equipment, laboratory services, environ - ing. Remember, whether it is reagents, mental services (items such as toilet contrast media, needles and syringes, toi - WHY AREN’T GPO CONTRACTS BETTER paper, c-fold towels and cleaning prod - let paper or cell phones, there is a dis - USED IN PHYSICIAN OFFICES? ucts), gas, suture, injectables and vac - count awaiting your practice. + Often, GPOs are confused with clinical cines, and diagnostic imaging supplies distributors. Your distributor delivers (like contrast media). But there are also References: products and a GPO negotiates lower savings in less obvious categories like of - 1. O’Conner D: Secrets to saving with your GPO. Find pricing on your behalf directly with the fice supplies, computers, waste manage - out how to get your money’s worth. Outpatient manufacturers of those products. ment, shredding, office refreshments, Surg, Oct 2008. Whereas hospitals receive automated landlines and cell phones, Yellow Pages downloads of contract pricing and up - advertising, and uniforms. Ms. Spratt is a supply chain analyst with dates, practices must actively manage In an Outpatient Surgery magazine ar - DoctorsManagement, LLC, in Kingsport, TN. their contract connections and pricing ticle, this example was used: “The Surgery Contact her at 800-635-4040, ext. 194, or through more interaction with their dis - Center of Centralia, IL, used to pay $22 [email protected]. tributor and their GPO account manager. per oxygen tank. Now it pays $6 per DoctorsManagement, LLC, is a TMA Since a typical practice manager or nurse tank….The ASC, which hosts 80 to 100 Corporate Partner. This information was has so many responsibilities, these pur - cases a month, goes through about three supplied by DoctorsManagement exclusively chasing discounts become less important. oxygen tanks per week, which projects to and for the benefit of our members. The TMA However, a knowledgeable practice real - a yearly savings of $2,300 a year.” Ac - does not accept responsibility for the infor - izes that GPO membership is the key to cording to Jason Fischer, RN, BSN, ASC fa - mation provided. long-term price protection. Once a GPO cility director, “As we got excited about

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 39

THE JOURNAL ORIGINAL CONTRIBUTION

Correlates and Predictors of Physical Inactivity among Tennessee Adults

By Peter D. Hart, MA; Tiago V. Barreira, PhD; and Minsoo Kang, PhD

ABSTRACT same chronic conditions. A position no leisure-time physical activity (LTPA) The purpose of this study was to investi - statement by the World Health Organiza - among Tennessee adults. A secondary gate the sociodemographic predictors and tion (WHO) and International Society purpose was to investigate the health-re - health-related correlates of no leisure- and Federation of Cardiology stated the lated correlates of no LTPA among the time physical activity (LTPA) in a repre - relationship between physical inactivity same population, while controlling for sentative sample of Tennessee adults. Data and coronary heart disease was in fact confounding variables. from 5,024 adults participating in the “plausible,” “biologically graded,” “ap - 2008 Tennessee Behavioral Risk Factor propriately sequenced,” “strong,” and MATERIALS AND METHODS Surveillance System (BRFSS) were used “consistent.” 2 Moreover, the report noted Survey: Data from 5,024 adults partici - for the analysis. Overall, 28.9 percent of that the most inactive people have almost pating in the 2008 Tennessee Behavioral Tennessee adults (26.2 percent of men twice the risk as their most active coun - Risk Factor Surveillance System (BRFSS) and 31.4 percent of women) reported no terparts. were used for the analysis. The BRFSS is LTPA. The sociodemographic predictors Despite the benefits that can be an annual cross-sectional random-digit of no LTPA were age, race, and education. achieved by being physically active, a telephone survey of non-institutionalized No LTPA was a useful predictor of health large percentage of U.S. adults remains U.S. adults 18 years of age and older. The status markers such as self-report health, physically inactive. 3 The Department of purpose of the BRFSS was to collect state- obesity, smoking, and cardiovascular dis - Health and Human Services has ac - specific information on the most common ease. This study found that selected so - knowledged this relationship and devel - health behaviors associated with the lead - ciodemographic characteristics were oped a set of objectives, contained in ing causes of premature death. To date, adequate predictors of no LTPA among Healthy People 2010 , designed to reduce the BRFSS is administered in each of the Tennessee adults. Also, the absence of physical inactivity. Specifically, the pri - 50 states as well as the District of Colum - LTPA was found to be a significant predic - mary objective is to reduce the preva - bia and U.S. Territories. tor of health status. lence of physical inactivity from 40 percent to 20 percent. 4 Tennessee is a Measures: The sociodemographic vari - state with high rates of chronic disease. 5 ables used were age (18-29 yr, 30-44 yr, INTRODUCTION In addition, when examining state-spe - 45-64 yr, 65-74 yr, 75+ yr), race (white, The health benefits received for partici - cific estimates of physical inactivity, Ten - black, Hispanic, other), and education (< pating in physical activity are uncon - nessee has ranked second, eighth, and high school graduate, high school gradu - tested. For just moderate amounts of fifth in the nation in prevalence of physi - ate, some college, college graduate). Five physical activity, adults can expect a re - cal inactivity in 2007, 2008 and 2009, re - health-related variables were used as sep - duced risk of all-cause mortality. Addi - spectively. 6 arate dependent variables. Self-reported tionally, physical activity is associated In order to decrease the prevalence health was assessed by asking the partic - with a reduced risk of both morbidity and of physical inactivity, a better under - ipant for their own opinion regarding mortality related to coronary heart dis - standing is needed of the physically inac - their health. Those who reported “good,” ease, cancer, stroke, and diabetes melli - tive population. Therefore, the purpose “very good” or “excellent” were grouped tus. 1 In contrast, physical inactivity is of this study was to investigate the multi - together and compared to those who re - associated with an increased risk of these variable sociodemographic predictors of ported “fair” or “poor.” Self-reported sat -

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 41 THE JOURNAL

isfaction with life was assessed by asking the participant about their general satis - TABLE 1. Prevalence of No LTPA by Sociodemographic Characteristics Among TN Adults. * faction with life. Those reporting “satis - fied” or “very satisfied” were grouped Men Women together and compared to those who re - No LPTA SE 95% Cl No LPTA SE 95% Cl ported “dissatisfied” or “very dissatis - fied.” Obesity was assessed by Overall Age (years) 26.2 1.78 22.69 - 29.68 31.4 1.13 29.22 - 33.66 self-reported height and weight measures 18-29 15.2 4.00 7.31 - 23.00 15.4 3.30 8.91 - 21.85 converted to a Body Mass Index (BMI) 30-44 26.5 4.09 18.50 - 34.56 30.2 2.41 25.48 - 34.91 measure. A participant was considered 45-64 28.6 2.03 24.66 - 32.63 33.1 1.56 30.04 - 36.17 obese if their BMI was greater than or 65-74 29.3 2.99 23.42 - 35.16 36.6 2.46 31.82 - 41.47 equal to 30.0 kg/m 2 and considered not 75+ 33.8 4.15 25.62 - 41.88 45.5 2.71 40.18 - 50.80 obese if their BMI was less than 30.0 kg/m. 2 Smoking status was assessed by Race asking a combination of two questions re - White 26.1 1.59 23.01 - 29.27 29.8 1.17 27.56 - 32.14 garding the total amount of cigarettes Black 21.0 4.10 12.98 - 29.08 43.2 3.85 35.63 - 50.73 smoked in lifetime and whether or not the Hispanic 59.4 17.32 25.42 - 93.35 23.7 7.09 9.79 - 37.59 participant currently smokes. Those who Other 14.4 5.71 3.23 - 25.64 19.9 5.92 8.33 - 31.56 reported smoking at least 100 cigarettes in their lifetime and reported currently Education smoking everyday or some days were con - College Grad 16.7 2.78 11.25 - 22.17 18.1 1.94 14.26 - 21.87 sidered a smoker and those who reported Some College 19.2 2.45 14.43 - 24.02 25.6 2.18 21.34 - 29.89 smoking at least 100 cigarettes in their High School 31.9 3.59 24.88 - 38.98 36.4 1.85 32.73 - 39.98 lifetime and reported not currently smok -

42 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 THE JOURNAL

mographic predictors of no leisure-time TABLE 2. Odds of No LTPA by Sociodemographic Characteristics Among TN Adults. * physical activity (LTPA) and to investigate the health-related correlates of no LTPA Men Women among Tennessee adults. OR 95% Cl OR 95% Cl The results of this paper suggest that knowledge of certain sociodemographic Age (years) information is predictive of physical inac - 18-29 1.00 1.00 tivity among Tennessee adults. For in - 30-44 2.18 1.06-4.50 2.56 1.53-4.27 stance, age is positively related with no 45-64 2.78 1.43-5.40 2.70 1.67-4.36 LTPA, with the odds of no LTPA at their 65-74 2.54 1.26-5.15 2.90 1.73-4.85 highest in the oldest age groups for both 75+ 3.16 1.50-6.67 3.80 2.24-6.44 men and women. These findings are con - sistent with national survey results. A re - Race port from the Centers for Disease Control White 1.00 1.00 and Prevention (CDC) showed the most in - Black 0.71 0.41-1.23 2.17 1.54-3.06 active U.S. adults were those in the oldest Hispanic 3.99 1.11-14.30 0.80 0.38-1.68 age groups, for both men and women. 7 Other 0.47 0.19-1.17 0.80 0.40-1.60 This age-related pattern is of particular concern, considering the aged population Education is the fastest growing segment in the U.S. 8 College Grad 1.00 1.00 Within race groups, Hispanic men were al - Some College 1.23 0.74-2.04 1.55 1.11-2.17 most four times as likely to report no LTPA High School 2.37 1.48-3.81 2.52 1.87-3.39 when compared to white men, while all

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counterparts. No LTPA was correlated with caused respondents to suffer poor health 5. U.S. Centers for Disease Control and Prevention satisfaction with life, with greater odds of status. Despite these limitations, this study (CDC): Tennessee: Burden of Chronic Disease. being dissatisfied (three times for men and has strengths in its use of a large sample National Center for Chronic Disease Prevention two-and-a-half times for women) among size and its ability to generalize to all non- and Health Promotion, 2008. those who are inactive. Satisfaction with institutionalized adults in Tennessee. 6. Centers for Disease Control and Prevention life is a measure often used to assess one’s (CDC): Behavioral Risk Factor Surveillance Sys - quality of life and has been shown to be CONCLUSION tem Survey Data. Atlanta, GA: U.S. Department of positively correlated with physical activity. This study found that selected sociodemo - Health and Human Services, Centers for Disease No LTPA was correlated with obesity, graphic characteristics were adequate pre - Control and Prevention, 2006-08. Available at with greater odds of being obese (approx - dictors of no LTPA among Tennessee adults. http://apps.nccd.cdc.gov/brfss . Accessed Oct 19, imately one-and-a-half times for both men Also, no LTPA was found to be a significant 2009. and women) among those who are inac - correlate of health status. The results of this 7. U.S. Centers for Disease Control and Prevention tive. Obesity itself is a major risk factor for paper should be used to help plan physi - (CDC): Trends in leisure-time physical inactivity chronic disease and premature death. Ten - cal activity health education and promotion by age, sex, and race/ethnicity—United States, nessee adults who reported no LTPA were programs among Tennessee adults. + 1994-2004. MMWR Morb Mortal Wkly Rep also more likely to be current smokers. 54(39):991-94, 2005. Smoking is another independent risk factor References: 8. Wright JD: The Graying of America: Implications for chronic disease and clusters itself with 1. United States Department of Health and Human for Health Professionals. Care Manag J 6(4):178- other negative health behaviors such as no Services: 2008 Physical Activity Guidelines for 84, 2005. LTPA. And finally, those who reported no Americans. Washington, DC: US Department of 9. Marshall SJ, Jones DA, Ainsworth BE, et al.: Race/eth - LTPA were twice as likely to report some Health and Human Services, 2008. Available at nicity, social class, and leisure-time physical inactiv - form of cardiovascular disease. http://www.health.gov/paguidelines/ . Accessed ity. Med Sci Sports Exerc 39(1):44-51, 2007. The results of this study have several Oct 19, 2009. 10. U.S. Centers for Disease Control and Prevention limitations. The BRFSS does not survey in - 2. Bijnen FC, Caspersen CJ, Mosterd WL: Physical in - (CDC): Trends Prevalence of Regular Physical stitutionalized adults, a population known activity as a risk factor for coronary heart disease: Activity among Adults—United States, 2001- to be more sedentary and less healthy, and a WHO and International Society and Federation 2005. MMWR Morb Mortal Wkly Rep may have biased our results toward the of Cardiology position statement. Bull World Hlth 56(46):1209-12, 2007. null. The study also relied on self-reported Org 72(1):1-4, 1994. information from the respondents. This 3. Haskell WL, Lee IM, Pate RR, et al.: Physical ac - Mr. Hart and Mr. Barreira are research assis - may have had some influence on the re - tivity and public health: Updated recommendation tants, and Mr. Kang is the director of the Ki - spondents’ answers regarding cardiovas - for adults from the American College of Sports nesmetrics Laboratory, Department of Health cular disease and therefore a cause of Medicine and the American Heart Association. and Human Performance, Middle Tennessee misclassification of unhealthy adults. Fi - Med Sci Sports Exerc 39:1723-1434, 2007. State University, Murfreesboro, TN. nally, the cross-sectional nature of the 4. U.S. Centers for Disease Control and Prevention For reprints, contact Mr. Hart at 1500 study does not allow for cause-and-effect (CDC): Healthy People 2010: understanding and Greenland Drive, PO Box 96, Murfreesboro, generalizations. In particular, these results improving health, 2nd ed. Washington, DC U.S. TN 37132 (address), phone: (615) 788- are unable to show that physical inactivity Government Printing Office, 2000. 3712; e-mail: [email protected].

HEALTH SYSTEM IMPROVEMENT (Continued from page 33) like the creation of an all-payer database are SUMMARY Ms. Nault is a PhD student in the Depart - an additional resource that can eventually be In conclusion, opportunities and challenges ment of Health Outcomes & Policy Re - shared throughout regions. And multi-stake - exist in our state for making meaningful search, Division of General Internal holder collaboratives like the Healthy Mem - change in our health system. Much is at stake Medicine, University of Tennessee Health phis Common Table foster the collaboration for all Tennesseans. We must learn from oth - Science Center. Dr. Bailey is a professor of needed to support regional health system im - ers as well as innovate our own solutions to Medicine, Division of General Internal provement efforts. The coordination of multi- the challenges ahead. Most importantly, we Medicine, University of Tennessee Health stakeholder, health improvement must step outside our comfort zone and work Science Center, Memphis, TN. collaboratives in each of the grand regions of together to achieve success. + The authors gratefully acknowledge the Tennessee also holds potential for heightened support provided by the Healthy Memphis regional and statewide cooperation required Common Table and its partners. in order to achieve meaningful change in our For reprints, contact Ms. Nault at 956 healthcare environment. Court Avenue, Coleman D224B, Memphis TN 38163; phone: 901-448-2476; email: 44 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 [email protected]. THE JOURNAL ORIGINAL CONTRIBUTION

Smoking Cessation: Barriers to Success and Readiness to Change By Alexander B. Guirguis, PharmD, BCPS; Shaunta’ M. Ray, PharmD, BCPS; Michelle M. Zingone, PharmD, BCPS, CDE; Anita Airee, PharmD, BCPS; Andrea S. Franks, PharmD, BCPS; and Amy J. Keenum, PharmD, DO

ABSTRACT ing should focus on helping patients re - There is a need to recognize factors linked Background and Objectives: Smok - solve barriers to cessation and reasons for to early discontinuation of tobacco cessa - ing cessation interventions should be indi - relapse, particularly stress and weight man - tion pharmacotherapy and contributions to vidualized based on patient history and agement. Pharmacotherapy should be uti - tobacco use relapse. Literature is limited in readiness for change. The objective of this lized when patients are ready to quit. describing motivation for cessation, barri - study was to assess stages of change and Increased intratreatment social support ers to cessation attempts, use of tobacco key components of smoking and cessation and counseling appear warranted to sup - cessation pharmacotherapy, and reasons history among a sample of primary care port behavior change and appropriate for relapse among tobacco dependent pa - patients. medication use. tients. Roddy et al. 3 found that within a sam - pling of patients in the United Kingdom, Methods: A telephone survey of current common barriers to utilization of tobacco or recent smokers identified smoking sta - INTRODUCTION cessation services included fear of judg - tus, stage of change, motivation, concerns, Cigarette smoking is the leading cause of ment, fear of failure, lack of knowledge of relapse history, pharmacotherapy, and so - preventable death in the United States re - services, and a perception that pharma - cial support. sulting in over 443,000 deaths annually. 1 cotherapy was ineffective or unsafe. The In 2009, an estimated 20.6 percent of transtheoretical model of change (TTM) Results: Of 150 participants, most were adults in the United States (46.6 million) can be used to individualize tobacco cessa - within precontemplation (22.7 percent) or were current cigarette smokers, indicating tion strategies based on an individual pa - contemplation (44.0 percent) stages of no change in smoking prevalence since tient’s readiness for behavior change. The change; 14.0 percent were in preparation, 2005. 1 Based on current trends, the TTM established a continuum of stages, in - 4.7 percent in action, and 14.7 percent in Healthy People 2010 objective of reducing cluding precontemplation, contemplation, maintenance. The primary motivation for cigarette smoking prevalence among U.S. preparation, action, and maintenance. 4-6 quitting was to improve general health adults to ≤ 12 percent will not be met. 1 Cig - The objectives of this study were to as - (42.3 percent). The most common cessa - arette smoking has been recognized as a sess patient barriers to smoking cessation tion-related concerns were: breaking the chronic disease that often requires re - and tobacco cessation pharmacotherapy habit, stress, and weight gain. Pharma - peated interventions for successful absti - and reasons for treatment failure or re - cotherapy was discontinued due to adverse nence. 2 Some patient-specific factors lapse, between current smokers and non - events in 31.5 percent of users. Intratreat - linked to higher abstinence rates include smokers. We sought to classify patients by ment social support was reported by 17.5 high motivation, readiness to quit within their current stage of change and then de - percent. The most common reasons for re - one month, confidence in one’s ability to scribe patient perceptions regarding pre - lapse were falling back into the habit (36 quit, and extratreatment social support. 2 vious quit attempts, including reasons for percent), stressful situations (27 percent), Tobacco cessation pharmacotherapy is fre - relapse and nonadherence with tobacco and being around other smokers (25 per - quently discontinued before the recom - cessation pharmacotherapy. cent). mended duration of therapy because of associated adverse effects and barriers to METHODS Conclusions: Targeted interventions are use. 2 Medication misconceptions and bar - Design, Setting and Participants: needed for patients in either precontem - riers to appropriate use are identified as Participants were recruited from two pri - plation or contemplation stages. Counsel - targets for research. 2 mary care practices affiliated with an aca -

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demic medical center in East Tennessee support. Race was obtained by patient self- nician. If patients received supportive during the summer of 2008. Patients were report. Smoking status assessment ad - counseling, they were asked to identify the identified by international classification of dressed the number of cigarettes per day source of counseling and frequency of ses - diseases (ninth revision) code 305.1 or and total years of smoking. Stage of change sions. Extratreatment social support was documented smoking history at an aca - was assessed by asking participants their defined as that provided outside of the ces - demic family medicine residency clinic and intentions regarding smoking cessation (or sation-related treatment (i.e., from family at a physician practice. how long it had been since quitting, if ap - or friends). Participants rated their extra - Before the initiation of telephone sur - plicable). TTM stages of change were cat - treatment social support using a 10-point veys, information was obtained from each egorized as follows: 6 precontemplation was Likert-scale, with 10 representing the most clinic site to compare overall payer mixes. no intent to quit within the next six months; support and one (1) representing no sup - In the family medicine residency clinic, contemplation was intent to quit within the port. nearly 50 percent of patients have next six months; preparation was intent to Categorical variables were analyzed Medicare as a payer source, over 20 per - quit within 30 days with behavioral steps using chi-square tests to assess differences cent have state Medicaid (TennCare) and toward action; action was cessation for less between current smoker and nonsmoker three percent are self-pay, with the rest than six months; and maintenance was ces - groups. A Mann-Whitney U test was per - consisting of private insurances. In com - sation for six months or longer. The num - formed to analyze rank data. parison, the physicians’ practice has a ber of quit attempts and most recent quit payer mix of approximately 18 percent attempt date were also ascertained. RESULTS Medicare, four percent TennCare, and Motivation for the most recent quit at - An attempt was made to contact 248 sub - three percent self-pay, with the remainder tempt was asked as an open-ended ques - jects, and 150 participants completed the being private insurances. tion, then categorized as: general health survey (response rate of 60.5 percent). All patients 18 years of age or older (including that of family members); major Subjects were excluded for the following with a diagnosis of tobacco dependence or minor changes in health; social or fam - reasons: invalid phone number (n = 35); within the past year from the date of list ily pressure; cost; pregnancy; or none (re - unreachable within three call attempts (n generation were eligible for inclusion. A list spondents could select multiple choices). = 33); refusal to participate (n = 28); in - of all eligible patients was compiled and Major changes in health were defined as eligibility (n = 2). There was a significant sorted using a random number generator. hospitalization, myocardial infarction, sur - difference in age of participants between Patients were excluded if they did not have gery, or cancer. Minor changes in health the two clinic sites (49.8 years at the physi - adequate means of telephone contact, were defined as recent smoking-related ill - cians’ practice clinic versus 56.0 years at could not be reached within three attempts, ness not requiring hospitalization or emer - the family medicine resident clinic; used tobacco products other than ciga - gent care. Patients were asked to choose p=0.002). No significant differences were rettes, did not speak English or declined from a list of cessation-related concerns in - detected between practice sites with regard participation. Participant enrollment con - cluding stress management, weight gain, to race, sex, smoking status and TTM stage tinued until 75 patients from each site fear of failure, withdrawal, habit, or other of change (data not shown). Participant (total 150) completed the questionnaire. (respondents could select multiple characteristics, grouped by smoking status, The study was approved by the appropri - choices). Additionally, patients were asked are summarized in Table 1. ate institutional review boards. to select from the following reasons for re - Table 2 includes summary data on mo - lapse: stressful situations; weight gain; tivations for quit attempt. Of 138 (92.0 per - Data Collection & Outcome Meas - withdrawal; habit; being around other cent) participants who had reported at ures: Participant-related data were docu - smokers; living with a smoker; or other least one past quit attempt, 58 (42.0 per - mented using a standardized survey. Age (respondents could select multiple cent) reported their motivation to quit was and sex were obtained from the medical choices). Medication assessment included to improve general health, followed by 29 record. Research assistants contacted par - agent(s) used, dose, frequency, duration of (21.0 percent) who were motivated due to ticipants by phone and obtained verbal use, timing of initiation of agent(s) in rela - a minor change in health, and 17 (12.3 consent using a standardized script. The tion to cessation attempt, reason for dis - percent) who were motivated following a survey was designed to take seven to 10 continuation of agent(s), and adverse major change in health. Among all partici - minutes to complete and included ques - effects. The 2008 guidelines 2 were used to pants, inability to break the habit, stress tions pertaining to: patient demographics; define recommended treatment durations management and weight gain were identi - smoking status; TTM stage of change; his - and timing of cessation attempt relative to fied as primary concerns regarding quit at - tory of quit attempts; motivation for cessa - drug initiation. All questions pertaining to tempts by 56 (37.3 percent), 50 (33.3 tion; cessation-related concerns; relapse medication use were open-ended; answers percent), and 45 (30.0 percent) partici - history; tobacco cessation pharmacother - were categorized by investigators. Intra - pants, respectively (Table 3). Reasons for apy used in most recent quit attempt; and treatment social support was defined as relapse among participants with history of intratreatment and extratreatment social counseling and support provided by a cli - any quit attempts are summarized in Table

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smoking at the time of the survey. TABLE 1. Patient Characteristics. Occurrence of adverse events (23 of 73, 31.5 percent) was the most common Category Current Smokers (%) Current Nonsmokers (%) reason for discontinuation of tobacco ces - n = 121 n = 29 sation pharmacotherapy, followed by per - Mean age (years)* 52.10 56.07 ceived lack of efficacy (13 of 73, 17.8 Female* 79 (65.29) 18 (62.07) percent). Adverse event discontinuation Race rates for nicotine replacement therapy, Nonwhite* 19 (15.70) 1 (3.45) bupropion, varenicline, and varenicline Smoking history plus nicotine replacement therapy were six Mean duration of smoking (years)* 31.48 32.52 (21.4 percent), two (25.0 percent), 10 Mean number of quit attempts* 45.43 39.64 (33.3 percent), and five (83.3 percent), Participants reporting no prior quit attempts (%)* 13 (10.74) 0 (0) respectively. Nausea was the most common Stage of change adverse event reported, which occurred in Precontemplation 34 (28.10) 0 (0) 18 subjects overall. Among varenicline Contemplation 67 (55.37) 0 (0) users, 10 of 12 (83.3 percent) who re - Preparation 20 (16.53) 0 (0) ported nausea discontinued medication Action 0 (0) 7 (24.14) due to this adverse event. Maintenance 0 (0) 22 (75.86) Twenty-one (14.0 percent) of all par - *p>0.05; **p<0.05 ticipants reported receipt of intratreatment social support counseling to aid in smok - ing cessation; there was no difference in TABLE 2. Motivation for Last Quit Attempt; response to: the proportion of smokers versus non - “What made you want to quit smoking the last time you tried to quit?” smokers receiving such support (p=0.971). Of those who received intra - Current Smoker Current Nonsmoker P-value treatment social support, the mean num - n = 109 (%) n = 29 (%) ber of counseling sessions was 4.7 (range General health 45 (41.28) 13 (44.83) 0.731 1–60). Ten participants (7.3 percent) re - Major change in health 15 (13.76) 2 (6.90) 0.317 ported having received at least two ses - Minor change in health 19 (17.43) 10 (34.48) 0.045 sions, while six (4.4 percent) participants Social pressure 4 (3.67) 1 (3.45) 0.955 reported receipt of more than eight ses - Family pressure 5 (4.59) 2 (6.90) 0.614 sions. The median rating for extratreatment Cost of tobacco products 13 (11.93) 0 (0) 0.040 social support was nine among nonsmok - Nothing 8 (7.34) 2 (6.90) 0.935 ers and six among current smokers. No Pregnancy 1 (0.91) 0 (0) 0.605 significant difference was detected in rank - Other 12 (11.01) 1 (3.45) 0.194 ing of extreatment social support among Participants could report more than one reason. smokers versus nonsmokers (Mann-Whit - ney U=1393.5, p=0.074). 4. Falling back into the habit, being around the product before completing six weeks other smokers, and stressful situations of therapy, and 13 (44.8 percent) did not DISCUSSION were the most commonly documented rea - attempt to stop smoking completely upon In this sampling of current or recent smok - sons for relapse. initial application. Among 35 varenicline ers, nearly half were within the contempla - Among 109 current smokers who re - users, 24 (68.6 percent) discontinued the tion stage of change. Targeted interventions ported at least one quit attempt, 60 (55.0 drug before completing 12 weeks of ther - are needed for promoting behavior change percent) used tobacco cessation pharma - apy, while only 10 (28.6 percent) tried to in this particular stage, as it appears com - cotherapy during their last quit attempt, stop cigarette use one week after starting mon for smokers to remain within it for compared with 13 of 29 (44.8 percent) the drug. Two participants who used the prolonged periods without progress. In ac - current nonsmokers (p=0.327). Ten of 73 nicotine patch and four who used vareni - cordance with the TTM, the goal should be (13.7 percent) tobacco cessation pharma - cline reported complete adherence to the to advance each individual to the next stage cotherapy users used combination drugs in regimen when accounting for dosing fre - of change rather than to attempt to bring their last quit attempt; five of these patients quency, usual duration of use, and time to about immediate behavior change. In a received varenicline in combination with cessation attempt following pharmacother - previous study of current smokers, the dis - nicotine replacement therapy. apy initiation. Five of the six participants tribution of subjects within precontempla - Twenty-three (79.3 percent) of 29 who reported complete adherence to ei - tion, contemplation, and preparation were nicotine patch users discontinued use of ther nicotine patch or varenicline were still approximately 40 percent, 40 percent, and

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20 percent, respectively. 7 Among current smokers in our population, the propor - TABLE 3. Worries about Quitting; response to: tions in comparison were 28 percent, 55 “What worried/worries you about trying to quit smoking?” percent, and 17 percent, respectively. Our survey did not assess socioeconomic status Current Smoker Current Nonsmoker P-value indicators, such as income or education n = 121 (%) n = 29 (%) level. However, disparities linked to so - Stress 43 (35.54) 7 (24.14) 0.242 cioeconomic status or education level may Weight gain 33 (27.27) 12 (41.38) 0.137 contribute to smokers’ readiness to quit Fear of failure 21 (17.36) 7 (24.14) 0.400 and eventual success in smoking cessa - Withdrawal 34 (28.10) 7 (24.14) 0.667 tion. 8,9 Habit 48 (39.67) 8 (27.59) 0.227 Concern over stress management was Other 22 (18.18) 8 (27.59) 0.255 a leading challenge to attempting smoking Participants could report more than one worry about quitting. cessation within our study sample; stress was also among the top reasons reported for relapse. Based on these findings, we be - TABLE 4. Reasons for Relapse in Prior Quit Attempt; response to: lieve efforts need to be intensified by pro - “Why did you restart smoking?” viding patients preparing to quit a structured set of counseling sessions. Such Current Smoker Current Nonsmoker P-value sessions should include preemptive indi - n = 109 (%) n = 29 (%) vidualized stress management strategies Dealing with stress 53 (48.62) 10 (34.48) 0.174 during the cessation process. To avoid/limit weight gain 13 (10.74) 2 (6.90) 0.439 Although clinical practice guidelines To avoid withdrawal 7 (6.42) 1 (3.45) 0.543 recommend pharmacotherapy for tobacco Fell back into habit 36 (29.75) 7 (24.14) 0.358 cessation attempts, fewer than 49 percent Being around other smokers 27 (22.31) 7 (24.14) 0.944 of participants used medication in their Living with a smoker 13 (10.74) 5 (17.24) 0.450 most recent quit attempt. Of the 73 partic - Other 24 (22.02) 7 (24.14) 0.808 ipants who used a medication cessation Respondents could report more than one reason for relapse. aid, only six (8.2 percent) used the med - ications according to package labeling. Additionally, these findings may suggest treatment social support. Twelve (16.4 per - This study was not designed to determine a need for improved medication counsel - cent) patients who used tobacco cessation the cause of this finding; however, partici - ing for those patients starting tobacco ces - pharmacotherapy also received intratreat - pants in our study had higher early dis - sation pharmacotherapy. Although ment supportive counseling. The one pa - continuation rates than those reported in conclusive comparisons are limited espe - tient who received 60 counseling sessions clinical trials. Our study population had cially by relatively low numbers of subjects was using the state-funded tobacco cessa - discontinuation rates due to adverse events in our study, the discontinuation rates of tion quit line and was smoke-free at the of 21.4 percent (nicotine replacement tobacco cessation pharmacotherapy ap - time of the survey. The 2008 guidelines 2 therapy), 25.0 percent (bupropion), 33.3 peared notably higher than those typically recommend the use of medication in com - percent (varenicline), and 83.3 percent reported in clinical trials. Reasons may be bination with counseling to improve absti - (varenicline plus nicotine replacement multifactorial but, as noted in our partici - nence rates. Estimated abstinence rates therapy). Other trials have reported dis - pants, these may include inappropriate increase when tobacco cessation pharma - continuation rates due to adverse events of drug combinations (varenicline plus nico - cotherapy is combined with two or three 4.3–6.6 percent (nicotine patches), 12.6– tine replacement therapy and varenicline counseling sessions (28.0 percent; 95 per - 15.9 percent (bupropion), and 8.0–14.3 plus bupropion), and prolonged time to cent CI 23.0 – 33.6), with the highest ab - percent (varenicline). 10-13 Some patients cessation attempt following product initia - stinence rates after more than eight were prescribed the inappropriate med - tion. Based on our data, it cannot be as - counseling sessions (32.5 percent; 95 per - ication combination of varenicline plus certained if inadequate pharmacotherapy cent CI 27.3 – 38.3). nicotine replacement therapy. Low rates of counseling led to higher than expected dis - There appears to be an association be - medication use, inappropriate medication continuation rates. tween the perceived levels of extratreat - combinations, nonadherence, and high Successful smoking cessation attempts ment social support and successful quit rate of adverse events with premature dis - may require a multifaceted approach that attempts. Those participants who rated ex - continuation suggest a need for improved includes prevention of withdrawal symp - tratreatment social support > 6 were patient and provider education related to toms using pharmacotherapy, behavioral nearly twice as likely to quit as those who pharmacotherapy for smoking cessation. counseling, and intratreatment and extra - rated it < 5. Because recent evidence sug -

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gests that interventions are ineffective in in - bacco Use and Dependence: 2008 Update. Clinical 13. Aubin HJ, Bobak A, Britton JR, et al.: Varenicline creasing extratreatment social support, 14,15 Practice Guideline. Rockville, MD: U.S. Depart - versus transdermal nicotine patch for smoking the current tobacco dependence guidelines ment of Health and Human Services. Public Health cessation: results from a randomized open-label no longer recommend interventions fo - Service, May 2008. trial. Thorax 63(8):717-24, 2008. cused in this area. 2 3. Roddy E, Antoniak M, Britton J, et al.: Barriers and 14. May S, West R: Do social support interventions motivators to gaining access to smoking cessation (“buddy systems”) aid smoking intervention for Strengths and Limitations: services amongst deprived smokers – a qualitative smoking cessation? A review. Tobacco Control Our questionnaire design is unique in that study. BMC Health Serv Res 6:147, 2006. 9:415-22, 2000. it combines data collection on participant- 4. Prochaska JO, Velicer WF: The transtheoretical 15. Park EW, Schultz JK, Tudiver R, et al.: Enhancing reported barriers to smoking cessation, model of health behavior change. Am J Health partner support to improve smoking cessation. stages of change, and tobacco cessation Prom 12(1):38-48, 1997. Cochrane Database Syst Rev (3):CD002928; DOI: pharmacotherapy utilization. Limitations to 5. DiClemente CC, Prochaska JO, Fairhurst SK, et al.: 10.1002/14651858.CD002928.pub2, 2004. this study include small sample size, re - The process of smoking cessation: an analysis of liance on participant self-reported point precontemplation, contemplation, and prepara - Drs. Guirguis, Airee and Zingone are as - prevalence of smoking abstinence (bio - tion stages of change. J Consul Clinical Psychol sistant professors with the Department chemically unverified), and exclusion of 59(2):295-304, 1991. of Clinical Pharmacy, University of Ten - participants without phone access or who 6. Glanz K, Rimer BK, Lewis FM (eds.): Health be - nessee College of Pharmacy. Dr. Keenum did not speak English. We also lacked so - havior and health education: theory, research, and is an associate professor with the De - cioeconomic and educational data on pa - practice. 3rd ed. San Francisco, Jossey-Bass, partment of Family Medicine, University tients surveyed. 2002. of Tennessee Graduate School of Medi - 7. Velicer WF, Fava JL, Prochaska JO, et al.: Distribu - cine. Dr. Ray is an assistant professor CONCLUSION tion of smokers by stage in three representative and Dr. Franks is an associate professor Despite public health initiatives and clinical samples. Prev Med 24(4):401-11, 1995. in the Department of Clinical Pharmacy, practice guidelines, individuals continue to 8. Wetter DW, Cofta-Gunn L, Irvin JE, et al.: What ac - University of Tennessee College of Phar - struggle with tobacco cessation. Clinicians counts for the association of education and smok - macy and with the Department of Fam - should provide tobacco cessation inter - ing cessation? Prev Med 40(4):452-60, 2005. ily Medicine, University of Tennessee ventions that target an individual patient’s 9. Jorneby DE, Leischow SJ, Nides MA, et al.: A con - Graduate School of Medicine. stage of change, and should discuss key is - trolled trial of sustained-release bupropion, a The authors would like to acknowl - sues including previous quit attempts, rea - nicotine patch, or both for smoking cessation. N edge Robert E. Heidel, MS, NCC, for pro - son for relapse, and perceived barriers to Engl J Med 340(9):685-91, 1999. viding statistical analyses of our data. cessation. If not contraindicated, pharma - 10. Gonzales D, Rennard SI, Nides M, et al.: Vareni - Also, we would like to acknowledge the cotherapy should be used for patients who cline, an alpha4beta2 nicotinic acetylcholine re - following student pharmacists/research are in the preparation stage, in addition to ceptor partial agonist, vs sustained-release assistants who enrolled and surveyed intratreatment social support. Counseling bupropion and placebo for smoking cessation: a participants: Brittany D. Brown, Misty topics should include practical problem randomized controlled trial. JAMA 296(1):47-55, Gray-Winnett, Lisa Pelletier, Courtney solving skills, stress management, and 2006. Davis, and Adam Thompson. proper use of the pharmacotherapy se - 11. Jorenby DE, Hays JT, Rigotti NA, et al.: Efficacy of No financial support was received for lected, including appropriate dosage and varenicline, an alpha4beta2 nicotinic acetylcholine this manuscript, and authors have no administration, timing of tobacco cessa - receptor partial agonist, vs placebo or sustained- conflicts of interest. tion, duration of treatment, and adverse ef - release bupropion for smoking cessation: a ran - For reprints, contact Dr. Ray at 1924 fects. + domized controlled trial. JAMA 296(1):56-63, Alcoa Highway, Box 117, Knoxville, TN 2006. 37934; phone: 865-974-2324; fax: 865- References: 12. Nides M, Oncken C, Gonzales D, et al.: Smoking 974-2022; email: [email protected]. 1. Centers for Disease Control and Prevention: Cur - cessation with varenicline, a selective alpha4beta2 rent cigarette smoking among adults aged > 18 nicotinic receptor partial agonist: results from a years: United States, 2009. MMWR Morb Mortal 7-week, randomized, placebo- and bupropion- Wkly Rep 59(35):1-6, 2010. controlled trial with 1-year follow-up. Arch Intern 2. Fiore MC, Jaén CR, Baker TB, et al.: Treating To - Med 166(15):1561-8, 2006.

Tennessee Medicine + www.tnmed.org + OCTOBER 2010 49 FOR THE RECORD TMA ALLIANCE REPORT

Alliance Works to Help the Health of Tennessee

By Gail M. Brabson, TMAA President

he Tennessee Medical Association reach between 1,500-2,000 preschool • Beth Kasper, Member-at-Large, T Alliance (TMAA) has eight county al - children; grant amount: $2,000. Clarksville, TN, Meals at Brandon Hill liances: Bedford County Medical Al - Youth Heritage Garden – The grant was liance, Chattanooga-Hamilton County • Nashville Academy of Medicine Al - given to Mt. Olive Cemetery Historical Medical Society Alliance, Kingsport Medical liance, “Fight a Fever” – this project Preservation Society to help teach at-risk Alliance (Sullivan County), Knoxville Acad - services 100 families in need of medical children and teens how to grow a gar - emy of Medicine Alliance (KAMA), Nashville supplies and non-prescriptive medica - den, plant healthy foods, harvest, and Academy of Medicine Alliance (NAMA), tion for monitoring and control of fever cook meals; grant amount: $1,650. Rutherford County/Stones River Alliance, symptoms. This program would be im - Washington-Unicoi-Johnson County Medical plemented through the Faith Family The TMAA is grateful to the TMA for its Alliance (WUJC ), West TN Consolidated Clinic, which provides primary health $10,000 donation to the TMAA Philan - Medical Assembly Alliance, and our TMAA care for the working uninsured and their thropic Fund, making these grants possi - Members-at-Large from 13 other counties. families. Each package is labeled “Pro - ble. We are well aware of the health issues Our county Alliances from across the state vided by the TMA, TMAA and NAMA;” that face Tennesseans and that we rank all work hard to promote the mission state - grant amount: $1,650. 47th in obesity. The TMAA is here to help ment of the TMAA, “The mission of the Ten - the TMA in any way possible to help edu - nessee Medical Association Alliance is to • Washington/Unicoi/Johnson County cate Tennesseans to live healthier lives. We partner with physicians to promote the Medical Alliance, Purchase of a colpo - want to continue to live up to our mission health of Tennessee and to support the Fam - scope for Children’s Advocacy Center statement! + ily of Medicine.” (CAC) – The colposcope will be used as One of the four focus groups for our a diagnostic tool for child sexual abuse; Alliance is Health Promotions. Each year grant amount: $2,500. our county Alliances have the opportunity to request grant money from the TMAA • West TN Consolidated Alliance, “Hands Philanthropic Fund to support and pro - are Not for Hitting” activity books and mote a health promotion project for their placemats – items go to the Exchange county. These requests are reviewed at the Club Carl Perkins Center for the Preven - TMAA annual meeting each April and the tion of Child Abuse; grant amount: $1,000. Philanthropic Board awards the grant money at that time. In April 2010, the fol - • Knoxville Academy of Medicine Al - lowing grants were approved: liance, SAVE materials – Literature and materials purchased from the AMAA will • Chattanooga-Hamilton County Medical be distributed to 40 Knox County Schools Society Alliance, “Hands Are Not for reaching approximately 9,000 elemen - Hitting Preschool Program” – part of tary students; grant amount: $2,000. the AMAA Stop America’s Violence Every - where (SAVE) program, which would

For membership information contact Sarah Higgins at 865-249-8835, 865-604-9288 (cell) or [email protected] ; or TMAA Executive Assistant Judy Ginsberg at 615-385-2100, ext. 151, 800-659-1862 (toll free) or [email protected]

50 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 NEW MEMBERS

COFFEE COUNTY MEDICAL SOCIETY Ms. Laura N. Grese, Memphis Ms. Ayana Akilah Smith, Memphis Valry Ward Barr, Jr., MD, Tullahoma Mr. Charles M. Groeschell, Memphis Ms. Kristen A. Stancher, Memphis Mr. Alexander H. Habashy, Memphis Mr. Matthew K. Stein, Memphis CONSOLIDATED MEDICAL ASSEMBLY OF Ms. Makida T. Hailemariam, Nashville Mr. Vikas Suri, Memphis WEST TENNESSEE Mr. Andrew Hall, Memphis Ms. Douglas R. Taylor, Memphis William Bradley Lofton, MD, Jackson Ms. Jordan Nicole Halsey, Memphis Mr. Wissam S. Tobea, Memphis Velmalia D. Matthews-Smith, MD, Jackson Mr. John H. Hamilton, Memphis Mr. Brandon L. Todd, Memphis Tori Hill Russell, MD, Jackson Mr. Thomas B. Hamilton, Memphis Mr. Drew B. Turner, Memphis Bethany Wardlow, MD, Jackson Ms. Jensen E. Hart, Memphis Ms. Ana Luisa Valente, Bristol Mr. William A. Hester, III, Memphis Mr. Mauricio Valenzuela, Memphis KNOXVILLE ACADEMY OF MEDICINE M r. Andrew P. Holt, Memphis Mr. Albert R. Vaughn, Memphis Charles Edward McBride, MD, Knoxville Mr. Jonathan A. Holt, Memphis Mr. Cory A. Vaughn, Memphis Mr. Jarad L. Hopper, Marion Mr. Yuefeng Wang, Memphis MAURY COUNTY MEDICAL SOCIETY M r. Lawrence McLean House, II, Memphis Mr. Josh B. Wasmund, Memphis Suresh V.K. Chitturi, MD, Columbia Mr. John B. Jasper, Memphis Ms. Allison N. Watts, Memphis Ms. Kristen L. Jeffreys, Johnson City Ms. Rebecca S. Weller, Memphis THE MEMPHIS MEDICAL SOCIETY Mr. Patrick W. Jennings, Memphis Mr. David H. Wheeler, Memphis Ms. Suneeta Acharya, Memphis Mr. Jonathan R. Jerkins, Memphis Mr. Gregory Shane White, Memphis Ms. Maritza Aitken, Memphis Mr. Michael G. Jerkins, Memphis Ms. Martha A. Wilcox, Memphis Ahmad Altabbaa, MD, Memphis Ms. Leah A. John, Germantown Ms. Julie L. Worthington, Memphis Mr. Tucker Anderson, Memphis Mr. Mark Taylor Jones, Cordova Mr. B. Jonathan Xu, Memphis Mr. Olusegun O. Aranmolate, Memphis Mr. Dudley K. Kelso, III, Memphis Mr. Michael Y. Yin, Memphis Mr. Joshua C. Bakke, Memphis Ms. Sneha Kemkar, Cleveland Ms. Renee A. Barnes, Memphis Paul Klimo, Jr., MD, Memphis MONTGOMERY COUNTY MEDICAL Mr. Oran Alvin Basel, IV, Memphis Mr. Christopher M. Knight, Bartlett SOCIETY Mr. John W. Bodford, Jr., Memphis Mr. Tyler H. Koestner, Franklin Ms. Gina Marie Wyatt, MD, Clarksville Mr. Andrew B. Boucher, Germantown Mr. James A. Layman, Memphis Mr. Joseph J. Boyd, III, Nashville Ms. Lauren K. Lazar, Memphis NASHVILLE ACADEMY OF MEDICINE Ms. Christine J. Brough, Memphis Mr. Weier Li, Memphis Hilary C. Akpudo, MD, Nashville Mr. Allen Clay Brown, Memphis Mr. Andrew H. Lichliter, Memphis Ms. Nkiruka Arinze, Nashville Ms. Christina L. Brown, Memphis Mr. Benjamin J. Maddox, Memphis Karen L. Ayres, MD Mr. Clifford Scott Brown, Memphis Mr. Steven J. Massaro, Memphis Andres Anthony Ayuso, MD, Franklin Mr. Gregory J. Burana, Memphis Ms. Jenna E. McKinnie, Memphis William C. Barrow, MD, Nashville Mr. Samuel Lucas Burleson, Memphis Ms. Marissa Anne Mencio, Memphis Mr. John Scott Austin Beeler, Nashville Wenlei Cao, MD, Germantown Mr. Nathan A. Miller, Memphis Billie Ann Bixby, MD, Nashville Charles L. Carter, MD, Memphis Mr. Robert H. Mitchell, Memphis Ms. Ashira D. Blazer, MD, Nashville Mr. John M. Cassidy, Memphis Mr. Jeffrey Bruce Morrison, Memphis Hani Ahmad Bleibel, MD, Nashville Mr. Samuel N. Che Casales, Memphis Ms. Clare K. Murphy, Nashville Ms. Rachel B. Bloch, Nashville Ms. Audrey K. Christiansen, Memphis Mr. Daniel Sallis Murrell, Memphis Steven A. Bondi, MD, Nashville Mr. Patrick A. Cleeton, Brentwood Mr. Zachary Paul Nahmias, Memphis Kathryn Elizabeth Bradley, MD, Nashville Mr. Tyler W. Clemmensen, Cordova Mr. Michael N. Ofori, Memphis Nathan Michael Bullington, MD, Nashville Ms. Lauren E. Coleman, Memphis Ms. Hyun Jeong Oh, Franklin Atuhani S. Burnett, MD, Nashville Mr. Austin R. Davidson, Memphis Ms. Brennan Palazola, Memphis Maria E. Carlo, MD, Nashville Mr. Jesse T. Davidson, IV, Memphis Mr. Dilan A. Patel, Memphis Justin Ray Chen, MD, Nashville Ms. Ellen E. Davis, Memphis Yolanda A. Payne-Jameau, MD, Memphis Stephanie Yuching Chen, MD, Nashville Mr. James C. Davis, Memphis Ms. Jacyln H. Pearson, Memphis Jason Cotter Cowan, DO, Franklin Ms. Amirtha Dileepan, Memphis Mr. Donald L. Pierce, Memphis Varalaxmi S. Dasari, MD, Nashville Mr. Whitman S. Dowlen, Signal Mountain Mr. Andrew S. Poole, Memphis William Frederick Dresen, MD, Nashville Ms. Hannah M. Dudney, Nashville Ms. Karen Rhea, Memphis Ugochukwu Onyibo Egolum, MD, Nashville Ms. Mallory Anne Duncan, Memphis Mr. Cody R. Richardson, Memphis Elosha Johnson Eiland, MD, Nashville Mr. Terence Sean Dunn, II, Memphis Ms. Kaitlin C. Ridder, Memphis Elizabeth Jane Embury, MD, Nashville Ms. Emily R. Earles, Memphis Mr. Samuel J. Riney, Memphis Savita Leanne Fanta, MD, Nashville Lucas Elijovich, MD, Memphis Mr. Quantel V. Rolle, Memphis Allison M. Floyd, MD, Nashville Ikechukwu U. Emereuwaonu, MD, Memphis Mr. Daniel J. Roubik, Smyrna John Thomas French, MD, Nashville Mr. Aaron M. Evans, Memphis Ms. Vicky Elise Ruleman, Memphis Melanie C. Green, MD Ms. Lindsay N. Flynn, Jackson Ms. Sara Rutter, Memphis Catherine J. Harris, MD, Nashville Mr. Ludwig I. Francillon, Helena Ms. Maanasi Samant, Memphis Amanda Kay Hester, MD, Nashville Mr. Donald Benjamin Franklin, III, Memphis Mr. Evan R. Sander, Memphis Katherine Collins Hoey, MD Mr. Scott J. Galloway, Memphis Mr. Ramy M. Sayed, Memphis Sheldon Levon Holder, MD, Nashville Ms. Keng C. Ghaila, Nashville Mr. Michael Cody Scarbrough, Memphis Nikhil Pollo Jaik, MD, Nashville Mr. Griffin F. Gibson, II, Cordova Mr. Faisal Shaikh, Germantown Jason K. James, MD, Nashville Tennessee Medicine + www.tnmed.org + OCTOBER 2010 51 NEW MEMBERS Valerie Malyvanh Jansen, MD, Chicago Taylor B. Wootton, MD, Nashville Ahmad L. Alazzeh, MD, Johnson City Neil Jariwala, MD, Nashville Elizabeth M. Wulff-Burchfield, MD, Nashville Charles E. Allen, Jr., MD, Jonesborough Ms. Pawina Jiramongkolchai, Nashville Olamide Zaka, MD, Nashville Dina M. Alshunnaq, MD, Johnson City Douglas Scott Johnson, MD, Nashville Sheeba Anand, MD, Johnson City Gagandeep Kaur Joshi, MD, Nashville ROANE-ANDERSON COUNTY MEDICAL SOCIETY Brian David Arbogast, MD, Johnson City Trisha Marie Juliano, MD, Nashville Katherine R. Kerchner, MD, Oak Ridge Bhavesh B. Barad, MD, Johnson City Steven Edward Kammann, MD, Nashville Celeste B. Beaudoin, MD, Johnson City Mr. Barry Kany, Nashville ROBERTSON COUNTY MEDICAL SOCIETY P h i lip Benfield, MD, Johnson City Clark David Kensinger, MD, Nashville John Mark Pennington, MD, Pleasant View Samit Bhatheja, MD, Johnson City Yasmin Wert Khan, MD, Nashville Daniel Alan Boyett, MD, Piney Flats Ewa Agnieszka Konik, MD, Nashville SULLIVAN COUNTY MEDICAL SOCIETY P a t r ick D. Bradley, MD, Johnson City John Goyee Kpaeyeh, Jr., MD, Nashville Emmanuel A. Adedokun, MD, Kingsport Lei Chen, MD, Johnson City Harish Krishnamoorthi, Nashville Benjamin Altman, MD, Johnson City Breehan S. Dean, MD, Johnson City Mr. Kevin K. Kumar, Nashville Daniel R. Anderson, MD, Kingsport Tatyana Der, MD, Johnson City Jonathan M. Lehman, MD, Nashville Charles L. Backus, MD, Johnson City Constantino Ramon Diaz, MD, Johnson City Elizabeth Marie Licalzi, MD, Nashville Michael L. Bacon, MD, FACEP, Kingsport Rayan Abdo Elkattah, MD, Johnson City Robin Nicole Ligler, MD, Nashville Ronald Kevin Carroll, DO, Johnson City Rabab I. Elmezayen, MD, Johnson City Colt Micheal McClain, MD, Nashville Kelly D. Chumbley, DO, Johnson City Alkesh B. Gajjar, MD, Johnson City Lauren Nicole McClain, MD, Nashville H. Phillip Claybrook, MD, Bristol Jami Nacole Goodwin, MD, Johnson City Ryan Townley McGrath, MD, Nashville William E. Devens, MD, FACEP, Kingsport Shiva K.Y. Gosi, MD, Johnson City Mark Rodney Melson, MD, Nashville Curtis Keith Drumwright, MD, Blountville Divya Gupta, MD, Johnson City Mr. Elliot Thomas Min, Nashville Gregory A. Gerlock, MD, Jonesborough Hennah K. Hashmi, MD, Johnson City Andrew Jacob Moore, MD, Nashville Bruce Nelson Gibbon, MD, Bristol Jonathan W. Hathaway, MD, Johnson City Anicia L. Ndabahaliye, MD, Nashville Jacalyn Paige Gilbert-Green, DO, Kingsport Raghava Induru, MD, Johnson City Michael Glenn O'Connor, MD, Nashville Kenton B.H. Goh, MD, Kingsport Susannah Johnson, MD, Johnson City Vivian Onunkwo, MD, Murfreesboro Ardel W.D. Gorospe, MD, Kingsport Hetvi K. Joshi, MD, Johnson City Toni Rochelle O'Reggio, MD, Nashville Carl Harris, DO, Kingsport Nesreen S. Khraisha, MD, Johnson City Ellen McCarley O'Shea, MD, Nashville Alicia Dawn Jackson, DO, Bristol Inna A. Loubskaia, MD, Johnson City Sajidkhan S. Pathan, MD, Smyrna Thomas A. Kitts, MD, Bluff City John Edward Loudermilk, MD, Bristol Devon Wayne Paul, MD, Nashville James C. Kneff, Jr., MD, Kingsport Sulleman Malik, MD, Johnson City Brandon Allen Perry, MD, Nashville Erin A. Koscinski, DO, Kingsport Melissa Sue Matrisch, MD, Johnson City Blake Andrew Phillips, MD, Nashville Christopher Norris Krone, MD, Kingsport Rohan V. Mehta, MD, Johnson City Erin R. Powell, MD, Nashville Ayad Hashim Latif, MD, Bristol Manisha M. Mishra, MD, Johnson City Marcus Andrew Presley, MD, Nashville Robert W. Lawson, MD, Kingsport Evans Neal Mize, MD, Johnson City Deepti S. Pruthi, MD, Nashville James Luna, MD, Kingsport Nikunjkumar T. Modi, MD, Johnson City Jessica Anne Quinlan, MD, Nashville Gregory C. Marcum, MD, Gate City Kalyan Kumar Reddy Mogili, MD, Johnson City Ms. Jennifer Denise Rahn, Nashville Thomas John Metcalf, MD, Unicoi Emmanuel E. Okon, MD, Johnson City Sankrant Reddy, MD, Brentwood Miranda N. Moretz, MD, Kingsport Andrea Marie Orvik, MD, Jonesborough Shilpa B. Reddy, MD, Nashville Todd L. Nguyen, MD, Bristol Mr. Andrew S. Parsons, Johnson City Mr. Quentin R. Reuter, Nashville Pius James A. Powers, MD, Kingsport Pragnesh P. Patel, MD, Johnson City Coleman Price Ritchie, MD, Brentwood Swate Pullamaraju, MD, Kingsport Pranav B. Patel, MD, Johnson City Allison M. Rose, MD, Nashville Jennifer Joy Skorupa, MD, Bristol Aimee G. Russell, DO, Johnson City Ms. Megan K. Ryan, Nashville Arthur H. Toups, MD, Kingsport Kamlesh P. Sajnani, MD, Johnson City Blake Saltaformaggio, MD, Franklin Kenneth E. Turner, Sr., MD, Kingsport Gaurav S. Shah, MD, Johnson City Mary Kathleen Sandquist, MD, Nashville Travis Watson, MD, Kingsport Kaushal Y. Shah, MD, Johnson City Ajay Bipin Shalwala, MD, Nashville Rachel Click Wilson, DO, Bristol Victoria Lynn Shankle, DO, Johnson City Frank Durham Stegall, Jr., MD, Nashville Jonathan W. Wireman, MD, Gray Mai Mohamed Kamel Shehata, MD, Johnson City Ms. Ilona Sarah Stol, Nashville John M. Woodard, MD, Johnson City Elnora N. Spradling, MD, Johnson City Navneet Taneja, MD, Brentwood Fatemeh Yamani, MD, Kingsport Frank Ryan Stump, MD, Johnson City Wudneh Muche Temesgen, MD, Nashville S heraz Younus, MD, Bristol Gagan T. Tindoni, MD, Johnson City Sumeer Thinda, MD, Nashville Inemesit W. Udoeyop, MD, Johnson City Seth J. Trifiro, MD, Nashville TMA DIRECT Adil Kabir Warsy, MD, Johnson City Ema Uko-Abasi, MD, Nashville Gerald Blake Chandler, MD, Paris Takeyia N. Williams, MD, Johnson City Michael Antonio Vella, MD, Nashville Robert B. Knowles, MD, Sparta Dia Rose Waguespack, MD, Nashville WILLIAMSON COUNTY MEDICAL SOCIETY Mr. Ata T. Wallace, Nashville WARREN COUNTY MEDICAL SOCIETY A my S. Ortega, MD, Franklin Eric Lee Wallace, MD, Nashville Andrew D. Kastello, MD, McMinnville Katie Davis White, MD, Nashville Jani C. Wilkerson, DO, Nashville W A SHINGTON-UNICOI-JOHNSON COUNTY Dwayne Wilson, MD, Nashville MEDICAL ASSOCIATION Mr. Eric Stephen Wise, Nashville Abdel K.M. Abu Malouh, MD, Johnson City 52 Tennessee Medicine + www.tnmed.org + OCTOBER 2010 IN MEMORIAM

ROBERT E. HANDTE, MD, age 84. Died MARION BERRY MCKINNEY, MD, age ROY JAMES RENFRO, JR., MD, age 80. March 19, 2010. Graduate of New York 90. Died August 22, 2010. Graduate of Died September 5, 2010. Graduate of Medical College. Member of University of Tennessee Center for Health University of Tennessee Center for Health Nashville Academy of Medicine. Science. Member of Knoxville Academy of Science. Member of Nashville Academy of Medicine. Medicine. FRANK HOUSTON LOWRY, JR., MD, age 83. Died August 12, 2010. Graduate of University of Tennessee Center for Health Science. TMA Direct member.

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Tennessee Medicine + www.tnmed.org + OCTOBER 2010 53 Position Wanted Board certified radiologist available for locums work after December 2010. All modalities covered except invasive. Dr. Bilbrey; work: 931-459-7324; home: 931-484-4743.

INSTRUCTIONS FOR AUTHORS LIST OF ADVERTISERS Manuscript Preparation – Manuscripts should be submitted to the Editor, David G. Gerkin, MD, 2301 21st Avenue South, Nashville, TN 37212. A cover letter should identify one author as correspondent and should include his complete address, phone, and e-mail. Alabama Gulf Coast CVB ...... 9 Manuscripts, as well as legends, tables, and references, must be typewritten, double-spaced on 8-1/2 x 11 in. white paper. Pages should be numbered. Along with the typed manu - BlueCross/ BlueShield of Tennessee ...... 14 scripts, submit an IBM-compatible 3-1/2" high-density diskette containing the manuscript. The transmittal letter should identify the format used. Another option is you may send the Career Opportunity Advertising ...... 54 manuscript via e-mail to [email protected] . If there are photos, e-mail them in TIF or PDF format along with the article. Centers for Medicare and Medicaid Services ...... 36 Responsibility – The author is responsible for all statements made in his work. Accepted manuscripts become the permanent property of Tennessee Medicine. DoctorsManagement, LLC ...... 40 Copyright – Authors submitting manuscripts or other material for publication, as a con - dition of acceptance, shall execute a conveyance transferring copyright ownership of such Drs. Wesley & Klippenstein ...... 4 material to Tennessee Medicine. No contribution will be published unless such a con - veyance is made. First Tennessee Bank ...... 30 References – References should be limited to 10 for all papers. All references must be cited in the text in numerically consecutive order, not alphabetically. Personal communi - LBMC ...... 22 cations and unpublished data should be included only within the text. The following data should be typed on a separate sheet at the end of the paper: names of first three authors Navicure ...... 13 followed by et al, complete title of article cited, name of journal abbreviated according to Index Medicus, volume number, first and last pages, and year of publication. Example: Novartis ...... 10 Olsen JH, Boice JE, Seersholm N, et al: Cancer in parents of children with cancer. N Engl J Med 333:1594-1599, 1995. Shared Health ...... 38 Illustrated Material – Illustrations should accompany the e-mailed article in a TIF or PDF format. If you are mailing the article and diskette, the illustrations should be 5 x 7 in. State Volunteer Mutual Insurance Company ...... 56 glossy photos, identified on the back with the author's name, the figure number, and the word "top," and must be accompanied by descriptive legends typed at the end of the paper. Tennessee Medical Foundation ...... 34 Tables should be typed on separate sheets, be numbered, and have adequately descriptive Tennessee Society for Laser Medicine titles. Each illustration and table must be cited in numerically consecutive order in the text. Materials taken from other sources must be accompanied by a written statement from both and Surgery, Inc...... 53 the author and publisher giving Tennessee Medicine permission to reproduce them. Pho - tos of identifiable patients should be accompanied by a signed release. The TMA Association Insurance Agency, Inc...... 6 Reprints – Order forms with a table covering costs will be sent to the correspondent au - thor before publication. TMA Physician Services, Inc...... 2, 47

54 Tennessee Medicine + www.tnmed.org + OCTOBER 2010