VOL. 111, NO. 1 | QUARTER 1, 2018

Examining views on medical

2018 Legislative Agenda

2018 TMA Voter Guide

The Truth About Balance Billing

tnmed.org VOL. 111,XXX, NO. NO. 1 X | | QUARTER QUARTER 1, 1, 2018 2018

Table of Contents

PRESIDENT 3 Legislative Agenda NITA W. SHUMAKER, MD TMA to focus on payment reforms, scope of practice, CHIEF EXECUTIVE OFFICER public health issues RUSS MILLER, CAE

EDITOR DAVID G. GERKIN, MD 5 Editorial: Another Tool to Reduce MANAGING EDITOR Narcotic Overdose Deaths in Tennessee JULIA COUCH Matthew Hines, MD EDITORIAL BOARD JAMES FERGUSON, MD KARL MISULIS, MD 7 Editorial: A Hospice Doctor Looks at GREG PHELPS, MD BRADLEY SMITH, MD Medical Marijuana JONATHAN SOWELL, MD Greg Phelps, MD ANDY WALKER, MD

ADVERTISING REPRESENTATIVE 13 Ask TMA MICHAEL HURST 615.385.2100 [email protected] 14 The Truth about Surprise Medical Bills Douglas Springer, MD and Jonathan Hughes, MD

16 Ruffner: Marijuana Update from AMA

18 Guide to 2018 TMA Leadership Elections

24 For the Record

Tennessee Medicine: Journal of the Tennessee Medical Association (ISSN 10886222) is published Quarterly by the Tennessee Medical Association, 701 Bradford Ave., Nashville, TN 37204. Tennessee Medical Association is a nonprofit organization with a definite membership for scientific and educational purposes, devoted to the interests of the medical profession of Tennessee. This Association is not responsible for the authenticity of opinion or statements made by authors or in communications submitted to Tennessee Medicine for publication. The author or communicant shall be held entirely responsible. Advertisers must conform to the policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $30 per year for US, $36 for Canada and foreign. Single copy $5.00. Payment of Tennessee Medical Association membership dues includes the subscription price of Tennessee Medicine. Periodicals postage paid at Nashville, TN and at additional mailing offices.

POSTMASTER: Send address changes to Tennessee Medicine, 701 Bradford Ave., Nashville, TN 37204. In Canada: Station A, P.O. Box 54, Windsor, Ontario, N94 6J5.

Copyright 2018, Tennessee Medical Association. All material subject to this copyright appearing in Tennessee Medicine may be photocopied for noncommercial scientific or educational use only. TENNESSEE MEDICINE 3 QUARTER 1 | 2018

2018 Legislative Agenda TMA Takes Aim at Episodes of Care, MOC, Balance Billing and More

TMA enters each legislative session with a short list of priority items it hopes to accomplish on behalf of members, followed by a bevy of other issues that physician Protecting leaders and staff lobbyists expect to arise. Tennessee’s The legislative package is set after months of deliberation by the TMA Legislative Favorable Medical Committee, which considers member requests and sorts through hundreds of pages of research to come up with a recommendation for the TMA Board of Trust. Liability Climate TMA claimed an early legislative Once session begins, lobbyists carefully review draft bills filed in the state legislature, win for 2018 when it announced looking for landmines and making sure lawmakers understand the implications for in November 2017 that a three- doctors and patients. Every piece of legislation is carefully examined to determine year push to dismantle and whether it relates to healthcare and, if so, how it could affect the business of medicine replace the state’s medical or the delivery of patient care. Ultimately, TMA advocates for or against each bill liability system had ended. based on whether the physician members deem it good public policy. A Georgia-based group called Patients for Fair Compensation Following are just a few of the highest priority issues for TMA’s lobbyists in the had since 2015 lobbied the second session of the 110th Tennessee General Assembly. Tennessee General Assembly to shift physician liability cases TennCare Episodes of Care from the civil court system to a TMA members have grown increasingly frustrated by the state’s inconsistent, government-run administrative inaccurate and ineffective episodes of care payment model. Decisions about the system. Doctors raised program are continually made without physician agreement and in many cases with fundamental concerns about physician opposition. TMA has long advocated for improvements but the state has verifying proponents’ claims that not addressed fundamental flaws in the design and implementation of the program. their plan would save the state money, and preserving medical TMA redoubled its advocacy efforts in late 2017 at the same time it stopped liability insurance in the event a participating in a state grant that funded episodes-related education efforts for patient compensation system did physicians and practices. TMA President-Elect Matt Mancini, MD of Knoxville not work. The opposing groups testified in a Senate Health Committee hearing on episodes of care in October could not resolve fundamental 2017. TMA officials followed that meeting with a letter to Sen. Rusty Crowe, Chair issues, and Patients for Fair of the committee, and reiterated concerns during multiple meetings with state Compensation assured TMA policymakers in late 2017 and January 2018. that it does not plan to introduce Despite TMA’s advocacy efforts, significant concerns remain about data collection, any related bills in the 2018 data reporting and accuracy, and overall transparency of the episodes of care legislative session. program. TMA is opposed to further expansion of the initiative until or unless these TENNESSEE MEDICINE 4 QUARTER 1 | 2018 TENNESSEE MEDICINE 5 QUARTER 1 | 2018

fundamental issues are satisfactorily to the legislation and is advocating for a medical boards from requiring MOC for EDITORIAL: addressed and tested. different name to avoid patient confusion initial licensure or renewal. A task force in a clinical setting. was also created to further explore MOC TMA has been given no assurance or as it pertains to hospital and insurance confidence that the state is going to credentialing. TMA hopes the task force Balance Billing address the ongoing fundamental design will propose a solution to address those Another tool to reduce narcotic issues with the program, which we have TMA wants to protect physicians’ rights issues in 2018. If not, TMA will work with outlined repeatedly and most recently to balance bill and will continue to fight the 2017 bill sponsors (Sen. Richard ranked in priority order at the state’s for a solution to “surprise medical bills” Briggs, MD of Knoxville and Rep. Ryan overdose deaths in Tennessee request. TMA will ask the legislature to that is fair to all parties, especially Williams of Cookeville) to try to pass a intervene and needs members to contact physicians and patients. TMA opposes stronger bill to prohibit hospitals and By Matthew Hines, MD their elected officials to educate them on any effort that gives health insurance health insurance companies from this complicated but important issue. companies even more undue leverage requiring MOC for physician to force providers to accept unfair credentialing or network participation. Learn more about TMA’s position contractual terms and proliferates the Our practices will soon intersect with the therapeutic use of marijuana and related advocacy work at trend of narrow networks. (). During the past four years, the reported annual use of marijuana among tnmed.org/episodes. Indoor Tanning American has doubled from 7% to 14%, while the use by teens has declined. See more on this topic on page 14 TMA will encourage Tennessee to join Is this a good thing? Remarkably, I think so. from Doug Springer, MD and 28 other states that have some type Doctor of Medical Science I used to believe the public health hazards of allowing comprehensive medical marijuana Jonathan Hughes, MD of Kingsport. of prohibition on dangerous indoor (or successor name) programs outweighed benefits. But after many hours of study, I’ve reached the opposite tanning for minors. TMA and other Legislation first introduced in 2017 conclusion: public health benefits predominate. groups in a coalition of advocates, would create a new academic degree for Maintenance of Certification including dermatology and pediatric physician assistants. Sponsors filed the For the second year in a row, TMA will The criminalization of the substance has resulted in increased expenditure on incarceration organizations, will educate lawmakers updated version of the bill in January. have legislation filed to give physicians rather than effective public health education. In Tennessee, the possession of 1 cannabis about the preventable dangers of The language is much improved from relief from the costly, burdensome and plant remains a felony. The cannabis plant is classified by the federal Controlled Substances indoor tanning, such as skin cancer. the 2017 version; it does not give PAs in many cases valueless requirement of Act as a Schedule 1 substance, while the psychoactive ingredient (THC), as a 100% pure synthetic substance (Marinol) is classified as Schedule 3. A schedule 3 drug has accepted independent practice but requires Maintenance of Certification. Follow TMA’s legislative progress at medical use, while abuse of the drug may lead to moderate or low physical dependence or PAs to collaborate with a supervising tnmed.org/legislative or on twitter TMA successfully worked for passage high psychological dependence. It seems to me an accurate description of the whole plant. physician in a team-based healthcare @tnmed and @tnmedonthehill. delivery model. TMA remains opposed of a bill in 2017 that prohibits the state ▪

Many studies have concluded that medicinal cannabis treatment results in a very significant decrease in opioid consumption. TMA CAUTIONS PATIENTS AGAINST WHITE COAT ASSUMPTIONS “Know Your Provider” Campaign to Help Educate, Clarify Roles on Healthcare Team Cannabis has a low potential for addiction. The Institute of Medicine found that fewer than TMA has launched a public education campaign to help inform and make more informed decisions about how they access care. 10% of persons who try cannabis ever met the criteria of drug dependence. By contrast, patients about different types of healthcare providers and the role The resource also points users to state-run databases where they can 32% of tobacco users 23% of heroin users and 15% of alcohol users met those criteria. of physicians on the healthcare delivery team. The Know Your research an individual provider’s licensure and disciplinary status. Provider campaign features online resources to help Tennesseans TMA encourages patients to share resources and participate The jury is still out on recreational cannabis, but where a properly regulated choose the right provider(s) for their medical situation. in the conversation using #KnowYourProviderTN. program exists, it’s unreasonable to conclude the program does more harm than good. More than 50 percent of people said it was difficult to identify Leading physicians in TMA maintain that unless a provider a licensed physician from looking at his or her title, credentials, volunteers his or her qualifications, patients may not be fully A recent interview by the Canadian Broadcasting Company (CBC) with Dr. Larry Wolk, services offered, and marketing materials, according the most informed — or worse, misinformed — about various healthcare recent Truth in Advertising survey from the American Medical Chief Medical Officer of the Colorado Department of Health, is enlightening. They wanted professionals or what their roles should be. Association. Healthcare providers are required by law to display his expertise, as Canada is moving to treat cannabis similarly to alcohol. their professional credentials (e.g. a badge with name and title) The number of distinctions and scope of practice for some disciplines when delivering care but do not have to proactively discuss within the healthcare sector has expanded in recent years to satisfy He’s not talking about medical cannabis. That program was authorized in 2000, and at their level of education, training or experience with patients. a growing demand for convenient, cost-effective care, particularly the end of 2016, the Colorado medical marijuana registry had approximately 95,000 active for non-emergent, routine services. But TMA survey data shows As part of the “Know Your Provider” campaign, TMA offers patients. Here, Dr. Wolk is describing what’s happened in the last three years since Colorado that 92 percent of patients still prefer a physician to have primary an online guide to help Tennesseans understand the different responsibility for leading and coordinating their healthcare. has granted legal access to adults, including the right to grow up to six plants at home. education and training requirements for healthcare providers (Continued on page 8) Learn more about TMA’s Know Your Provider campaign at tnmed.org/knowyourprovider. TENNESSEE MEDICINE 7 QUARTER 1 | 2018

REKINDLE YOUR PASSION EDITORIAL: FOR HEALTHCARE A Hospice Doctor Looks

with the world’s longest-running and most preferred at Medical Marijuana Physician’s Executive MBA By Greg Phelps, MD

True Story slightly altered to protect privacy.

Some years ago, I had a patient who All I could do was look surprised, and addicts for over 20 years. In all that Physician-only Personalized Applied CME credits Minimal No business was dying of ovarian cancer and was hold up my hands as if to be handcuffed. time treating addicts, I never once program with leadership projects built into number of pre-requisites suffering from terrible . We had heard an addict say, “Ya know doc, 650+ alumni development deliver ROI the program days away or GMAT tried everything: Phenergan, Haldol, “Oh no,” he said, “I asked you if it all started when I first tried marijuana.” cocaine addicts such as Reglan, there was anything else we could Not once. But I still hear the concept anticholinergics, 5-HT3 agents. Nothing do and you are willing to consider all of marijuana as a “Gateway” drug from was helping. We started a Phenergan the possibilities, and I appreciate it.” time to time even though the concept drip, and I went out to the house at the with that he waved me out, and I has largely been debunked. Three outlying county to meet with the patient beat a hasty retreat. of the four past presidents of the US and her husband to explore what else admit to using marijuana (whether they This week as I begin this article, we could do. I reviewed all the options inhaled or not.) As to the fourth and I reflect back on a health care summit we had taken so far. The husband current President, he said he supports I attended for the Coalition to Transform arrived after I did, apologizing that work medical marijuana “100%.” In May Advanced Care in Washington D.C. it held him longer than expected. We of 2017, Donald Trump signed a bill The Summit Co-chairs were former discussed the possibility of Marinol including a continuing rider that forbids US Senators Frist and Daschle. The which was not in our hospice formulary. the Justice Department from using Summit was about how to improve The cost of the husband would be close federal funds to prosecute marijuana care for patients in the advanced (and to $900 which he said he didn’t have. businesses. Now, this view is not often terminal) stages of illness. It was “Isn’t there anything else we could try?” shared, of course, by the current heavily tilted towards hospice and he asked? Attorney General, who would like to palliative care. rev up prosecution of drug offenses. “Well, Tennessee is not a medical The first plenary speakers were the This becomes a matter of justice. marijuana state” I started tentatively. authors of Driving Ms. Norma who was “However…” Harry Anslinger was a veteran of the a 90-year-old diagnosed with uterine Bureau Prohibition and became the first cancer. When offered chemotherapy “It gave me a greater understanding The husband ruefully shook his head head of the Bureau of Narcotics from she said,” Heck no, I’m 90 years old. of how the business of medicine works, and “No I don’t think so, I wouldn’t 1930 to the 1960s. Anslinger’s use of strengthening my leadership skills. It gave me I’m hitting the road.” Thus did she, even know where to get it.” statistics was described as “creative.” skills I’ve never had before and re-energized her son and daughter-in-law tour of the me mid-career for other things to come.” One author characterized his essays “Neither would I. I guess I’d have to United States. The speakers described on marijuana as “over the top.” Wrote ask my kids.” I quipped. their tour and how as she declined, - DORU BALI, MD, MBA Harry, “no one knows when he places a Class of 2015, Vice Chief - Emergency Department one of the places they detoured by was marijuana cigarette to his lips, whether The husband walked me out, and Colorado to try medical marijuana. They he will become a philosopher, a joyous we stopped at the back door. He found that it helped. So much so that reveler… Or a murderer.” The essay also apologized again for being late and Norma asked to go back to the shop included the possibilities for young making conversation I asked, “so and stock up before they moved on. 1 what do you do?” people to rob, rape, murder strangers, I am writing this article as a Boarded police officers and even members of “Oh, I work for the courthouse. their own families.2 This portrayal resulted http://pemba.utk.edu hospice physician, but I am also a I’m a bailiff for the Sheriff’s office.” certified addictionologist and treated in the 1930s movie Reefer Madness +1 (865) 974-1772 (Continued on page 11) TENNESSEE MEDICINE 8 QUARTER 1 | 2018

(Continued from page 5)

CBC: What have you seen since recreational cannabis has been legal in Colorado?

Dr. Wolk: The short answer is we have not seen much. We have not experienced any significant issue as a result of legalization. I think a lot of people think when you legalize you are going from zero to some high-use number, but they forget that even when marijuana is not legal, one in four adults and one in five kids are probably using on a somewhat regular basis. What we’ve found since legalization is that those numbers haven’t changed.”

CBC: Do we know if cannabis legalization is leading to higher uses of hard drugs?

Dr. Wolk: We are not seeing those kinds of increases.

CBC: What about drugged driving?

Dr. Wolk: We have actually seen an overall decrease in DUI’s since legalization. So, the short answer is: There has been no increase since the legalization of marijuana here.

We need to ask whether cannabis, as a whole plant, has legitimate medical applications. It does. The National Academy of Sciences recently released a report on the topic and noted: “There is substantial evidence that cannabis is an effective treatment for chronic pain in adults.”

Cannabis has not been shown to be a not used cannabis in the prior month, The guidelines include the presence gateway to more dangerous substances. showing a protective effect from of a physician-patient relationship, cannabis use. Patients in drug appropriate patient evaluation, There is strong evidence it acts as a rehabilitation clinics who occasionally informed and shared decision-making, stepping stone away from dependence used cannabis were more likely to a written treatment agreement, ongoing on opioids, benzodiazepines, and complete treatment and stay off more monitoring, provisions for consultation alcohol. This is largely why, in my dangerous drugs. and referral, and the maintenance of opinion, regulated cannabis provides a appropriate medical records. net benefit regarding harm reduction. A study published in International Journal of Drug Policy found that The Medical Board of California has Here are a few examples 63% of medical cannabis users published an informed consent called from the literature: substituted cannabis for their a Medical Cannabis Agreement, similar prescription drugs, mostly opioids, to the chronic pain management JAMA Internal Medicine noted that and medication, and 25% had agreements with which we’re familiar. states with medical marijuana laws reduced their alcohol consumption. have rates of anticipated opioid-related When I visited with an Arizona deaths averaging 25 percent lower The Journal of Psychopharmacology physician who performs medical than states that don’t have such a reported that over 75% of regular cannabis evaluations, I learned how program. The longer the medical opioids users cut their dose once they she communicates with the dispensary cannabis program was in place, the started cannabis. 72% decreased the staff. The recommendation sheet lower the overdose death rate. use of anti-anxiety medication, 65% she provides specifies the approximate cut back on sleep medication, and THC and CBD content to dispense. Many studies have concluded that 42% reduced their use of alcohol. medicinal cannabis treatment results Several states now require physicians to in a very significant decrease in complete CME on the topic of medical opioid consumption. How are states with established medical cannabis as a condition of being able to recommend cannabis for a specific For example: The Journal of Drug and cannabis laws proceeding? medically qualified condition. The Alcohol Dependence published that In April 2016, the Federation of State upcoming Tennessee legislation will among injection drug abusers, persons Medical Boards published guidelines likely contain a similar provision. who had used cannabis within the for cannabis in patient care, and various ▪ previous 30 days used opioids only states are adopting these. about half as often as those who had TENNESSEE MEDICINE 11 QUARTER 1 | 2018

(Continued from page 7)

which my generation watched in college percentages and yet minorities are four many use marijuana but only admit it mainly for its comedic value. Up until times more likely to be arrested for when the question is put to them, for the 1930’s, marijuana was much more drug possession and are 85% of drug fear that we’ll refuse care. commonly known as cannabis. arrests. Under President Bush, the Anslinger took a page from the nation’s drug czar tried to come after I had a patient who had lung cancer, Prohibition days and how prohibition tied the DEA registrations of physicians who he was bed bound and declining. alcohol to “others” and “otherness.” recommended marijuana. This was He was getting Marinol from the VA, In the run-up to prohibition, various quickly slapped down by the 9th circuit and we had to keep upping his dose public figures tried to attach alcoholism court in Conant vs. McCaffrey where to control his nausea. This eventually and drunkenness to African-Americans. the court said: “the government could led to a strange conversation with a To quote Frances Willard: “the grog shop not initiate criminal proceedings against VA pharmacist what called to tell me is the Negro’s center of power. Better a doctor simply for recommending my last prescription had gone past whiskey and more of it is the rallying cry marijuana.” the recognized and recommended of great dark-faced mobs.”3 upper limit for marinol. (In hospice we The fact is a LOT of my hospice patients love restrictions like these, they give Likewise with cannabis. The name have found benefit from marijuana. us something to shoot for!) I told the “Marihuana” (as it was spelled then) I remember one of the first patient’s I pharmacist the new dose was helping was popularized by advocates of had after fellowship. An elderly, grizzled the patient. Prohibition to exploit prejudice against mountain dweller in a cabin. He said “despised minority groups, especially he’d come into hospice IF, he could still “But you don’t understand doctor! Mexican immigrants.” use his marijuana. I felt obligated to The patient might die!” point out that marijuana was illegal in A long pause on my end (fatal overdose Interestingly in both the 1930s and then the state of Tennessee. again in the 1970s with Richard Nixon’s by marijuana is rare. In fact, the DEA “War on Drugs,” scientific Commissions He looked at me, as he snorted itself has no record of fatal marijuana were impaneled to provide the medical mordantly: “What are they gonna do? overdoses according to Politifact). facts that would backup the politics. In Kill me?” Here in lies the essential point. I replied: “You do know I’m a hospice both cases, the LaGuardia Report in Patients in hospice and palliative care doctor, the patient has lung cancer and the 1930s and the Shafer Commission by definition, have life-limiting illnesses. has maybe a week or so to live?”

Pharmacist: “Oh,” then in his best Emily (Saturday Night Live) Litella “Penalties against possession of the drug should not voice “…Nevermind.” be more damaging to an individual in the use of the drug itself.” So does the stuff work? The feds say no, there isn’t the research to show —President Jimmy Carter it does. This is a bit of a tautology because the federal government places numerous hurdles in the way of doing appointed by Richard Nixon, ended up If standard treatment was effective, research. This keeps research to a repudiating the politics. Said the Shafer they would not be life limited. minimum. Only one heavily regulated commission: “the commission is of That changes the equation from facility at the University of Mississippi is the unanimous opinion that marijuana live “forever” to keeping a patient allowed to grow marijuana for medical use is not such a grave problem that comfortable. Dr. Atul Gawande in research. Of note, the palliative medicine individuals who smoke marijuana, and the book, “Being Mortal,” made the blog, Pallimed, “the research literature possessive for that purpose, should point. “…our most cruel failure in how on marijuana use exclusively in hospice be subject to criminal procedures.” we treat the sick and aged is the failure and palliative care populations is quite In both cases, politics overrode science to recognize that they have priorities thin — only 110 articles could be found and were ignored by the politicians. beyond merely being safe and living in a 2015 search.” Medical marijuana To this day race and ethnicity play a longer: that the chance to shape one’s will not work for every patient. But then strong role in the prosecution of drug story is essential to sustaining meaning nothing does. There is a fascinating crimes. In fact, whites and most in life.5 Once I was comfortable asking website called www.TheNNT.com that minorities use marijuana in similar a hospice patient, I was surprised how shows the number needed to treat, TENNESSEE MEDICINE 12 QUARTER 1 | 2018 TENNESSEE MEDICINE 13 QUARTER 1 | 2018

adequately, many medications. It is addictive potential including opioids, ‘anything,’ there are a multiplicity of stunning how many people may take a sedatives, and anti-anxiety medications. other ways to ingest marijuana, and medication for only one to show benefit. When I’ve had hospice patient’s families its by-products that include vaporizers, Even with opioids, the NNT is 2.5. But express concern about addictions pills, foodstuffs, transdermal oils, Ask opinion is shifting. Surgeon General I gently pointed out the patient has a sublingual application, etc. under Pres. Obama, Dr. Vivik Murthy, fatal illness, and there is “no trip to the notes that “in some medical situations Betty Ford Center” at the end. As the point is made elsewhere in this marijuana can be helpful.” issue, in some cases marijuana and TMA In 2017, West Virginia became the its byproducts may help in avoiding or In his book, “Stoned: A Doctor’s Case 29th state in the union to adopt a lowering opioid doses which would be for Medical Marijuana,” palliative care medical marijuana law. Many states a win in the current opioid crisis. physician David Casarett, examines including Tennessee have a “Right to Additional studies in JAMA Internal literature and spends time with patients Try” law. These laws are supposed Medicine found a sharp decline of concluding that marijuana is particularly to give terminally ill patients the 25% in opioid overdose deaths in states helpful for nausea as well as neuropathic opportunity to try medications that with medical marijuana laws.6 Additional pain and may well help with seizures. He have passed phase 1 safety trials. studies show declines in Medicare and also makes a case for CDB oils which Medicaid prescription spending in An insurance plan just requested a copy of my may have more therapeutic benefit than It would seem that this should also medical marijuana states.7 I firmly Q: renewed medical license and I just realized that include marijuana and its compounds. the THC component. believe the terminal ill patients have the it expires at the end of this month. I did not receive The Institute of Medicine published right to any medication that will help Casarett, also looks at the addiction a report in1999 the said: “the them feel better in their final days. any type of renewal notice from my licensing board. issue and finds marijuana less addictive accumulated data indicate a potential At the very least, I would quote Pres. How do I renew my license? (9%) than cocaine (12%) or alcohol therapeutic value for drugs, Jimmy Carter in his Drug Abuse (15%). Some heavy use patients particularly for symptoms such as pain Message to Congress where he said: may exhibit withdrawal behavior relief, control of nausea and , “penalties against possession of the characterized by anxiety and agitation and appetite stimulation.” 90% of the drug should not be more damaging and insomnia. Of course, most of the US population supports the concept to an individual in the use of the In 2013, all Tennessee health professional licensing boards medications used in hospice and of medical marijuana. For those drug itself.” ▪ A: began sending renewal notifications electronically approximately palliative care have habituating or physicians opposed to patient’s smoking 45 days prior to the expiration date of the license. A licensee needs to go to https://apps.tn.gov/hlrs/ and complete the registration process in order to receive the electronic notices. This is also where you will renew

your medical license. If your email address changes, you need to update this system or you will miss the notification. SELECTED RESOURCES: Contact the Legal Department with any questions at 800.659.1862 1. Driving Miss Daisy: One Family’s Journey Saying “Yes” to Living. Tim Bauerschmidt and Ramie Liddle. HarperCollins 2017. or [email protected].

2. Marijuana: a short history. John Hudak, the Brookings Institution Press, 2016 page 36

3. Last Call: the Rise and Fall of Prohibition. Daniel Okrent. Scribner, 2010 page 42

4. Stoned: a Doctor’s Case for Medical Marijuana. David Casarett MD, current& 2015

5. Being Mortal; Dr. Atul Gawande. 2014, Metropolitan Books

6. Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2019. Buchhuber, MA, Saloner B, Cunningham C.C, Barry, CL. Jama Internal Medicine 2014; Oct 174(10) 1668-73.

7. Medical Marijuana Laws Reduce Prescription Medication Use in Medicare Part D. Bradford, A.C, Bradford, W.D., Health Affairs July 2016. pps 1230- 36 TMA members can “Ask TMA” by emailing [email protected] or calling 800.659.1862. Questions and comments will be answered personally and may appear anonymously in reprint for the benefit of members. TENNESSEE MEDICINE 14 QUARTER 1 | 2018 TENNESSEE MEDICINE 15 QUARTER 1 | 2018

Society and Tennessee College of providers without fixing the real If it were not for the TMA and its partners, The truth about Emergency Physicians — opposed the problem for patients. providers would already be forced to legislation because it would have created comply to unreasonable rules that would As a result, the legislature created a task operational slowdowns and more force more inefficiencies into a system that force to study the issue in 2017 but never surprise medical bills, unnecessary administrative hassles for already has enough burdens. developed any final recommendations. PART I

Originally published by the Kingsport Times News November 26, 2017 PART II By Douglas Springer, MD and Jonathan Hughes, MD The following was submitted by Dr. Douglas Springer, past president of the Tennessee Medical Association, and Your favorite aunt (we will call her Aunt including who pays and how much, has rates, resulting in lower premiums. Buyer Dr. Jonathan Hughes, Sullivan County Medical Society board member. Part 1 of their article, published last week, beware of these “affordable” plans. You Beatrice for illustrative purposes) goes to become so complex that it can overwhelm addressed the issue of “surprise” medical bills. the Emergency Department of her local the average patient. Even doctors and must investigate thoroughly to ensure that hospital with the sudden onset of hospitals have a hard time keeping pace. the plan offers adequate providers and Originally published by the Kingsport Times News December 3, 2017 abdominal pain. The emergency room This complexity results in patients getting services because if you go “out of network” physician examines her and orders testing. a “surprise bill” from a hospital-based you will be responsible for the full amount Remember Aunt Beatrice and her surprise have an obligation of transparency their costs and ultimately transfer the real Labs and a CT scan are performed. The doctor or other health care providers, just of the services rendered. medical bills? Since insurance companies to health care consumers. If patients costs to unsuspecting patients. lab work is reviewed by the ER doctor, as Aunt Beatrice did in the above story. In the fictional case above, how would are intensifying their efforts to narrow choose a plan based on low premium and the X-ray is read by a radiologist. She 5. Patients need a simple and transparent She is not just getting a co-pay bill, but Aunt Beatrice investigate which providers networks and force more hospital-based monthly costs, then it should be made is found to have acute appendicitis. The avenue to be able to take their billing a bill for the full amount of the service she should see and request in the middle physicians out of network, a fair and clear about the magnitude of their out- “on call” surgeon is immediately consulted grievances to the health insurers and the provided because the insurance company of an emergency? How is her “on call” equitable solution should be developed to of-pocket expenses and their potential and takes her to the operating room. out-of-network physicians to get their is not going to pay any part of the bill doctor supposed to advise her in the protect unsuspecting patients from paying coverage gaps as it would relate to She is reviewed by the anesthesiologist, bills amicably resolved for all parties. submitted by the professionals that were middle of an emergency about whether high, unexpected out-of-pocket charges. balance billing and care. Thus, insurers who will sedate her for the surgery. The Our legislature can facilitate putting the “not in network.” Aunt Beatrice has no her particular policy includes his/her must clearly inform their enrollees of appendix is removed and the specimen Contract negotiations between physician type of structure in place. option but to pay the balance owed practice in the “panel of approved the limits of their coverage and prior to is sent to pathology. practices and health insurance companies because of the contracts written by her providers” or what she would owe as a elective and non-emergency scheduled 6. Out-of-network payments should be are usually one-sided, take-it-or-leave-it Aunt Beatrice is in the hospital for insurance company. She is not happy! balance without the help from their office procedures, provide enrollees with based on reasonable charges for the negotiations in which the insurers have 36 hours and released. She feels confident personnel who may not be available to reasonable and timely access to same service in the same geographic The health care industry refers to the all the leverage. Many providers feel that her bill will be minimal because she them at the time Aunt Beatrice came into in-network physicians. area utilizing physician charges that are “surprise billing” scenario as “balance forced to choose between accepting lower has insurance. She has interacted with the hospital? How is it reasonably prudent geographically specific, transparent billing,” and it can make an otherwise than standard fees or not participating 3. The vast majority of physicians want to health insurance before and expects, at for providers to spend hours of their day and independent of the control of positive clinical experience unnecessarily in the plans. participate in network with insurance most, that she will owe some reasonable digging up these facts? either insurance companies or doctors. frustrating and confusing for the patient. companies. Why? The reasons for agreeing co-pay amount. The TMA is currently working with Also by not paying a reasonable fee to Because the insurance company will Insured patients who are treated in the to be in-network are the volume of patients various health plans, state legislators out-of-network providers, the insurance This was the case for her visit to the not pay the providers who make your hospital should be confident that their a pracsee, ease/reimbursement of claims. and other stakeholders on solutions to companies virtually eliminate access to hospital and ER, the labs, the CT scan diagnosis, give you anesthesia, read health insurance will cover them. However, they can only do so when prevent this scenario, so patients stop and deny the potential benefit of these and the surgeon. Why? Because they were your X-ray or interpret your pathology Unfortunately, a growing number of insurers negotiate in good faith for receiving surprise bills. Here is what providers. “on the panel” of previously negotiated specimen, those providers are forced to patients are finding out too late that their fair reimbursement. This cannot be can and should be done to solve the fees with her health plan. Aunt Beatrice’s try to collect the charges directly from coverage is far less comprehensive than legislated directly but could be influenced 7. Patients who are seeking emergency issue of “balance billing” from the Explanation of Benefits and bills from the you. The amount is typically much higher they had previously understood. Insurers as outlined further below. care should be protected under the TMA perspective: various providers reflect the reasonable than what you would have paid “out of are making unsuspecting patients “prudent layperson” legal standard as 4. Some insurance companies and state co-pays she expected. pocket” if the insurance policy had responsible for huge additional payments. 1. The TMA is advocating for our state established in state and federal law, officials want to prohibit balance billing covered the various providers. government to adopt clear and objective without regard to prior authorization But the bills for the ER doctor, radiologist, The Tennessee General Assembly debated without addressing the real drivers of standards for the adequacy of plan or retrospective denial for services after pathologist and anesthesiologist began But why don’t insurance companies this issue in 2016 and 2017. Lawmakers the problem as noted in points 1 and 2. networks. This should include adequate emergency care is rendered. arriving 30 days later and totaled $5,000 cover all the providers in the hospital? considered legislation that would have Holding insurance companies to network access to specialty care, including access (a made-up figure, but illustrates the How did we get to this point? Answer: required health care providers who are not adequacy standards and compelling them Your physician does not want you to get a to hospital-based physician specialties. issue). Aunt Beatrice is confused and asks, In their quest to attract more employers contracted with the patients’ insurance to offer reasonable reimbursement to surprise medical bill. That is why TMA is State regulators should uphold such “How can this be?” and patients to their plan, insurance carrier to give an estimate of anticipated hospital-based physicians would solve working diligently on patients’ behalf to standards in approving the various companies have used “narrow networks” charges to patients. The Tennessee Medical most of the issues. If this is not done, treat the cause of this problem and not put The answer is balance billing. health insurance plans. to hold down costs and limit what they Association and its partners — Tennessee insurance companies will continue to a Band-Aid on the symptoms. ▪ The manner in which medical services are pay for services by having a restrictive Society of Anesthesiology, Tennessee 2. All persons and entities involved in exclude even more providers and services bought and sold in our health care system, list of providers and deeply discounted Society of Pathology, Tennessee Radiology providing and financing health care in “narrow networks” in efforts to control TENNESSEE MEDICINE 16 QUARTER 1 | 2018 TENNESSEE MEDICINE 17 QUARTER 1 | 2018

A Marijuana Update from the AMA

By B. W. Ruffner, MD

The AMA has addressed the social and medical challenges of cannabis in four reports over the past fifteen years. This paper will summarize CASPH Report 5, presented at this year’s Interim Meeting in November, with two goals in mind. First, our legislature continues to struggle with pressure to make marijuana more available, and our thoughts are important. Second, physicians must respond to patients’ inquiries about its use for a variety of conditions. The AMA report updates the current legal status in various states, has a thorough review of the , both positive and negative, and presents AMA policies. Their most significant findings included has documented a 48% increase in auto observations is substantial evidence for chronic pain. They found “moderate” fatalities among drivers with positive the development of schizophrenia and evidence that chronic neuropathic pain blood level for . Other states other psychoses in some regular users. STATE LAWS ON CANNABIS prescriptions are more often called taking their chemotherapy. The patients was improved but noted that a report in have also noted increases. ACOG has ‘recommendations’ or ‘referrals’ because reluctantly confided to the staff that they Only eight states have approved Annals of Internal Medicine found the officially discouraged marijuana use AMA POLICY recreational use of marijuana. Most have of the federal prescription prohibition.” had discovered that if they smoked a evidence unconvincing.3 There is also during and when The Report includes all current AMA done so by referendum. Vermont is the “” beforehand, they had less nausea evidence that patients receiving opioids because of possible effects on neural policies, including encouragement of only state to do so by legislation, but MEDICAL EFFECTS, from their treatment. This discovery led for pain require less when supplemented development. In Colorado, 5.7% of women continued research on the potential value the governor vetoed the proposal until POSITIVE AND NEGATIVE to the development of some compounds, by cannabinoids. Chemotherapy-Induced consumed marijuana during pregnancy further data was available on its ramifi- available by prescription, for this purpose. of cannabis products. They note that An overview of the chemistry of the nausea. As noted above a purified product and 4.2% when breastfeeding. There is also cations for the health of the state. Some Nabilone (Cesamit) and drobanilol the fact that marijuana is a Category I many components of marijuana may is effective. Anorexia from HIV also benefits, an increase in the number of low birth states are attempting to collect data on the (Marinol) are cannabinoids extracted from, product makes it difficult for researchers be helpful. Few patients know that not as does spasticity in patients with MS, weight babies. Smokers have an increased benefits and risks, but in most cases, the or modified chemically from, marijuana. to obtain specific strains that might be all marijuana is the same. The main and children with Dravet Syndrome and incidence of chronic bronchitis, and there legal use has only occurred in the past one The drugs are rarely used because important, and that there are legal desirable component for “recreational” Lennox-Gastaut Syndrome (). is marginal evidence of an increase in lung or two years, so data is scarce. In 2017, 20 other options are more effective and less obstacles to studying it. “Our AMA use is or THC. There is no convincing evidence for use and head and neck cancers. state legislatures have introduced bills to expensive. Older patients complained supports research to determine the The second component with definite for the post-traumatic syndrome, other legalize marijuana for recreational use. of sedation and dysphoria, but younger There is strong evidence of “impaired consequence of long-term cannabis use, medical value is cannabidiol or CBD seizure disorders, irritable bowel syndrome patients had fewer complaints. These domains of learning, memory, and especially among youth, adolescents, which is very effective for some causes of or for achieving abstinence from other The National Conference of State are examples of an ideal process, where attention with acute cannabis use” which pregnant women and women who are pediatric epilepsy. CBD has no euphoric addictive substances. Legislators updated their survey of state compounds are extracted, evaluated in is obviously a concern with adolescents, breastfeeding,” and our AMA urges 1 effects. There are many other chemicals in activity in September. Twenty-nine states, drug trials and approved by the FDA for There are many concerns about legalized and that heavy users are underachievers “legislatures to delay initiating the the leaves of cannabis that may be useful. including Tennessee, have legalized prescription use. marijuana, however. Colorado data at school. There is moderate evidence that legalization of cannabis for recreational medical use of marijuana or cannabinoids, There are two main species, but growers suggest that after legalization, use in users become dependent, but states with use until further research is completed but most restrict its use to carefully crossbreed plants in hopes of getting Report 5 gives a detailed overview of ages 35 – 43 has increased, but use recreational use document that the risk on the public health, medical, economic, defined medical conditions. The update varieties with enhanced properties. the data. It reviews a National Academy among adolescents has not. Colorado is not great. One of the most frightening and social consequence of its use.” ▪ notes that “Some of the common policy Where legally sold, products include report which attempts to evaluate the 2 questions regarding medical marijuana “Tijuana Gold” and “Tom Cruise Purple.” significance of the available studies. include how to regulate its recommendation, In most cases, the ratio of THC to CBD The AMA report has a four-page table is the same, but the potency may vary of their findings. For each therapeutic dispensing, and registration of approved SELECTED RESOURCES: patients. Some state and localities without tremendously. In Israel, selective breeding value or risk, they attempt to give a score, dispensary regulation are experiencing a has produced a variety with high from “substantial evidence” to “no or 1. National Conference of State Legislatures. State Medical Marijuana Laws. 2017. boom in new business, in hopes of being concentrations of CBD, but little THC, insufficient evidence.” A link to the study http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx approved before presumably stricter known at Avidekel. is available from the TMA. It is important 2. The National Academies of Sciences Engineering and Medicine. The health effect of cannabis and cannabinoids: Current state of evidence and regulations are made.” Their report to note that in almost all cases, the studies About 50 years ago, an oncology fellow recommendations for research. Washington DC. The National Academies Press 2017 also reminds that since marijuana is a were conducted with oral, carefully at the Sloan Kettering Cancer Institute Schedule I substance, distribution is a defined products — not on street corner noticed that young adults with Hodgkin’s 3. Nugent SM, Morasco BJ et.al. The Effects of cannabis Among Adults with Chronic Pain and an Overview of General Harms: A Systematic Review federal offense, so “Medical marijuana “joints” or “marijuana oil.” Disease slipped into the restroom before Ann Intern Med 2017; 167(5):319-331. 2018 TMA VOTER GUIDE

Meet the Candidates

LEADERSHIP PRESIDENT-ELECT 2018 TMA VOTER GUIDE VOTER TMA 2018 Serves as head of the Tennessee Medical Association for the year following the election. Responsibilities include serving as official spokesperson with media, government officials, and other entities. The president-elect will serve one year as president-elect, one year as president and one year as immediate past president. 2018 ELECTIONS President-Elect Nominee: Elise Cheng Denneny, MD, FACS In 30 years of practicing medicine across every kind of practice setting, I’ve seen the relevance and impact of organized medicine. It impacts the lives of physicians, patients, families and communities. TMA fights for those interests, along with federal, state and local societies. TMA has great momentum on the back of recent legislative successes. Looking forward, we must leverage that momentum and IT’S ELECTION SEASON! 2018 TMA stand to influence discussion on issues that will define the immediate and long term future. Foremost Use this voter guide to review nominees before casting among these issues are improving clinical workflow and mitigating burnout, better access for patients your ballot online. All election materials are available and reducing payer obstructions, and navigating the transitioning reimbursement landscape. These NOMINEES are pivotal times, and we must present a clear vision as an organization to improve the lives of our at tnmed.org/elections. patients and colleagues.

President-Elect City: Knoxville • Voting will be open Feb. 1 – Feb. 28, 2018.  Elise Denneny, MD, CMS: Knoxville Academy of Medicine • All active dues-paying members and veteran members as of Knoxville Specialty: Otolaryngolog y— Head and Neck Surgery Dec. 31, 2017, will be eligible to vote in the election.  Jane Siegel, MD, Medical School: Rush Medical School Nashville Email: [email protected] • All votes must be cast online. 

• Every member with an email address in the TMA system will receive Board of Trustees an electronic notice with his or her TMA member number, verification Region 2 of voting region and a link to the ballot.  W. Kirk Stone, MD President-Elect Nominee: • Members without active email addresses on file with TMA can access Region 4 the ballot at tnmed.org/elections.  Jane Siegel, MD Rodney P. Lewis, MD Many of you may recognize me as the former Speaker of the House of the Tennessee Medical • Association. I have been a TMA member for many years and have participated on various committees No login is required to vote, but a valid TMA member number and Region 5 region number will be required.  including the insurance issues committee, have been involved in the TAG advisory groups and met James Wilson Cates, Jr., MD with legislators on Capitol Hill. There are many important issues that continue to challenge the house of medicine in Tennessee, including the opioid crisis, independent practice by mid-levels and the • All ballots will include space for write-in votes.  Region 7 ever-changing insurance landscape. More and more physicians are choosing to be employed while others band into larger groups. Individual and small practices are seemingly under siege. We need • Timothy S. Wilson, MD All ballots must be cast by 5 p.m. CST on Wednesday, Feb. 28, 2017, to open lines of communication, listen to the needs of all physicians in Tennessee, understand the in order to be counted.  diverse nature of our profession and try to come together with common purpose. I will challenge myself to rein in the forces driving us apart and find common ground for which we can work together • A runoff election will take place March 21-28, if necessary. Judicial Council as a true association. Region 1 Nashville Justin Monroe, MD City: CMS: Nashville Academy of Medicine ALL BALLOTS MUST BE CAST ONLINE BY 5 P.M. CST ON Region 3 Specialty: Orthopaedic surgery WEDNESDAY, FEB. 28, OR THEY WILL NOT BE COUNTED. Omar Hamada, MD Medical School: Vanderbilt University Medical School Email: [email protected] Region 5 James C. Gray, MD

Region 7 For more information: contact Amy Campoli at [email protected] John W. Lacey, III, MD or 615.460.1650. TMA BOARD OF TRUSTEES

The TMA Board of Trustees determines the policy and details of management of the association between meetings of the TMA House of Delegates. Trustees carry out the directives given by the House. They serve two-year terms.

Region 2 Nominee: W. Kirk Stone, MD 2018 TMA VOTER GUIDE VOTER TMA 2018 My name is W. Kirk Stone, MD. I am a family physician society as well as statewide functions such as Doctors’ in Union City. I have been a TMA member for more Day on the Hill. I look forward to continuing to serve than 20 years. During that time, I have served in my fellow physicians. several capacities. I was president of my local society for several years. I have served on the judicial council, City: Union City the IMPACT board, the public health committee, and CMS: Northwest Tennessee Academy of Medicine We’ve got a mortgage have been chair of the credentials committee for the Specialty: Family Practice last several years. I also served a previous six-year Medical School: University of Mississippi term on the board of trustees. I am completing my current term on the Board and am seeking re-election Email: [email protected] that fits you. to another term. I have been very active in my local

Region 4 Nominee: Rodney Lewis, MD Rodney Lewis, MD graduated Summa Cum Laude for two years. He has also served as a delegate to with a Bachelor of Science degree in Biology from the TMA for many years and is an active member of Emory and Henry College located in Virginia. He the TMA Membership Committee. Dr. Lewis enjoys received his Doctor of Medicine degree from University spending time with his wife and three children. His of Virginia School of Medicine. Dr. Lewis completed hobbies include music, golf, sports, gourmet cooking his internal medicine internship and residency at and reading. University of Tennessee Baptist Hospital in Nashville. Also, he participated in residencies in ophthalmology City: Nashville at Medical College of Georgia and general surgery and CMS: Nashville Academy of Medicine anesthesiology at Vanderbilt University Medical Center. Specialty: Internal Medicine He is a member of the American College of Physicians Medical School: University of Virginia and has served on the board of the Tennessee Medical Association and the Nashville Academy of Medicine Email: [email protected] Ask us about our low mortgage rates. Region 5 Nominee: James Wilson Cates, Jr., MD Jamie Cates attended Meharry Medical School and as the 2017 president of the Upper Cumberland TMA Members and their employees are completed his residency training in family practice at Medical Society-TMA. the University of Tennessee Medical Center. He is a eligible to receive a $500.00 discount off member of numerous societies including American City: Cookeville Academy of Family Practice, Tennessee Academy CMS: Upper Cumberland Medical Society of Family Practice and the American College of Specialty: Family Practice closing costs on a home mortgage. Sports Medicine. His leadership training includes Medical School: MeHarry Medical School the Executive Physician Harvard Medical School and TMA’s Physician Leadership Lab. Dr. Cates served Email: [email protected] Keith Collison, Managing Director Finworth Mortgage  Region 7 Nominee: [email protected] 615.345.9905 Timothy S. Wilson, MD NMLS #174913 I have been a delegate for the TMA House of of Medicine. I believe in and fully support the mission Delegates for five years. I have been on several of the TMA and am willing to work to protect the rights organized medicine boards including the Knoxville of both patients and physicians. Academy of Medicine and the Southeastern Society of Plastic and Reconstructive Surgeons, and have City: Knoxville served on numerous committees with the American CMS: Knoxville Academy of Medicine Society for Aesthetic Plastic Surgery. I am Chief of Specialty: Plastic Surgery Staff-elect at Parkwest Hospital in Knoxville and am Subject to credit & other restrictions Medical School: University of Tennessee currently President-elect to the Knoxville Academy Email: [email protected] 2018 TMA VOTER GUIDE

TMA JUDICIAL COUNCIL

The Judicial Council meets annually, or more often if necessary, to investigate alleged improper conduct and oversee formal disciplinary action against members or component medical societies. Councilors also assist component medical societies in maintaining viability in the region. Each region has one councilor serving on the Judicial Council. Councilors serve two-year terms.

Region 1 Nominee: Justin Monroe, MD Currently serving as TMA Judicial Council since 2016, City: Memphis and Memphis Medical Society Delegate since 2009. CMS: The Memphis Medical Society Participated in John Ingram Leadership Institute in Specialty: Colorectal Surgeon 2012 and the John Ingram Leadership College in Medical School: University of Tennessee at Memphis 2011 and 2012. Board certified in both general and colorectal surgery. Fellow of the American College of Email: [email protected] Surgeons and a member of the American Society of Colon and Rectal Surgeons.

Region 3 Nominee: Omar Hamada, MD, MBA Dr. Omar Hamada is a proven leader in and out of academic, corporate, pharmaceutical, and military the TMA. He has been a member for more than 20 environments. He is a veteran of the United States years, is a 2011 graduate of the Physician Leadership Army’s Special Forces (Airborne). College, and has served in several capacities within TMA, including the Judicial Council, the IMPACT City: Brentwood Board, and as an Ex-Officio Member of the Board of CMS: Williamson County Medical Society Trustees. He has a medical degree from the University Specialty: Obstetrics and Gynecology of Tennessee and is Board Certified in Obstetrics and Medical School: University of Tennessee Center Gynecology, Family Medicine, and is Board Eligible in for Health Science Sports Medicine. He has an MBA from Vanderbilt’s Owen School. Omar has valuable experience in the Email: [email protected]

Region 5 Nominee: James C. Gray MD My goal during my first term on the Judicial Council 100 members) to 3 (>100 members). If re-elected, I was to give physicians in all 14 counties of the plan to focus on sustainable growth of the TMA in Upper Upper Cumberland Development District (UCDD) Cumberland the next two years. I believe this will be an opportunity to participate in a TMA Component accomplished as we offer physicians even in the smallest medical society. Putnam County Medical Society was counties peer support and an opportunity for physician the only remaining active society in the UCDD. We leadership through membership in their TMA component petitioned the HOD and successfully changed the medical society. name from Putnam to the Upper Cumberland Medical Society (UCMS-TMA). The UCMS-TMA has now been City: Cookeville chartered and we strive to serve physicians in all CMS: Upper Cumberland Medical Society counties in the UCDD that do not have a component Specialty: Obstetrics and Gynecology medical society. The Upper Cumberland’s representation Medical School: Medical College of Georgia in the TMA House of Delegates has grown from 2 (< Email: [email protected]

Region 7 Nominee: John W. Lacey, III, MD I am a past president of the Knoxville Academy of (KAPA). KAPA is a program of the Knoxville Academy of Medicine and recently retired from The University of Medicine Foundation and has coordinated more than Tennessee Medical Center Knoxville where I served as $210 million in care for more than 25,000 uninsured the Chief Medical Officer/Senior Vice President since East Tennesseans since 2006. 1998. Throughout my 40 years of practicing medicine, I have dedicated much time and energy to supporting City: Knoxville the medical profession and improving community CMS: Knoxville Academy of Medicine wellness. To this end, I have served as chair of the TN Specialty: Internal Medicine Governor’s Health Task Force, Chair of the United Way Medical School: University of Tennessee Annual Giving Campaign, and as the volunteer medical director/founder of Knoxville Area Project Access Email: [email protected] TENNESSEE MEDICINE 24 QUARTER 1 | 2018 TENNESSEE MEDICINE 25 QUARTER 1 | 2018

P. Livingston Brien, MD SULLIVAN COUNTY Saagar B. Karlekar, MD UPPER CUMBERLAND FOR THE RECORD Curtis L. Baysinger, MD MEDICAL SOCIETY Jason L Kastner, MD MEDICAL SOCIETY - TMA Manoj Srinath, MD Brenden L. Kootsey, MD Mark S. Wathen, MD ROANE-ANDERSON COUNTY Heather Lehmann, MD Mary Caroline Loghry, MD MEDICAL SOCIETY THE MEMPHIS MEDICAL SOCIETY Sarah Marie Mian, MD Robert Anthony Comparin, MD Michael L. Douglas, DO James Kevin Stamps, MD Samuel Judson Murray, II, MD Arthur Judson Nash, Jr., MD New Members Amit Sai Bhakoo, MD Steven T. Riley, MD ROBERTSON COUNTY Victoria R. Rundus, MD WASHINGTON-UNICOI-JOHNSON MEDICAL SOCIETY Jeremy Scott Avila, MD Maher Ghawji, MD Marlon L. Shell, MD COUNTY MEDICAL ASSOCIATION Jennifer Singleton Ashworth, MD BLOUNT COUNTY MEDICAL SOCIETY NASHVILLE ACADEMY OF MEDICINE Chinye Azuh-Showole, MD Lachaundra Latrice Johnson, MD Raza Ur-Rehman Hashmi, MD Charles Norman Spencer, MD Tony O’Neal Haley, MD Ben Hunter Butler, MD Michael Todd Damron, MD Nicklaus P. Atria, MD Justin Matthew Bachmann, MD Huong Thi Thu Le, MD Denise Francis Stuart, MD Elizabeth Anne Lawson, MD Erika Lachelle Crawford, MD Mahdi Mphammad Budayr, MD Nathan R. Belt, MD Ayodeji O. Balogun, MD Stephen Lee, MD TMA DIRECT MEMBER Megan Nicole Tackett, MD John F Robertson, III, MD Suzanne Elizabeth Glover, MD Michael P. Bunch, MD Meredith A. Brown, MD Erik Benitez, MD Chenai Saaku Nettey, MD Brent A Webb, DO Catherine Oelschig Wiggleton, MD Nigel I. Dsouza, MD Anjeli K. Wilson, MD Irina Chelnokova, MD Adam J. Canter, MD Philip A. Brooks, MD Chinenye M. Okukpon, MD Hak Sok Seo, MD Alyson Ann Wills, MD Kenneth B. Lewoczko, MD Julie Ann Corcoran, DO Amy L. Douglas-McVay, MD Cedrina Calder, MD Mina Ossei, MD Jo Ann Cook Collins, MD Kenneth Noel Wyatt, MD Timothy P. Zajonc, Jr., MD Michael D Floyd, MD, FACP Farhad Firoozbakhsh, MD Orville C Campbell, MD Rita Patrick, MD Kevin McCoy James, MD Roland W. Gray, MD David Thanh Duong, MD Rene Hulet Powell, DO Yaw Otchere-Boateng, MD Scott A. Harshman, MD Ogonna Eze, MD Kourtnei M. Robinson, MD Michael C. Prostko, MD Nazek Shabayek, MD Celia Ezidiegwu, MD Todd A. Rubin, MD Jack T. Roberts, Jr., MD, FACP Edward Brooks Weller, II, MD Naima Farah, MD Hanyuan Shi, MD Koovapudi Jayaram Shankar, MD Michael E. Aberra, MD Ghino L. Francois, MD Joseph S. Simon, MD Deaver Timothy Shattuck, MD Makarem Abu Limon, MD Dillobar Gelfond, MD Muthu Vel Sivasankaran, MD In Memoriam Nicole M. Soto, MD Rabie Ibrahim Adam-Eldien, MD Abel H. Gimisso, MD Nicole Stephens, MD Xuan-Lan M. Griffith, MD, MPH Benjamin E. Studdard, MD Laura Elizabeth Yount, MD Sameer Aggarwal, MD Allen F. Anderson, MD | age 67 Inga Marie Himelright | age 60 William Emil Rentrop | age 92 Otis S. Apau, MD Osakhuemen W. Ihenyen, MD Yihan Wang, MD Died November 12, 2017. Graduate of Died December 31, 2017. Graduate of Died October 9, 2017. Graduate of University BRADLEY COUNTY Vagan Arutiunian, MD Paschal Ike, MD Keith F. Watson, MD University of Tennessee College of Medicine. University of South Florida College of Medicine. of Tennessee College of Medicine. Member MEDICAL SOCIETY Ni Aung, MD Diseiye F. Iyebote, MD Summer A. Williams, MD Member of Nashville Academy of Medicine. Member of Knoxville Academy of Medicine. of Memphis Medical Society. William Russell May, Jr., MD Allen Avedian, MD Rose Izuchi, MD Berhanu Zegeye, MD

CHATTANOOGA-HAMILTON John M. Bryan, MD | age 86 Melvin M. Kraus, MD | age 93 Robert M. Roy, MD | age 93 COUNTY MEDICAL SOCIETY Died November 10, 2017. Graduate of Died November 20, 2017. Graduate of Died October 6, 2017. Graduate of Radhika Mayank Shah, MD University of Tennessee College of Medicine. University of Tennessee College of Medicine. Vanderbilt University School of Medicine. Maikel Elia Botros, MD Member of Bradley County Medical Society. Member of Memphis Medical Society Member of Nashville Academy of Medicine. Gregg A. Willis, MD Robert H. Mitchell, MD Roza Adamczyk, MD Robert L. Chironna, MD | age 65 Dee Lamar Metcalf, III, MD | age 74 Robert Joseph Smith, MD | age 83 Aaron Kristopher Blakeney, MD Died December 14, 2017. Graduate of Died January 24, 2018. Graduate of Died December 15, 2014. Graduate of William John Fritsch, Jr., MD New York Medical College. Knoxville University of Tennessee College of Medicine. University of Tennessee College of Medicine Jonathan L. Humberd, DO Academy of Medicine Member. Member of Greene County Medical Society. graduate. Member of Consolidated Medical Ramses Luis Vega-Casasnovas, MD Assembly of West Tennessee. Paula J. Stewart, MD Bennett Young Cowan, MD | age 94 J. Pervis Milnor, Jr., MD, FACP | age 99 Keith D. Bohman, MD Died December 2, 2011. Graduate of Died November 13, 2017. Graduate of W. Shaen Sutherland, MD | age 89 Maribeth Banks Hamrick Harvard Medical School. Member of University of Tennessee College of Medicine. Bosshardt, MD Died September 28, 2017. Graduate of Sullivan County Medical Society. Member of Memphis Medical Society. Wesley Lane Davis, MD Loma Linda University School of Medicine. Jason Hideo Horinouchi, MD Dormant Medical Society Member. Yuvraj Kalra, MD Donald Baker Gibson MD | age 85 Charles E. Morton, III, MD | age 70 Alexandra Martin, MD Died August 21, 2015. Graduate of Died December 7, 2017. Graduate of Donald W. Tansil, MD | age 75 Christina Rebecca Parkhurst, MD Medical College of South Carolina. Member University of Tennessee College of Medicine. Died September 30, 2017. Graduate of Billy D. Worley, MD, MPH of Bradley County Medical Society. Member of Nashville Academy of Medicine. University of Tennessee College of Medicine. KNOXVILLE ACADEMY OF MEDICINE Member of Upper Cumberland Medical Society. Gurpreet Dhindsa Bullen, MD Robert Morris Glasgow, MD | age 84 Roy B. Parsons, MD | age 88 Marc A. Campbell, DO Died October 5, 2017. Graduate of University Died November 20, 2016. Graduate of J. Trent Ellenburg, DO of Tennessee College of Medicine. Member Loma Linda University School of Medicine. William H Tucker, MD | age 81 Blake A. Moore, MD of Sullivan County Medical Society. Member of Knoxville Academy of Medicine. Died November 4, 2017. Graduate of William R. Oliver, MD University of Tennessee College of Maya Aravind Raiman, MD Charles Newman Hatfield, MD | age 84 Thurman L Pedigo MD | age 81 Medicine. Member of Northwest TN Joseph B. Thurman, MD Academy of Medicine. Died December 19, 2017. Graduate of Died July 23, 2017. Graduate of University Dennis R. Van Dorp, MD University of Tennessee College of Medicine. of Tennessee College of Medicine. Member Allison Babelay Johnsen, MD Member of Blount County Medical Society. of Nashville Academy of Medicine. PHYSICIAN’S HEALTH REPORT Physician Burnout Don’t Wait to Ask For Help

By Michael Baron, MD, MPH TMF Medical Director

Forty years ago, the Tennessee Medical impact that changing pressures are having The first large study of burnout among U.S. Foundation’s Physician’s Health Program on physicians. Physicians are now being physicians was in 2011. That and subsequent was just getting started, and the problem referred to the TMF-PHP with increasing studies have found that more than 50 percent of Physician Burnout had not yet been frequency for behavioral problems including of physicians have substantial symptoms described. At the current time, burnout boundary violations, disruptive behavior, of burnout; physicians working in the among physicians and other health and for being “distressed.” trenches of primary care have the highest professionals is not only well described, incidence. Burnout is nearly twice as but is pervasive. What is a Distressed Physician? prevalent in the physician workforce as in The distressed physician is a coined term non-medical matched cohorts. Physician Burnout is a problem of national that really implies burnout. The distressed importance because it not only impacts the physician is not keeping their medical What’s the Solution? physician, it impacts the quality of care the records current; they are short or Physician burnout has become widely physician provides. Burnout is a syndrome inappropriate with staff, peers, and even recognized and of national importance, characterized by a high degree of emotional patients. Their efficiency has declined, but there is still little information on how exhaustion, cynicism, and a low sense of which means they are seeing fewer patients to address this problem. The evidence personal accomplishment related to work. per day. Something has happened to their indicates that changes at the national, state, TMF Adapts to Changing Physician Needs smile and bedside manner; they have lost organizational, and individual levels can enjoyment and no longer get pleasure from make a difference. However, progress is In 1978, the Tennessee Medical going to work and being a doctor. unlikely to occur at these grand levels until Association established a committee there is a coordinated effort to remedy the offering professional assistance to What is the source of this level of distress — complex causes. Given the dysfunction physicians suffering from alcoholism this loss of passion, energy, and purpose? Better safe than hacked. ingrained in these layers above the and drug addiction. The next year the The problems facing today’s physicians individual physician, there is little chance TMA’s Impaired Physician Peer Review are more complex than ever. Financial that meaningful change can occur quickly. Committee was born, being only the restraints, quality metrics, reimbursement That leaves the individual physician to fourth state physician health program structures, and institutional governance are implement tactics and strategies that will help in the country. In 1992, the TMA just a few of the external confines that make prevent, treat, protect, or reverse burnout. Physicians are increasingly exposed to privacy-related claims such as hacking, transferred oversight of the program us shudder. Add MOC, ACA, and EHR, and to the Tennessee Medical Foundation, The TMF-PHP is working to develop lost laptops, dishonest employees, and virus attacks, which can result in an we get OMG. We are required to navigate a 501(c)3 organization. Five years later resources, personnel, and strategies to help an ever-expanding knowledge base, all while embarrassing and costly loss. We offer a cyber Liability insurance Plan that the name Physician’s Health Program the individual physician with burnout; dealing with excessive workload, regulatory replaced the Impaired Physician’s Program. resilience building, mindfulness-based provides a comprehensive suite of first-party cyber, third-party cyber, and cyber requirements, clerical inefficiency, Now, 20 years later, the Tennessee Medical stress reduction, and preventive mental meaningful use, and a loss of autonomy. crime coverages, including: Foundation Physician’s Health Program health services are steps we are pursuing. The TMA AssociATion It is estimated that for every hour of clinical (TMF-PHP) is once again making We need your support to provide these insurAnce Agency, Inc. work, primary care physicians now spend • cyber, Privacy & network security Liability • Digital Data recovery changes to meet the needs of Tennessee’s resources. As always, if you, a colleague, two hours on clerical work or other EHR- Exclusive Insurance Plan Administrator physicians. That current need has to do friend, or significant other have burnout, • Payment card Loss • Telephone Toll Fraud related tasks. for the Tennessee Medical Association with Physician Burnout. please don’t wait — contact the TMF-PHP • regulatory Proceedings • network extortion Physicians have maintained responsibility for help. Your call is confidential. For the first 25 years of the TMF-PHP’s but with loss of control — a situation that • Media Liability • computer Fraud existence most of our new identifications We all have a vested interest in addressing is almost guaranteed to be unfeasible and Contact us today! had a substance use diagnosis. That physician burnout before it becomes • cyber incident response Fund • Funds Transfer Fraud induce despondency. Is anyone surprised majority has now decreased to about something more serious. A healthy that burnout has become an issue for • Business interruption • social engineering Fraud 50 percent. The once-predictable referral physician provides better care. practicing physicians? 800.347.1109 patterns are rapidly changing to reflect the cyber Liability insurance can make the difference between staying in business TMAinsurance.com or shutting your doors after an attack. contact us for a professional cyber For assistance or to make a tax deductible contribution to the Physicians Health Program, contact the Tennessee Medical Foundation at 615-467-6411; write to the review or for more information on this valuable coverage. Tennessee Medical Foundation, 5141 Virginia Way, Ste 110, Brentwood, TN 37027; or visit e-tmf.org to send a confidential email or donate online. ADVERTISERS IN THIS ISSUE INSTRUCTIONS FOR AUTHORS TMA MEDICAL BANKING ...... INSIDE COVER Manuscript Preparation according to Index Medicus, volume number, first and last Electronic manuscripts should be submitted pages, and year of publication. Example: Olsen JH, Boice JE, TMA DAY ON THE HILL ...... 2 to the Editor, David G. Gerkin, MD, via email at Seersholm N, et al.: Cancer in parents of children with cancer. HASLAM COLLEGE OF BUSINESS ...... 6 [email protected]. A cover letter should N Engl J Med 333:1594-1599, 1995. identify one author as correspondent and should TMA INSURANCE ...... 9 Illustrated Material include his/her complete address, phone, and e-mail. Illustrations should accompany the emailed article Manuscripts, as well as legends, tables, and references, STRATEGIC FINANCIAL PARTNERS ...... 10 in a JPG, TIF, JPG or PDF format; files must be high must be typed, double-spaced on 8-1/2 x 11 in. white resolution, at least 300 dpi. Photos must be identified FINWORTH MORTGAGE ...... 21 paper/Word document. Pages should be numbered. The with the author’s name, the figure number, and the transmittal letter should identify the format used. If there TENNESSEE DRUG CARD ...... 22 word “top,” and must be accompanied by descriptive are photos, e-mail them separately in TIF, JPG or PDF legends typed at the end of the paper. Tables should SUNDANCE ...... 24 format along with the article; photos and illustrations be typed on separate sheets, be numbered, and have must be high resolution files, at least 300 dpi. adequately descriptive titles. Each illustration and TENNESSEE MEDICAL FOUNDATION ...... 26 Responsibility table must be cited in numerically consecutive order TENNESSEE OCULOPLASTICS ...... 28 The author is responsible for all statements made in in the text. Materials taken from other sources must his work. Accepted manuscripts become the permanent be accompanied by a written statement from both the SVMIC ...... 30 property of Tennessee Medicine. author and publisher giving Tennessee Medicine permission to reproduce them. Photos of identifiable Copyright patients should be accompanied by a signed release. Authors submitting manuscripts or other material for publication, as a condition of acceptance, shall execute Consideration a conveyance transferring copyright ownership of such Please be aware that due to the volume of submissions, material to Tennessee Medicine. No contribution will be article consideration by the Editor and/or Editorial Board published unless such a conveyance is made. may take three months or more. References Publication References should be limited to 15 for all papers. All Publication of accepted submissions could take up to references must be cited in the text in numerically consecutive a year or more; TMA Members enjoy an expedited order, not alphabetically. Personal communications and publication benefit that could reduce the wait time by unpublished data should be included only within the text. The up to several months. All articles and abstracts will be following data should be typed on a separate sheet at the end published in an online forum and open for peer review of the paper: names of first three authors (last name first on our website, and online database for journals, initial[s] with no commas or periods) followed by et al., articles, and resources available to TMA members only. complete title of article cited, name of journal abbreviated In our world, STAYING SHARP has nothing to do with your instruments.

We strive to bring the latest theories and practices right to our physicians through online and in-person education and consultation.

®

svmic.com | 800.342.2239

SVMIC_TMA_2018.indd 1 1/10/2018 1:20:20 PM